Policy and Procedure manual updates

Progressions Behavioral Health Systems, Inc.

POLICIES AND PROCEDURES MANUAL for

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

Revised October, 2015

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TABLE OF CONTENTS:

Admissions …………………………………………………………….……………………………… Page 4 Appointments/Rescheduling ……………………………………….………………………… Page 6 Assessment for BHRS Services ………………………………………………………………. Page 7 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

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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

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ADMISSIONS: Date Revised: January, 2010 Policy statement: Progressions’ Behavioral Health Rehabilitation Services (BHRS) will evaluate any child or youth up to the age of 21 for the treatment of serious emotional and/or behavioral problems. Progressions’ Outpatient (OP) 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 Progressions sites that offer BHRS services, this policy applies to all children and teens up to the age of 21 who are residents of Pennsylvania, 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 Progressions sites that offer OP services, this policy applies to adults, in addition to youth as described in the preceding sentences.

Progressions 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. Legal references: 55 PA Code §5200.32(a)(2); 28 PA Code §709.30(2); 28 PA Code §709.91(4); 55 PA Code §157.41(a)(1); 28 PA Code §709.91(2); PA Code §157.41(b)(1)&(2); 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 Progressions 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 OP 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, BHRS, or outpatient 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 Progressions Consent for Treatment. If the Initial Assessment results in a recommendation for OP services, or the Comprehensive Biopsychosocial Evaluation results in a prescription for either OP or BHRS services, the Site Director (or Case Manager) will begin to make arrangements to provide services as soon as possible.

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Criteria for admission: In order for a child or youth 21 years of age or younger to be evaluated for BHRS or OP 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 (OP) 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 BHRS services unless there are exceptional reasons. For logistical and administrative reasons, Progressions BHRS services are generally limited to youths who reside within the following counties: Berks, Bucks, Carbon, Chester, Delaware, Lehigh, Montgomery, Monroe, Northampton, Philadelphia, and Pike. For similar considerations, Progressions OP services are generally limited to youths and adults who reside in Berks, Bucks, Montgomery, and Philadelphia counties. Funding for services is generally provided through the Medical Assistance program of the State of Pennsylvania. In order for an adult to be evaluated for OP 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: Progressions’ 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 BHRS and OP 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 BHRS and OP 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 BHRS and OP staff will make every attempt to provide services in a more timely 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 BHRS 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 BHRS staff and/or the client/family, then the family should take the client to the nearest mental health crisis intervention center; BHRS staff will provide the family with the appropriate phone number and address of the crisis center. For existing clients who are receiving OP 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.

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APPOINTMENTS/RESCHEDULING: Date Revised: March, 2012 Policy statement: Progressions 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 Progressions BHRS and OP staff. Applicability: This policy applies to all clients, parents or legal guardians, as well as to Progressions BHRS and OP staff. Procedure: All appointments will be scheduled at the convenience of the client (and/or family, if appropriate), dependent upon the availability of Progressions staff. If Progressions staff fail 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 BHRS 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 Progressions staff, and should inform the staff person’s supervisor if they feel that they have been asked to do otherwise.

For OP 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 Progressions 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.

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ASSESSMENT FOR BHRS SERVICES: Date Revised: February, 2012 Policy statement: Progressions staff will provide a thorough evaluation of any youth up to the age of 21 with moderate to serious behavioral health issues to determine the most appropriate course of treatment. In addition, Progressions BHRS will provide a comprehensive re-evaluation of the youth 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 take into account all relevant biopsychosocial factors that could impact the youth, in order to formulate the most effective and appropriate Treatment Plan possible. Applicability: This policy applies to all children and teens up to the age of 21 who are residents of Pennsylvania, 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. Progressions 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 Pennsylvania- 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 BHRS 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 BHRS 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

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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 BHRS 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, judgement 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).

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 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-IV five-axis diagnosis must be included, as will 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.

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ASSESSMENT FOR OUTPATIENT SERVICES: Date Revised: August, 2012 Policy statement: Progressions OP 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 Pennsylvania, 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. Progressions 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.

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 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.

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CLIENT RIGHTS AND INFORMED CONSENT POLICY: Date Revised: January, 2010 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 Progressions. 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 Progressions 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 Progressions BHRS and OP age 14 or older and to the parents or legal guardians of clients who are less than 14 years of age. Legal references: 28 PA Code §709.91(4); 55 PA Code §5100.73(a)&(b). 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:

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 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.

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CLINICAL DOCUMENTATION: Date Revised: January, 2010 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 Progressions BHRS. Procedure: 1. All client charts shall contain: a. Initial clinical assessment b. Progress notes c. Medication record d. Treatment Plan e. Intake information f. Consent to treatment g. Discharge summary 2. 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.

3. 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.

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

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CLINICAL SUPERVISION: Date Revised: July, 2015 Policy statement: Progressions 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 Progressions BHRS. Legal references: 28 PA Code §704.9; 55 PA Code §5200.23; 55 PA Code §5200.22(j). Procedure: Progressions will adhere to all pertinent Pennsylvania 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 BHRS and OP staff. The Chief Operating Officer of ambulatory services oversees the overall provision and administration of services; the Clinical Director of BHRS 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 Progressions 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.

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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 3. Supervision of BSCs, MTs, LCs, and GMTs: All BSCs, MTs, LCs, and GMTs 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 BSC, MT, LC, and GMT. 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 BSC will coordinate and schedule weekly supervisory meetings with the TSS. It is the BSC’s responsibility to chart the attendees and the content of each meeting. The BSC will schedule weekly contact with the TSS (if one is assigned). Meetings with the TSS

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will last at least 30 minutes if the TSS works less than 20 hours/week total, and will last at least an hour if the TSS works more than 20 hours/week. 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.

