Policy Class

Myrtle J. Scott-Franklin Network, LLC.

POLICIES AND PROCEDURES MANUAL

Behavioral Health Rehabilitation Services

and

Outpatient Counseling Services

Please Direct Any and All Changes to The Chief Operating Officer Before Modifying Anything in This Manual

58

TABLE OF CONTENTS:

Assessment for Outpatient Services …….………………………………………………. Page 10

Client Rights and Informed Consent ……………..………………………………………. Page 12

Clinical Documentation ………………………..…………………………………..………….. Page 14

Clinical Supervision ……………………………………………………………………………….. Page 15

Complaints by Clients or Caregivers…………………………………………..…………… Page 18

Compliance Policy …………………………………………………………………………...……. Page 19

Confidentiality of Client Information………………………………………………………. Page 21

Credential, Health, & Background Checks for Employees & Contractors. Page 25 Critical Incidents ………………………………………….………………………………………… Page 27

Cultural Competency……………………………………………………………………………… Page 29

Dangerous or Inappropriate Items Brought on Premises ….……..…………… Page 30

Demographic Information ………………………………………………………..…………… Page 31

Discharges – Administrative or Against Facility Advice……………..…………… Page 32

Discharge Documentation ………………………………………………………..…………… Page 34

Emergency Procedures: General Preparedness ……………………….…………… Page 36

Evacuation ………………………………………………………………………… Page 37

Fire ………………………………………………………………………… Page 38

Flood ………………………………………………………………………… Page 39

Hurricane ………………………………………………………………………… Page 40

Medical Emergencies ……….……………..………….…………..……..………. Page 41

Nuclear Accident ……………………………………………………………………… Page 42

Snowstorm …………………………………………………………..…………… Page 43

Threat of Violence……………………………………………………………………… Page 44

Tornado ………………………….……………………..…………………………… Page 46

Utility Failures …………….. ………………………………………………………… Page 47

Employee and Contractor Absences Affecting Client Care ……………...…… Page 48

Employee and Contractor Orientation ………..…………………………….………… Page 49

Employee and Contractor Rehire Policy ……..……….…………….………………… Page 50

Employee and Contractor Sanctions ………...….…………………………..………… Page 51

Equal Opportunity Employment……………………………………………………………. Page 52

Ethical Conduct……………………………………………………………………………………… Page 54

Hazardous Waste Policy….…………………………………………………………………….. Page 56

Job Openings ………………………………………………………………………………………… Page 58

Management of Escalation …………………………………………………………………… Page 61

Media Relations & Publicity………………………….…………………….………………….. Page 63

Medical Information …………………………………………………………........…………… Page 64

Metabolic Syndrome Screening ………………………………………………….………… Page 65

On-Call Emergency Protocol …………………………………………………….…………… Page 66

Outcome Measurement ………………………………………………….……….………….. Page 67

Performance Evaluations ……………….……………………………………………………. Page 68

Physical Plant Standard ………….……………………………………..….…….……………. Page 69

Preventative and Diagnostic Healthcare ………..……………………………………… Page 70

Progress Notes ………………………………………………………………………..……………. Page 71

Psychiatric Prescribing and Documentation ………………………….……………… Page 72

Quality Assurance …………………………………………………………………..…………….. Page 74

Record Maintenance and Destruction ………………………………….…………….. Page 76

Referral Systems ………….…………………………………………..……………..……………. Page 80

Release of Information ………….……………………………………..………………………. Page 82

Risk Management Assessment ……………………………………………..…………….. Page 84

Staff Credential Policy …………………………….…………..…….………………………….. Page 85

Staff Exclusionary Sanctions Policy ……………………………………………………….. Page 86

Staffing Policy ……………………………………………………………………………………….. Page 87

Strategic Planning ………………………………………………………………………………… Page 88

Subpoenas, Warrants, and Government Investigations ….…….………………. Page 89

Suicide Assessment ………….………………………………………...............……………. Page 94

Tardive Dyskinesia Screening ……………………………….………………………………… Page 95

Technology and Assistive Devices ……………………………………….……………… Page 96

Tobacco Policy ……………..………………………………………………………………………. Page 97

Training Policy for Employees and Contractors ……………………………………. Page 98

Treatment and Transition Plan …………..………………………………….…………… Page 101

Witnessing of Documents ……………….……………….……………………………….… Page 103

Corporate Compliance

I. POLICY:

A. It is the policy of Myrtle J. Scott-Franklin Network, LLC (MJSFN) to provide services that fully comply with all federal, state, and local regulations and applicable laws, and to adhere to explicit ethical standards throughout all facets of the organization’s operations. Myrtle J. Scott-Franklin Network, LLC will ensure these conditions of operation are met through an organized and ongoing comprehensive corporate compliance program.

B. Myrtle J. Scott-Franklin Network, LLC’s Corporate Compliance Program seeks to meet the following overall goals:

1. Maintain and enhance the quality of services.

2. Demonstrate a sincere effort to comply with all applicable state, federal, and local laws.

3. Revise and develop new policies and procedures to enhance compliance.

4. Enhance communications with governmental entities to ensure compliance.

5. Empower all involved parties to prevent, detect, respond to, report, and resolve conduct that does not conform to applicable laws and regulations, and the organization’s ethical standards/code of conduct.

6. Establish mechanisms for staff members to ensure that questions and concerns about compliance issues are appropriately and timely addressed.

II. PROCEDURES:

A. Organizational Responsibilities:

1. Corporate Compliance Officer: The Myrtle J. Scott-Franklin Network, LLC shall serve as the Corporate Compliance Officer (CCO) and provide leadership and oversight of the Corporate Compliance Program. The CCO’s duties shall include, but not be limited to:

a. Serve as the organization’s internal and external point of contact for overall corporate compliance issues.

b. Develop, implement, and monitor the organization’s Corporate Compliance Plan, including internal and external monitoring, auditing, investigative and reporting processes, procedures, and systems.

c. Provide regular communication to the Program Director concerning all areas of the Corporate Compliance Program.

d. Provide specific guidance and ongoing education to staff members who are expected to know and comply with specific laws and guidelines related to their regular job duties.

e. Ensure that mechanisms for preventing, detecting, reporting, and resolving compliance issues are operating in a functional manner.

f. Ensure that the organization’s reporting mechanisms enhance and encourage active participation of all staff members, and provide confidentiality in the reporting process.

g. Ensure that all suspected violators and/or violations are handled according to documented policy and resolved in a manner that ensures the integrity of the organization’s compliance with applicable guidelines and laws.

h. Submit an annual report to the CEO that includes a summary of all allegations, investigations, and/or complaints processed in the preceding 12 months, a complete description of all corrective actions taken, and any recommendations for changes to the organization’s policies and/or procedures.

i. In performance of his/her duties, the CCO shall have direct and unimpeded access to the organization’s legal counsel and/or accounting firm, for matters pertaining to corporate compliance.

2. Compliance Officer’s Job Duties: The duties of the CCO, or designee, will include, but not be limited to:

a. Ongoing identification and assessment of compliance systems and issues.

b. Plan and provide guidelines for development of service specific compliance procedures through the development, revision, and ongoing monitoring of the organizational Corporate Compliance policies and process.

c. Plan and provide support for educational training and programming.

d. Disseminate compliance information.

e. Provide controls to prevent and reduce errors, and to identify wrongdoing.

f. Receive, evaluate, and respond to reports of potential violations.

g. Work with administrative and clinical leadership to implement remedial actions, and take appropriate corrective and disciplinary actions.

3. The CEO will have the ultimate authority and responsibility for corporate compliance.

B. Employee Training:

1. The Corporate Compliance Program will be fully integrated into the organization’s education and training systems through the following processes:

a. All new employees will review the Corporate Compliance Program Policy and the organization’s Code of Conduct as part of the new employee orientation process.

b. All staff members will review the organization’s Code of Conduct as part of their annual performance review evaluations.

c. Regional directors and program coordinators will inform staff members of specific ongoing compliance issues that pertain to their job duties at regularly scheduled staff meetings.

d. All staff members will participate in ongoing compliance in-service presentations and competency-based trainings.

e. Regular publication of reporting mechanisms will occur throughout the organizations communication systems. These will include, but not be limited to, email notification, internal memos, and postings on bulletin boards in staff and public areas.

f. Employee exit interviews will include compliance-related questions.

C. Monitoring and Auditing:

1. Myrtle J. Scott-Franklin Network, LLC will utilize the CCO to ensure that it conducts business in an ethical manner and ensure that any questionable business practices are thoroughly investigated through the organization’s written investigation procedures.

2. All programs shall implement internal controls, including monitoring activities to ensure compliance with the organization’s program.

3. Internal self-audits will include, but not be limited to, fiscal services, marketing, contractual services, health and safety practices, use of agency resources, confidentiality, dual relationships, and medical necessity.

4. Ongoing monitoring and auditing activities will be reported to the Program Director for review and appropriate actions, if necessary.

D. Reporting System:

1. Myrtle J. Scott-Franklin Network, LLC will provide mechanisms to assist staff members and/or agents in reporting suspected violations of possible criminal conduct or violation of the organizational code of ethics by persons within the organization, without fear of retribution.

2. Specific processes of reporting suspected violations include the following:

a. Web/Server Based: All employees can access the Myrtle J. Scott-Franklin Network, LLC employee’s web site to report suspected violations. A link will be available on the web site that will allow the reporting party to provide anonymous information which will be forwarded to the corporate compliance officer.

b. Compliance Forms/Letters: All employees will be given self-addressed stamped envelopes and compliance reporting forms to use for submitting information to the corporate compliance officer concerning possible violations.

c. Employee and /or client grievances …..

E. Investigation Procedures:

1. The CCO shall initiate and conduct investigations of all reported alleged incidents.

2. The investigation of the reported alleged incident will begin within three (3) days of the CCO being informed of the incident.

3. Upon receiving information of an alleged incident or violation, the COO will inform the CEO of the allegation.

4. If a member of the Corporate Compliance Committee is directly connected to the alleged incident that is being investigated, he/she will be excused from the team/investigation until the final outcome and corrective action plan has been completed.

5. All information concerning the alleged incident with be held in strict confidentiality by all parties involved in the process, and will not be shared with any other staff member.

6. The CCO will conduct an initial investigation through an interview process with staff members who are assigned to duties and areas related to the alleged violation.

7. The COO will determine from the initial investigation whether the situation would benefit from the involvement of the organization’s legal counsel in the investigation process, and recommend such action to the CEO should it be appropriate.

8. The employee is notified that there is a complaint and, if warranted by the initial information and involves a direct service situation, may be instructed to not continue direct services with a client until the issue is resolved. The supervisor assisting with the investigation will take primary responsibility for helping the client with access to a clinician that can provide services during the investigation should a change in clinicians be warranted.

9. If the suspected violation of the Code of Conduct involves the executive management of the organization, the organization will enlist assistance from their legal counsel to serve as the final approval of outcome and recommendations.

10. The investigation may involve interviews with witnesses and clients, as well as reviewing other relevant information. At all times the client’s rights will be respected.

11. If at any time during the investigation it is determined that the client’s rights have been violated, the appropriate advocacy representative or entity will be immediately contacted to begin their own investigation process according to applicable laws and guidelines.

12. If involved, the organization’s legal counsel will help ensure the confidentiality and attorney-client privilege of any information which may be complied, help management focus on critical issues which should be investigated, and help design a strategy for effectively using the findings of the investigation.

13. Following an investigation, the CCO will file a report to the CEO that will include a summary of all allegations, results of the investigation, and recommendations for corrective actions.

14. The CCO, COO, Program Director, and the supervisor of the staff member(s) involved in the incident will review the recommendations and develop a corrective plan of action.

15. Should the investigation indicate a serious violation of policy, the organization’s legal counsel will advise the CEO and COO with regard to the need to self-report the violation to the appropriate government regulatory agency, and will assist in the process should it be necessary.

16. A written report will be compiled and submitted within fourteen (14) days from the notification of the complaint. The report will detail the following:

a. The nature of the complaint, including time, date, persons involved, services involved.

b. The person whom the complaint is lodged against.

c. Results of persons interviewed and investigation of circumstances surrounding the incident.

d. A recommendation based on the gathered information.

17. The Corporate Compliance Officer will make one of three possible findings in the recommendation to The CEO and COO:

· Founded: The suspected violation of the Code of Conduct was found to have occurred.

· Unfounded: The suspected violation of the Code of Conduct was found not to have occurred.

· Undetermined: It cannot be determined whether or not a violation of the Code of Conduct has occurred.

18. Once approved by the Program Director, the supervisor will inform the employee, who is the subject of the investigation, of the outcome of the investigation.

19. If the finding was unfounded, the paperwork of the complaint and the investigation will be destroyed.

20. If the finding was undetermined, the supervisor will adjust the supervision of the employee to a level necessary to ensure that the suspected behavior is not occurring. The employee will be informed of the details and will be actively involved with the supervisor in this process.

21. If it is determined that the suspected violation is a consumer right’s violation, then the investigation, notification, and appeal procedure will follow the consumers right’s policy and procedures.

22. When an investigation of ethical complaints are found to have merit, the incident will be reported to the executive management as a critical incident, and will be reviewed within the appropriate format to assist in quality improvement, risk management, and corrective measures.

23. The CCO will monitor and evaluate the corrective plan interventions through consistent communication and contact with the supervisor in charge, and will reevaluate the actions/corrections on a monthly basis.

24. The CCO will provide updates on the investigation to the CEO and COO until the situation has been resolved.

25. The incident, investigation, and outcome will be included in the annual corporate compliance report to the CEO and COO.

26. The Program Director will utilize all information consistent with an incident, investigation, and outcome to recommend revision and development of policy, procedures, and guidelines in the area of corporate compliance.

F. Enforcement and Discipline:

1. Remedial Actions:

a. Remedial actions are not disciplinary and are done to correct mistakes, and enhance compliance with the Corporate Compliance Program and State and Federal regulations. In most cases, remedial actions are designed to improve performance of individual staff members. Upon investigating what appears to be behavior requiring remedial actions, the CCO will clarify policies, and will review, and revise if necessary, administrative procedures to prevent future errors.

b. If remedial action is deemed necessary, the affected staff member will be notified, prior to the initiation of the action, and informed of the concerns regarding his/her performance.

c. Examples of behaviors that could require remedial action might include but not limited to, failure of an individual to understand and carry out organizational-wide required procedures and policies, inappropriate or improper implementation of the organization’s specific corporate compliance policies and procedures, ambiguous communications regarding job performance expectations, or negligent behavior.

d. Examples of remedial actions may include, but not be limited to staff members required to take part in an education program focused on the problem area, future money management handled in a specifically designated manner, a staff member reassigned, or a change in duty until remediation has successfully corrected the error.

2. Corrective or Disciplinary Actions:

a. In cases of repeated violations of intentional misconduct, or after documented remedial actions have failed to correct the problem, the organization will initiate corrective or disciplinary actions where necessary to address wrongdoing or malfeasance. The initiation of corrective or disciplinary action by the organization does not preclude or replace any criminal proceedings that may be taken by legal authorities.

b. Should the organization initiate corrective or disciplinary action, it will do so in accordance with existing and applicable personnel policies.

G. Prevention:

1. Education and training will serve as the core of Myrtle J. Scott-Franklin Network, LLC prevention efforts to ensure minimal violations of law, ethics, and code of conduct. Prevention efforts will include, but not be limited to:

a. New employee orientation training.

b. Training related to the staff members’ specific position.

c. Documentation of competency in required areas through performance appraisals and/or competency based exams.

d. Routine, targeted, and random audits of systems and medical charts.

STRATEGIC PLANNING POLICY AND PROCEDURES

I. POLICY:

A. It is the policy of Myrtle J. Scott-Franklin Network, LLC to utilize an ongoing strategic planning process to produce decisions and actions that guide and shape the organization in determining the ongoing relevancy of its mission, establishing strategic goals consistent with our consensual mission, and identifying specific strategies to meet the established goals.

B. Myrtle J. Scott-Franklin Network, LLC Strategic Plan is the result of a structured and disciplined administrative process guided by the Maxie Franklin CEO to utilize the input of persons representing the organization. The Strategic Plan represents the course our organization will take over the next three-years to meet the assessed external and internal environmental demands in a manner supportive of our financial, service delivery, and human resource stability and growth.

C. The Strategic Plan is a critical element of a comprehensive planning process within our organization. The components of organizational planning, and how they support the planning process are as follows:

1. Strategic Plan: The Strategic Plan represents the course our organization will take over a one to five-year period to meet the assessed external and internal environmental demands to support financial, service delivery, and human resource stability and growth.

2. Ongoing Work Plans: Ongoing work plans include goals, strategies, objectives, responsibilities, and timelines that are focused on specific areas of organizational functioning and typically contain short-term goals that can be met within a 12-month period. When goals on ongoing work plans require timelines that exceed one year, and/or require resources beyond the projected budgets of our organization, those goals may be noted simultaneously on our organizational strategic plan. Our organization’s work plans are as follows:

a. Accessibility Plan

b. Cultural Diversity and Competency Plan

c. Technology Plan

d. Risk Management Plan

e. Financial Plan/Budget

f. Performance Improvement Plan

g. Community Relations Plan

h. Diversion Plan

3. Analysis Documents: Analysis documents serve to assess, evaluate, and analyze the outcomes of organizational goals, actions, and processes, contained in organizational planning and performance improvement documents. The analysis documents represent processes that support the revision of strategic, work, and performance improvement plans. The organization’s analysis documents are as follows:

a. Annual Performance Analysis of Business and Service Deliver Functions (includes analysis of Strategic Plan progress and outcomes)

b. Accessibility Status Report

c. Annual Review of Formal Complaints

d. Annual Critical Incident Analysis

e. Annual Review or Audit of Financial Records

f. Quarterly Budget and Expense Reviews

g. Management Team Meeting Minutes

D. The process of developing, actualizing, reviewing, and revising the Strategic Plan will be based on taking advantage of the organization’s strengths and opportunities while addressing our weaknesses and threats in the following areas:

1. The Expectations of the Persons Served

2. The Competitive Environment

3. Financial Opportunities

4. Financial Threats

5. Organizational Capabilities

6. Service Delivery Needs

7. Community Demographics

8. The Regulatory Environment

9. The Legislative Environment

II. PROCEDURES:

A. Identification of Planning Participants: The participants and their key roles in Myrtle J. Scott-Franklin Network, LLC strategic planning process are as follows:

1. Leadership: CEO, COO, Program Director, Clinical Director

Leadership Role: Advocates for the strategic planning process and supports individual roles and responsibilities of those involved in the process. Identifies the members of the planning group and encourages participation. Seeks and identifies facilitator of planning process. Reviews plan drafts and analyzes for final approval. Responsible for final approval of plan and facilitates the communication of final plan within the organizational system. Has oversight of the monitoring and revision of plan, as needed, on an ongoing basis.

2. Planning Facilitator: Program Director

Planning Facilitator Role: Facilitates the organization’s strategic planning process in coordination with leadership.

3. Planning Group: Planning group will consist of the CEO, Program Director, and Clinical Director.

Planning Group Role: Directly involved in the planning process of assessing the issues the organization faces and developing ideas and options for the future.

4. Plan Writer: Executive Administrative Assistant will take all notes at all Planning Group meetings and place all progress into an action plan format.

Plan Writer Role: Assembles the planning group’s process and resulting decisions into a functional document. Creates draft of the strategic plan based on notes of planning meetings.

5. Persons Served: Data will be collected from the Client Satisfaction Questionnaire, suggestion boxes, complaints, and incident reports to address the population served.

Strategic Planning Process:

The organization’s strategic planning process is as follows:

1. Initiation of Planning Process:

a. The identified time cycle for strategic planning is every three years.

b. The quarterly review of the company’s data will help initiate the planning process.

2. Completion Target Date:

a. The Management Team Myrtle J. Scott-Franklin Network, LLC will determine a target date for completion of the planning process by identifying the date of a future meeting for adopting the plan.

3. Approval of Resources for Planning Process:

a. Upon the recommendations of the Management Team, the CEO (Jerome Ford) will consider approval of the following components of the planning process:

1. Approval of recommended employee to serve as the strategic planning facilitator(s) and any associated training to support the employee.

2. Approval of training site and logistical costs.

3. Approval of planning date(s) and the recommended participants for the organizational planning session.

4. Approval of costs associated with the training (training materials, food, etc.).

4. Meeting with Facilitator:

a. Prior to the organizational planning sessions, the designated strategic planning facilitator will meet with the management team to provide an overview of the planned strategic planning process and assess the overall organizational needs. The session will focus on gathering and presenting information in the following areas:

1. Current issues that the organization is facing.

2. An overview of the planning process, by the facilitator

3. An assessment and discussion of any acute issues within organization’s current operations.

4. A discussion regarding the management team’s expectations or expected outcome of the planning sessions.

5. Strategic Planning Process/Organizational Planning Session(s):

a. Mission Statement Review: Facilitated process in which the full group of participants responds to questions, such as: What are we? Who are we? What do we do? What are the basic social, political, environmental, financial issues or problems the organization exists to address? What is the social/community justification for the organization to exist? How does the organization recognize, anticipate, and respond to the identified needs and problems? What does the organization value? What makes the organization unique and gives it a competitive advantage?

b. Organizational Regulatory Requirements and Mandates: Facilitated process in which the full group of participants responds to questions that address mandates, both formal (regulatory, no choice in meeting) and informal (expectations of clients or staff and how organization responds). Questions for facilitation of this process may include: What are we supposed to do and who requires us to do it? Responses are listed under formal or informal headings. After the brainstorming, individual participants rate the top three, in terms of importance (Techniques for this include providing each participant with three adhesive circle dots and instructing them to place them by the top three requirements in terms of importance. Then a consensus can be identified by the top 4-5 rated items)

c. Mission Statement Gaps: A facilitated discussion to determine if the identified expectations are represented in the mission statement, and a listing of potential gaps.

d. Review of Past Outcomes: A facilitated process to determine what opportunities, threats, strengths, and weaknesses the organization has had to deal with over the past 5 years. The group is instructed to identify a list of positive and negative outcomes of the organization’s operations for a specific range of years. (May go back five years. Through the separation into years, new employees can participate in the process by reviewing the past year first). Further instruction includes asking participants to identify themes in the generated lists of outcomes, and to identify antecedents that may have influenced the outcomes that are identified (loss of funding, change in leadership, etc.). Large group discussion is facilitated to organize the responses into categories of Opportunities, Threats, Strengths, and Weaknesses (over the past 5 years) and, as they are being listed and identified, how each was dealt with by the organization.

e. A Vision of the Future: A facilitated process to develop what the organization will look like in 5 years. Participants are instructed to spend 5-10 minutes, in silence to imagine that they left the organization today and came back in five years to visit. After writing down their thoughts, the group leader solicits comments of the group, lists the comments, and combines common items, thus developing a master list. All participants are given three adhesive dots to place on the master list beside items they view as most important. The top 5 items become “high priority” for the planning phase of the process.

f. SWOT Analysis of Current Environment (Strengths, Weaknesses, Opportunities, Threats): A process whereby each SWOT component is identified and a brainstorming session of noting (writing a list) current issues related to the area is completed. All participants are given 12 adhesive dots and instructed to place a dot beside three items within each SWOT category on the posted lists. The top five items in each SWOT category are noted for the planning phase of the process.

g. Identification of Planning Themes: A process whereby the top 5 “Vision for the Future” items, the top 5 Strengths, and the top 5 Opportunities are listed in descending order. A large group process is facilitated whereby some or all of the following questions can be asked, and the identified themes can be revised accordingly:

1. Are all the themes consistent with the organization’s mission? If not, should the mission be revised?

2. Are the themes consistent with each other? If not, have contradictions within the organization’s operations and/or environment been missed?

3. Are the items distinct enough that they can be categorized (physical plant, services, personnel, etc.)? Are there interrelated themes among the items (need new programs/lack of physical space)?

4. Is there anything missing? Are the themes focused on immediate needs? Are the themes to global or general? How do the themes match up with the issues identified by the management team at the initial meeting with the facilitator?

5. Are the themes understandable to everyone? Did the process change an item to the point that the original meaning/intent has changed?

h. Identification of Action Steps and Time Frames: A facilitated process whereby each of the 15 identified themes (will probably be less due to combining common themes) is listed separately and the large group brainstorms anticipated major steps to achieve each one. All ideas are listed, regardless of possible differences. A separate sheet of paper is created for each of the next five years. Individual participants will identify the major steps under each theme, write it on a post-it note (use three colors of post it notes, one for each theme category) and will then place each note in the year they believe they think it will be completed. A facilitated process with the large group reviews notes posted within the years, reviewing themes and the sequencing of items. Questions asked include: Are the major steps in the correct order? Are completion dates realistic? What are the linkages between the themes? What are some of the identified weaknesses and threats that will affect the organization’s ability to complete each step? What resources will be needed to accomplish each major component, and are they available or must they be acquired?

i. Identification of Goals/Themes and Objectives/Actions: Facilitator, with support from the previously identified plan writer, will list an overall set of goals and action-oriented objectives and discuss with large group to clarify and revise according to group consensus.

6. Writing, Reviewing, and Adopting the Plan:

a. Writing a Draft of the Strategic Plan: At this stage, the plan writer will assemble the information into a format that communicates the key areas the planning sessions identified, allowing the organization to move forward with implementing the plan. The draft of the plan will include these elements:

1. Mission of the Organization

7. The Organization’s Mandates

1. Summary of the SWOT Analysis

2. Vision of Future (Key items identified in the visioning exercise)

3. Strategic Issues, Goals, and Objectives

4. Financial Considerations

5. Timeline for Reviews and Updates

a. Review and Revision of Mission: A representative group of strategic planning participants (including the management team), led by the facilitator, will review the original mission statement, review the areas identified early that raised questions about the statement, review the planning themes, discuss linkages between the statement and planning themes, and identify possible areas of the statement that do not connect with the planning themes. Adding or deleting items from the mission statement and/or from the strategic issues will make changes. The process will continue until the mission statement accurately reflects the organization’s current and future strategic goals.

b. Adopt the Plan: The management team will meet and review drafts of the plan and make a final recommendation for approval. The CEO/Ownership of the organization will be responsible for the approval any mission revision and the strategic plan.

8. Reviewing Plan Progress:

a. Progress Checks: The Management Team will review the plan’s progress, and revise as needed, every three months.

This follows PROCESS EXAMPLE #1, with the following exceptions:

1. Management Team (or similar entity) will recommend an outside facilitator, based on organizational needs and other selection processes.

2. CEO/Owner will approve the selection of the facilitator and associated costs.

3. Outside facilitator will be involved with the planning process starting with the initial meeting with the management team to assess the overall issues facing the organization, and ending with the final approval of the plan by the CEO/Owner.

4. Facilitator may have alternative approaches to strategic planning than what this policy provides as an example. Procedures in your strategic planning policy and procedure should follow the process of the facilitator. A description of the actual planning process could be abbreviated much further than the described procedures in the example policy.

5. Facilitator may or may not have an associate who is the Plan Writer. This will need to be clarified initially with the facilitator. It is typical that the facilitator will use the materials from the training to develop the draft plan, or will have someone skilled in documenting the planning activities to provide the service.

The organization’s strategic planning process is as follows:

1. Initiation of Planning Process:

a. It is Myrtle J. Scott-Franklin Network, LLC time cycle to review strategic planning, every three (3) years, upon recommendation of the CEO.

2. Completion Target Date:

a. The directors will determine a target date for completion of the planning process by identifying a date for a future executive staff meeting for adopting the plan.

3. Approval of Resources for Planning Process:

a. Upon recommendation of the CEO, Program Director, and Clinical Director following discussion, the directors will approve the following components of the planning process:

1) Approval of outside strategic planning facilitator(s) and associated cost.

2) Approval of site and logistical costs.

3) Approval of offsite planning date(s) and the recommended participants.

4) Approval of any miscellaneous costs (travel, lodging, per diem, training materials, food, etc.).

4. Meeting with Facilitator(s):

a. Prior to the organizational planning sessions, the strategic planning facilitator (s) will meet with the executive management team to provide an overview of the planning process and to assess the overall organizational needs. The session will focus on gathering and presenting information in the following areas:

1) Current issues that the organization is facing.

2) An overview of the planning process, by the facilitator(s)

3) An assessment of any acute issues within organization’s current operations.

4) A discussion regarding the organization’s expectations or expected outcome of the planning sessions.

5. Strategic Planning Process Directors Participation:

a. Mission Statement Review: Facilitated process in which the full group of participants responds to questions, such as: What are we? Who are we? What do we do? What are the basic social, political, environmental, financial issues or problems the organization exists to address? What is the social/community justification for the organization to exist? How does the organization recognize, anticipate, and respond to the identified needs and problems? What does the organization value? What makes the organization unique and gives it a competitive advantage?

b. Organizational Regulatory Requirements and Mandates: Facilitated process in which the full group of participants responds to questions that address mandates, both formal (regulatory, no choice in meeting) and informal (expectations of clients or staff and how organization responds). Questions for facilitating this process may include: What are we supposed to do and who requires us to do it? Responses are listed under formal or informal headings. After the brainstorming, individual participants rate the top three, in terms of importance (Techniques for this include providing each participant with three adhesive circle dots and instructing them to place them by the top three requirements in terms of importance. Then the top 4-5 rated items can identify a consensus).

c. Mission Statement Gaps: A facilitated discussion to determination if the identified expectations are represented in the mission statement, and a listing of potential gaps.

d. Review of Past Outcomes: A facilitated process to determine the opportunities, threats, strengths, and weaknesses the organization has experienced over the past 5 years. Small groups are instructed to identify a list of positive and negative outcomes of the organization’s operations for a specific range of years. (May go back up to five years. By the separation into years, new employees can participate in the process by reviewing the past year first). Further instruction includes asking groups to identify themes in the lists of outcomes and to identify antecedents that may have influenced the outcomes identified (loss of funding, change in leadership, etc.). Large group discussion is facilitated to organize the small group’s responses in the categories of Opportunities, Threats, Strengths, and Weaknesses over the past 5 years and, as they are listed and identified, determine how each was dealt with by the organization.

e. A Vision of the Future: A facilitated process to develop what the organization will look like in 5 years. Small group members are instructed to spend 5-10 minutes to imagine that they left the organization today and came back in five years to visit. After writing down their thoughts, the group leader lists comments of the group and combines common items. Groups report to facilitator(s) who then develop a master list. All participants place three adhesive dots on the master list beside items they view as most important. The top 10 items become “high priority” for the planning phase of the process.

f. SWOT Analysis of Current Environment (Strengths, Weaknesses, Opportunities, Threats): A process whereby small groups are assigned a SWOT component and complete a brainstorming process of identifying (listing) current issues related to the specific SWOT area (For example: Strengths: Identification of organizational strengths). Groups rotate to the next group’s list and note any additional issues in that group’s identified SWOT item. Process ends after each group has rotated through all other group’s lists and added any additional issues to the list. All participants are given 12 adhesive dots and instructed to place three dots beside three items on each SWOT category on the posted lists. The top five items in each SWOT category are noted for the planning phase of the process.

g. Identification of Planning Themes: A process whereby the top 5 “Vision for the Future” themes, the top 5 Strengths, and the top 5 Opportunities are listed in descending order. A large group process is facilitated whereby some or all of the following questions can be asked, and the identified themes can be revised accordingly:

1) Are all the themes consistent with the organization’s mission? If not, should the mission be revised?

2) Are the themes consistent with each other? If not, have contradictions within the organization’s operations and/or environment been missed?

3) Are the items distinct enough that they can be categorized (physical plant, services, personnel, etc.)? Are there interrelated themes among the items (needed new programs/lack of physical space)?

4) Is there any thing missing? Are the themes focused on immediate needs? Are the themes to global or general? How do the themes match up with the issues identified by the board of directors at the initial meeting with the facilitator(s)?

5) Are the themes understandable to everyone? Did the process change an item to the point that the original meaning/intent has changed?

h. Identification of Action Steps and Time Frames: A facilitated process whereby each of the 15 identified themes (will probably be less due to combining common themes) is listed separately and the large group brainstorms anticipated major steps to achieve each one. All ideas are listed, regardless of possible differences. A separate blank sheet of paper is posted for each of the next five years. Individually, participants will determine the major steps they believe will accomplish the overall goal/theme under each theme, write it on a post-it note (use three colors of post it notes, one for each theme category) and place each one in the year they believe it will be completed. A facilitated process with the large group reviews notes posted within the years, reviewing themes, and the sequencing of items. Questions asked include: Are the major steps in the correct order? Are completion dates realistic? What are the linkages between the themes? What are some of the identified weaknesses and threats that will affect the organization’s ability to complete each step? What resources will be needed to accomplish each major component, and are they available or must they be acquired?

i. Identification of Goals/Themes and Objectives/Actions: Facilitator(s), with support from the previously identified plan writer, will list an overall set of goals and action-oriented objectives, discuss with large group, and clarify the overall results with the large group, adjusting based on consensus.

6. Writing, Reviewing, and Adopting the Plan:

a. Writing a Draft of the Strategic Plan: At this stage, the facilitator and/or plan writer will assemble the information into a format that communicates the key areas the planning sessions identified and allows the organization to move forward with implementing the plan. The draft of the plan will include these elements:

1) Mission of the Organization

2) The Organization’s Mandates

3) Summary of the SWOT Analysis

4) Vision of Future (Key items identified in the visioning exercise)

5) Strategic Issues, Goals, and Objectives

6) Financial Considerations

7) Timeline for Reviews and Updates

b. Review and Revision of Mission: A representative group of participants in the strategic planning process, led by the facilitator(s), will review the original mission statement, review the areas identified early that raised questions about the statement, review the planning themes, discuss linkages between the statement and planning themes, and identify possible areas of the statement that do not connect with the planning themes. Adding or deleting items from the mission statement and/or from the strategic issues will make changes. The process will continue until the mission statement accurately reflects the organization’s current and future strategic goals.

c. Adopt the Plan: The representative group of persons who participated in the large planning process, along with the plan writer and the senior management of the organization, will meet and review drafts of the plan and make a final recommendation to present the plan to the CEO for final approval. The CEO will approve any mission revision and the strategic plan.

7. Reviewing Plan Progress:

a. Progress Checks: The directors will review the plan’s progress, and revise as needed, every three months.

CULTURAL COMPETENCY:

Policy statement: Given that our clients come from diverse cultural backgrounds that can profoundly affect treatment, staff will become as competent as feasible so that they will be able to be conversant with and understanding of their clients. To further promote this goal, MJSF&N will seek to recruit persons who are demographically representative of our clients, for staffing all levels of our organization. Further, the management staff of MJSF&N will assess progress on these goals by June of every year.

Purpose: To foster greater understanding and compatibility of staff for the diversity of cultural, racial, ethnic, and socioeconomic backgrounds of our clients.

Applicability: This applies to all MJSF&N staff.

Procedure:

1. As part of the professional competency expected of employees, they shall strive to be culturally competent in order to understand their clients’ culture and customs, traditions and taboos, and apply such understanding as part of their treatment approach.

2. Employees shall understand the importance of valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, and having knowledge of their clients’ cultures.

3. Employees shall adapt accordingly and show flexibility in treatment approach as a result of learning of their clients’ cultural customs, traditions, and taboos.

4. Employees shall maintain nondiscriminatory practices in treatment approach of all clients.

5. Employees shall be sensitive to all cultures and respect their clients’ customs, traditions and taboos.

6. In order to promote greater sensitivity to the perspectives of our clients, MJSF&N encourages the recruitment of staff from ethnic, racial, and cultural backgrounds similar to our clients. On an annual basis, the Site Directors will survey the demographics of their client population and compare their client profile to the demographic make-up of their staff. Substantial discrepancies between these two groups (clients and staff) will be identified on a site-by-site basis. This information will be utilized to help guide recruiting decisions in order to seek an approximate equivalence between the demographics of clients and staff for each site.

7. By June of each year, the management staff will conduct an annual evaluation of progress in fostering diversity and cultural competency in our staff. Cultural competency will be assessed by means of a survey designed to measure the cultural sensitivity and awareness of MJSF&N staff; responses will be anonymous, but will be used to assess strengths and deficiencies in the cultural competency of staff. Deficiencies will be addressed on a site-by-site basis through targeted trainings.

CONFLICTS OF INTEREST

Purpose

It is important for MJSF&N staff to be aware that both real and apparent conflicts of interest or dualities of interest sometime occur in the course of conducting the affairs of the agency. Conflicts occur because the many persons associated with the agency should expect to have, and do in fact generally have multiple interest and affiliations and various positions of responsibility within the community.

The purpose of the conflict of interest policy is to protect the agency’s interest when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer or director of the agency or might result in a possible excess benefit transaction.

As an employee or independent contractor of MJSF&N, employee and/or independent contractors are expected to act at all times in the Agency’s best interests and to exercise sound judgment unclouded by personal interests or divided loyalties. Both in performing your duties at MJSF&N and in outside activities, you should avoid the appearance as well as the reality of a conflict of interest.

A conflict of interest exists if your circumstances would lead a reasonable person to question whether your motivations are aligned with the Agency’s best interests. If, for example, you are involved in an outside activity or have a financial or other personal interest that might interfere with your objectivity in performing company duties and responsibilities, you may have a conflict of interest.

Interested Person

1. Any director, principal officer, or member of a committee with governing board delegated powers, which has a direct or indirect financial interest, as defined below, is an interested person.

Financial Interest

A person has a financial interest is if the person has, directly or indirectly, through business, investment, or family:

· Having a financial interest in any business transaction with MJSF&N.

· Owning or having a significant financial interest in, or other relationship with, a competitor, customer or supplier.

· Accepting Gifts, Kickbacks and Rebates, entertainment or other benefit of more than a nominal value from a MJSF&N’s competitor, customer or supplier.

· Use of Company Information for Private Gain.

· Outside Activities – Non-Profit and Civic Organizations

· Employment Outside of Agency – Moonlighting

· Service on the Technical Advisory Boards of MJSF&N’s competitor, customer or supplier’s

· Family and Romantic Relationships - Spouses, Domestic Partners, Immediate Family Members or Relatives as Suppliers, Vendors, and other Business Partners

Anyone with a conflict of interest must disclose it to management and remove themselves from negotiations, deliberations or votes involving the conflict. You may, however, state your position and answer questions when your knowledge may be of assistance to MJSF&N.

Procedures

Duties to Disclose

In connection with any actual or possible conflict of interest, the individual must disclose the existence of conflict of interest and be given the opportunity to disclose all material facts to directors and members of committees with governing board powers considering the proposed transaction or arrangement.

Determining a Conflict of Interest Exists

After disclosure of a conflict of interest and all material facts, and after any discussion with the interested person, he/she shall leave the governing board meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board members shall decide if a conflict of interest exists.

The board shall meet on the following Friday that a conflict of interest is reported or discovered.

Procedures for Addressing the Conflict of Interest

1. An interested person may make a presentation at the board meeting, but after the presentation, he/she must exist the meeting during the discussion of, and the vote on, the transaction involving the possible conflict of interest.

2. The chairperson shall, if appropriate, appoint a disinterested person to investigate alternatives to the proposed transaction or arrangement.

3. The governing board shall determine whether the agency can obtain with reasonable efforts a more advantageous transaction that would not give rise to a conflict of interest.

4. If a more advantageous transaction is not reasonably possible under circumstances not producing a conflict of interest, the governing board shall determine by a majority vote of the disinterested persons whether the arrangement is in the agency’s best interest, for its own benefit, and whether it is fair and reasonable. In conformity with the above determination it shall make its decision as to whether to enter into the arrangement.

Violations of Conflict of Interest Policy

1. If the board has reasonable cause to believe a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose.

2. If, after hearing the member’s response and after further investigation as warranted by the circumstances, the board determines the member has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective actions.

Records of Proceedings

Minutes

The minutes of meeting will contain:

1. The names of the persons who disclosed or otherwise were found to have financial gain in connection with an with an actual or possible conflict of interest, the nature of the financial gain, any action taken to determine whether a conflict of interest was present, and the board’s decision as to whether a conflict of interest in fact existed.

2. The names of the persons who were present for discussions and votes relating to the arrangement, the content of the discussion, including any alternatives to the proposed arrangement, and a record of any votes taken in connection with the proceedings.

Annual Statements

Each board member with governing delegated powers shall annually sign a statement that affirms such person:

1. Has received a copy of the conflict of interest policy.

2. Has read and understands the policy.

3. Has agreed to comply with the policy.

Annual Reviews

To ensure the agency operates in a manner consistent with its mission and does not engage in activities that could jeopardize its status, annual reviews shall be conducted. The annual reviews shall, at minimum, include the following subjects:

1. Whether compensation arrangements and benefits are reasonable, based on competent survey information and the result of bargaining.

RISK MANAGEMENT

Risk Management

I. POLICY:

A. It is the policy of The MJSFN to assign responsibility for operational implementation of risk management, and to assess for potential and actual risks to persons served, to the public, to staff members, and to the overall working and service delivery environment and facilities. Assessments will result in preventive measures and interventions that will serve to reduce risk and loss within the organization.

B. MJSFN is committed to long-range planning to ensure service continuity and, therefore, to a formal and periodic risk management process as a method to identify loss exposures, analyze and evaluate loss exposures, identify a strategy to be taken to counter any potential loss, implement the most effective strategy, provide ongoing management/governance oversight of the efficacy of decisions made regarding risk management/loss prevention activities, and implement any necessary changes as may be indicated by a changing service and/or business environment.

II. PROCEDURES:

1. The Program Director will coordinate activities designed to result in reduction of risk and loss and continuously improve the quality of care.

2. The Program Director is charged to identify and assess risk, develop a plan with interventions, actions, and systems to control risk, conduct periodic evaluations to assess results of actions and reformulation of planning, and ensure that financial support is available to meet the goals of the risk management plan.

3. The Program Director will assess the organization’s exposure to loss in the following causation areas:

a. People: This area is defined as acts or behaviors that may expose the organization to loss and liability. Appropriate areas for assessment would include, but not be limited to, incident reports, code of conduct standards and violations, safety standards, reports, consumer rights and grievance complaints, and purchasing/fiscal practices. For additional information, refer to the Corporate Compliance Policy.

b. Organization: This area is defined as the policies, procedures, and legal guidelines that the organization is legally responsible to follow. Appropriate areas for assessment would include, but not be limited to, a review of the organization’s policies and procedures compared to actual practices, a review of federal and state safety, fiscal, third party, and clinical guidelines compared to actual practices, and a review of current industry standards of care compared to actual practices.

c. Hardware: This area is defined as the conditions that exist within the organization. Appropriate areas for assessment would include, but not be limited to, the physical structures in which services are provided, equipment used throughout the organization, health and safety reports, incident reports, maintenance reports, and the organization’s tools for maintaining and transmitting information.

d. Insurance: This area is defined as the overall insurance program that the organization has in place to protect all assets and protects persons served, staff members, the designated authority members, and others associated with the organization, against reasonable claims due to adverse events for which the organization is liable. Appropriate areas for assessment would include, but not be limited to, appropriate insurance coverage for buildings, equipment and inventory, workers’ compensation, bonding of personnel, and vehicles. In addition, assessment also includes the areas of professional liability, products and services, and designated authorities’ errors and omissions.

4. The Program Director will conduct a formal Risk Management Assessment (RMA) and report the findings of that assessment to the organization’s designated authority. The Risk Management Assessment Questionnaire Form will be utilized to guide the assessment process.

5. The Program Director will facilitate and encourage staff member involvement in assessing risk and loss through the distribution of a risk assessment questionnaire that provides basic education regarding risk management and directs the staff member to provide opinion and feedback regarding their perception of risk within their work environment. The Program Director will facilitate the staff member assessment process through department and/or program educational presentations.

6. The Program Director will review the organization’s historical losses, or potential for loss in all areas assessed, and will utilize this information to establish a standing Risk Management Plan. The plan will be directed towards investigation, continued assessment, and/or coping with a specific issue, solving a particular problem, or reaching a clearly identified objective. Each goal will contain specific objectives, time lines, persons responsible, review dates, and target dates for completion.

7. When developing, managing, monitoring, and revaluating the Risk Management Plan, the Program Director will address issues through a continuous review of the following:

a. Can the problem or potential problem be eliminated?

b. If a problem cannot be eliminated, can action be taken to maintain an acceptable level of risk?

c. If a loss occurs, can the severity of the loss be reduced?

d. What are the various causes that can lead to the problem?

e. What are the possible event frequencies and consequences related to the various causes?

f. What alternatives can be established to deal with potential problems?

g. Would a combination of technical and organizational measures increase the level of prevention?

h. What are the results of selected control measures?

i. Periodic evaluation of control measures.

j. Corrections of control measures if they are not carried out properly.

k. Evaluation of risk financing options.

l. Evaluation of overall goal results.

m. Ongoing reformulation of the plan.

8. The Program Director will provide an annual summary of its activities, and results of planning and interventions to the CEO to provide information for management decision making and planning, and inclusion in the organization’s reports to persons served, staff members, third parties, referral sources, regulatory agencies, and other stakeholders.

RISK MANAGEMENT PLAN - FY 2020 begins 7/1/19

The risk management plan serves to maintain continuity of services and manage potential risks which may cause a loss in service capacity or resources. Risk management includes:

1. Identification of potential or actual loss exposures

2. Analysis and evaluation of potential or actual loss exposures

3. Development of strategies to prevent or reduce losses

4. Implementation of activities

5. Ongoing management of activities

The following are identified as potential risks and plans that could be adopted to mitigate them:

A. Risk: Deficiencies in building layout at the offices:

1. Overcrowded parking lots create unsafe conditions for clients and other pedestrians.

2. Insufficient space in service area results in clients standing and waiting in hallways, blocking entrances and exits.

3. Common entrance and waiting area for forensic and child and family service areas creates awkward and unprofessional environment.

Strategy to Mitigate:

1. Acquire additional land adjacent to existing facilities and construct new clinical services facility.

Target Date

Status:

B. Risk: Privatization of Medicaid transportation brokering has resulted in fewer providers and increased number of consumers using our transportation.

Strategy to Mitigate:

1. Implement new policy and procedure to regulate client transportation and use of our own vehicles.

Target Date: Implement policy by

2. Complete phase out of use of private garages for vehicle repair and maintenance and use only County garage.

Target Date:

Status: Policies were developed, implemented and all staff and clients are abiding by these procedures as of

C. Risk: Lack of growth or further reductions in state funding limits the organization’s ability to maintain its current level of services.

Strategy to Mitigate:

1. Increase service generated fee revenues via the following:

a. Develop management reports to target specific underperforming services. Target Date: Quarterly management reports starting third quarter FY 2019

b. Add Financial Management as a standing item on Quality Improvement Committee agenda.

Target Date:

c. Revise case management program to match Medicaid definition and transfer cases not eligible for billing to programs with reduced accountability. Set target for billing eligible cases to meet revenue budget.

Target Date:

d. Request assistance from state to review cases marginally ineligible for billing to determine if service plan revision or other changes will result in eligibility to bill.

Target Date: Immediately

Status:

1. Items;

a) Target date not reached.

b) Target date not reached.

c) Target date not reached.

d) Ongoing process. Appears to be effective although final report and changes have not been completed.

D. Risk: The federal government’s increased emphasis on enforcement of compliance with reimbursement regulations places the organization at risk of payment recoupments and fines.

Strategy to Mitigate:

1. Fully implement the Corporate Compliance Plan. (Client records-charting, billing procedures)

Target Date:

Status:

E. Risk: Increase in civil/legal actions in the state within the past two years regarding liability of community-based services and workers involved in those services. Presents a financial risk for the company and a physical risk for employees.

Strategy to Mitigate:

1. Increase length and depth of initial and ongoing safety training for community-based staff.

Target Date:

2. Review of insurance coverage to determine if additional coverage is needed. Target Date: Immediately.

3. Review safety policies for community-based services and determine if additions to our technology plan could strengthen safety through technological tools and systems available for safety and security.

Target Date:

Status:

a. Target date not reached.

b. Coverage was reviewed by management team and found to be adequate

c. Target date not reached.

F. Risk: The annual written analysis of critical incidents demonstrated a significant area of health and liability risk in the area of medication errors.

Strategy to Mitigate:

1. Follow the recommendations of the management team:

a. Review medication policy and procedures by contract physician and nurse consultant.

Target Date:

b. Revise policy and procedures.

Target Date:

c. Implement policy and procedure education and changes.

Target Date:

Status:

MEDIA RELATIONS & PUBLICITY:

Date Revised: August 2019

Policy statement: MJSF&N staff will seek to present MJSF&N in a respectful manner. Further, all media inquiries regarding critical incidents will be directed to Senior Management.

Purpose: This policy is designed to promote the responsible dissemination of information about MJSF&N.

Applicability: This policy applies to all staff affiliated with MJSF&N.

Procedure: Public Relations/Marketing staff members, through their many contacts, will provide input with regard to needed services and community or media concerns.

MJSF&N strives to assure responsiveness to the community by designating the Director of Marketing as MJSF&N’ community/media liaison.

A primary responsibility of the Marketing Director is to disseminate information and respond to requests from the public for information about the organization. The Marketing Director directs MJSF&N’ publicity efforts for the public using a combination of tools; regular external and internal publications as well as brochures, pamphlets and other printed materials, press releases, public service announcements, advertising and community education activities.

Various procedures are in place to effectively address community concerns and complaints.

Community relations efforts and community contacts are documented in Board minutes and an annual Marketing Report.

Telephones at MJSF&N have voicemail with emergency information answered 24 hours/day, 7 days/week. MJSF&N will respond to voicemail messages within 24 hours.

Social Media Policy (for all employees)

The MJSFN may provide social media venues that encourage collaboration with staff members, clients, vendors, and other industry professionals. The primary goal of these venues is an interactive exchange of ideas in the pursuit of professional and personal development. Other social media may include personal blogs, Facebook, LinkedIn, MySpace, Twitter, YouTube and others. It is important that the following policies are adhered to:

1. No confidential information may be shared at any time. This includes private information with regard to clients, co-workers or other business associates. Providing any information about clients, even if a client’s friends or family members online have already disclosed the information is illegal.

2. Staff members should identify themselves by name and, when relevant, title. Staff members must make clear they are representing their own views and not that of MJSFN. The following disclaimer may be used:

“I am an employee of MJSFN. The statements or opinions expressed are my own and do not necessarily represent those of MJSFN.

3. Individuals creating a website or blog that will mention our organization are required to receive authorization from their manager.

4. MJSFN sites may not be used to endorse any outside person, product, service or organization. External links may only be used with the permission of a manager.

5. If an employee’s affiliation with MJSFN on a social media website is known, (such as LinkedIn) the conduct must be consistent with the professional standards of MJSFN. External endorsements should not be given or requested.

6. Discriminatory, harassing, intimidating, or offensive language is not consistent with the policies of MJSFN. All communication must be free from harassment regarding racial, ethnic, religious, physical, gender, sexual orientation or any other protected classification.

7. Proprietary or confidential company information may not be shared. This includes revenue, business performance, future plans, employee compensation, or share prices.

8. MJSFN logos, trademarks or proprietary graphics may only be used with the expressed consent of MJSFN.

QUALITY ASSURANCE POLICY:

Date Revised: August 2019

Policy statement: MJSF&N and OP will continuously strive to improve the quality of its services through both formal and informal means.

Purpose: This policy is designed to regularly improve the quality of services provided.

Applicability: This policy applies to all MJSF&N and OP staff.

Procedure: Quality assurance will be conducted in a variety of ways, supervised by the Director of Quality Assurance.

For MJSF&N cases, the Case Managers review every billable note entered (e.g., evaluations, treatment plans, BSC notes, MT notes, TSS notes), to assess adherence to MJSF&N policies. Entries that conform to accepted standards are approved by the Case Manager, whereas any irregularities are referred to the Site Director and the Director of Quality Assurance. In addition, on a semiannual basis, Case Managers will conduct phone calls to parents, guardians, and clients aged 14 years or older. Case Managers will document the feedback from these contacts, which will be reviewed on a semiannual basis by the Site Director, Clinical Director, and Training Director.

Staff who demonstrate serious or consistent problems with treatment approach and/or documentation will be referred for professional development, which will be provided 1:1 on a weekly basis with a licensed psychologist. Staff who demonstrates improvement to a satisfactory level after a month of such supervision will return to normal status; staff who fail to demonstrate satisfactory improvement during that period will be terminated.

For Outpatient cases, the OP Supervisor review every billable note entered (e.g., assessments, treatment plans, progress notes), to assess adherence to MJSF&N OP policies. Entries that conform to accepted standards are approved, whereas any irregularities are brought to the attention of the therapist. The chart review process will also identify whether confidential information was released appropriately and whether treatment goals were revised when appropriate.

In addition to the above, all MJSF&N and OP staff are strongly encouraged to informally engage in continuous quality improvement. Any problem area that is identified by an employee should be brought to his or her supervisor’s attention, and a means for effecting improvement in that area will be discussed; the supervisor, in turn, is encouraged to discuss all quality improvement issues with his or her supervisor. It is expected that MJSF&N and OP will continuously improve its delivery of services.

In order to promote state-of-the-art prescribing practices, an annual utilization review of med effectiveness will be conducted. On an annual basis, the Medical Director will review the record of medication errors. In addition, the Medical Director will review at least 10 psychiatric charts comprising the various psychiatrists employed by MJSF&N. The Medical Director will consider med appropriateness (based on client needs and preferences) and med efficacy, and including whether side-effects, contraindications, and possible drug interactions are considered. The Medical Director will record any recommendations he or she may have to encourage more effective treatment. The recommendations will be given to the appropriate psychiatrists, and a record of this review will also be submitted to the Directors.

In addition, a satisfaction survey of the caregiver and client (if age 14 or older) will be taken on a semiannual basis to elicit their feelings about the services provided by MJSF&N. The survey should be administered within 30 days after admission, then once every 6 months around the same time period as the Comprehensive Biopsychosocial Re-evaluation, and then finally within 30 days post-discharge. The results of the survey will be reviewed on a semiannual basis by the Directors, who will identify staff who receive particularly high or low ratings. Such ratings will inform the supervision of such staff, though care will be taken, whenever possible, to keep the source of this information confidential.

In addition to the above “internal” quality monitors, “external” quality monitors regularly review the provision of services by MJSF&N staff. These external monitors include representatives from the State Office of Mental Health as well as from the relevant managed care organizations, including CBH, MBH, and CCBH.

Clinical Requirements

ASSESSMENT FOR MJSF&N SERVICES:

Date Revised: August 2019

Policy statement: MJSF&N staff will provide a thorough evaluation of any adult or youth up to the age of 21 with moderate to serious behavioral health issues to determine the most appropriate course of treatment. In addition, MJSF&N will provide a comprehensive re-evaluation of the client approximately every 180 days, in order to assess the success and appropriateness of the current treatment and determine to what extent changes in the treatment plan need to be made.

Purpose: This policy is designed to provide all youth who qualify with thorough and comprehensive evaluations that consider all relevant biopsychosocial factors that could impact the client, in order to formulate the most effective and appropriate Treatment Plan possible.

Applicability: This policy applies to all clients who are residents of Baltimore, and who consent to treatment if they are age 14 or older, or who have the consent of their parent(s)/legal guardian(s) if they are less than 14 years old. MJSF&N will not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, disability, or religion.

Procedure: All assessments (i.e., Comprehensive Biopsychosocial Evaluations and Comprehensive Biopsychosocial Re-Evaluations) must be legible and must be performed and signed by a Baltimore-licensed psychologist or psychiatrist (or by a psychology or psychiatry intern, and supervised and signed by a licensed psychologist or psychiatrist) within 30 days from the time that MJSF&N services are requested by a client (if over 14 years of age) or by a parent/legal guardian. The assessment is essential for determining the need for and the form that MJSF&N services and related treatments should take, for the ensuing 180-day period. (A licensed psychologist or psychiatrist must devote at least one hour (2 units) to the completion of the evaluation.) [For CBH clients: Each evaluation must contain an accompanying document that specifically indicates the date and clock hours of the time spent on the evaluation by each participant, with an accompanying legible signature by each contributor to the evaluation.] The assessment must be conducted face-to-face with the client, although collateral information should also be collected, such as observations of the child at school or in the home, and other treatment records. The assessment will strive to be a complete gathering of ecological information though consumer interview, discussion with family members and/or caretakers, review of clinical records, input from treatment staff (if a CBR), and contact with collaborating agencies, with the aim of formulating a biopsychosocial assessment, diagnosis, and treatment plan. Ideally, the interview with the client and caregiver would also include the presence of relevant treatment staff.

The assessment will include the following:

· Demographic information.

· The assessment will thoroughly describe all presenting problems identified by the client and/or family, in a behaviorally defined manner; the presenting problems will be characterized in terms of duration, intensity, and frequency, as well as the context in which the problem behaviors occur.

· Purpose of the evaluation.

· The assessment must reflect both a comprehensive past and present history, in chronological order, of the behavioral issues, including exacerbations and remissions, and the factors that may have contributed to them.

· The assessment will convey a treatment history, including responses to various forms of treatment, as well as remissions and exacerbations even if no treatment was provided. Relevant treatments include: psychiatric hospitalization, partial hospital program, outpatient counseling, Family Based Treatment, psychotropic medications, residential treatment programs, substance abuse treatment, specialized treatments (e.g., rape counseling), and past MJSF&N services.

· A history of precipitating and aggravating factors will be included.

· The assessment will include a developmental history, including pregnancy and birth, adoption history, and physical development, as well as emotional, cognitive, speech, maturational, spiritual, nutritional, vocational, legal, sexual, and social elements of the client’s life.

· The assessment will include emotional maturity and temperament, peer relations, family relationships, conscience and values, interests and hobbies, and unusual or traumatic events.

· The child’s educational history will be described, including grades, learning difficulties, IEPs and functional behavioral analyses, as well as conduct issues including detentions and suspensions.

· The assessment will include a comprehensive medical history, including at a minimum, current and past medications, responses to those medications including adverse effects, non-psychiatric medical illnesses, history of significant head trauma, seizures, CNS infections, surgeries, other medical treatments the client is receiving, current medical condition, food, environmental, and drug allergies, current measurement of height and weight which should be used to determine the Body Mass Index, and family history of significant medical, psychiatric, or substance abuse conditions.

· Laboratory tests will be included (e.g., urine tox screens, blood alcohol levels) when available and appropriate.

· A comprehensive substance abuse history of the client will be included, with a recommendation for urine tox screens if deemed necessary.

· Whenever possible, objective testing and structured assessments will be included, such as results from the WISC.

· The client’s and family’s strengths and barriers to treatments will also be fully described, as will the client’s and family’s goals for treatment.

· The assessment will also include the biological family’s history and background as well as the current composition of the family.

· Living arrangements will be described as will government benefits and involvement with government social agencies (e.g., child welfare, juvenile justice, foster placement, office of mental retardation).

· The assessment will include attachment patterns and coping challenges, the parents’ own issues with their own families of origin that might influence attitudes and behavior, ethnic, cultural, and religious background.

· The assessment will include a developmental history, as well as a brief notation of speech, hearing, and visual functioning, immunization history, prenatal exposure to detrimental substances, and caretakers’ preferences re: participation in services.

The assessment will further include a mental status examination, which will include:

· The mental status examination will document current signs and symptoms of psychiatric disorder, appearance and behavior, mood and affect, speech and language (including rate and rhythm, reading and writing), current thoughts and perceptions (including worries, cognitive and perceptual symptoms, orientation, hallucinations, delusions, and thought disorder), motoric activity and coordination, overall intelligence, attention and concentration, memory, neurological functioning, judgment and insight, and preferred mode of communication (e.g., play, drawing, direct discourse).

· The assessment will convey a history of the client’s past and current risk for aggression, abuse, and suicidality (to determine potential risk of harm to self or others).

· The assessment must include current information on the client’s support system.

· The assessment must include a problem list as well as the client’s goals for treatment.

A Biopsychosocial Formulation will be included in the evaluation that summarizes and synthesizes the preceding information in a coherent manner. The formulation will include a description of the interactions between the client, the client’s family members, and the evaluator. In addition, the formulation will include predisposing, precipitating, perpetuating, and protective factors. The individual’s personal and family strengths will be utilized. Information will be included on: adaptive strengths, supports available, stressors, relationships, prominent themes, medical issues, special needs, and social and environmental stressors. A full DSM-5 diagnosis must be included, as well initial discharge planning. The assessment will identify specific recommendations for biological, psychological, and social interventions that include the details of when, where, and who will implement the recommendations. The overall prognosis, as well as specific expectations and responses to those expectations, will also be identified. This also includes any referrals that will be made. Reasons for referrals include: for additional medical consultation or psychological testing if indicated, physical examination, neurological examination, examination of hearing, speech or language, psychoeducational testing through the school district as needed, and referrals for child safety and welfare.

Comprehensive Biopsychosocial Re-Evaluations will adhere to the same approach as used for Comprehensive Biopsychosocial Evaluations.

If a non-licensed psychology resident or intern is providing evaluations on a full-time basis, the intern or resident must meet with the supervising licensed psychologist for at least one hour every week to discuss relevant clinical issues. All evaluations by a resident or intern must be supervised and signed by a licensed psychologist or psychiatrist supervisor. All guidelines of the American Psychological Association, as well as appropriate State regulations, will be adhered to in the supervision of residents and interns. All trainees will be treated ethically, with dignity and respect. The immediate supervisor of the resident or intern will be ultimately responsible for the trainee’s performance and, therefore, ultimately responsible to the client and family. The client and family will be made aware of the trainee’s status. The client and family will be provided with the means to contact the supervising clinician. All clinical notes by the trainee will be reviewed and signed by the supervisor.

Date Revised: August 2019

Policy statement: MJSF&N PRP staff will evaluate any individual with mild to moderate behavioral health issues to determine the most appropriate course of treatment.

Purpose: This policy is designed to provide all individuals who qualify with a thorough intake assessment that takes into account all relevant biopsychosocial factors that could impact the individual, in order to formulate an appropriate Treatment Plan.

Applicability: This policy applies to all individuals who are residents of Baltimore, and who consent to treatment if they are age 14 or older, or who have the consent of their parent(s)/legal guardian(s) if they are less than 14 years old. MJSF&N will not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, disability, or religion. To be eligible to receive services, individuals must receive funding through Medical Assistance.

Procedure: All Intake Assessments must be legible and must be performed and signed by a mental health professional. The Intake Assessment is essential for determining the need for and the form that OP services and related treatments should take for the ensuing 120-day period. The Intake Assessment must be conducted face-to-face with the client, although collateral information could also be collected, such as other treatment records. The assessment will strive to be a complete gathering of ecological information though consumer interview, discussion with family members and/or caretakers, and review of clinical records, with the aim of formulating a biopsychosocial assessment, diagnosis, and basic treatment plan.

The Intake Assessment will include the following:

· Demographic information.

· The assessment will describe all presenting problems identified by the client and/or family, in a behaviorally defined manner, as well as the context in which the problem behaviors occur.

· The assessment should reflect both past and present history of the behavioral issues, including exacerbations and remissions, and the factors that may have contributed to them.

· The assessment will convey a treatment history. Relevant treatments include: psychiatric hospitalization, partial hospital program, outpatient counseling, Family Based Treatment, psychotropic medications, residential treatment programs, substance abuse treatment, and specialized treatments (e.g., rape counseling).

· A history of precipitating and aggravating factors will be included.

· The assessment should include developmental, emotional, cognitive, maturational, spiritual, nutritional, vocational, legal, sexual, and social elements of the client’s life.

· The client’s educational history should be briefly described.

· The assessment should include a medical history, including current medications, non-psychiatric medical illnesses, history of significant head trauma, surgeries, other medical treatments the client is receiving, current medical condition, allergies, and current measurement of height and weight which should be used to determine the Body Mass Index.

· Laboratory tests will be included (e.g., urine tox screens, blood alcohol levels) when available and appropriate.

· A substance abuse history of the client will be included, with a recommendation for urine tox screens if deemed necessary.

· The client’s (and family’s, if appropriate) strengths will also be described.

A full DSM-IV five-axis diagnosis must be included, as will initial discharge planning. This also includes any referrals that will be made. Reasons for referrals include: for additional medical consultation or psychological testing if indicated, physical examination, neurological examination, examination of hearing, speech or language, psychoeducational testing through the school district as needed, and referrals for child safety and welfare.

SUICIDE ASSESSMENT POLICY:

Date Revised: August 2019

Policy statement: MJSF&N and PRP clinical staff will continuously monitor the risk posed by clients, particularly the risk of suicide, and respond appropriately to such risk as it may present itself. This policy includes provisions for the safety of the client as well as procedures for documentation of suicidal ideation and/or behavior.

Purpose: This policy is designed to ensure the safety of all clients.

Applicability: This policy applies to all clients of MJSF&N.

Procedure: All MJSF&N employees must attend mandatory training addressing suicide prevention and de-escalation. The training will focus on the recognition of suicidal ideation, the signs that a client may be contemplating suicide, and the procedures to be implemented should such behavior occur. (OP Therapists are encouraged, though not required, to attend this training as well.)

All clinical staff assigned to a client (e.g., RCMs, MTs, TSSs, OP Therapists) are responsible for recognizing suicidal feelings and observing suicidal behavior in clients. Any clinical staff member of MJSF&N who observes or overhears a client discussing profound feelings of depression or extreme mental distress will meet with the client to discuss their thoughts and feelings, to determine the severity of the suicide risk. If a TSS is processing with the client their suicidal feelings, the TSS will consult with the BSC (or MT if one is assigned and the BSC is not available) as soon as possible. If there is any credible risk of suicidal behavior, the staff member will inform the parents/legal guardian as soon as possible of the degree of suicide risk. In addition, the staff person will inform the other members of the MJSF&N team as soon as is practical, but not more than two hours after first learning of it.

If the risk is deemed to be low – e.g., suicidal ideation without intent, then the parent/legal guardian will be advised to be supportive and to observe the client for any changes in mood or behavior. If the risk is deemed to be potentially serious – e.g., a plan, some intent to act – then the staff person will advise the parent/legal guardian to seek a psychiatric evaluation as soon as possible, preferably at a hospital ER or mental health crisis center.

For adult PRP clients, if the risk is deemed to be serious, the Therapist will seek to persuade the client to go for an evaluation at a hospital ER or mental health Crisis Center. If the client refuses and the risk is deemed to be highly serious, the Therapist should pursue a 302 commitment.

The therapist who first learns of the client’s suicidal feelings is responsible for entering a progress note in the client’s record. This note will include the events precipitating the need for assessment, the client’s mood, affect, behavior, any significant statements by the client, the time the parent (and supervisor, if applicable) was notified of the need for assessment, and the recommended level of care.

If there is any question that the client may not be safe, he/she will not be left alone at any time. Either the clinician or his/her designee will remain with the client until further treatment recommendations can be instituted. If it is determined that the suicide risk is not imminent, treatment options will be discussed with the client and the appropriate level of care will be instituted.

REFERRAL SYSTEM POLICY:

Date Revised: August 2019

Policy statement: MJSF&N and PRP will have a coherent system for receiving referrals from other agencies and for making referrals to other agencies as appropriate to the client’s current and aftercare needs.

Purpose: This policy is designed to ensure continuity of behavioral healthcare at the optimal, least restrictive level of service.

Applicability: This policy applies to all clients of MJSF&N and PRP.

Procedure: Case Managers (for MJSF&N clients) or the Supervisor (for PRP clients) are responsible for obtaining incoming referrals from other agencies. (See “Admissions Policy” for more details regarding admissions procedures.) The Case Manager or Supervisor will first obtain Consent for Release Authorizations for the pertinent materials, such as discharge summaries and psychiatric/psychological evaluations. The Case Manager or Supervisor will request such documents from the referring agency. The Case Manager or Supervisor will obtain all relevant clinical evaluations, discharge summaries, or assessments. At a minimum, the Case Manager or Supervisor will obtain the client’s name, address, phone number, name of parent(s) and/or legal guardian(s), MA number, school, grade, IEP status, and presenting problem. The Case Manager or Supervisor is responsible for using the Eligibility Verification System to determine status of Medical Assistance. Within a week of the initial contact, the Case Manger or Supervisor is responsible for scheduling the Intake and, in the case of MJSF&N services, also the Inter-Agency Team Meeting and Psychological/Psychiatric Evaluation appointments. If possible, for the client/family’s convenience, the scheduling of these appointments should be completed the same day as the initial contact. The actual appointments will occur within twenty-one (21) days of the formal initiation of the admission process, which begins once a Site Director has concluded that an individual is an appropriate candidate for non-hospital mental health services and the client (if age 14 or older) or the parent/legal guardian (if the client is under 14 years of age) has signed a MJSF&N Consent for Treatment.

When a client’s discharge from MJSF&N is anticipated, the Treatment Team will determine appropriate aftercare referrals (if any). The Behavior Specialist Consultant or OP Therapist will make these referrals, unless, in the case of MJSF&N services, there is no assigned BSC, in which case the Case Manager will make the appropriate referrals in consultation with the Treatment Team. The referring aftercare agency will be sent a Discharge Summary, as long as written consent for release of this information has been given by the client (if age 14 or older) or the parent/legal guardian. For MJSF&N services, the Case Manager is responsible for assuring that this process occurs; for PRP services, the Therapist is responsible.

Attempts to receive discharge information from referring agencies and to send discharge information to aftercare agencies will be documented. For the content of the Discharge Summary, refer to “Discharge Documentation”.

ADMISSIONS:

Date Revised

Policy statement: MJSF&N’ Behavioral Health Rehabilitation Services (MJSF&N) will evaluate any child or youth up to the age of 21 for the treatment of serious emotional and/or behavioral problems. MJSF&N’ Psychiatric Rehabilitation Program (PRP) counseling services will evaluate any individual, child or adult, for the treatment of mild to moderate emotional and/or behavioral problems.

Purpose: This policy is designed to allow all individuals who qualify to be provided with the opportunity to receive appropriate and integrated behavioral interventions, within the least restrictive setting.

Applicability: For MJSF&N sites that offer MJSF&N services, this policy applies to all adults and children up to the age of 21 who are residents of Baltimore, and who consent to treatment if they are age 14 or older, or who have the consent of their parent or legal guardian(s) if they are less than 14 years old.

For MJSF&N sites that offer PRP services, this policy applies to adults, in addition to youth as described in the preceding sentences.

MJSF&N will not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, disability, or religion.

Procedure: Any parent or legal guardian may refer a child or adolescent to be evaluated for the most appropriate level of behavioral treatment. In addition, any adult may refer himself or herself to be evaluated for the most appropriate level of behavioral treatment. A MJSF&N Site Director will first perform screening and information-gathering, usually by phone. If the prospective client is an adult who is clearly at serious and imminent risk of causing harm to self or to others, then the Site Director will advise him or her to go to a hospital ER or mental health Crisis Center immediately. If, on the other hand, the prospective client is a minor, the Site Director will advise the parent/legal guardian to transport the child to a hospital ER or mental health Crisis Center immediately.

If, however, the prospective client is an adult and is deemed by the Site Director to be a possible candidate for outpatient services, then the Site Director will schedule him or her for an PRP intake appointment. If, on the other hand, the prospective client is a minor and is deemed by the Site Director to be a possible candidate for partial hospital, MJSF&N, or PRP services, then an appointment will be made for the child to be formally evaluated by a licensed psychologist or psychiatrist. (See “Assessment Policy” for more details regarding the information to be included in the initial evaluation.) The child should be accompanied to the intake by the child’s parent(s)/legal guardian(s) if the child is under 14 years of age; if it is not possible for any parent or legal guardian to attend the intake for a child under 14 years of age, then formal written permission for the provision of treatment must be obtained ahead of time from the parent/legal guardian. The admission process officially begins once a Site Director has concluded that a prospective client is an appropriate candidate for non-hospital mental health services and the prospective client (if age 14 or older) or the parent/legal guardian (if the prospective client is under 14 years of age) has signed a MJSF&N Consent for Treatment. If the Initial Assessment results in a recommendation for PRP services, or the Comprehensive Biopsychosocial Evaluation results in a prescription for either PRP or MJSF&N services, the Site Director (or Case Manager) will begin to make arrangements to provide services as soon as possible.

Criteria for admission: In order for a child or youth 21 years of age or younger to be evaluated for MJSF&N or PRP services, he or she must have emotional and/or behavioral problems. For youths with mild to moderate problems, the Site Director will most likely choose to schedule an Initial Assessment to determine appropriateness for Outpatient (PRP) counseling. For youths with moderate to serious problems, the Site Director will most likely choose to schedule him or her to receive a Comprehensive Biopsychosocial Evaluation. However, if the youth is actively suicidal or homicidal, or at serious risk of elopement or of major destruction of property, then referral to a more intensive level of service (e.g., psychiatric hospitalization or residential treatment facility) may be deemed appropriate. Children under the age of 2 will not usually be considered for MJSF&N services unless there are exceptional reasons. For logistical and administrative reasons, MJSF&N services are generally limited to youths who reside within the Baltimore metropolitan area. For similar considerations, MJSF&N PRP services are generally limited to youths and adults who reside in Baltimore Metropolitan area. Funding for services is generally provided through the Medical Assistance program of the State of Baltimore.

In order for an adult to be evaluated for PRP services, he or she should present with mild to moderate emotional and/or behavioral problems. Should the prospective adult client present with serious emotional issues, he or she may be referred to a partial program or, possibly, to a hospital ER or mental health Crisis Center.

Hours of Operation: MJSF&N’ administrative offices are generally open weekdays from 9 a.m. to 5 p.m., excluding official holidays, although special accommodations may be made for families who require times outside of these.

(Considerable flexibility is expected in the provision of services to clients and their family who receive MJSF&N and PRP services. Hours of services typically include from 8 a.m. to 9 p.m. on weekdays, and weekend hours as well. The specific hours provided by MJSF&N and PRP staff will be guided foremost by consideration of the needs of the client and family.)

Appointments for service are generally scheduled on a “routine” basis, meaning usually within five (5) business days following a request by the client/family. A Comprehensive Biopsychosocial Evaluation or Initial Assessment will usually be scheduled within 21 days of admission.

If an emergency arises, such as a sudden and dramatic worsening in the client’s behavior, then MJSF&N and PRP staff will make every attempt to provide services in a timelier fashion. For new clients, every effort will be made to schedule a CBE or Initial Assessment within 7 days. For existing clients who are receiving MJSF&N services, the BSC and/or MT will make telephone contact and, if feasible, face-to-face contact, with the client and/or family within 24 hours. If this contact is deemed insufficient by MJSF&N staff and/or the client/family, then the family should take the client to the nearest mental health crisis intervention center; MJSF&N staff will provide the family with the appropriate phone number and address of the crisis center. For existing clients who are receiving PRP services, the OP therapist will strive to make phone contact with the client within 24 hours and to schedule a face-to-face appointment within one week.

DEMOGRAPHIC INFORMATION:

Date Revised

Policy statement: MJSF&N will maintain appropriate information pertinent to the client and his or her family.

Purpose: This policy is designed to ensure that informed and comprehensive treatment can be provided in a professional manner

Applicability: This policy applies to all clients and their families.

Procedure: All MJSF&N and PRP staff assigned to a particular client/family are authorized to collect, at a minimum, the following information:

· Name

· Address

· Telephone Number

· Emergency Contact

· Gender

· Ethnicity

· Religion

· Date of Birth

· Primary Language

· Social Security Number

· Primary Care Physician

· Insurance Information

· Parent(s)/Legal Guardian(s)

· School and grade

· Date and time of interview

· Staff signature

· Client’s affectional or sexual orientation (when appropriate)

Because in most instances clients substantially benefit when both of their parents are involved in their treatment and in their lives in general, staff will make a particular effort to inquire about both biological (or, if applicable, adoptive) parents and to obtain contact information for both parents whenever possible. In those instances when a single parent is providing the demographic information to staff and that parent states that information about the other parent is not relevant, staff will urge the parent to nevertheless provide the contact information for the other parent, to enable the treatment team to seek to involve the other parent in the client’s treatment. If, however, the parent providing the information insists that it would be fundamentally detrimental to involve the other parent in the client’s treatment, staff will respect that parent’s wishes and document the reasons for not contacting the other parent.

TREATMENT AND TRANSITION PLAN POLICY:

Date Revised: August 2019

Policy statement: MJSF&N clinical staff will utilize a Treatment Plan and a Transition Plan (or Discharge Criteria, in the case of PRP clients) in the care of each client, formulated by the Behavior Specialist Consultant or OP therapist in consultation with the client (and, in the case of MJSF&N services, with his or her family). The Treatment Plan should specify target behaviors, goals for change, appropriate interventions to be made by specified members of the treatment team, the client’s progress, and discharge criteria.

Purpose: This policy is designed to ensure that the Treatment Plan serves as a tool whereby the care provided to each client is designed, implemented, assessed, and updated in an orderly, coordinated, and clinically sound manner.

Applicability: This policy applies to all clients of MJSF&N and PRP.

Procedure: Staff Roles:

Outpatient services primarily consist of the Therapist and, if appropriate, a Psychiatrist. The OP Therapist is responsible for creating the Treatment Plan in consultation with the client (and Psychiatrist, if he or she is actively involved in the case). In any event, the Treatment Plan should be reviewed and signed by the Psychiatrist.

MJSF&N Services can include the following members of a “Wrap Around team”:

1) A Licensed Psychologist or Psychiatrist evaluates the child in order to formulate a CBE or CBR, which makes formal recommendations for MJSF&N services as well as related services as deemed appropriate.

2) A Behavior Specialist Consultant (BSC) has obtained at least a Masters Degree in a Behavioral Science-related field. The BSC is responsible for developing the Treatment Plan.

3) A Mobile Therapist (MT) is an individual who has obtained at least a Masters Degree in a Behavioral Science-related field. The MT works directly (face-to-face) with the client and/or family to process feelings and behaviors that impact adversely on their quality of life.

4) A Therapeutic Support Staff (TSS) is an individual who has obtained at least the equivalent of an Associates Degree in a Behavioral Science-related field. The TSS works under the direction of the BSC, and carries out the interventions specified in the Treatment Plan.

5) A Case Manager (CM) manages all of the administrative requirements and oversees the provision of services by Wrap Around staff.

The Treatment and Transition Plans will be developed by the Behavior Specialist Consultant; if no BSC is assigned to the case or available, then the Treatment and Transition Plans will be developed by the Mobile Therapist. The Treatment and Transition Plans must reflect input from all disciplines involved with the client, such as psychiatric, educational (if school issues are present), and substance abuse treatment, as well as input from the client and his or her parents/legal guardians/custodians. The Treatment Plan should seek to involve both biological (or adoptive) parents in the client’s treatment

A Treatment Team Meeting will be held as soon as possible after the completion of the Comprehensive Biopsychosocial Evaluation or Re-Evaluation. The Treatment Team Meeting will include the client, and the parents or legal guardian as well as the MJSF&N staff assigned to the client. The Treatment Team will review the assessment (CBE or CBR) and the Treatment and Transition Plans. The purpose of this meeting is to decide upon and confirm the goals of treatment. The BSC will schedule Team Meetings that include the BSC, MT, in-home TSS, in-school TSS, Case Manager, parents, and the client (especially if the client is age 14 or older).

Privacy and confidentiality of the client and his or her family must be maintained throughout the process of developing the Treatment and Transition Plans. A new Treatment and Transition Plan must be developed every 180 days, within 45 days of a Comprehensive Biopsychosocial Evaluation or Re-Evaluation; the Treatment Plan must reflect the 5-axis DSM-IV diagnosis in the CBE or CBR, and must also reflect the target behaviors and treatment approaches specified in the CBE or CBR. In addition, the Treatment Plan must document the admission date, the date of the initial Treatment Plan, and the date of the present Treatment Plan, as well as the date of the subsequent Treatment Plan. The expected duration of treatment will also be documented and discharge criteria described in the Transition Plan.

The Treatment Plan must define the target behaviors using behaviorally defined problem statements. Treatment Plan goals must be realistic, objective, stated in measurable terms, and behaviorally based. The Treatment Plan must further be strengths-based, and must identify the strengths as well as the barriers relevant to the client. The Treatment Plan must reflect the methods of treatment, and must also specify the interventions and action steps. The Transition Plan will specify the discharge planning. The Treatment Plan will specify the responsibilities of each individual involved in the client’s treatment, including the client and the parents/legal guardians/custodians, and the specific interventions to be utilized by each participant.

It should be noted that a client’s Treatment or Transition Plans may be changed at any time by the client (if 14 years of age or older), the parents/legal guardians/custodians, the Behavior Specialist Consultant, or the Mobile Therapist, should the goals and objectives be deemed inappropriate and/or unnecessary for any clinical reason. All Treatment Plans following the initial Treatment Plan must document progress (or lack thereof) that the client and his or her family has made on the goals set; lack of progress will be subjected to careful scrutiny by the treatment team in the formulation of the Treatment Plan, in order to develop more productive approaches. The active participation of the client is to be encouraged, as is the active participation of the parents/legal guardians/custodians, in the formulation of the Treatment and Transition Plans as well as of any revisions to the plans. The signatures of these individuals and of all members of the Treatment Team are required on the document. The signature of the client and parents/legal guardians/custodians must clearly endorse a statement that the individual understands, participated in the formulation of, and approves the Treatment and Transition Plans. All Treatment and Transition Plans and signatures must be legible. A copy of the written Treatment and Transition plans will be given to the client/family as well as other individuals involved in the development of the transition plan.

Date Revised: August 2019

Policy statement: MJSF&N recognizes that appointments for treatment may be occasionally missed by clients or their families as well as by staff, due to unforeseen contingencies as well as due to human error. Over the course of treatment, the occurrence of a missed appointment would not in itself be a cause for concern. However, if a continued pattern of missed appointments by a given individual were to occur, this could substantially interfere with the provision of treatment, necessitating reconsideration of the appropriateness and utility of treatment.

Purpose: This policy is designed to set reasonable and appropriate expectations for setting appointments by clients, their families, and MJSF&N and PRP staff.

Applicability: This policy applies to all clients, parents or legal guardians, as well as to MJSF&N and PRP staff.

Procedure: All appointments will be scheduled at the convenience of the client (and/or family, if appropriate), dependent upon the availability of MJSF&N staff. If MJSF&N staff fails to appear for a scheduled appointment, the client and/or legal guardian should communicate this to the staff person and/or to their supervisor. A pattern of repeated missed appointments by staff should always be communicated by the client and/or parent/legal guardian to the staff person’s supervisor and the staff person may be replaced if either the client (if age 14 or older) or caregiver requests this and/or the supervisor deems it appropriate.

For MJSF&N services, the client (if 14 years of age or older) or the parent/legal guardian (if the client is less than 14 years of age) should always sign the timesheet for the staff person, designating the amount of time that service was provided for the current day. The client and/or legal guardian should never sign for services not rendered by MJSF&N staff, and should inform the staff person’s supervisor if they feel that they have been asked to do otherwise.

For PRP services, the client is expected to sign in and out of the session, usually with the receptionist.

If a client or parent misses an appointment, then MJSF&N staff will call the client or parent/guardian (as appropriate) to reschedule the appointment as soon as is practical. If the client (if age 14 or older) or parent/guardian is not able to be directly contacted by phone, then a letter will be sent informing the client or parent/guardian (as appropriate) of the need to reschedule, and requesting them to call their assigned staff or Case Manager for this purpose. If a client repeatedly misses his or her appointment, then the policy for “Discharges” should be followed, found elsewhere in this manual.

Date Revised: August 2019

Policy statement: All client/families are free to end treatment with MJSF&N or PRP at any time. Further, MJSF&N and PRP may choose to discharge clients/families who consistently fail to adhere to agency policy.

Purpose: This policy is designed to affirm a client’s or family’s right to refuse treatment. This policy also affirms MJSF&N’ right to end treatment when the client and/or family is not deemed to be maintaining minimal standards of commitment to treatment, and this has been communicated to the client and/or family as appropriate.

Applicability: This policy applies to all clients/families in treatment with MJSF&N.

Procedure: All clients (if age 14 or older) and their legal guardian(s) have the right to refuse treatment. If a client (if age 14 or older) or a parent/legal guardian makes known to MJSF&N staff their desire to end treatment, this will be communicated to all members of the treatment team assigned to the client/family. The BSC and/or the MT and/or the Outpatient Therapist and/or the Site Director will discuss with the client (if age 14 or older) and/or the parent/legal guardian (i.e., if the client is a minor) the nature of their reasons for wishing to end treatment. If a suitable resolution cannot be achieved (e.g., by replacing a staff member), then the family will be allowed to terminate treatment, and alternative treatment options will be offered. (If a client is deemed to be at serious imminent risk of harm to self or others, then a 302 commitment may be pursued by MJSF&N staff.) If the client/family chooses to terminate treatment against the advice of the MJSF&N treatment team, then this will be documented in the client’s treatment record by the BSC and/or the MT and/or the Outpatient Therapist and/or the Site Director. The lead clinician (e.g., BSC, MT, or OP Therapist) will complete a Discharge Summary. An Aftercare Plan will also be completed, which will include alternative treatment recommendations, and which will be given to the parent/legal guardian or client (if over 14 years) within 7 days of the request to leave treatment AFA. The recommended aftercare plan will be explained to the parent/legal guardian (or client, if age 14 or older), and their signature will be requested to affirm that the suggested aftercare plan has been explained to them. The clinical management staff of the appropriate managed care corporation will be consulted prior to any client leaving against facility advice.

Should MJSF&N or PRP choose to discontinue treatment to a client/family, the appropriate managed care corporation will be informed. MJSF&N may choose to terminate a client/family if minimal standards of treatment are not maintained by the client and/or family. This could include a consistent and willful disregard on the part of the parent/guardian or client (if over 14 years of age) for the basic provision of treatment.

Another reason for an administrative discharge could be if the client and/or parent/guardian misses three (3) consecutive appointments or three (3) appointments within thirty days, barring truly exceptional and unavoidable reasons. In such an event, a letter will be sent to the client (or caregiver if the client is a minor), informing them of MJSF&N’ decision to close their case due to missed appointments. The letter should consist of the following (depending on whether the client is an adult or a minor):

For clients who are minors:

[Date]

Dear __________ (caregiver),

This letter confirms your decision to discontinue (“MJSF&N” – or – “Outpatient”) services for (name of client) through MJSF&N. (Name of client) missed the last few scheduled appointments and has not responded to our phone calls and letters sent regarding (name of client)’s treatment.

If you feel that (name of client) may need treatment now or in the future and can make the effort to keep scheduled appointments, please feel welcome to call me or this office.

Sincerely,

[Name of Case Manager or Site Director]

For clients who are adults:

[Date]

Dear __________ (name of client),

This letter confirms your decision to discontinue Outpatient services through MJSF&N. You missed your last few scheduled appointments with us and you have not responded to our phone calls and letters sent regarding your treatment.

If you feel that you may need treatment now or in the future and can make the effort to keep scheduled appointments, please feel welcome to call me or this office.

Sincerely,

[Name of Case Manager or Site Director]

If there is no response to this letter after two weeks, then the case may be closed. If a client and/or guardian responds to this letter seeking a resumption of treatment, then treatment may be resumed. However, if once again the client repeatedly misses appointments, barring truly exceptional and unavoidable circumstances, then the case may be administratively closed, at the discretion of the staff, in consultation with the Site Director and the managed care organization.

DISCHARGE DOCUMENTATION:

Date Revised: August 2019

Policy statement: MJSF&N and PRP will adequately document the treatment record when a client/family terminates treatment, in order to provide a clear summary of the nature of the treatment provided, the progress achieved over the course of treatment, and the recommended plan of aftercare.

Purpose: This policy is designed to ensure that the treatment record will adequately communicate the nature and course of treatment provided, as well as the reasons for the termination of treatment.

Applicability: This policy applies to all client/families of MJSF&N and PRP.

Procedure: Whenever a client/family is discharged, a Discharge Note will be written in the treatment record by the BSC (or MT if no BSC is assigned) for MJSF&N cases and by the Outpatient Therapist for PRP cases. The note will document the termination of the therapeutic process, describing the client’s general behavior and demeanor and the client’s (and family’s, if the client is a minor) attitude regarding termination. The Discharge Note will discuss the clinical progress achieved by the client (and family, if appropriate), as well as the remaining challenges. If a follow-up appointment has been made (e.g., with an outpatient counseling center), this will be described in the Note, and a letter will be sent to the client/family affirming this. Whenever possible in the case of MJSF&N services, the follow-up appointment will be made prior to the discharge of the client from MJSF&N services, and MJSF&N staff will offer to assist in this process.

Upon termination from MJSF&N services, the client/family will be provided with a written Aftercare Plan, which will include all recommended forms of treatment, including outpatient counseling and/or psychiatric management, if applicable, to be pursued by the client/family. The client (if 14 or older) or parent/legal guardian will sign this Aftercare plan, to be kept by MJSF&N in the client’s treatment record, with a copy given to the family.

For MJSF&N clients, a Discharge Summary shall be composed by the BSC (or MT if no BSC is assigned), to provide accurate discharge status information to aftercare providers in a timely manner. This will be entered into the client’s treatment record within one week of discharge. The Program Director or Clinical Director will review and co-sign the Discharge Summary. The following types of discharge may be designated: successful completion of treatment, transfer to a lower level of care, transfer to a more intensive level of care, termination against facility advice, or administrative discharge. The Discharge Summary will include the following information, at a minimum:

· Reasons for Treatment

· Initial and Final 5-Axis DSM-IV Diagnoses

· Services offered and provided

· Summary of treatment progress (or lack thereof)

· Medication information (if applicable)

· Recommendations for aftercare

· Special needs of the client/family

· Client’s and family’s status upon termination

· Medical and psychosocial problems of the client/family

· Anticipated problems/concerns for future compliance

· Primary Care Physician

Advanced Directive Policy

I. DEFINITION

An advance directive outlines a person’s wishes in the event that he or she is incapacitated or unable to express wishes for health care and treatments. Under federal law, any facility receiving Medicare or Medicaid reimbursements is required to use advance directives. Individuals with a substance abuse and/or behavioral health illness are covered under this mandate.

II. POLICY

In accordance with state and federal law, MJSFN will to give the right to all clients the right to express his or her preferences on where to receive care and what treatments they are willing to undergo. Clients also have the right to identify an agent and/or representative with the legal authority to make healthcare decisions on his or her behalf. These decisions may include the use of all or certain medications and preferred facilities for services.

II. PROCEDURES

A. Advanced directive will be explained during orientation process. As part of the intake/admission process all clients will be given the opportunity to complete advanced directive form.

B. A statement of one’s intent in creating an advance directive for behavioral healthcare decision-making

C. The designation of another person to make decisions for an individual if he or she is determined to be legally incompetent to make choices. Generally, this designation also includes provisions for who should be appointed as guardian if a court decides to name one.

D. Specific instructions about preferences for hospitalization and alternatives to hospitalization, medications, electroconvulsive therapy, and emergency interventions, including seclusion, restraint, medication, and participation in experimental studies or drug trials

E. Instructions about who should be notified immediately if and when the person is admitted to a psychiatric facility. Instructions should also include who should be prohibited from visiting and who should have temporary custody of minor children or pets.

F. Personal rights to refuse or suspend or terminate an advance directive at anytime and must be documented and placed in client’s file.

G. A signature page with two witnesses and a notary who sign the advance directive.

H. Sign an acknowledgement form

ADVANCED DIRECTIVE ACKNOWLEDGEMENT FORM

Date: ________________

I, (client name) ___________________ was informed during the admission process of my right to request or decline an Advanced Directive. I do understand that I can change my mind at anytime.

I decline an Advanced Directive (initial) _____________

I request an Advanced Directive to be completed (initial) ____________

_____________________________

Client Name

_____________________________

Client Signature

_____________________________ __________

Witness Date

Confidential Information Dissemination Policy

I. POLICY:

A. It is the policy of MJSFN Center to ensure that all verbal and written information of persons served is released in a manner that protects the individual’s right to confidentiality. Information may not be released without the individual’s written permission, except as the law permits or requires. MJSFN Center will make reasonable efforts to limit use, disclosure of, and requests for private health information to the minimum necessary to accomplish the intended purpose.

II. PROCEDURES:

A. Information may be released in written and/or verbal form. The release of information will occur upon receipt of an authorization determined as valid. Validity is determined by the presence of each of the following items:

2) The name of the person about whom information is to be released, including social security number.

3) The specific content of the information that is to be released.

4) The person to whom the information is to be released.

5) The signature of the person who is legally authorized to sign the release and the date on which the release is signed.

6) The expiration date of the authorization, not to exceed one year.

7) Information that defines how and when the authorization can be revoked.

C. Requests for Information:

1) All requests for information will be in writing.

2) Requests for information from an individual’s record will be answered within five (5) days from the date of receipt. If the information cannot be provided within this period, the requester will be informed in writing of the reasons for the delay and the anticipated date the information will be available.

3) Requests for records that have been incorporated into MJSFN Center records from outside sources will not be released and the requestor will be encouraged to seek those records from their original source.

D. Release of Sensitive Information:

1) Information contained within the individual records may have a serious adverse effect on an individual’s mental or physical health if disclosed to the individual. Such information may contain materials requiring an explanation or interpretation to assist in its acceptance and/or assimilation in order to avoid an adverse impact on the individual’s health. To minimize the risk of a release of information adversely impacting a person served, the following guidelines will apply:

a. The Program Coordinator will review all requests of individuals seeking direct access to their records. Information identified, as potentially sensitive will be reviewed by Program Coordinator. This review will occur within one working day of the referral.

b. All materials directly related to behavioral health treatment that includes a diagnosis, assessment, or Clinical Director will review interpretative data.

c. If after the professional review of the record, it is believed that disclosure of the information directly to the individual could have an adverse effect on that individual, arrangements will be made to disclose the information to a professional staff member selected by the individual. The staff member will discuss the information with the individual prior to the release.

d. Should it be determined by the professional staff member that after a careful and conscientious explanation of the information to the individual has been made, and it is the opinion that access to the information could be harmful, physical access would be denied. The justification for making the denial will be fully documented by the staff member and Clinical Director will make final concurrence. The individual will be advised of the denial, the reasons for the denial of the request, and advised of the right to file a grievance, should the individual disagree with the decision.

E. MJSFN Center legal counsel will be consulted when the release of information involves the following circumstances:

1) Any request for records that are to be used in a suit against the organization or in a prosecution against a person served.

2) All subpoenas for records that were not accompanied by a written consent signed by the person served.

3) All requests for information, which indicates a possible liability for the cost of, care and services.

F. Information may be released without the consent of persons served under the following conditions:

1) For use by any MJSFN Center employee who has a need for the information in the performance of their duties to ensure continuity of care.

2) To medical personnel who have a need for the information for the purpose of treating a condition, which poses an immediate threat to the health of a person, served.

3) To public health authorities related to infection with HIV when there is a written request for the information and there is a fine or penalty for failure to comply.

4) To a spouse or sexual partner of an individual when it is reasonably believed that the individual will not provide disclosure of information related to infection with HIV when that information is necessary to protect the health of the spouse or sexual partner.

5) To recover or collect the costs of medical care from third party health care insurance carriers contracted with by the persons served and required by the health plan to be disclosed.

6) To Federal, State, or local government agencies or entities charged under applicable laws with the protection of public health and safety. In such cases, the information may be release with the consent of the individual whose records are being requested, or upon receipt of a written request from the head of the government entity. A request for release under these circumstances may be either a standing written requested based on reporting requirements, or a specific written request from the head of a law enforcement agency for a special law enforcement purpose. Standing requests must be updated in writing every year.

7) Disclosure as a result of a court order from a court of competent jurisdiction.

8) To the Department of Children and Family Services for the purpose of investigating abuse, neglect or exploitation.

9) To the Medical Examiner, in conjunction with an investigation of a suspicious death.

10) To professional review organizations, in accordance with government contracts (Medicare/Medicaid).

11) Disclosure of information to a third-party payer in a care cost recovery action will be limited to date of birth; social security number; payment history; and account number, unless the individual provides a written consent designating further information to be released.

G. An accounting record will be maintained on all records released by MjSFN. It will include the date, nature and purpose of each disclosure, the name of the party to whom the disclosure is made. This accounting record will be maintained in the record from which the disclosure was made. In addition, a logbook will be maintained for all release of information for data reporting purposes.

H. Special consent is required to release records that contain information related to drug and alcohol addiction and abuse, and tests for, or infection with human immune virus. Any authorized disclosure from records containing information of this type will be limited to that information which is necessary for the purpose of the disclosure. Because of the special nature of this information, Clinical Director or Designee will assure compliance with the special regulatory requirements must process the release.

I. The following type of communications do not constitute disclosure of information/records:

1) Communication of information between any MJSFN Center employees who have a need for the information in connection with their official duties.

2) Communications with law enforcement offices, which are directly related to the person, served committing or threatening to commit a crime on the organization’s property or against an employee of the organization.

3) Communication of information, which does not provide an individual’s identifying information.

J. MJSFN Center will protect the confidentiality of private health care information when transferring data electronically by adherence to the following guidelines:

1) All data sets containing individual names transferred on a diskette, e-mail or any other electronic medium, will be password encrypted.

2) The sending and receiving parties prior to transfer of the electronic data will negotiate passwords.

3) Passwords will be at least eight characters in length, contain both letters and numbers, and must not be commonly used words.

4) Passwords for encrypted files may not be mailed in the same shipping package as the encrypted file.

K. MJSFN Center will adhere to the following guidelines when mailing confidential private health information:

1) Stamp all envelopes containing records as confidential.

2) Clearly indicate a particular office on the address where the envelope is to be delivered.

3) Whenever possible, include in the address the name of the staff member authorized to open the envelope.

4) All envelopes individually addressed will contain the following statement in the outside of the envelope: “TO BE OPENED BY ADDRESSEE ONLY”.

L. When faxing confidential information, the following guidelines will apply:

1) Confidential private health information will only be transmitted by fax when absolutely necessary or required by the requestor, and other traditional methods such as confidential mail is not possible to deliver the information.

2) All fax cover pages for confidential information will contain the following:

a. The name and program of the person to whom the fax is intended.

b. The name, program, and phone number of the person sending the fax.

c. The statement “Confidential Information” in a large bold font.

d. A statement that clearly identifies the accompanying material as confidential information that reads as follows: “The documents accompanying this facsimile transmission contain confidential information which is legally privileged. The information is intended only for the use of the recipient named above. If you have received this facsimile in error, please immediately notify us by telephone to arrange for return of the documents to us, and that you are hereby notified that and disclosure, copying, distribution or the taking of any action in reliance on the contents of this facsimile information is strictly prohibited.”

3) In situations where the information is not being regularly faxed to a common organization and individual, a phone call will be made to the person receiving the fax to verify the fax number and a follow-up call will be made to ensure the receipt of the fax.

4) Fax transmissions will be restricted to persons specifically authorized to transmit confidential information.

5) Fax machines will not be situated in common public areas.

6) Fax number lists will be current, accurate, and regularly checked.

7) All transmission records will be checked to detect possible transmission errors and retained for confirmation purposes.

8) Upon the receipt of any confidential misdirected fax, the sender will be contacted and the information will be shredded.

9) When the fax machine is unattended at night or on weekends, the print memory will be activated to prevent printing of confidential information when staff are not present.

10) When a fax server is used in lieu of a machine, password protocols will be in place that will restrict and define user access.

M. Any information released verbally over the phone, can only be done after verification of the caller’s identity through taking the phone number and making a call back prior to releasing the information.

N. All telephone calls from outside the organization that request confirmation of an individual being served by MJSFN Center, will be handled by repeating the following statement: “I can neither confirm or deny that the individual in question is receiving services or has ever received services without a written authorization from that individual.”

O. Any MJSFN Center employee who knowingly and/or willfully violates provisions of this policy and procedures will face administrative disciplinary action that may result in termination of employment.

SUBPOENAS, WARRANTS, AND GOVERNMENT INVESTIGATIONS

Date Revised: August 2019

Policy statement: MJSF&N will comply with all appropriate legal inquiries and investigations.

Purpose: This policy is designed to clarify how and when staff should release information of any sort to courts and government investigators.

Applicability: This policy applies to all MJSF&N staff.

Procedure:

1. MJSF&N is committed to ensuring the privacy and security of client records. Under Baltimore laws and regulations, MJSF&N cannot disclose a client’s record pursuant to a subpoena. Client records may only be disclosed with a written authorization from the client’s legal guardian (if the client is a minor) or from the client (if the client is of legal age) or pursuant to a court order.

2. It is the policy of MJSF&N to comply with Baltimore laws and regulations regarding the release of client records of individuals currently receiving or who have received treatment by MJSF&N. MJSF&N will not release an individual's record pursuant to a subpoena unless the client (if 18 or older) or the client’s legal guardian (if the client is a minor) has specifically provided MJSF&N with a written authorization to release such information or unless the subpoena is accompanied by a court order. All subpoenas, warrants, and court orders submitted to MJSF&N staff are reviewed with

MJSF&N’ corporate counsel for consultation and guidance.

3. MJSF&N is allowed to disclose a client’s record without a valid authorization under the following circumstances:

(a) to those MJSF&N employees actively engaged in treating the client;

(b) in response to a court order;

(c) where the client's life is in immediate jeopardy and the records are needed to prevent serious risk of bodily harm or death;

(d) where the provider is required to report child abuse or other such reasons as required by law; or

(e) where the provider believes the client intends to harm another individual, thereby allowing MJSF&N to waive confidentiality by warning the identified victim and police of a specific threat of harm (documentation of real and imminent danger is necessary).

4. Information disclosed will be limited to that which is specifically authorized by the client or his or her guardian, or requested in the court order, or as required by law.

DEFINITIONS

A “Subpoena" is a command to appear at a certain time and place, to testify upon a certain matter. A “Subpoena Duces Tecum" requires the production of documents which are under the possession, custody or control of that person. (Collectively, in this manual, either will be referred to as a “Subpoena”.

A Subpoena is issued at the request of an attorney. Although the subpoena is signed by a clerk of the court, a Subpoena, is not a court order as it is not authorized or signed by a judge.

SUBPOENAS

1. Every Subpoena received should be given to the Site Director.

2. Baltimore law requires that MJSF&N respond to every Subpoena received. Failure to respond can result in the court issuing a bench warrant for the individual named in the subpoena and holding the individual in contempt.

3. If the client has provided MJSF&N with a signed release authorizing it to disclose his or her records and/or to testify pursuant to the Subpoena, MJSF&N is required to abide by the terms of the client’s release. The following procedures will apply;

(a) MJSF&N will provide a copy of the client’s record as requested in the client's release to that individual named in the release. Prior to sending the records, the fee for reproducing and mailing the records will be determined and provided to the requesting party. Records will be forwarded only upon receipt of the fee. Fees charged for providing sued records will be in accordance with Baltimore law relating to the limit on charges for records provided pursuant to a Subpoena (42 Pa. C.S.§ 6152).

(b) If the client's release authorizes the clinician to testify pursuant to the Subpoena, the clinician will testify regarding the factual information contained in the records. A witness fee must be paid at the time of delivery of the subpoena. A witness fee includes one day's appearance fee and roundtrip mileage. If the witness fee is missing in a hand-delivered Subpoena, the Subpoena should be returned to the issuing party with a request that the fees be paid at the time of delivery.

(c) If the clinician is requested to provide her or his opinion as an expert witness, the clinician should charge for his or her time to review the file and to testify. The current rate for such service should be determined by the COO and must be paid in advance of any such review or testimony.

4. Where MJSF&N has not received a valid authorization from the client to release the client's records or to testify, the procedures provided below apply:

(a) The party issuing the subpoena must be contacted and informed that the records are confidential and cannot be released without a valid authorization from the client or without an order of the court Both the client and the client’s attorney (if known) must be contacted and informed of the Subpoena. The client's attorney may assist in protecting the records of the client from disclosure.

(b) If the issuing party fails to produce a valid authorization and refuses to release the clinician or MJSF&N from the Subpoena, MJSF&N’ legal counsel will be contacted, it may be necessary for legal counsel to prepare a motion before the court to quash the Subpoena. This motion will be filed with the court either prior to or on the same day as the MJSF&N employee is to appear with the records.

(c) If the motion to quash is to be heard the same day as the clinician is scheduled to testify and/or produce records, the clinician should accompany legal counsel to court. Legal counsel will present the motion before the judge.

(d) When. appearing before the Court, take a copy of the original records identified in the court order. Before going to court, it is wise to review and prepare information if the judge orders the documents to be disclosed.

(e) If the judge issues an order to release the records, legal counsel will negotiate to limit the extent of the client’s records disclosed. Surrender to the Court the copies of only those records

the judge has ordered released; A copy of the judge's court order must be placed in the client's chart.

RESPONSE TO GOVERNMENT INVESTIGATIONS

1. Government investigators may arrive unannounced at any office of MJSF&N or the homes of present or former employees and seek interviews and documentation concerning services rendered by MJSF&N employees.

2. MJSF&N will cooperate with any appropriately authorized government investigation or audit; however, MJSF&N will assert all protections afforded it by law in any such investigation or audit.

REQUESTS BY GOVERNMENT INVESTIGATORS TO INTERVIEW STAFF

1. When government investigators request an interview, there is no obligation to consent to an interview, although anyone may volunteer to do so. One may request that the interview be conducted during normal business hours, at MJSF&N or another location.

2. The staff member should always be polite and should obtain the following information:

(a) The name, agency affiliation, business telephone number, and address of all investigators;

(b) The reason for the visit.

3. When the investigator arrives, ask if there is a subpoena or warrant to be served and request a copy of the subpoena or warrant.

4. The interview may be stopped at any time, with a request that the investigator return when counsel can be present. MJSF&N will be represented by its corporate counsel; employees have the right to their own individual legal counsel. Counsel should be present for interviews whenever possible.

5. If an employee chooses not to respond to the investigator's questions, the investigator has the authority to subpoena the employee to compel testimony.

6. Any staff member contacted by an investigator should immediately notify his or her supervisor. Provide the supervisor with as much information and documentation about the investigation as is known. The request should be reported to the COO.

SEARCHES BY GOVERNMENT INVESTIGATORS

1. Request an investigator on premises to wait until either the COO or legal counsel arrives (both referred to as "the person in charge").

2. MJSF&N employees and staff members must not alter, remove, or destroy permanent documents or records of MJSF&N. All records are subject to state or nationally recognized retention guidelines and may be disposed of only in accordance with these guidelines. Once there has been notice of an investigation, the destruction portion of any policy on record retention is suspended.

3. If the investigators present a search warrant, the investigators have the authority to enter MJSF&N’ premises, search for evidence, and seize those documents or other items listed in the warrant. If there is no search warrant, they may only take such actions with approval by MJSF&N.

4. Request copies of the warrant and the affidavit providing reasons for the issuance of the warrant.

5. All staff members should request an opportunity to consult with MJSF&N' counsel before the

search commences. Provide counsel with a copy of the warrant immediately. If counsel can be reached by telephone, put counsel directly in touch with the lead investigator.

6. Cooperate with the investigators, but do not consent to the search.

(a) The person in charge should instruct the lead investigator that:

(i) MJSF&N objects to the search.

(ii) The search is unjustified because MJSF&N is willing to voluntarily cooperate with the government; and

(iii) The search will violate the rights of MJSF&N and its employees.

(b) Under no circumstances should employees or staff obstruct or interfere with the search. Although they should cooperate, any employee or staff member should clearly state that this does not constitute consent to search.

(c) Whenever possible, keep track of all documents given to the investigators and what information the documents contain given to the investigators.

7. The person in charge should attempt to negotiate an acceptable methodology with the investigators to minimize disruptions and keep track of the process. Considerations include the sequence of the search; whether investigators are willing to accept copies in place of originals; and if so, who will make the copies and how; whether MJSF&N will be permitted to make its own set of copies; and arrangements for access to records seized.

8. The person in charge should point out limitations on the premises to be searched and on the property to be seized based on the search warrant.

(a) Avoid expansion beyond the proper scope of the search due to confusion or overreaching.

(b) Never consent to an expansion of the search.

(c) The MJSF&N staff should not prevent the investigators from searching areas they claim to have the right to search.

(d) Investigators generally have the right to seize evidence of crimes that is in their "plain view" during a search regardless of whether such evidence is described in the warrant.

9. The person in charge should take appropriate steps to protect other MJSF&N staff members.

(a) MJSF&N should send all but essential personnel to other areas when a warrant is served.

(b) Selected employees or staff should remain along with the person in charge and/or MJSF&N' counsel to monitor the search.

(c) Investigators should never be left alone on MJSF&N’ premises, and no employee or staff member should be left alone with the investigators,

10. The person in charge should keep a record regarding the search.

(a) Ask investigators for proper identification, including their business cards.

(b) List the names and positions of all the investigators with the date and time. Verify the list with the lead agent and request he or she sign it.

(c) Monitor and record the manner in which the search is conducted. Note in detail the precise areas and files searched, the time periods when each of them was searched, the manner in which the search was conducted, the agents who participated, and which items were seized.

(d) Several individuals probably will be needed to monitor the different areas being searched simultaneously.

(e) If the monitor is ordered to leave, contact the lead investigator. A person should only be ordered to move if they are in the way, not to avoid being observed. Never provoke a confrontation with an agent.

11. If possible, do not release a document to the investigators unless it has been reviewed by counsel. This is not possible under a search warrant.

12. If possible, the person in charge should make a record and a copy of all records seized.

(a) If this is not possible, before the agents leave MJSF&N' premises, request an inventory of the documents seized.

(b) Request the lead agent to note the date and time the search was completed, as well as sign the inventory with the agent's full title, address, and telephone number.

(c) When the documents are seized, the investigators are required to give the occupant a copy of the warrant.

(d) Copies of the seized documents should be requested as well, especially medical records, as this is the most efficient way to inventory the documents seized.

(e) Create a parallel inventory of the documents seized.

(f) Download copies of files from the hard drives of computers or other memory storage devices, especially if the material is essential to the ongoing operations of MJSF&N.

Client Orientation Policy

I. POLICY:

A. It is the policy of MJSFN Center to orient each person served to the organization and its programs in a manner that is understandable to the person served and ensures that all persons served will have a functional awareness of the components of the services to be provided. This process is designed to increase the ability of the person served to achieve maximum benefit from services.

II. PROCEDURES:

a. All persons who enter MJSFN Center programs will receive a comprehensive orientation, provided by the person coordinating their treatment, or a representative of the program assigned to provide the orientation.

b. The provider of the orientation will utilize a Client orientation checklist to ensure that all relevant components of orientation are systematically covered in the process.

c. Each person served will be provided a handbook to review during the orientation. The handbook will contain the components of the orientation in a manner understandable to the person served and will serve to provide them with a reference in the future of all the components of the orientation.

d. Following a review of all items on the Client orientation checklist, the person served will be asked to sign the checklist indicating they have an understanding of the information presented, understand the program rules, and are fully aware of any restrictions or privileges that may be imposed due to a violation of the program rules.

e. The orientation, Handbook and handouts includes an explanation covering the following service components:

1. Consumer rights and responsibilities, including availability of an advocate, and grievance and appeal procedures.

2. Methods and opportunities for providing input to the organization.

3. A description of the services provided, expected level of participation, and hours of operation.

4. Access to emergency services outside the hours of the program.

5. The organization’s code of ethics/conduct.

6. The organization’s policy on input from persons served.

7. The confidentiality policy.

8. Limits of confidentiality.

9. Notification and purpose of participation in the outcome’s management process.

10. Fire, safety, and emergency precautions, including familiarization with the emergency exits, fire suppression equipment and first aid kits.

11. The program’s policies regarding the use of tobacco products.

12. The program’s policies regarding any elicit or licit drugs brought into the program.

13. Identification of the person responsible for service coordination.

14. The program’s policy on weapons.

15. A copy of the program rules that identify any restrictions the program may place on the person served, any situation that may lead to loss of rights and privileges, and the means by which a person can regain their rights and privileges.

16. Identification of the purpose and process of the assessment.

17. How the individual treatment plan is developed and the person’s participation in developing the plan.

18. Discharge/transition criteria and procedures.

19. Services provided.

20. Days and hours of operation.

21. Expected level of participation.

22. Rights and grievance procedures.

23. Program rules, including: (Restrictions and the Loss and Regaining of Rights).

24. HIV prevention and treatment information.

25. Hepatitis prevention and treatment information.

26. Rules and procedures for:

a. Voluntary medication withdrawal and discharge.

b. Involuntary medication withdrawal and discharge.

c. Noncompliance.

d. Discharge.

27. Overview of:

a. Nature of addictive disorders.

b. The recovery processes.

c. Signs and symptoms of overdose.

d. When to seek emergency assistance for an overdose.

f. All employees providing the orientation will be provided with training prior to their participation to assure all employees are providing orientations in a consistent manner.

g. Following the orientation, the signed orientation checklist will be filed in the person’s served record.

Date Revised: August 2019

Policy statement: MJSF&N staff will encourage clients to receive periodic healthcare screening as appropriate.

Purpose: To provide a holistic perspective on the client’s needs.

Applicability: All MJSF&N clients.

Procedure: At the time of admission, the assigned MJSF&N Case Manager will urge all clients to obtain a physical examination by their PCP, if one has not been obtained within the past year. In addition, all clients (or their caregiver if the client is less than 14 years of age) will be asked to sign a release authorization permitting two-way communication with their PCP.

MJSF&N staff will assist clients in accessing critical preventative and diagnostic healthcare services through referrals or coordination with community healthcare supports. Such prevention, screening and diagnostic supports will include but are not limited to the following: Tuberculosis (TB) testing, blood pressure screening, child well-visits and immunizations, annual physical exams, dental checkups, and other routine medical screening.

Date Revised: August 2019

Policy statement: At the time of intake and at every 1-year anniversary of continuous treatment thereafter, the Case Manager will inform clients (if age 14 or older) or their legal guardian of their rights in receiving behavioral health services through MJSF&N. Further, informed consent will be obtained from all clients age 14 or older, and from the parents/legal guardians of clients if the client is under 14 years of age. Informed consent will also be obtained for every medication prescribed during the course of treatment.

Purpose: This policy is designed to ensure that all clients of MJSF&N and their parents/legal guardians are fully informed as to the nature of the treatment that is provided to them, and that as informed consumers they will be able to provide input into the nature of the treatment provided.

Applicability: This policy applies to all clients of MJSF&N and OP age 14 or older and to the parents or legal guardians of clients who are less than 14 years of age.

Procedure: All clients and their parents/legal guardians have the right to be provided in writing with clearly stated information regarding his or her behavioral healthcare and possible treatment options, including the prescription of medications. This information must explain the proposed intervention(s), treatment(s), and potential for the implementation of medication(s) during the therapeutic process, as well as any potential benefits, risks, and side effects due to the suggested therapeutic regimen. The client and his or her parents/legal guardians will be informed of their right to refuse treatment interventions, including medication, to the extent permitted by law.

The client’s and guardian’s orientation will also include an explanation of client and caregiver rights and responsibilities, complaint & appeal procedures, how input can be provided, transition and discharge criteria, and staff standards of professional conduct. The legal guardian will be informed that access to legal entities will be provided, if requested, for appropriate representation should the need arise.

Further, the type of service(s) to be offered will be identified in writing, and the form will also include a statement that all of the client/parent/legal guardian’s questions have been answered and that the signer understands what they are affirming by their signature. The therapist or psychiatrist will discuss with the client/parent/legal guardian the meaning of the form and the nature of the treatment to be provided. In addition, all of the client’s, parents’, and/or legal guardian’s questions will be answered, to the fullest extent possible. Informed Consent will be confirmed by the signature of the parent or legal guardian or by the client, if age 14 or older. Ordinarily, the Case Manager will be the employee responsible for providing informed consent prior to and during the initiation of formal treatment. In the case of pharmacotherapy, the psychiatrist will be responsible for providing and obtaining informed consent. When necessary, a translator will be provided. The original of the informed consent will be made a part of the client’s permanent treatment record, and the client (if age 14 or older) or the parents or legal guardian will be offered a copy of this document. Further, client rights will be communicated annually to clients and documented in the chart.

Informed Consent regarding the prescribing of medication: When a psychiatrist proposes the prescription of medications, he or she will document the following:

· Specific name of the medication

· Evidence that the risks, benefits, and side effects have been discussed with the client/parent/legal guardian.

· Evidence that reasons were given to the client/parent/legal guardian as to why there wan an initial prescription, increase, decrease, or discontinuation of a medication.

· Evidence that the client/parent/legal guardian agrees to the usage of the medication prescribed and understands all of the information noted above.

· Legible physician’s signature follows the entry.

Date Revised: August 2019

Policy statement: All client charts shall be organized in a consistent way and treated with all due care to preserve confidentiality of Protected Health Information.

Purpose: This policy is designed to ensure that client information is maintained in an organized and secure manner.

Applicability: This policy applies to all clients of MJSF&N

Procedure: All client charts shall contain:

· Initial clinical assessment

· Progress notes

· Medication record

· Treatment Plan

· Intake information

· Consent to treatment

· Discharge summary

1. Closure of charts: If a client is not active in treatment, a follow up call will be made or a letter will be sent inquiring whether the client or their legal guardian is still interested in continued treatment. If there is no response or if the client or guardian (if the client is a minor) indicates no further interest in treatment, the client chart will be closed.

2. Open records shall be maintained in a locked storage room, either on site or at the Corporate office. Charts shall be signed out if a clinician needs to review it outside of the chart room. Charts shall be signed back in upon return.

3. Closed charts shall be kept in a designated locked storage site, either on or off site.

RECORD MAINTENANCE AND DESTRUCTION:

Date Revised: August 2019

Purpose: It is the policy of MJSF&N to maintain all client records and other types of documents in accordance with responsible clinical practice as well as all applicable Federal and State laws. In addition, the Sarbanes-Oxley Act makes it a crime to alter, cover up, falsify, or destroy any document with the intent of impeding or obstructing any official proceeding. This policy provides for the systematic review, retention and destruction of documents received or created by MJSF&N. in connection with the transaction of MJSF&N business. This policy covers all records and documents, regardless of physical form, contains guidelines for how long certain documents should be kept and how records should be destroyed. The policy is designed to ensure compliance with federal and state laws and regulations, to eliminate accidental or innocent destruction of records and to facilitate MJSF&N' operations by promoting efficiency and freeing up valuable storage space.

Document Retention: MJSF&N follows the document retention procedures as outlined below. Documents that are not listed, but are substantially similar to those listed in the schedule, will be retained for the appropriate length of time.

Electronic Documents and Records: Electronic documents will be retained as if they were paper documents. Therefore, any electronic files, including records of donations made online, that fall into one of the document types listed below will be maintained for the appropriate amount of time and in a manner consistent with MJSF&N’ e-mail policy.

Emergency Planning: MJSF&N' records will be stored in a safe, secure and accessible manner. Documents and financial files that are essential to keeping MJSF&N operating in an emergency will be regularly duplicated or backed up.

Document Destruction: MJSF&N' Chief Compliance Officer is responsible for the ongoing process of identifying its records, which have met the required retention period and overseeing their destruction. Destruction of financial and personnel-related documents will be accomplished by shredding. Documents will be destroyed only after they have been electronically scanned and stored.

Document destruction will be suspended immediately, upon any indication of an official investigation

or when a lawsuit is filed or appears imminent according to MJSF&N’ litigation hold policy.

Destruction will be reinstated upon conclusion of the investigation.

Compliance: Failure on the part of employees to follow this policy can result in possible civil and criminal sanctions against MJSF&N and its employees and possible disciplinary action against responsible individuals. The MJSF&N Board will periodically review these procedures with legal counsel or the organization's certified public accountant to ensure that they are in compliance with new or revised regulations.

1. Psychiatrists must retain client records for a minimum of seven (7) years from me last date of service. Psychologists and other mental health professionals should retain client records for a minimum of five

(5) years from the last date of service.

2. The client record and all billing records for a minor shall be retained until two years after the minor client reaches majority (age 18), even if this means that the record is retained for a period of more than five (5) years.

3. Records maintained under OSHA including employee exposure records and related client records for that employee shall be retained for the course of employment plus a period of thirty (30) years.

4. Records related to an audit, investigation, or litigation (including a subpoena or a warrant) shall be maintained until the final determination has been made with regard to the audit, investigation or litigation.

5. Paper records shall be destroyed according to the schedule below. The appropriate method for destruction is shredding, burning, pulping, or pulverizing.

6. Documentation of such destruction of records shall be maintained indefinitely and shall include

· Date of destruction

· Method of destruction

· Description of the records (e.g., client names, dates), and

· A statement that records were destroyed in the normal course of business.

If using an outside company to destroy the records, MJSF&N shall obtain a certificate that the records were destroyed in compliance with Federal and State laws.

Corporate Records:

Annual Reports to Secretary of State/Attorney General

Articles of Incorporation

Board Meeting and Board Committee Minutes

Board Policies/Resolutions

Bylaws

Construction Documents

Fixed Asset Records

IRS Application for Tax-Exempt Status (Form 1023)

IRS Determination Letter

State Sales Tax Exemption Letter

Contracts (after expiration)

Correspondence (general)

Permanent

Permanent

Permanent

Permanent

Permanent

Permanent

Permanent

Permanent

Permanent

Permanent

7 years

3 years

Accounting and Corporate Tax Records

Annual Audits and Financial Statements

Depreciation Schedules

General Ledgers

IRS 990 Tax Returns

Business Expense Records

IRS 1099s

Journal Entries

Permanent

Permanent

Permanent

Permanent

7 years

7 years

7 years

7 years

Invoices

Sales Records (box office, concessions, gift shop)

Petty Cash Vouchers

Cash Receipts

5 years

3 years

3 years

3 years

Credit Card Receipts

Bank Records

Check Registers

Bank Deposit Slips

Bank Statements and Reconciliation

Electronic Fund Transfer Documents

Permanent

7 years

7 years

7 years

Payroll and Employment Tax Records

Payroll Registers

State Unemployment Tax Records

Earnings Records

Garnishment Records

Payroll Tax returns

W-2 Statements

Permanent

Permanent

7 years

7 years

7 years

7 years

Employee Records

Employment and Termination Agreements

Retirement and Pension Plan Documents

Records Relating to Promotion, Demotion or Discharge

Accident Reports and Worker's Compensation Records

Salary Schedules

Employment Applications

I-9 Forms

Time Cards

Permanent

Permanent

7 years after termination

5 years

5 years

3 years

3 years after termination

2 years

Donor Records and Acknowledgement Letters Grant Applications and Contracts

7 years

5 years after completion

Legal, Insurance and Safety Records

Appraisals

Copyright Registrations

Environmental Studies

Insurance Policies

Real Estate Documents

Stock and Bond Records

Permanent

Permanent

Permanent

Permanent

Permanent

Permanent

Trademark Registrations

Leases

OSHA Documents

General Contracts

Permanent

6 years after expiration

5 years

3 years after termination

Client Grievance Policy

I. POLICY:

A. It is the policy of MJSFN Center that the persons served are encouraged to state complaints and/or grievances if they believe their rights have been violated, and to pursue a resolution to their concerns in a structured format that provides fair and equitable results through due process.

II. PROCEDURES:

B. Persons served will be fully informed of the grievance procedures during their orientation to services. In addition, they will receive printed materials that will provide an overview of this process for later reference.

C. Day-to-day issues affecting the persons served shall be resolved informally between the person served and the primary staff member responsible for his/her service coordination (Counselor, House Manager, e.g., Provider). If the problem or complaint is not resolved to the satisfaction of the person served, the Program Director will adhere to the guidelines contained in this policy and assist the person served in accessing the procedures necessary to resolve the concern.

D. Persons served have the right to due process with regard to grievances, and the organization will afford every reasonable opportunity for informal and/or formal resolution of the grievance.

E. Persons who may bring grievances include, but are not limited to:

a. The person served.

b. The guardian of the person served.

c. The attorney, designated representative, or a representative of a rights protection or advocacy agency of the person served.

F. A grievant shall in no way be subject to disciplinary action or reprisal, including reprisal in the form of denial or termination of services, loss of privileges, or loss of services as a result of filing a grievance.

G. Notices summarizing a person’s right to due process in regard to grievances, including the process which grievances may be filed and copies of forms to be used for such purpose shall be available within each facility and program area.

H. Each person served will be informed of his/her right to grieve and the right to be assisted throughout the grievance process by a representative of his/her choice, in a manner designed to be understandable to the person served.

I. During a formal grievance procedure, the person served will have the right to the following:

a. Assistance by a representative of his/her choice.

b. Review of any information obtained in processing the grievance, except that which would violate the confidentiality of another person served.

c. Presentation of evidence of witnesses pertinent to the grievance.

d. Receipt of complete findings and recommendations, except those that would violate the confidentiality of another person served.

J. In all grievances the burden of proof shall be on the organization, facility, or program to show compliance or remedial action to comply with the policies and procedures established to ensure the rights of persons served.

K. All findings of a formal grievance procedure shall include:

a. A finding of fact.

b. A determination regarding the adherence of the organization, program, or employee, or the failure to adhere, to specific policies or procedures designed to ensure the rights of persons served.

c. Any specific remedial steps necessary to ensure compliance with organizational policies and procedures.

L. The steps of a formal grievance are as follows:

a. Formal grievances shall be filed first with the supervisor/director of the service unit or program in which the grievance arises.

b. A copy of the grievance shall be forwarded to the administrative head of the organization.

c. The supervisor/director of the service unit or program will meet with the grievant, and/or representatives, immediately following the filing to brainstorm resolution of any related issues that may get in the way of full participation in services. Actions may include, but not be limited to, a change in direct care providers or an adjustment in programming schedules and/or program environments.

d. The organization will issue a formal written response to the grievant, and/or the designated representatives, within five working days, excluding weekends or holidays, of the complaint.

M. The steps to appeal a written response to a grievance:

a. If the grievant is unsatisfied with the findings of the written response to a grievance, he or she may appeal the decision to the Program Director within five days, excluding weekends or holidays.

b. The Program Director will issue a formal written response to the grievant, and/or the designated representatives, within five working days, excluding weekends or holidays, of the complaint.

c. If the grievant is unsatisfied with the findings of the written response, he/she will be referred to a third party outside of the organization. Third parties may include organizations such as children’s or adult protective services, professional licensing boards, nursing home ombudsmen, or other appropriate organizations that may serve as an advocate for the person served.

N. All staff members of MJSFN Center will be trained in the implementation of this policy and procedures during orientation, and will receive ongoing training of the procedures to ensure the process is applied in a comprehensive manner is a grievance is filed.

O. Grievances regarding the actions of specific staff members will be handled in accordance with personnel rules and contract provisions. No disciplinary action may be taken, nor facts found with regard to any alleged employee misconduct, except in accordance with applicable personnel rules and labor contract provisions.

P. A Grievance Log will be maintained by the organization detailing the nature of the complaint, relevant information obtained in the investigation, and the outcome of the process. All information contained will maintain the confidentiality of the participants in the process. This record will be reviewed annually by the CEO/Program Director/Clinical Director to determine if there are trends in the complaints, and to identify areas to initiate performance improvement activities.

EMPLOYEE ORIENTATION

I. POLICY

A. The MJSFN uses the orientation process to assist newly hired employees in understanding the values and culture, and as a result, encourage commitment to the mission. As an ongoing process, orientation begins during recruitment and selection, and continues as needed throughout the individual's employment. The Program Director supports this process with an orientation program for new staff members.

B. The responsibility for the initial orientation is a process understood throughout the agency and the new employee. The newly hired employee will complete orientation within the first 90 days of employment.

II. PROCEDURES

A. Agency Responsibility

1. Provide new employee with an orientation they will include required trainings, job description & duties and organizational chart.

2. Provide in-service training as required for position.

a. Record keeping and reporting;

b. Confidentiality and Privacy of Protected Health Information (PHI)

c. Client Rights

d. Conflict of Interest

e. Cultural Diversity

f. Ethical Issues

g. Professional Boundaries

h. Performance Improvement Plan

i. OSHA, safety and infection control

j. Incident Reporting

k. Crisis Training

l. Emergency Preparedness

m. Communication Barriers

n. Compliance Program

3. Provide employee with Employee Handbook.

B. Employee responsibility

1. Complete all required training within the first 30 days of hire date.

2. Review and acknowledge receipt of New Employee Handbook.

3. Complete and return New Employee Checklist Form to program director.

CLINICAL SUPERVISION:

Date Revised: August 2019

Policy statement: MJSF&N will provide appropriate and sufficient supervision to all staff.

Purpose: This policy is designed to ensure that the highest possible professional standards are adhered to in the provision of behavioral health services.

Applicability: This policy applies to all staff affiliated with MJSF&N.

Procedure: MJSF&N will adhere to all pertinent Baltimore state guidelines as well as all discipline-specific guidelines (e.g., the Ethics Code of the American Psychological Association) regarding the provision of supervision to all MJSF&N and OP staff. The Chief Operating Officer of ambulatory services oversees the overall provision and administration of services; the Clinical Director of MJSF&N and OP services oversees the clinical care provided by staff.

The supervisor who provides supervision is in a unique role to act as a change agent in facilitating staff development and program transformation. For example, supervision should support a trauma-informed approach to assessment and service delivery. Further, evidence-based practices that MJSF&N adopts should be supported during supervision. Above all, supervision should be supportive and strength based.

Although the minimum frequency of supervision is specified below for various staff, staff persons requiring increased support will receive supervision reflecting these needs. All supervision must be documented.

1. Supervision of Psychiatrists

Every 12 months, the Medical Director will perform a review of each psychiatrist, assessing the appropriateness of his or her prescribing and documentation. A written record of this review will be maintained. In addition, during this same period every 12 months, the Clinical Director will conduct a “360-degree review” of each psychiatrist, in which anonymous feedback will be sought from all staff who interact with the psychiatrist. The Clinical Director will compile the findings from the Medical Director’s review as well as the staff feedback and present this to each psychiatrist. A permanent record of this review will be kept in the psychiatrist’s HR file.

2. Supervision of Psychologists

The Clinical Director should meet with each Psychologist at least once per month for individual supervision, in addition to a monthly group meeting with the Psychologists to discuss administrative and procedural issues. The individual meetings will include a review of a sample evaluation of the evaluator by the Clinical Director.

Individual supervision notes should be maintained for each supervision session for Psychologists. These notes should include:

· Supervisee’s name

· Supervisor’s name

· Date and times of each session

· A narrative descriptive summary of the points discussed during the session

All BSWs, MSWs, LCSWs, and PEERS will meet at least one hour per month with a licensed psychologist for supervision. This supervision, and the issues discussed, will be documented by the licensed psychologist.

Individual supervision notes should be maintained for each BSWs, MSWs, LCSWs, and PEERS. This should include:

· Supervisee’s name

· Supervisor’s name

· Level of care

· Modality (individual or group)

· Date and times of each session

· Caseload

· Hours worked per week

· A narrative descriptive summary of the points discussed during the session

· Additional requirements for BSC supervision: Must indicate the number of ASD and non-ASD individuals. For those supervision sessions where ASD services are discussed, this must be indicated in the context of the note

4. Supervision of TSSs:

All TSSs hired after 7/1/01 must receive on-site Assessment and Assistance in the environment where services are being provided before working alone with a child, as follows:

· Less than 6 months of previous TSS experience: will receive at least 6 hours of on-site assessment and assistance by a qualified supervisor (i.e., a licensed mental health professional, or an individual with a graduate degree in Mental Health and one year full-time experience working in a CAASP system (C&Y, JJS, MH, Spec. Ed., D&A) or employed by a MH services agency (only work with children and adolescents counts for these purposes). Each supervisor will provide supervision to no more than 9 full-time equivalent TSS workers.

· More than 6 months of previous TSS experience: must receive at least 3 hours of assessment and

assistance.

Assessment and assistance must occur prior to onset of work as a TSS.

Ongoing TSS supervision requirements: The BSW will coordinate and schedule weekly supervisory meetings with the TSS. It is the BSW’s responsibility to chart the attendees and the content of each meeting. The BSW will schedule weekly contact with the TSS (if one is assigned). Meetings with the TSS

All supervisory sessions must be documented. Supervision must include a review and discussion of each child on the TSS worker’s caseload at least once per month. Individual supervision notes should be maintained for each TSS and should include:

· Supervisee’s name

· Supervisor’s name

· Level of care

· Modality (individual or group)

· Date and times of each session

· Caseload

· Hours worked per week

· A narrative descriptive summary of the points discussed during the session

· Number of ASD and non-ASD individuals. For those supervision sessions where ASD services are discussed, this must be indicated in the context of the note

· Client’s Progress

· Implementation of Treatment Plan, including specific interventions

· Integration of efforts with other treatment team members

· Efforts to collaborate with family and to apply CAASP principles

· Outcome of action steps planned in preceding supervisory sessions

· Projected action steps for the next supervisory session

All Outpatient Therapists must meet, individually or as a group, with their Director at least one hour per month to discuss clinical concerns as they arise.

MEDICAL INFORMATION POLICY:

Date Revised: August 2019

Policy statement: MJSF&N and OP will collect and document all essential medical information as it pertains to the provision of MJSF&N services.

Purpose: This policy is designed to ensure that MJSF&N and OP staff acquire a thorough understanding of all the factors that impact on a client, including medical/biological factors.

Applicability: This policy applies to all clients of MJSF&N and OP services.

Procedure: MJSF&N staff will inquire regarding all pertinent medical and health-related information, and document that information in the client’s treatment record. For MJSF&N clients, it is the particular responsibility of the psychologist or psychiatrist conducting a Comprehensive Biopsychosocial Evaluation or Re-Evaluation to collect and document such information. The role of the Case Manager is to assist in this process, monitor that it is properly occurring, and be responsible for ensuring that it is correctly and completely done. For OP clients, both the Intake Evaluator and the OP Therapist will be responsible for acquiring this information.

Information to be documented includes, though is not limited to:

· Medical condition of the client

· Current medications (including drug name, dosage, compliance with regime, and prescribing physician)

· Other medical treatments the client is receiving

· Drug, food, and environmental allergies

· Other pertinent health-related information

· Primary care physician, if known

Date Revised: August 2019

Policy statement: All MJSF&N and OP employees will maintain professional standards, charting all instances of contact with clients, their families, and other outside agencies.

Purpose: This policy is designed to ensure that all contact with clients, their families, and other outside agencies is appropriately documented, to ensure the maintenance of a consistent record of treatment, and a means for the provision of continuity of care and the verification of professional conduct.

Applicability: This policy applies to all MJSF&N and OP staff.

Procedure: Progress notes are to be written following all individual, group, therapeutic, psychoeducational encounters, and case management activities within twenty-four (24) hours of service/activity. The type of note, date and time of service must be documented in each note; both the beginning and ending clock time of service will be noted. All employees of MJSF&N and OP who are authorized to have contact with the client/family are permitted to make documentation in the client’s treatment record, as appropriate. Staff will utilize the format appropriate for each discipline. All Progress Notes will be dated, with the clinician’s full signature with credentials. All Progress Notes must be legible.

Progress notes will focus on the relevant interventions and goals derived from the Treatment Plan. The Progress Note will be objective, include measurable criteria, and reflect Treatment Plan goals whenever appropriate. Interventions utilized and implemented will be documented, as will responses to the interventions. However, notes will additionally contain a succinct description of all relevant events that occurred during a session, regardless of their relevance to the current Treatment Plan; for example, even if the Treatment Plan makes no mention of violence, if threatened or actual physical harm occurs during a session, this will be included in the Progress Note, along with the staff’s response. (The Treatment Plan may be modified accordingly by the BSC, MT, or OP Therapist to take into account emergent clinical issues.) Every clinical progress note involving contact with the client will include an assessment of the client’s behavior, mood, and interpersonal functioning.

Specific modalities of treatment identified in the Treatment Plan (e.g., BSC, TSS, MT, OP) will be reflected in the Progress Notes when provided; each member of the Treatment Team will document their contact with the client, and the notes from each member will reflect a consistency and continuity of purpose in the overall Treatment Plan.

If any errors in the clinical record are discovered, care must be taken to always avoid obscuring the original entry; a single line will be drawn through the erroneous portion of the entry, corrective text inserted above it if possible, and the initials of the writer (if the same person as the original writer) or the full legible signature (if a different staff person) will be placed next to the correction. If an addendum needs to be made to the existing treatment record, both the actual date that the entry is made and the date of the original event referred to in the addendum will be clearly included.

PSYCHIATRIC PRESCRIBING AND DOCUMENTATION:

Date Revised: August 2019

Policy statement: All psychiatrists affiliated with MJSF&N and OP will maintain professional practices consistent with their profession. This includes, but is not limited to, their prescribing of medication and their charting of all relevant information pertaining to their treatment of and prescribing for clients.

Purpose: This policy is designed to ensure the following: that all contact of MJSF&N psychiatrists with clients is performed in a professional manner, that the most appropriate treatment is provided to clients, that a consistent and complete medical record of treatment is maintained, and that a means for the provision of continuity of care and the verification of professional conduct is maintained.

Applicability: This policy applies to all psychiatrists affiliated with MJSF&N and OP, in their professional contact with clients.

Procedure: Psychiatrists affiliated with MJSF&N will maintain professional standards in their provision of treatment to clients. They will remain current in their profession, and will provide the most appropriate treatment to clients, based on the client’s behavioral and emotional issues, demographic factors, health issues, allergic reactions, concurrent meds, and other factors as deemed relevant by the psychiatrist.

Psychiatric progress notes are to be written following all treatment encounters with clients immediately after providing the service. The date and time of service must be documented in each note; both the beginning and ending clock time of service will be noted. All Psychiatric Progress Notes will be dated, with the psychiatrist’s full signature with credentials. All Psychiatric Progress Notes must be legible. All psychiatric progress notes will be documented using the Medication Log. This form must contain the following information:

· Client’s name

· Date of service

· Name of all medications taken by the client, including both prescribed and nonprescribed

· Dosage, route of administration, and schedule of administration of the medication

· Evidence that effectiveness, drug interactions, and side-effects have been assessed

· Reasons for starting, changing (including: dosage or schedule), or discontinuing the medication

· Lab work (if appropriate)

· Legible signature, including credentials

· For prescribed medications:

o The prescribing professional and phone number.

o Dispensing pharmacy and contact information, if known.

In addition, the Medication Log must include evidence that the physician has provided the child/parent/guardian with information about the medication(s), why the medication(s) are being prescribed, expected benefits and side-effects, and what to do in the event of an emergency. Meds will be prescribed only if informed consent is given (at least orally) by the client if over age 14, or by the

client’s legal guardian, for each med prescribed. The psychiatrist will document the client’s and/or guardian’s informed consent for each med prescribed.

The psychiatrist or his/her designee (often the Case Manager) will coordinate as needed with the physician providing primary care.

The psychiatrist shall review all medications prescribed to the client (by any physician) on at least an annual basis and document this review, making note in particular of any possible drug interactions.

If antipsychotic meds are prescribed, then the AIMS (Abnormal Involuntary Movement Scale) should be administered at their initiation and every 6 months thereafter.

The client (if age 14 or older) and/or legal guardian (if the client is a minor) will be provided with information about resources for:

a. Advocacy to assist them in being actively involved in making decisions related to the use of medications.

b. Training and education regarding medications, which will include the following, as appropriate:

—How the medication works.

—The risks associated with each medication.

—The intended benefits.

—Side effects.

—Contraindications.

—Appropriate knowledge of adverse interactions between multiple medications and

food.

—The importance of taking medications as prescribed.

—The need for laboratory monitoring.

—The rationale for each medication.

—Alternative medications.

—Alternatives to the use of medications.

—Signs of nonadherence to medication prescriptions.

—Potential drug reactions when combining prescription and nonprescription medications, including alcohol, tobacco, caffeine, illicit drugs, and alternative

medications.

—Instructions on self-administration, if appropriate.

—The availability of financial supports and resources to assist the family with handling the costs associated with medications.

MJSF&N staff will comply with all applicable laws and regulations pertaining to medications and controlled substances.

a. If applicable, the client and caregiver will be informed of any special dietary needs or restrictions associated with the medication use, and this will be documented in the client’s chart.

b. Clients may be continued on a proprietary med if a generic version is not available.

c. The client’s transition plan will instruct how to maintain the continuity of the prescribing of the client’s meds, when appropriate.

d. The psychiatrist will document and report, as appropriate:

(1) Any adverse medication reactions experienced by the client.

(2) Any medication errors.

Clients and their caregivers will be issued written instructions to contact the psychiatrist in the case of emergencies related to the use of medications. Also, on the same form, the client and caregiver will be issued the telephone number of the poison control center, if the psychiatrist is not available in the case a medication emergency should occur.

In those cases when a psychiatrist is considering prescribing medication for a woman of reproductive age, the psychiatrist must recognize the potential teratogenicity (i.e., likelihood of causing birth defects) of the medication under consideration. As part of this consideration, the psychiatrist should also be sure to assess the woman's pregnancy status and fertility intentions. In short, the psychiatrist should consider teratogenicity each time he or she prescribes medications to women of reproductive age.

Any woman of reproductive age who is taking or considering taking a teratogenic medication should be encouraged to articulate her fertility goals. Particularly for women with chronic medical conditions, regardless of her stated fertility intentions, the implications of a patient's medical condition for her pregnancy, including the risk of teratogenic medications, must be regularly discussed. Pregnancy intentions should be assessed regularly as they may change with time. When possible, pregnancy intentions should be assessed in an open-ended way, which may be more consistent with women's actual experience. For example, questions can be phrased as 'How would you feel about becoming pregnant?'. Ambivalence about becoming pregnant is common and is a risk factor for use of less effective contraceptive methods. If the psychiatrist senses such ambivalence, he or she should be aware that unplanned pregnancy is more likely and teratogenic medications should be avoided as much as possible.

For women desiring pregnancy, the teratogenicity of a given medication must be discussed in detail and documented, with acknowledgement of the uncertainty surrounding such issues. In addition, the risks and benefits of stopping a given medication must be discussed. It should be noted that women who have depression or anxiety may be more likely to have inflated concerns about the teratogenic risks associated with medications. Psychiatrists should be particularly aware of this, given the risk of depression during pregnancy; physician reassurance can often mitigate patients' concerns.

For patients of reproductive age who are sexually active and have no history of surgical sterilization, a pregnancy test should be conducted prior to initiation of a teratogenic medication. The psychiatrist should consider periodic pregnancy testing for sexually active women who are not using prescription contraception. For women desiring pregnancy, this will facilitate early diagnosis and appropriate monitoring as needed.

For acute, relatively mild medical conditions that do not pose a significant risk to a woman or her pregnancy, medications should be avoided during the first trimester if possible. When the benefit of a medication is felt to outweigh potential risks, clinicians should consider prescribing the lowest effective dose of the medication with the most data on safety in pregnancy. Older medications with good safety records are generally preferred to newer medications with less supporting data.

As part of the quality monitoring and improvement system, a separate record will be maintained of all medication errors, which will be kept by the psychiatrist and available to the Site Director. This record will include the psychiatrist’s name, the client’s name, date, and the nature of the medication error, which may include:

—Unauthorized drug use

—Dispensing errors.

—Prescribing errors.

—Administration errors, including:

–Medication omissions.

–Incorrect drug.

–Incorrect rate or dose.

–Incorrect route.

–Incorrect timing.

–Incorrect labeling.

–Incorrect identification of person served.

—Medication documentation errors.

No medications (including samples) will be stored on MJSF&N’ premises. (In some cases of financial hardship, MJSF&N psychiatrists are able to provide pharmaceutical vouchers.)

In order to promote state-of-the-art prescribing practices, an annual utilization review of med effectiveness will be conducted by several MJSF&N psychiatrists. (See policy on “Quality Assurance”.)

Human Resources

EMPLOYEE TRAINING POLICY

The purpose of the MJSFN Credentialing and/or Continuing Education Policy is to assure that all clinical and peer support staff is qualified to practice through training, educational and clinical experience. The credentialing and continued education process is viewed as part of the quality management plan and assures that all clinical and peer support staff maintains an appropriate training to practice.

1. All MJSFN clinical programs are operated under the clinical direction of the Executive Director and the Clinical Director. Ultimate clinical authority of the program lies with the Clinical Director.

2. The Clinical Director determines competency for all clinical staff.

3. Competency Criteria at the Time of Employment:

At the time of employment, the job applicant's education, experience and abilities are reviewed through the employment application and interviewing process. The Program Director is responsible for assuring job applicants meet required educational, licensing and experiential criteria as outlined in each job description.

4. Initial Clinical Competency Assessment:

The employee's level of competence to provide clinical and peer support services is initially assessed during the employee's introductory period, which begins with the MJSFN orientation. During the orientation, the Program Director completes a Credentialing and Continuing Education Worksheet. At the end of the introductory period, the employee will be evaluated for practice privileges to function independently or conditionally with supervision.

5. Credentialing Review:

To assure that staff continues to meet competency standards, non-direct care staff must complete a minimum of 10 hours of ongoing continued education units annually; all direct care staff must complete a minimum of 20 continued education units annually. The Credentialing and Continued Education will be completed to indicate the employee’s competency status. In the event that an employee is promoted to a position in which there are different standards, a new Credentialing and Continuing Education Worksheet will be completed. Copies of the employee's performance assessments and credentialing/continuing education worksheet are found in the employee’s permanent personnel record.

6. In Service Training:

All staff (clinical and support) must complete annual in-service training to remain in compliance with agency policy.

7. The In-Service Trainings are prioritized to job description. These trainings are as followed:

a. All staff (clinical & support) requirements

· Confidentiality (parts 1 & 2),

· Corporate compliance,

· Critical incident reporting,

· Cultural competency (parts 1 & 2),

· Customer service (parts 1 & 2),

· Client rights and responsibilities (parts 1 & 2),

· Infectious Disease Control,

· Safety training,

· Personal conduct (parts 1 & 2),

· Workplace violence (parts 1 & 2),

· Blood-borne pathogens,

· Universal precautions, and

· Sexual harassment training.

b. Additional annual training requirements for clinical staff.

· Person centered treatment planning (parts 1 & 2),

· Anger Management,

· Conflict Resolution,

· Role of the counselor,

· ASAM,

· Clinical Notes,

· Time Management

· Dealing with Problems, and

· Continuing professional education (CSC-AD, CAC-AD, & LCADC 20 CEU per year; Trainees are exempt from this requirement).

The Program Director will review all personnel records to assure compliance.

COMPLAINTS BY CLIENTS OR THEIR CAREGIVERS:

Date Revised: August 2019

Policy statement: MJSF&N will thoroughly seek to remedy any complaints made by clients and/or their caregivers.

Purpose: This policy is designed to ensure that the highest possible professional standards are adhered to in the provision of behavioral health services and that complaints about the services provided will be thoroughly pursued so that an appropriate remedy can be found.

Applicability: This policy applies to all staff affiliated with MJSF&N and OP services.

Procedure: When a client or their caregiver has a minor complaint or grievance, s/he should report it to the staff person concerned. If the complaint is not able to be resolved to the client’s or caregiver’s satisfaction, then s/he should inform the Case Manager or Lead Case Manager. If the complaint is not able to be resolved to the client’s or caregiver’s satisfaction, s/he shall be directed to the Site Director.

Complaints shall be handled within three business days of receipt. Complaints shall be resolved and resolution shall be reviewed with client. Client complaints and grievances are to be handled as priority items, none of which should require more than three business days for a response.

Clients and caregivers shall be given a fair opportunity to be heard and to have their questions answered. If a grievance is filed against a member of the staff, a review of the case shall be conducted by the Site Director for the express purpose of grievance adjudication.

There shall be no barriers to treatment or services or events of retaliation by staff members against any client or caregiver who files a complaint.

Penalties may not be initiated prior to final resolution, with the exception that penalties may be initiated against anyone who has committed or threatened to commit physical violence.

If the client or caregiver is dissatisfied with the above responses, then the complaint is turned over to the COO or designee. The COO or designee shall handle the complaint within two business days. The complaint shall be resolved and resolution shall be reviewed with client.

All written complaints shall be reviewed and filed with the COO. In addition, a written record of the complaint will be forwarded to the Compliance Officer. An Annual Review shall be conducted with the COO, Compliance Officer, and Site Managers.

COMPLIANCE POLICY:

Policy: MJSF&N has a zero-tolerance policy for any form of abuse or fraud and maintains a commitment to integrity.

Purpose: To ensure that all staff, including contractors and agency personnel, maintain the highest standards of integrity in the provision of services and in the documentation of those services. To ensure that all clinical documentation accurately reflects client strengths, needs and clinical interventions being used. In addition, the self-audit procedures described below support our fraud and abuse prevention initiatives.

Applicability: This policy applies to all MJSF&N and OP staff.

Procedure:

The Compliance Committee consists of the Director of Quality Assurance/Compliance and the Site Directors with Clinical/Training support if applicable to review issues related to quality of services, fraud, waste and abuse. The Committee usually meets on the fourth Thursday of each month and reports quarterly to the Corporate Director of Compliance. In addition, senior management (including the Director of Compliance) meets weekly to review any concerns related to compliance. HR is apprised of and/or consulted on issues if applicable.

The Director of Training oversees the provision of a comprehensive training on MJSF&N’ compliance policies which all staff are required to take on an annual basis. (This may be provided via a live training or online.) The Human Resources Department tracks the completion of this annual requirement by all staff.

The Compliance Committee oversees the auditing of clinical documentation, the specific procedures for which are as follows:

Tier #1

Case management staff will perform at minimum a biweekly review of every single note submitted for that billing period (to ensure that all of the notes are read at least once prior to becoming part of the client record). No notes will be approved without being reviewed by at least one case manager. These reviews will include monitoring the following quality indicators:

1) Ensuring that the times and dates on progress notes and encounter forms match,

2) Cohesion between the identified goals on the progress note and treatment plan,

3) Signatures on the encounter form appear to be original and are reflective of the identified individual present for the session,

4) Clinical integrity of the progress note, to include screening for vagueness of description of client behavior and excessive duplication of content (e.g., ensuring that there are appropriate changes in plans from week to week).

When the case manager approves a note, they are agreeing that they have read the note and believe it

to be an accurate representation of the service provided. When the case manager identifies any one of the above issues, they are to bring it to the attention of the Site Director within 24 hours. When the concerns center primarily around item #4 above, the psychologist or other identified clinical staff are called in to review documentation.

Documentation that is not approved is not submitted for billing to a managed care organization. Clinical staff (including both contractors and employees) who have submitted documentation that is determined to contain questionable content or is excessively vague will receive additional training and individual supervision or they may be terminated.

Tier #2

On a monthly basis, chart audits will be conducted on a minimum of10% of the site’s caseload. For MJSF&N clients, this audit will be performed by the case managers. For OP clients, this will be performed by the OP Supervisor.

Whenever there is a complaint or grievance filed or whenever a serious critical incident has occurred, the Director of Compliance will review all aspects of the issue in order to achieve a satisfactory conclusion. This review will include a comprehensive audit of the client’s file, including utilization of the Chart Review Tools for Progress Notes and Treatment Plans when appropriate.

At the time of re-evaluation (i.e., a CBR), the evaluating psychologist will review the previous Treatment Plan for relevance and integrity. The psychologist also signs off on the new Treatment Plan when it has been developed.

Tier #3

Staff found to have submitted fraudulent records will be terminated. MJSF&N has zero tolerance for fraud and maintains a commitment to full transparency. When we identify instances of fraud, waste or abuse, such instances are investigated by a team (to include the COO, the Site Director, Regional Director, and Director of Compliance). The investigation typically includes a review of the file of the client in question as well as documentation for other clients submitted by the staff in question. All relevant parties (e.g., the MCO, State, etc.) are notified and, when warranted, funds inappropriately paid to MJSF&N are refunded to the MCO.

CONFIDENTIALITY OF CLIENT INFORMATION:

Date Revised: August 2019

Policy statement: MJSF&N will protect the confidentiality of all Protected Health Information (PHI), as specified by all applicable laws.

Purpose: This policy is designed to guarantee that all Protected Health Information) PHI related to the client and his or her family, including all pertinent treatment records, will be kept strictly confidential. No information pertaining to the client may be released to any third party unless requested in writing by the client (if age 14 or older) or the parent/legal guardian, or by a Court order.

Applicability: This policy relates to the handling by the staff of MJSF&N of all information pertaining to clients and their families.

Procedure: All Protected Health Information (PHI) will be maintained in strict confidentiality, in accordance with all relevant State and Federal regulations. The treatment record will be available only to MJSF&N staff who are directly involved in a client’s treatment, as well as to supervisors of such staff. All treatment records may be released to an outside party only with the expressed written consent of the client (if age 14 or older) or of the client’s parent/legal guardian, or by Court Order. In the event that a Court Order is issued, MJSF&N will comply only upon approval of the Program Director or of MJSF&N’ Legal Counsel.

MJSF&N will protect the confidentiality of all Protected Health Information (PHI) in its records at all stages of collection, use, storage, disclosure, and destruction. Every MJSF&N employee has the crucial responsibility for strictly safeguarding the confidentiality of all information pertaining to the client.

The Protected Health Information (PHI) that is referred to in this section includes all written clinical information, observation, reports or fiscal documents relating to prospective, present, or former clients, when the creation or retention of those documents is either required or authorized as a part of MJSF&N’ operations. This includes but is not limited to: demographics, medical treatment, mental health treatment, mental retardation records, child abuse and neglect, substance abuse treatment, contraceptive/abortion services, information received from county child and youth agencies, sexually transmitted diseases, and HIV information. If the child is age 14 or older, MJSF&N staff will ask the client if any information is to be shared with their parent/legal guardian; if the client consents, then the client will be asked to sign a release authorization specifying what information may be shared, and with whom. This request will be honored by all MJSF&N staff, except as otherwise required by court order.

The Protected Health Information (PHI) will be available to all MJSF&N staff (including the BSC, MT, TSS, CM, and/or OP therapist) who are directly responsible for the provision of treatment for a particular client/family, as well as their supervisors. The client record will be maintained in a locked and secure medical records room or other secure area, accessible to the Site Director and Case Manager.

1. When disclosing PHI in accordance with this Policy, MJSF&N will follow the policies and procedures relating to the applicable disclosure policy (i.e.., abuse and neglect reporting, Disclosure for law enforcement purposes).

2. Personnel asked to make a Disclosure Required by Law will determine whether the requesting Individual is a person with whom MJSF&N has a known relationship.

3. Personnel will follow appropriate policies and procedures for verifying the identity and authority of Individuals requesting PHI.

4. Once it is determined that a Use or Disclosure is appropriate, the medical records

administrator with appropriate access clearance will access the Individual's PHI using proper access and Authorization procedures.

5. The requested PHI will be delivered in a secure and confidential manner, such that the information cannot be accessed by employees or other persons who do not have appropriate access clearance to that information.

6. The medical records administrator will appropriately document the request and delivery of the PHI.

7. In the event that the identity and legal authority of an Individual or entity requesting PHI cannot be verified, personnel will refrain from disclosing the requested information and report the case to the Privacy Officer in a timely manner.

8. Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer.

In the event of a medical emergency, confidential information may be released to responsible parties (e.g., parents, legal guardians, mental health professionals directly involved in the provision of emergency services) without obtaining formal consent as described above. That is, if there is serious and imminent risk of physical harm to a client or person associated with the client, and information contained in the client’s record is deemed pertinent to reducing this risk, then this information may be released to responsible parties by MJSF&N staff only to the extent that the risk might be lessened. Such release must be fully documented in the client’s treatment record, including all circumstances that justified the release of the information, the nature of the information released, and to whom it was released.

Specifically, information may be released without signed authorizations only in the following instances:

· To those employees of MJSF&N who are currently providing treatment to the consumer to the extent that they need the information to provide proper care and treatment.

· To the Director of a County Office of Mental Health and Mental Retardation (or their designee) if the information is requested as part of a psychiatric commitment process.

· A judge or court in response to a court order, only if the court has actually issued an order directing the release. Note: A subpoena is not a court order. If a provider receives a subpoena only, check with legal counsel.

· To lawyers who provide written proof that they represent the consumer, which is usually accompanied by a signed authorization.

· To police or other government officials, if: an official need to know if a consumer is present or absent from a facility, he/she may only receive information under the following circumstances:

o the consumer is involuntarily committed to the treatment program AND

o the request for information occurs as part of a legitimate governmental function AND

o the only information that can be released is information stating whether the consumer is present or absent in a particular treatment program AND

o the facility’s Medical Director has determined that it is in the best interests of the consumer

to release information

· To insurance companies or other third-party payers, including CBH, MBH, or CCBH if those entities who require information to confirm that the consumer received treatment services for which the organization is being requested to pay. The information that may be released in this instance is limited to names, dates, types and costs of therapy and services, and a short description of the general purpose of each treatment session or service.

· To physicians, other medical professionals, or police officers, if the consumer is involved in a medical emergency and the information sought is needed to prevent death or serious risk of bodily harm. This applies only to information that is pertinent to relieving the emergency. This includes an emergency where a psychiatric client threatens to harm a third party.

· To Federal or Commonwealth reviewers and inspectors, and/or participants in peer or utilization reviews. This includes Commonwealth employees who need treatment information to perform their duties, JCAHO inspectors, and persons participating in PSRO or utilization reviews.

· To investigators of child or client abuse when the release is part of an effort to report suspected child abuse, as is required by the Child Protective Services Law, which overrides confidentiality.

· To the consumer. You may refuse to release information to the consumer only if:

o The facility Medical Director determines that releasing a portion of the information would be substantially detrimental to the consumer’s treatment.

o When revealing a portion of the information would reveal the identity of someone who

gave information on the agreement that his or her identity would remain confidential

If the person is denied access to all or part of his or her record, the denial as well as the rationale for it shall be noted in the client’s record.

This policy regarding confidentiality does not apply to documents that were public before MJSF&N received them, even if the documents now happen to be a part of the client’s file. Refer to the actual “Release of Information” for additional information.

In the event that federal and Baltimore laws or regulations governing the Use or Disclosure of PHI are in conflict, MJSF&N will exercise reasonable care to comply with Baltimore laws that are more stringent and that provide greater privacy protection to the Individual.

Presence of Visitors and Minors in the Office Area: No visitors, children included, should ever be unattended by staff in the vicinity of confidential information. In order to avoid HIPAA violations or

even the appearance of potential HIPAA violations, children (whether clients, siblings of clients, or the relatives of staff) may not wander or play in the vicinity of confidential information. Further, no children of staff are to be in the office except in unusual situations, for brief periods and with only with the approval of the Site Director or designee. Children are only allowed in the waiting room/ reception area or one of MJSF&N’ offices under direct supervision of staff.

TECHNOLOGY AND ASSISTIVE DEVICES:

Date Revised: August 2019

Policy statement: MJSF&N will seek to provide assistive technology whenever possible to permit staff, clients, and other stakeholders with disabilities to perform work-related tasks that would otherwise be overly burdensome or unachievable.

Purpose: To enable individuals with disabilities to function as effectively as possible.

Applicability: This policy applies to all individuals who interact in any capacity with MJSF&N.

Procedure:

On an annual basis (or more frequently, if desired), the accessibility needs of clients, staff, and other stakeholders will be identified by the Clinical Director, who will seek to determine through a survey to what extent assistive technology might help such individuals to function more effectively.

This report will be communicated to the COO, who will make a determination based on needs and costs as to what extent MJSF&N will be able to provide assistive technology to facilitate the functioning of such individuals.

EMPLOYEE AND CONTRACTOR ORIENTATION POLICY:

Date Revised: August 2019

Policy statement: MJSF&N will provide thorough training on all pertinent topics for all new staff including line-staff and supervisors.

Purpose: This policy is designed to enable staff to provide consistently professional service to clients and their families.

Applicability: This policy applies to all contracted and salaried employees of MJSF&N and OP.

Procedure: All new employees will receive training by there Site Director or designee. The following topics will be covered in detail and the new employee will be tested on their knowledge of this information:

· Fire Safety & Prevention

· Suicide Precautions

· Management of Escalation

· Cultural Awareness

· Infection Control/Universal Precautions/Blood-Borne Pathogens

· Disaster Training

The Site Director will review with the new employee the Code of Conduct for MJSF&N staff, to ensure that all employees of MJSF&N act in an ethical and legal manner. The Site Director also reviews with the new employee all details of job responsibilities, including documentation, chart management, professional conduct, staff roles, and how to resolve disagreements that may arise among staff and/or families.

The Site Director will conduct competency evaluations for all new hires 60 days after the start date of their employment. This evaluation will assess both knowledge-based as well as performance-based competencies. If the Director determines that the employee requires additional training, the reasons for this will be conveyed in writing to the employee. The employee will be re-evaluated in 30 days, and after the additional 30 days, the same evaluation will be used to assess the employee’s performance-and knowledge-based competencies. If the employee still does not meet minimal competency standards, then the Site Director will terminate that individual’s employment.

All new Therapeutic Staff Support (TSS) employees will be supervised by a Behavior Specialist Consultant (BSC) prior to working independently with clients and their families. TSSs with at least 6 months’ prior experience working with children and/or adolescents will be required to receive at least 3 hours of Assessment and Assistance. TSSs with less than 6 months’ prior experience working with children and/or adolescents will be required to receive at least 6 hours of Assessment and Assistance.

EMPLOYEE AND CONTRACTOR REHIRE POLICY:

Date Revised: August 2019

Policy statement: Employees and contractors must have left MJSF&N in good standing in order to be eligible for rehire.

Purpose: To adhere to consistent and sensible guidelines with regard to rehiring former employees or contractors.

Applicability: This policy applies to all former MJSF&N employees and contracted staff.

Procedure:

If an employee or contractor contacts a Director for rehire, the Director must contact HR to determine if the employee or contractor is eligible for rehire. (On the payroll form that was submitted at the time of the employee’s or contractor’s separation, it will state whether they are eligible for rehire or not.

Ineligibility would be based on the employee or contractor being terminated or if the employee or contractor did not give proper notice at the time of resignation.

If the employee or contractor is eligible for re-hire, the Director should send any pertinent information to HR so that the employee or contractor can be rehired and re-credentialed. If any clearances are more than a year old, the employee or contractor will need to update those clearances. If the ppd is more than a year old, the employee or contractor will need to have an updated ppd. All employees or contractors being rehired must pass a new pre-employment drug screen.

Once the employee or contractor is fully credentialed, HR will notify the Director that the employee or contractor may begin working and taking cases.

EMPLOYEE AND CONTRACTOR SANCTIONS POLICY:

Date Revised: August 2019

Policy statement: MJSF&N and OP requires all employees and subcontractors to inform their supervisor (or HR Director if applying for employment) of any criminal convictions, reports of child abuse, and/or any license or certification suspension or revocation at the time of hire and throughout their tenure of employment with MJSF&N.

Purpose: This policy is designed to protect all clients and their families from potential harm, and to ensure that the highest possible professional standards are maintained in the provision of services to them.

Applicability: This policy applies to all prospective employees, as well as all current contracted and salaried employees, throughout their term of hire.

Procedure:

An employee or subcontractor may be terminated for any gross infraction of ethical or professional standards.

It is the duty of all prospective and current staff to inform their Supervisor (or HR Director if applying for employment) of any criminal arrests, convictions, reports of child abuse, and/or any license or certification suspension or revocation. This duty exists both at the time of hire, as well as throughout the employee’s or subcontractor’s entire term of employment with MJSF&N. If information is received in this regard by the Supervisor that contradicts what the employee, subcontractor, or prospective employee has provided, then he or she will be informed of this discrepancy in writing. Other potential infractions include:

· Performing duties under the influence of alcohol or illicit drugs

· Mistreating a child

· Leaving a child alone

· Consistently failing to complete required paperwork on time

· Consistently failing to attend mandatory trainings and/or supervision

· Falsifying paperwork (especially including hours worked)

In the event that evidence emerges of an ethical or professional infraction, such as – but not limited to – those listed above, an investigation will be conducted by the Site Director, Regional Director, or COO. In addition, the Compliance Office or HR may be involved. If the allegations are felt to be sufficiently serious, the employee or subcontractor will be informed that he or she is prohibited from having any contact with clients until this matter is resolved.

If the circumstances of the specific infraction are too ambiguous or mild to warrant termination, then the employee or subcontractor will be given a letter of warning, a copy of which would become a permanent part of their personnel file. Should that individual persist in engaging in similar behavior after receiving such a written warning, then the employee or subcontractor may be terminated by the Supervisor, in consultation with the Site Director, Regional Director, COO & HR.

If at the end of the investigation it is determined that the employee or subcontractor has committed misconduct or gross misconduct, their service with the company will be terminated.

EQUAL OPPORTUNITY EMPLOYMENT

Date Revised: August 2019

Policy statement: It is the policy of MJSF&N to provide equal employment opportunity to all individuals regardless of their race, creed, religion, age, color, sex, marital status, national origin, sexual orientation, disability, or covered veteran status, unless such is a bona fide occupational qualification.

Purpose: This policy is designed to protect staff and potential hires from all forms of discrimination based on race, creed, religion, age, color, sex, marital status, national origin, sexual orientation, disability, or covered veteran status.

Applicability: This policy applies to all prospective employees, as well as all current contracted and salaried employees, throughout their term of hire.

Procedure:

MJSF&N will affirmatively recruit, hire, train, and advance in employment, employees based upon their abilities, achievements, and experience. This policy applies to all personnel policies and practices, including: recruitment, work assignment, hiring, training, promotion, compensation, benefits, transfer, training programs and organization-sponsored social and recreational programs. Any form of harassment related to an employee's race, creed, religion, age, color, sex, marital status, national origin, sexual orientation, disability, or covered veteran status, may result in disciplinary action, up to and including termination from employment.

Harassment includes, but is not limited to slurs, jokes, other verbal, graphic, or physical conduct related to a group or individual's race, creed, religion, age, color, sex, marital status, national origin, sexual orientation, disability or covered veteran status.

A qualified individual with a disability is an individual with a disability who with or without reasonable accommodation can perform the essential functions of the position.

1. The Human Resources Manager will: (a) advise managers and supervisors on the requirements of various state and federal laws regarding equal employment opportunity and assist them in arriving at solutions to problems in accordance with the law; (b) ensure that state and federal posters relating to equal employment opportunity, as well as organization's EEO policy statement, are conspicuously posted in working and employment areas; and (c) ensure that all employees and applicants for employment are afforded a full opportunity to participate in all organization-sponsored educational, training, recreational, and social activities as appropriate.

2. All help-wanted advertising will include the phrase "Equal Opportunity Employer" (EOE).

3. Supervisory personnel will ensure that the principles of non-discrimination are implemented in all policies and procedures affecting the employee's status with the facility, to include, but not limited to, recruitment, selection, interviewing, training, promotion, retention, discipline, termination, compensation, benefits, transfers, layoffs, recall from layoff, and educational, social, or recreational programs.

4. Supervisory personnel will ensure this policy is communicated on a continuing basis by personnel engaged in employment, placement, and training.

5. Human Resources will be responsible for ensuring that records relating to a covered disability will be maintained on a confidential basis and will be used solely for purposes of safe and efficient job placement and making any reasonable accommodation. Job descriptions shall include physical demands.

6. Any form of harassment related to an employee's race, color, religious creed, ancestry, national origin, age, sex, sexual preference, or physical or mental disability is a violation of this policy and will be immediately dealt with and treated as a serious disciplinary matter. Any employee who believes that he or she has been discriminated against because of race, color, religion, sex, marital status, age, national origin, disability, or covered veteran status should contact his or her supervisor or the Human Resources Manager immediately, who shall be responsible for initiating a prompt and confidential investigation.

7. Supervisory personnel should report any violations, alleged or substantiated, of this policy to the Human Resources Manager for action.

8. Employees who report any alleged or substantiated violation of this policy shall not be intimidated by any personnel in any manner. A decision to discipline an individual for a violation of this policy will not be undertaken without a thorough review of the facts and evidence surrounding the allegation.

EMPLOYEE AND CONTRACTOR ABSENCES:

Date Revised: August 2019

Policy statement: In the event of an unplanned absence of direct service staff, MJSF&N will strive to ensure continuity of support for clients.

Purpose: To ensure continuity of care for MJSF&N clients and also to ensure that employees and contractors (staff) are working on a regular basis.

Applicability: This policy applies to all contracted and salaried employees of MJSF&N and OP.

Procedure: Should a member of MJSF&N staff, either contracted or salaried, who provides direct service to clients experience an unplanned absence of more than one week (for BSCs , MTs, or OP Therapists) or of any duration (for TSSs), the legal guardian (or client, if 14 years of age or older) will be contacted by the Case Manager and asked if they would like a substitute staff member to be provided. If the legal guardian or client (if 14 or older) replies affirmatively, the Case Manager will seek to find a qualified staff member to serve as a temporary replacement. The legal guardian or client (if 14 or older) may, however, waive their right to be provided with substitute staff, though they may revoke such waiver at any time.

Employees and contractors who have not worked for 90 days will be separated (unless they are out on FMLA, worker’s compensation or have an approved leave of absence).

HR emails Directors at least monthly rel6garding employees and contractors who have not had a paycheck. Directors will follow up with those employees and contractors to see if they are still available to work. If the employee or contractor doesn’t respond or hasn’t picked up any cases within 90 days, then they will be separate

ETHICAL CONDUCT POLICY:

Date Revised: August 2019

Policy statement: MJSF&N upholds and sustains the right of all employees and members of the professional staff, clients, families and referral sources to participate in the identification, review or consideration in a respectful and confidential manner of ethical issues that arise in the provision of care. All employees/interns/volunteers are oriented to the Code of Ethics and Conduct as part of orientation process. Individuals are also expected to uphold the professional standards and/or codes of ethics established by their professional organizations. All employees are expected to behave in a manner that is appropriate and sensitive in providing quality care. At all times, employees are expected to be courteous with clients and their families. Every employee is expected to exercise good judgment when dealing with clients, families, referral sources, supervisors and fellow employees. It is important that each employee understands the rules and the penalty for misconduct.

Purpose: To ensure that all actions by MJSF&N staff are performed in an ethical manner.

Applicability: This policy applies to all MJSF&N and OP Staff.

Procedure: Ethical issues and concerns that are identified are addressed at the Site Manager’s meetings with staff or through the organizational chain of command.

An employee brings ethical issues or concerns to the attention of his/her immediate supervisor. In the event that a resolution is determined unsatisfactory, the appropriate chain of command will be followed up to and including the COO/CEO. Any individual may also utilize the steps in the Complaint policy. The COO/CEO ensures administrative availability for employees, clients, families, physicians or referral sources to assist in the resolution of identified ethical dilemmas. Clinical staff ensure that clients and families are informed of their rights and responsibilities and provide them with information and education regarding the consideration of ethical issues as well as providing them with information and education regarding the policy for the resolution of identified complaints regarding quality of care.

The following are examples of areas of particular importance where employees have constant responsibility:

1. Employees must not divulge confidential information concerning clients. Clients are not to be named or discussed with anyone outside the organization.

2. Discussions regarding clients are not to be held in front of other clients or any person not privileged to that communication. Problems of a client are not to be discussed with another client by staff members.

3. Personal problems or concerns of staff members are not to be discussed with the client or any member of the client’s family.

4. Clients are to be dealt with equally and fairly and the selection of "favorites" is not beneficial.

5. Staff members who will be working with a client, but who did not participate in the initial assessment, will make sure that they are informed about the client before meeting him/her.

6. Socialization or communication with clients or their family members outside of scheduled

work hours are not permitted. Socialization by staff members with clients' families is unacceptable.

7. Physical contact between staff members and clients is prohibited.

8. Counseling of the client regarding personal problems or involvement of staff in therapeutic

discussions with clients outside the realm dictated by the treatment plan is discouraged.

9. Non-clinical employees, in their relationship with the clients, are not permitted to counsel, do favors for, loiter in conversation with or in any manner interfere with the clinical relationship established between clients and clinical staff. All requests or conversations beyond the normal

routine duties of one's position must be referred to the client's clinical staff.

10.Staff may not give gifts to clients.

11.Staff may not accept monetary or other gifts from clients or their families. Staff may not solicit tips from clients or family members.

12. Appropriate language is to be practiced at all times in all areas. Immoral, rude or disorderly conduct is not tolerated.

13. Negligence, abuse and/or inconsiderate treatment in the care of the clients are not tolerated. Interfering with the work performance of another employee or threatening, intimidating, coercing or sexually harassing another employee is likewise not tolerated.

14. Habitual absence or tardiness and failure to report absence to one's supervisor is not acceptable, nor is sleeping or loitering while on duty.

15. Assigned duties and the instructions or directives of a Site Manager must be performed.

16. Information concerning the internal management and operation of organization is also considered confidential. It is improper for an employee to discuss organizational business with a non-employee.

17. Falsifying records, reports or information of any nature, theft, misappropriation, unauthorized possession, removal from its usual location or use of property belonging to the organization or to any client, visitor or employee are all expressly prohibited. Willful or careless destruction, mishandling or defacing of equipment and/or property is likewise prohibited.

18. Use or possession of alcohol or other drugs of abuse on the premises or reporting to work under

the influence of such a substance is grounds for dismissal. Likewise, possession of a lethal weapon on the premises is grounds for dismissal.

19. Willful or careless violation of fire, safety or security regulations is not tolerated.

20. Smoking in the building is not permitted.

21. Solicitation of clients for own private practices is prohibited.

22. A dual relationship between clients or their families on the one hand and staff on the other (i.e., in addition to having professional responsibilities to a client through MJSF&N, also having, for example, a personal friendship or a business relationship with a client or their family) is strictly prohibited. However, since it may not always be clear if and how some of these relationships may be inappropriate, ambiguous situations should be discussed with the Site Director, Clinical Director, or COO.

The foregoing are examples only. MJSF&N reserves the right to administer discipline or sever employment in these circumstances or in any other circumstance it deems appropriate. Questions about the above areas, questions about the expectations of job performance, or questions about the appropriateness of staff behavior with clients should be directed to the Site Director.

I. POLICY:

B. It is the policy of MJSFN Center to resolve workplace issues and problems by providing employees with an internal grievance procedure that ensures any problems or complaints are considered quickly, fairly, and without fear of reprisal. 


C. The Program Director is responsible for ensuring that the procedures in this policy are followed and met. 


D. A grievance may be filed by an employee for any of the following reasons:

6. Any disciplinary action taken by a supervisor. These include written warnings, disciplinary suspension without pay, demotion or dismissal. 


7. Any instance of illegal discrimination perceived by an employee. 
Note: All employees have the legal right to file a discrimination complaint with state and federal regulatory agencies and are not restricted to the internal grievance procedure, nor required to file an internal grievance. 


8. Any instance of unlawful workplace harassment perceived by an employee. 
Note: All employees have the legal right to file a discrimination complaint with state and federal regulatory agencies and are not restricted to the internal grievance procedure, nor required to file an internal grievance. 


II. PROCEDURES:

A. INFORMAL RESOLUTION:

1. A positive relationship between employees and supervisors is based on mutual trust, respect, and open communication. If employees have a problem in the workplace related to employment, they are encouraged to first discuss the issue or concern with their immediate supervisor. In most cases, these discussions can resolve any misunderstandings or conflicts. 


2. If informal discussion is not effective in resolving concerns, employees are encouraged to utilize the formal grievance resolution procedures. 


B. FORMAL RESOLUTION

1. Steps of the Grievance Review:

· Step 1: To initiate a grievance, an employee must file a written Notice of Grievance within 14 days of the contested action or incident with the program coordinator. The notice must state specifically what is being grieved, what relief is being sought, and must include a description of the efforts the employee took to settle the complaint informally. 


· Step 2: The program administrator will initiate an investigation of the complaint by taking the following actions:

· Sending a copy of the Notice of Grievance to the supervisor involved, if applicable. 


· Conducting interviews with persons involved, if appropriate.

· Rendering a final decision, in writing. 


· Step 3: The program coordinator will provide a written response to the grievant within 7 days of receiving the Notice of Grievance. The written response will contain one of the two following outcomes:

· Grievance Unfounded: This outcome may include a brief justification regarding the decision. 


· Grievance Founded: This outcome may include actions that will be taken to resolve the problem and/or information related to meeting with specific management employees to assist in remedying the situation. 


· Step 4: Should the written response not the grievance as unfounded; employees may appeal the decision to CEO. The appeal must be in writing within four days of the employee receiving the “unfounded” response. A copy of the prior Notice of Grievance and written response must be attached. 


· Step 5: The CEO will provide a written response to the grievant within 7 days of receiving the written appeal of the initial grievance response. The written response will contain one of the two following outcomes:

a. Grievance Unfounded: This outcome may include a brief justification regarding decision. 


b. Grievance Founded: This outcome may include actions that will be taken to resolve the problem and/or information related to meeting with specific management employees to assist in remedying the situation. 


NOTE: THERE ARE TWO OPTIONS (THAT FOLLOW) TO CHOOSE, OR CONSIDER AT THIS POINT IN THE POLICY/PROCESS

OPTION ONE:

2. Should the appeal of the initial written response result in a second “unfounded” outcome, internal options for seeking resolution of the grievance are exhausted. Should an employee continue to pursue resolution of a perceived problem after a second written response of “unfounded”, they are encouraged to seek assistance from external entities, on their own time and at their personal expense.

OPTION TWO:

C. GRIEVANCE REVIEW BOARD

· Should an employee wish to continue to the grievance process following an “unfounded” result of an appeal of the initial outcome, they may initiate a review by the Grievance Review Board by indicating in writing to the Administration Director that they wish to participate in the review board process.

· The Grievance Review Board is composed of five employees chosen by the CEO, COO, clinical director, clinical supervisor, and administration coordinator.

· Procedural information related to the proceedings, will be provided to all parties prior to the proceedings.

· The administration coordinator will serve in a non-voting advisory capacity to the review board to assist with procedural structure.

· The Grievance Review Board will operate according to the following procedural guidelines:

a. Both of the opposing parties (employee and supervisor) will be present during presentation of the case to the Board of Review. Neither party may interrupt the case being presented by the other side. The board will have the right to limit lengthy discussion deemed to not focus directly on the grievance.

b. Each party will have the right to provide evidence or documentation relevant to the case. Both parties will be required to submit any documentary material or witness lists three days prior to the review.

c. Documentation not submitted and/or witnesses not listed will not be entered into the process once the review board convenes.

d. Each party may receive a copy of the other parties’ documentary material and witness list on the workday preceding the review from Program Director.

e. Each party has the right to call witnesses; however, witnesses will only be present during their testimony. It will be the responsibility of the grievant and the supervisor to notify their witnesses of the time, place and date of review.

f. The grievant and the supervisor may recommend the order of testimony and the appearance of witnesses for their respective sides.

g. Documentary material and/or testimony may be denied, by the review board, in the hearing if deemed to be unnecessarily repetitive or irrelevant.

h. The Review Board will reach its findings and present its recommendations to the CEO within 14 calendar days of the review.

i. The CEO may accept the review board’s recommendation in whole or in part, or may reject the board’s recommendations.

j. The grievant will be informed of the final decision by the clinical director, in writing, within 7 days of receiving the recommendations from the review board.

Should the appeal to the Grievance Review Board result in a dissatisfactory outcome for the employee they are encouraged to seek assistance from external entities, on their own time and at their personal expense.

CREDENTIAL, HEALTH, AND BACKGROUND CHECKS FOR EMPLOYEES AND CONTRACTORS:

Date Revised: August 2019

Policy statement: MJSF&N will verify on a regular basis the credentials and the criminal and child abuse history of all staff that comes into contact with clients and their families.

Purpose: To ensure that all employees and contractors are treated consistently with regard to the need to maintain current credentials. To try to ensure that the credentials of employees and contractors do not lapse in order to provide consistent service to their clients.

Applicability: This policy applies to all MJSF&N employees and contractors, both clinical and non-clinical.

Procedure: Employees and contractors who have a clearance that expires must stop working and getting paid from the date of the credential’s expiration. Employees and contractors will be given 30 days from the clearance’s expiration to obtain the updated clearance or be separated. If a clearance (FBI, Child Abuse or Criminal Clearance) is returned that shows a conviction that prevents employee or contractor from working with children based upon the Baltimore child protective services law (Title 23 PA C.S.A. Chapter 63), that employee or contractor will be immediately terminated.

All newly hired employees and contractors will be required to be tested for tuberculosis (TB). If they are found to have a positive TB skin test or TB blood test, further testing, such as a chest x-ray and/or a sample of sputum, will be required to determine whether the staff person has active TB disease. If a staff member tests positive for TB, he or she will be referred for appropriate medical treatment, and may not come into contact with clients until such treatment has been completed, as attested by a written statement by a medical doctor which shall be kept on file in the staff person’s personnel file.

In addition, every two (2) years, beginning as a condition of their initial hiring, all MJSF&N employees and contractors who provide direct care to clients and/or their families, as well as all non-clinical staff, are required to undergo independent credential verification as well as criminal, FBI, and child abuse history clearance checks. Any original child abuse, FBI clearance and/or criminal history clearance submitted prior to hiring by MJSF&N must be dated no more than one (1) year prior to the hiring of the new employee or contractor. If either clearance (child abuse, FBI or criminal) is more than one (1) year old, new clearances will be obtained immediately. Per Act 80, employees or contractors may be hired on a provisional basis for 30 days (or 90 days for out-of-state applicants) until appropriate credential verifications and history clearances have been obtained by MJSF&N. MJSF&N maintains the responsibility to keep current credentials and child abuse, FBI and criminal history clearances on all employees and contractors (including non-clinical staff) who have direct contact with the client and/or family.

All prospective employees and contractors of MJSF&N or OP will be required to sign a Staff Disclosure Statement that attests to the fact that the applicant’s clearances will not include founded reports of child abuse and/or conviction of one or more of the following offenses: Criminal Homicide, Aggravated Assault, Harassment and Stalking, Kidnapping, Unlawful Restraint, Rape, Statutory Sexual Assault, Involuntary Deviant Sexual Intercourse, Aggravated Indecent Assault, Indecent Exposure, Incest,

Concealment of the Death of a Child, Endangering the Welfare of Children, Dealing with Infant Children, Prostitution and related offenses, Obscene or Other Sexual Materials, Corruption of Minors, or Sexual Abuse of Children.

In addition, prospective employees and contractors may not have been convicted under a felony offense under the act of April 14, 1972, known as the controlled substance, drug, device and cosmetic act committed within the last 5 years.

Employees and contractors who have a clearance that expires must stop working and getting paid from the date of the credential’s expiration. Employees and contractors will be given 30 days from the clearance’s expiration to obtain the updated clearance or be separated. If a clearance (FBI, Child Abuse or Criminal Clearance) is returned that shows a conviction that prevents employee or contractor from working with children based upon the Baltimore child protective services law (Title 23 PA C.S.A. Chapter 63), that employee or contractor will be immediately terminated.

HR emails all employees and contractors to their MJSF&N email address both 60 and 30 days prior to any clearance that is about to expire. Directors will be copied on the 30-day notice.

All communication from HR on this subject with employees and contractors will be through their MJSF&N email accounts or through Credible. It is their responsibility to check their MJSF&N email and Credible on a regular basis and to respond to messages accordingly. The employee or contractor should also make sure that their MJSF&N office/HR/and payroll have their updated contact information including address and phone number if changes occur.

The HR Director sends a reminder to the Directors any time that an employee’s or contractor’s credential is about to expire within the upcoming week.

If the employee or contractor doesn’t submit a renewed credential to MJSF&N prior to expiration, the employee or contractor is taken off any cases or suspended from work until they submit an updated clearance.

If a time period of 30 days transpires and the employee or contractor still didn’t submit an updated clearance, they will be separated (unless an extenuating circumstance is approved by the Director).

If a criminal clearance, FBI clearance or Child Abuse clearance is submitted with a conviction of one of the offenses under Title 18 (relating to crimes and offenses) or if there is a felony conviction under the act of April 14, 1972 (P.L.233, No. 64), known as the Controlled Substance, Drug, Device, and Cosmetic Act committed within the five years period preceding the verification, the employee or contractor will be terminated.

Criminal Background Office of Inspector General (OIG) & National Sex Registry Check Policy

MJSFN Center will conduct criminal background, Office of Inspector General (OIG) exclusion list check and National Sex Registry checks on a 2-year cycle as part of the continued employment process. This search will include a web search of OIG exclusion list check and National Sex Registry. Criminal background checks will be obtaining directly from a State approved fingerprinting agency.

A. Criminal record checks will be conducted in accordance with applicable law. Applicants or employees will be notified if a criminal record check will be conducted and will be asked to complete a Disclosure and Authorization request form authorizing the background check. If requested, the applicant or employee will be provided with a copy of this criminal background check policy.

B. OIG exclusion list web searches will be completed quarterly on all employees with the results placed in employee file.

C. National Sex Registry checks will be conducted quarterly on all employees with the results placed in employee file.

D. MJSFN program director is responsibility for reviewing OIG, National Sex Offender Registry and criminal background reports in the decision-making process for employment.

E. Unless otherwise provided by law, a criminal record will not automatically disqualify an applicant from employment. All potential and existing employee placed on OIG exclusion list will not be hired or employment ended.

F. Rather, determinations of suitability based on criminal record checks will be made consistent with this policy and any applicable law or regulations.

G. If a criminal record is received, the authorized individual will closely compare the record provided with the information on the Disclosure and Authorization Form and any other identifying information provided by the applicant or employee, to ensure the record relates to the applicant or employee.

H. If MJSFN is inclined to make an adverse decision based on the results of the criminal background check, the applicant or employee will be notified immediately. The applicant or employee will be provided with a copy of the criminal record, the MJSFN's criminal background policy and will be advised of the part(s) of the record that make the individual unsuitable for the position. MJSFN will provide the applicant or employee with an opportunity to dispute the accuracy and relevance of the criminal record.

I. Applicants or employees challenging the accuracy of a criminal record shall be provided a copy of information concerning the process in correcting a Criminal Record. If the criminal record provided does not exactly match the identification information provided by the applicant or employee, MJSFN will make a determination based on a comparison of the criminal record and documents provided by the applicant or employee. If MJSFN reasonably believes the record belongs to the applicant or employee and is accurate, then MJSFN will determine the applicant or employee’s suitability for the position at issue. Unless otherwise provided by law, factors considered in determining suitability may include, but not be limited to the following:

a) Relevance of the crime to the position sought;

b) The nature of the work to be performed;

c) Time since the conviction;

d) Age of the candidate at the time of the offense;

e) Seriousness and specific circumstances of the offense;

f) The number of offenses;

g) Whether the applicant has pending charges;

h) Any relevant evidence of rehabilitation or lack thereof;

i) Any other relevant information, including information submitted by the candidate or requested by the hiring authority

MJSFN will notify the applicant or employee of the decision and the basis of the decision in a timely manner.

EMPLOYEE DISCLOSURE OF CRIMINAL HISTORY

A record of criminal conviction is not an automatic bar to employment. Each case is considered on its own merits. Factors such as job-relatedness, age at the time of conviction, nature of the offense, success of rehabilitation, number of convictions, and recentness of the conviction(s) are taken into consideration to determine whether a criminal record disqualifies a candidate for employment.

Background and criminal record checks to include fingerprinting are routinely completed for all appointments.

Discovery of fraudulent, irregular or inaccurate information will be reported to appropriate State agencies.

Falsification of this form, or any other employment application form, will result in automatic rejection of the employment application, withdrawal of commitment, or immediate dismissal from employment.

HAVE YOU EVER BEEN CONVICTED , RECEIVED A PROBATION BEFORE JUDGMENT , OR RECEIVED A NOT CRIMINALLY RESPONSIBLE DISPOSITION OF ANY CRIMINAL CASE OTHER THAN A MINOR TRAFFIC VIOLATION?

_________ YES (If YES, give complete details on the second page of this form.)

_________ NO

____________________________________ _____________________

SIGNATURE (FULL NAME) DATE

____________________________________

PRINT FULL NAME

SUPERVISOR’S SIGNATURE

PLEASE PRINT

1. CRIME CONVICTED OF: ______________________________________

DATE OF INCIDENT: ______________________________________

DATE CONVICTED: __________________________________________

DISPOSITION OF CASE: _______________________________________

2. CRIME CONVICTED OF: ______________________________________

DATE OF INCIDENT: ______________________________________

DATE CONVICTED: __________________________________________

DISPOSITION OF CASE: _______________________________________

3. CRIME CONVICTED OF: ______________________________________

DATE OF INCIDENT: ______________________________________

DATE CONVICTED: __________________________________________

DISPOSITION OF CASE: _______________________________________

4. CRIME CONVICTED OF: ______________________________________

DATE OF INCIDENT: ______________________________________

DATE CONVICTED: __________________________________________

DISPOSITION OF CASE: _______________________________________

Applicant’s Name: _____________________________________ Date: __________

Please Print

CRITICAL INCIDENT POLICY:

Date Revised: August 2019

Policy statement: MJSF&N will identify, report, manage, and investigate all reportable significant incidents involving a client or family member who is involved in treatment with this agency.

Purpose: This policy is designed to ensure that the highest professional standards and level of care is maintained.

Applicability: This policy applies to all staff affiliated in any manner with MJSF&N or OP, in their contact with any client or individual associated with the identified client.

Procedure: MJSF&N will identify, report, manage, and investigate all reportable significant incidents involving a client who is involved in treatment with this agency. Reportable significant incidents are defined as: “Any event in which there has been injury or serious potential for harm either to or by a client.”

This policy is applicable whenever an employee of MJSF&N reports a significant incident involving an adult or child consumer of mental health services, whether they are CBH, MBH, or CCBH members receiving in-plan services or county-funded individuals receiving supplemental funding through the Office of Mental Health, or those served by the Behavioral Health Special Initiative.

· In the event of a critical incident, if the client is at serious risk of harming himself or herself, or of causing harm to others, crisis intervention services will be utilized.

· If a reportable significant incident occurs, MJSF&N will fax a copy of the incident report to the BHS within 24 hours of occurrence, via the Significant Incident Report form. One copy will be sent to the Quality Review Unit of CBH, MBH, or CCBH as appropriate, and the second copy to the Office of Mental Health Children’s Unit.

· When an investigation is warranted, the investigative report will be sent to the program funders (e.g., CBH, MBH, CCBH, OMH) within 30 days of the incident.

· Incidents involving likely physical and/or sexual abuse and/or neglect of minors will be reported as soon as possible to the State by telephone.

MJSF&N will notify the client’s parent, legal guardian, or custodian (when applicable) of any reportable incidents, unless precluded by court order or applicable confidentiality standards.

MJSF&N will report a missing person who is “at-risk” to the Mental Health Delegates, by faxing a Missing Person Report Form.

All medical emergencies will be documented, including the date and time of incident, along with the date and time of physician notification.

The staff person most directly involved in the incident will ordinarily be responsible for completing the Significant Incident Report Form. If for some reason this is not feasible, then the Site Director will be responsible for gathering information and completing the Significant Incident Report. In any event, the Site Director must co-sign the Significant Incident Report, and forward a copy to the Program Director, Clinical Director, and Regional Director.

Following the emergency, a timely de-briefing and follow-through will be conducted by the Site Director, who will interview all staff who were directly involved in the incident. This should ordinarily occur as soon as possible but no longer than a week following the incident.

Significant Incidents will be reviewed at least every 6 months by the Program Director, Clinical Director, Regional Director, and Site Directors, with the aim of identifying and improving any areas of service that are deemed to be deficient.

Reportable incidents include, but are not limited to, the following:

· Death of a client

· Homicide committed by a client who is in service or who has been discharged within thirty (30) days

· Suicide attempt requiring medical intervention or hospitalization

· Act of violence with injury requiring emergency treatment by or to a client

· Adverse drug reactions to medication administered by MJSF&N that requires medical attention

· Alleged or suspected abuse (physical, financial, sexual) of or by a client

· Neglect that results in serious injury or hospitalization

· Misuse of client’s funds

· HIPAA violations

· An outbreak of a serious communicable disease.

· Arrest of a client

· Fire or serious property damage at the site where behavioral health services are delivered

· Biohazardous accidents

· The use or unauthorized possession of weapons and the unauthorized use or possession of legal or illegal drugs

HUMAN RESOURCES PERSONNEL POLICY

The purpose of the MJSFN Human Resource’s Personnel Policy is to assure that both administration and clinical staff is appropriately qualified to practice through educational and clinical experience. The credentialing and privileging process is viewed as part of the quality management plan and assures that all clinical staff maintains an appropriate level of practice.

1. All MJSFN clinical programs are operated under the clinical direction of the Executive Director and the Clinical Director. Ultimate clinical authority of the program lies with the Clinical Director.

2. The Clinical Director determines competency for all clinical staff.

3. Competency Criteria at the Time of Employment:

At the time of employment, the job applicant's education, experience and abilities are reviewed through the employment application and interviewing process. The Program Director is responsible for assuring job applicants meet required educational, licensing and experiential criteria as outlined in each job description.

4. In order to establish proper credentials, the following information is collected prior to the candidate’s employment:

a. On-line License Verification/College Transcript/High School Diploma

b. Professional License

c. Driver's License

d. Social Security Card

e. Curriculum Vitae

f. Criminal Background Check

g. National Sex Registry Check

h. Three Professional References

5. Initial Clinical Competency Assessment:

The employee's level of competence to provide clinical services is initially assessed during the employee's introductory period, which begins with the MJSFN orientation. During the orientation, the Program Director completes a Credentialing and Privileging Worksheet. At the end of the introductory period, the employee will be evaluated for practice privileges to function independently or conditionally with supervision.

6. Credentialing Review:

To assure that staff continues to meet competency standards, at least annually (prior to the annual performance review), there shall be a competency review. The Credentialing and Privileging Worksheet will be completed to indicate the employee’s competency status. In the event that an employee is promoted to a position in which there are different standards, a new Credentialing and Privileging Worksheet will be completed. Copies of the employee's performance assessments and credentialing/privileging worksheet are found in the employee’s permanent personnel record.

7. In order to meet credentialing standards, the employees must receive a performance rating of at least satisfactory on the review scale. If the overall rating is less than "Meets Expectation", a corrective plan of action is established and this is noted on the performance evaluation.

8. Factors to be considered for credentialing include:

a. Licensing and/or Certification requirements: If position requires, Human Resources will maintain on-line verification of all Maryland State Clinical License. Each employee must submit a copy of any required certification(s) to Human Resources.

b. Driving Safety: All staff that drives a company vehicle must complete the MJSFN driver safety program bi-annually.

c. Completion and renewal of required in-service trainings: Requirements presented when hired. Records maintained in Human Resources. For additional information see the orientation section of manual.

d. Supervision Plan: The employee must demonstrate competent work as observed by the Program Director and Medical Director/Staff Psychiatrist. All Program Directors who conduct supervision are required to complete a supervisory log. A copy of the supervision log is forwarded to the employee’s permanent personnel file. As staff requires less supervision for the completion of certain clinical activities, individual supervisory plans are changed. These changes shall be reported in the annual performance evaluation.

e. Employees may experience accomplishments or problems that are not reflected in the competency plan, but which nevertheless affect their ability to perform on the job. These factors are also noted in the performance appraisal.

9. In the event the employee does not meet the requirement for the position (e.g. due to license expiration or missing training, etc.) the employee will be removed from the work schedule and not permitted to practice until the necessary criteria has been met. MJSFN is committed to providing quarterly on-site training opportunities in order for employees to complete all required training

I. Purpose

This policy provides guidance to employees about his/her privileges and obligations with respect to his/her personnel records, and guides MJSFN Center personnel responsible for producing and maintaining personnel records and the appropriate handling of those records.

II. Scope

These provisions apply to All MJSFN employees (clinical and/or support) and to applicants seeking employment for available positions.

III. Definitions

Personnel File - For the purposes of this policy, a personnel file consists of any employment-related or personal information about an MJSFN employee, former employee or applicant for employment gathered by the agency.

Personnel Record – a document within a personnel file.

Employment-related information includes information related to an individual’s:

· On-line License Verification/College Transcript/High School Diploma

· Professional License

· Driver's License

· Social Security Card

· Resume`/Application

· Criminal Background Check

· National Sex Offender Database Check

· Office of Inspector General Exclusion Check

· Three Professional References

· Job Description,

· Salary

· Leave

· Benefits

· Performance evaluation forms, and

· Suspension, disciplinary actions and termination.

Personal information includes an individual’s:

· Home address,

· Social security number,

· Personal financial data,

· Marital status, dependents and

· Beneficiaries.

IV. Policy

1. It is the policy of MJSFN Center to maintain the official personnel record for each current full-time, part-time, contractual, intern, and volunteer’s employee, and benefits files for agency. Personnel files for all full-time, part-time, contractual, intern, and volunteer’s employee are maintained by the Program Director. All personnel files are maintained in a secure area.

2. Personnel files must be protected from unauthorized disclosure by maintaining files in a locked secure area. Access will be limited to CEO, COO, Program Director, and designee. When employment has ended, all files will be maintained by the agency and stored for a period of seven (7) years.

3. Proper handling of employee personnel records by MJSFN requires coordination of the interests of the employees and the agency. Maryland law places certain requirements on handling state employee personnel records and establishes penalties for the violation. No access to or disclosure from employee personnel records is permitted except in accordance with these requirements.

V. Contents of Personnel Records

1. Personnel Records for MJSFN contains both confidential information and records that are considered public information (or records open to inspection).

A. Public Information / Records Open for Inspection

1. The law requires MJSFN to allow the public to have access to the following information from MJSFN’s personnel records:

· Name.

· Age (not date of birth).

· Date of original employment or appointment.

· Current position.

· Title

B. Confidential Information

1. All employment-related and personal information in an employee’s personnel file not specified under “Records Open for Inspection” is confidential.

MJSFN only maintain information that is relevant to accomplishing personnel administration purposes. Information obtained regarding the medical condition or history of an applicant that is collected by the agency must be maintained in a separate file in compliance with the Americans with Disabilities Act (42 U.S.C. 12112).

Advisory Note: Some information may be kept in an employee’s personnel file which an employee believes is confidential but which does not fall into any of the above categories (e.g., information about an employee’s benefits). If a public records request is made for any information that is kept in an employee’s personnel file, and the information is not open for inspection under G.S. 126-23, the University should get both the consent of the employee and the advice of counsel before releasing such information.

2. All requests for access to staff personnel information from any person or agency except the subject employee or the employee’s supervisors (see section V below) should be referred to the Program Director.

VI. Disclosure of Personnel Records

1. The public information/records open for inspection listed above shall be made available upon written request for inspection and examination and copies thereof made by any persons during regular business hours, subject to the following provisions:

A. All disclosures of records shall be accounted for by keeping a written record of the following information:

· Name of employee

· Information disclosed

· Date information was requested

· Name and address of the person to whom the disclosure is made (if the person requesting the information is willing to provide such information)

The information must be retained for a period of two years. This does not apply to the processing of personnel records for routine credit reference.

B. Upon request, the record of disclosure shall be made available to the employee to whom it pertains.

C. Any person denied access to records shall have a right to seek compliance with these provisions by application to a court for a writ of mandamus or other appropriate relief.

VII. Location of Personnel Records

A. Employees - Personnel records for MJSFN employees are retained by the Program Director.

B. Applicants – Records on all unsuccessful applicants for MJSFN are retained by the Program Director for three years, and then destroyed.

VIII. Employee Inspection of His/her Personnel File

1. A staff employee, former staff employee or applicant who wishes to inspect his/her file should make a written request to the Program Director.

a. The Program Director will arrange for an administration staff to schedule a time for the individual to inspect his/her personnel file per legal guidelines.

IX. Maintaining Confidentiality and Permitting Access

1. Employees responsible for maintaining personnel records and files of MJSFN employees should permit access to those records only in accordance with the requirements in this section unless they receive special instructions from their supervisor.

2. Individuals requesting access to confidential information must submit a written request and will be required to submit satisfactory proof of identity.

3. A record shall be made of each disclosure (except disclosures to the employee and his or her supervisor) and the record shall be placed in the employee’s official personnel file.

4. All information in an employee’s personnel file shall be open for examination to the following persons:

a. The supervisor of the employee: for this purpose, supervisor is any individual in the chain of administrative authority above the employee within the agency.

b. A party by authority of a proper court order.

c. An official of an agency of the Federal, State or any political subdivision thereof. An official is a person who has official or authorized duties in behalf of an agency; it does not imply a necessary level of duty or responsibility. Such an official may inspect any personnel records when such inspection is deemed necessary and essential to the pursuance of a proper function of said agency.

d. The employee (or his/her authorized agent), applicant for employment, or former employee who is the subject of a personnel record may have access to the personnel record in its entirety, except for confidential letters of recommendation solicited prior to employment and certain medical records.

1. Confidential letters of recommendation include notes from telephone reference checks and statements from MJSFN and other individuals solicited prior to the initial date of employment.

2. Information concerning a medical disability, mental or physical, that a prudent physician would not divulge to a patient are not available to the employee. The medical record may be disclosed to a licensed physician designated in writing by the employee. When medical information is obtained on any employee, the physician should indicate any information that should not be disclosed to the employee.

· Due to special confidentiality requirements, all copies of such documents should be forwarded to the Program Director.

· Employees responsible for maintaining personnel files are expected to review the personnel file for the presence of confidential recommendations and medical records before permitting any employee access to his or her personnel file.

X. Records of Former Employees and Applicants for Employment

1. The provisions for access to records apply to former employees and applicants the same as they apply to present employees. Personnel files of former MJSFN employees who have been separated from the agency for five or more years may be open to inspection and examination as defined in this policy.

XI. Releasing Confidential Information

1. Each individual requesting access to confidential information will be required to submit satisfactory proof of identity.

2. A record shall be made of each disclosure (except disclosures to the employee and his or her supervisor) and the record shall be placed in the employee’s file.

3. The Program Director may, under the conditions specified, take the following action with respect to an applicant, employee or former employee employed by or assigned to the agency, whose personnel file is maintained by MJSFN. The Program Director may allow the employee’s personnel file or a portion of the personnel file to be inspected and examined by any person or corporation when the Program Director determines that inspection is essential to maintaining the integrity of the agency, or maintaining the level or quality of services provided by the agency. Under these circumstances, the Program Director may, in his or her discretion, inform any person or corporation of any:

· Promotion,

· Demotion,

· Suspension,

· Reinstatement,

· Separation,

· Dismissal,

· Employment or non-employment of such applicant, employee, or former employee, or

· Other confidential matters contained in the personnel file.

4. Prior to releasing such information or making such file or portion thereof available as provided herein, the Program Director shall prepare a memorandum setting forth the circumstances that the agency has determined requires such disclosure, and the information to be disclosed, with a copy of the memorandum sent to the employee and the memorandum retained as a public record in the personnel file.

XII. Relevance

1. Information and documents not relevant to personnel administration should not be retained in the personnel file.

XIII. Remedies for Employee Objections to Material in the Personnel File

1. Any present or former employee is legally entitled to take either or both of the following actions if he or she considers the material in the personnel file to be inaccurate or misleading:

· Place in the file a statement relating to the material considered inaccurate or misleading.

· Seek removal of material in the file in accordance with the grievance procedure applicable to the employee’s category of employment.

XIV. Notice to Employee of Disclosure of Confidential Information to Outside Agencies

1. Unless prohibited by law, the agency will notify the employee as promptly as possible when it makes a disclosure of confidential information required or permitted by law, as in response to a subpoena, court order, or to a properly authorized government official. The agency official making such disclosure is responsible for notifying the employee in writing, with a copy of the notice to the personnel file. No such notice will be given when the only information requested is information available to the general public.

XV. Access to Information Used for Personnel Actions

1. Information used in making a determination about employment or other personnel actions should be, to the extent practical, obtained directly from the individual. There may be instances where it is necessary to obtain information from other sources. This may be obtained either directly from those sources or by the use of a consumer-reporting agency.

CREDENTIALING AND/OR CONTINUING EDUCATION

The purpose of the MJSFN Credentialing and/or Continuing Education Policy is to assure that all clinical and peer support staff is qualified to practice through training, educational and clinical experience. The credentialing and continued education process is viewed as part of the quality management plan and assures that all clinical and peer support staff maintains an appropriate training to practice.

1. All MJSFN clinical programs are operated under the clinical direction of the Executive Director and the Clinical Director. Ultimate clinical authority of the program lies with the Clinical Director.

2. The Clinical Director determines competency for all clinical staff.

3. Competency Criteria at the Time of Employment:

At the time of employment, the job applicant's education, experience and abilities are reviewed through the employment application and interviewing process. The Program Director is responsible for assuring job applicants meet required educational, licensing and experiential criteria as outlined in each job description.

4. In order to establish proper credentials, the following information is collected prior to the candidate’s employment:

a. On-line License Verification/College Transcript/High School Diploma

b. Professional License

c. Social Security Card

d. Curriculum Vitae

e. Criminal Background Check

f. National Sex Offender Check

g. Three Professional References

5. Initial Clinical Competency Assessment:

The employee's level of competence to provide clinical and peer support services is initially assessed during the employee's introductory period, which begins with the MJSFN orientation. During the orientation, the Program Director completes a Credentialing and Continuing Education Worksheet. At the end of the introductory period, the employee will be evaluated for practice privileges to function independently or conditionally with supervision.

6. Credentialing Review:

To assure that staff continues to meet competency standards, non-direct care staff must complete a minimum of 10 hours of ongoing continued education units annually; all direct care staff must complete a minimum of 20 continued education units annually. The Credentialing and Continued Education will be completed to indicate the employee’s competency status. In the event that an employee is promoted to a position in which there are different standards, a new Credentialing and Continuing Education Worksheet will be completed. Copies of the employee's performance assessments and credentialing/continuing education worksheet are found in the employee’s permanent personnel record.

7. MJSFN will provide training through the calendar year will include:

a. Emergency disaster training;

b. Customer service (how to handle grievances/complaints);

c. How to handle communication barriers;

d. Ethical training;

e. Infectious control;

f. Client rights and responsibilities;

g. Crisis intervention;

h. Treatment planning;

i. Conflict resolution; and

j. Anger management techniques.

8. In the event the employee does not meet the requirement for the position (e.g. due to license expiration or missing training, etc.) the employee will be removed from the work schedule and not permitted to practice until the necessary criteria has been met. MJSFN is committed to providing quarterly on-site training opportunities in order for employees to complete all required training.

ON-CALL EMERGENCY PROTOCOL POLICY:

Date Revised: August 2019

Policy statement: MJSF&N and OP will ensure that clients and their families/legal guardians/custodians are informed as to the procedures to follow in the event of a behavioral emergency during non-business hours.

Purpose: This policy is designed to provide guidelines so that clients and their caretakers can have access to competent professional care regardless of the time of day.

Applicability: This policy applies to all clients and their families/legal guardians/custodians.

Procedure: During the initial orientation of new clients/families, the Case Manager (for MJSF&N clients) or Intake Evaluator (for OP clients) will inform clients and their families of the procedures to follow in the event of a behavioral emergency during non-business hours. This will be conveyed orally by the CM or IE as well as in the Client Handbook. In addition, clients/families will be provided with the phone numbers of all staff assigned to them. However, it will be up to the individual staff person (BSC, MT, TSS, OP Therapist) as to whether they wish their phone number to be utilized by the family after normal business hours. Families will also be referred to the Crisis phone number for their respective county:

· Baltimore Crisis Response Inc (BCRI) The phone number is 410-576-5097.

· Baltimore County Crisis Services. Hotline 410-931-2214.

· Dial 911 and ask the operator to send the B.E.S.T. Police Officer.

In addition, MJSF&N’ after-hours phone message consists of the following: “Thank you for calling MJSF&N. We are unable to come to the phone at this time. If this is a psychiatric emergency, please go to your nearest hospital or dial 911. All of our extensions have changed, so if you would like our company directory, please press 1. If you know your party’s new extension, you may dial it now. Our normal business hours are from 9 a.m. to 5 p.m., Monday through Friday. You may leave a voicemail in the general voice mailbox after the tone.”

OUTCOME MEASUREMENT:

Date Revised

Policy statement: Specific structured tools will be periodically utilized to track clinical progress of all clients.

Applicability: This applies to all clients of MJSF&N Behavioral Health Services.

Procedure: Upon admission and at each subsequent 6-month interval, the treatment staff and caregivers of clients with a diagnosis of Autism Spectrum Disorder (ASD) will complete an Autism Treatment Evaluation Checklist (ATEC). When completed, the ATEC yields an overall score as well as 4 subscale scores: I. Speech/Language Communication, II. Sociability, III. Sensory/ Cognitive Awareness, and IV. Health/Physical/Behavior.

In a parallel manner, upon admission and at each subsequent 6-month interval, the treatment staff and caregivers of clients who do not have an ASD diagnosis will complete a Child and Adolescent Needs and Strengths (CANS). (If the client is age 14 or older, he or she will be asked to participate in the scoring.)

The CANS provide 35 different dimensions on which a youth may have issues, which are grouped into five general categories: I. Problem Presentation, II. Risk Behaviors, III. Functioning, IV. Child Safety, and V. Family/Caregiver Needs and Strengths.

At the time of each Comprehensive Biopsychosocial Reevaluation, the evaluator will assess the client’s status on their most recent ATEC or CANS and compare their most recent scores to their previous ones in order to inform the most appropriate direction for treatment.

In addition, at 6-month intervals, an Outcomes Committee (consisting of the Clinical Director and several other staff) will assess system wide improvement on the major dimensions of the ATEC and CANS. Clinical improvement of clients will be determined for the staff assigned to each client, to determine whether some staff are substantially more effective than other staff. These results will be reported to the Directors.

PERFORMANCE EVALUATIONS:

Date Revised: August 2019

Policy statement: MJSF&N and OP supervisors will periodically provide thorough assessments of the strengths and weaknesses for all new and existing staff.

Purpose: This policy is designed to enable staff to recognize their strengths as well as those areas in which they need improvement.

Applicability: This policy applies to all contracted and salaried employees of MJSF&N and OP.

Procedure:

1. Following their hire, a new staff person will be reviewed by their Supervisor by means of a 60-day evaluation, utilizing observation and performance appraisal. This review will be conducted annually from the date of hire or from the date of a change in position thereafter. Competency will be determined by such methods including but not limited to annual management by development process, direct observation, chart reviews, treatment team meetings, individual supervision, feedback from clients and family members, and client and parent satisfaction surveys.

2. Performance appraisals shall be prepared on all employees annually. The appraisals shall be related to the job description and job performance, and the criteria used to evaluate job performance shall be valid, reliable, and objective. Annual performance appraisals may be considered as part of a decision for merit increase and promotions. The performance appraisal is to be viewed as an instrument to find opportunities for improvement. The appraisal should be discussed with the employee and the employee should be given the opportunity to review the evaluation form and comment upon it.

3. When there is deemed to be a deficiency in the employee's job performance, the employee should be informed of the reasons for the deficiencies and the actions that should be taken to improve their job performance. A performance improvement plan should be put in place with a specified date for improvement. If it is determined that job has not improved sufficiently, the staff member may be terminated.

4. The supervisor providing the performance appraisal and the employee should sign and date the evaluation form. The evaluation forms should be maintained in the employee's personnel file.

5. All personnel employed by this organization will receive supervision. Job descriptions will specify the method, procedure, and degree of supervision. Generally, supervision will be based on personal observation, quality improvement criteria, and production. Written documentation will be used in performance appraisals where applicable and written peer review instruments will also be used in clinical areas where such instruments exist.

Responsibilities of Supervisors include but are not limited to departmental orientation, competency tests, work assignments, evaluations, disciplinary procedures, first level complaint resolution, promotion, approval for PTO, and other duties as may be found necessary.

Health & Safety

Medical Emergencies Policy

I. POLICY:

A. It is the policy of MJSFN to provide prompt attention and appropriate assistance to persons served, staff members, and visitors in the event of a medical emergency. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations.

II. PROCEDURES:

A. The Safety Officer is responsible for oversight of emergency disaster plans and drills and ensuring that all of the organization’s facilities are well prepared to respond effectively to any emergency.

B. Specific procedures will be maintained for medical emergencies. In addition, medical emergency drills will be conducted annually.

C. The overall components of the organization’s medical emergency plan are as follows:

1.) A medical emergency is defined as an incident that requires interventions beyond simple first aid available at the facility in order to stabilize a condition that may result in a serious medical outcome. Conditions include, but are not limited to, excessive bleeding which is unable to be controlled, accidents involving serious injury, failure or obstruction of the respiratory system, failure of the circulatory system, chest pain or severe abdominal pain, loss of consciousness unrelated to predictable seizure activity, or any type of distress that is determined to seriously limit an individual’s normal level of daily functioning.

2.) When an event occurs that is determined to be an emergency health care incident, 911 will be immediately called to access emergency personnel to assist and transport the individual to medical services.

3.) The organization’s critical incident policy will be followed for all medical emergency events.

4.) If determined to support the stabilization of a serious and acute medical condition, staff members who hold current certification in CPR and First Aid will implement CPR and/or First Aid procedures, when appropriate, to stabilize a condition prior to the arrival of external emergency personnel.

5.) If the individual is a person served, the Emergency Medical Treatment Form will be accessed, contact made with the emergency contact names, and pertinent information will be given to the transporting emergency technicians. All Emergency Medical Treatment Forms will include:

· Name, address, and telephone number of the physician to be called.

· Name, address, and telephone number of a relative or other person to be notified.

· Medical insurance company name and policy number, or Medicaid/Medicare number.

· Information concerning the use of medication, medication allergies, and significant medical problems.

D. Employees will not transport individuals in their personal vehicles and/or the organization’s vehicles in emergency health care situations.

E. Following containment of the emergency, a progress note will be completed in the record of the person served and a Critical Incident Report form will be completed.

F. If the emergency involves an employee, the designated staff responsible for the sited human resource files will access the Employee Emergency Contact Form. Employee emergency medical forms will include the following information:

a. Name and number of primary care physician

b. Name and number of emergency contact person

c. Allergies and blood type

d. Any medical conditions that the employee may deem important and voluntarily disclose on the form that could assist emergency responders, such as medications and physical health conditions.

e. Preferred medical treatment location.

G. Contact will be made with the emergency contact person named, if requested to do so by the staff member. A contact will always be made if the staff member is incapacitated and unable to request or deny the contact.

H. The telephone number of the local poison control center will be posted throughout the organization. All staff members and persons served will be orientated to the location of this information.