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COMPLAINTS BY CLIENTS OR THEIR CAREGIVERS: Date Revised: May, 2012 Policy statement: Progressions 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 Progressions BHRS 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.

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COMPLIANCE POLICY: Date Revised: June, 2015 Policy: Progressions 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 Progressions BHRS and OP staff. Procedure: The Compliance Committee consists of the Director of Quality Assurance/Compliance and the Site Directors, Regional Directors and COO, 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 Progressions’ 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

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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 BHRS 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. Progressions 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 Progressions are refunded to the MCO.

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CONFIDENTIALITY OF CLIENT INFORMATION:

Date Revised: August, 2010 Policy statement: Progressions 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 Progressions of all information pertaining to clients and their families. Legal references: HIPAA; 28 PA Code §709.28; 55 PA Code §5100.31(c)&(h); 55 PA Code §5100.31- 5100.39. 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 Progressions 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, Progressions will comply only upon approval of the Program Director or of Progressions’ Legal Counsel. Progressions will protect the confidentiality of all Protected Health Information (PHI) in its records at all stages of collection, use, storage, disclosure, and destruction. Every Progressions 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 Progressions’ 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, Progressions 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 Progressions staff, except as otherwise required by court order. The Protected Health Information (PHI) will be available to all Progressions 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.

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1. When disclosing PHI in accordance with this Policy, Progressions 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 Progressions 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 Progressions BHRS 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 Progressions who are currently providing treatment to the consumer to the extent that they need the information to provide proper care and treatment (Legal references 55 P.S. §7111; 55 PA Code §5100.32(a)(1)).

 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, i.e., a petition filed under §§ 302, 303, 304, or 305 of the Mental Health Procedures Act (1976). (Legal reference: 55 P.S. §7101 et seq. 55 P.S. §7111; 55 PA Code §5100.32(a)(5)).

 A judge or court in response to a court order, only if the court has actually issued an order directing the release. (Legal reference: 55 P.S. §7111; 55 PA Code §5100.32(a)(6)and(7)). Note: A subpoena is not a court order. If a provider receives a subpoena only, check with legal counsel. (Legal reference: 55 PA Code §5100.35(b)).

 To lawyers who provide written proof that they represent the consumer, which is usually accompanied by a signed authorization. (Legal reference: 55 P.S. §7111; 55 PA Code §5100.32(a)(11)).

 To police or other government officials, if: an official needs to know if a consumer is present or absent from a particular facility, he/she may only receive information under the following circumstances:

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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 (Legal reference: 55 P.S. §7101 et seq. 55 P.S. §7111; 55 PA Code §5100.32(a)(5)).

If any of the above elements are missing, do not release the information requested. (Legal reference: 55 PA Code §5100.32(f)).

 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. (Legal reference: 55 PA Code §5100.32(a)(2)).

 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. (Legal reference: 55 PA Code §5100.32(a)(9)). This includes an emergency situation where a psychiatric client threatens to harm a third party. (Legal reference: Ms. B. v. Montgomery County Emergency Service, 799 F.Supp. 534 (E.D. Pa. 1992), aff’d, 989 F. 2d 488 (3

rd cCir. 1993), cert. den., 114 S.Ct. 174

(1993)).  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. (Legal reference: 55 PA Code §§5100.32(4), 5100.36).

 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. (Legal reference: 11 P.S. §1101 et seq.; 55 PA Code §5100.38).

 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 (Legal reference: 55 PA Code §5100.33).

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 Progressions 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 Pennsylvania laws or regulations governing the Use or Disclosure of PHI are in conflict, Progressions will exercise reasonable care to comply with Pennsylvania 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

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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 Progressions’ offices under direct supervision of staff.

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CREDENTIAL, HEALTH, AND BACKGROUND CHECKS FOR EMPLOYEES AND CONTRACTORS: Date Revised: September, 2015 Policy statement: Progressions will verify on a regular basis the credentials and the criminal and child abuse history of all staff who come 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 Progressions employees and contractors, both clinical and non- clinical. Legal references: 35 P.S. §10225.502(a)(1)&(2); 18 PA C.S.A. §9109; 28 U.S.C.A. §534(a)(1). 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 Pennsylvania 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 Progressions 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 Progressions 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 Progressions BHRS. Progressions BHRS 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 Progressions BHRS 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,

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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 (P.L. 233, No. 64), 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 Pennsylvania 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 Progressions 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 Progressions email accounts or through Credible. It is their responsibility to check their Progressions email and Credible on a regular basis and to respond to messages accordingly. The employee or contractor should also make sure that their Progressions 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 Progressions 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.

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CRITICAL INCIDENT POLICY: Date Revised: March, 2012 Policy statement: Progressions 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 Progressions BHRS or OP, in their contact with any client or individual associated with the identified client. Procedure: Progressions 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 Progressions BHRS 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, Progressions 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 to the Commonwealth’s CHILDline at 800-932-0313.

Progressions 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. Progressions will report a missing person who is “at-risk” to the Mental Health Delegates, by faxing a Missing Person Report Form to 215-732-2508. 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.

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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 Progressions BHRS 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 (as defined in 28 PA Code §27.2 relating to reportable diseases)

 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

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CULTURAL COMPETENCY: Date Revised: April, 2012 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, Progressions will seek to recruit persons who are demographically representative of our clients, for staffing all levels of our organization. Further, the management staff of Progressions 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 Progressions 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, Progressions 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 Progressions 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.

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DANGEROUS OR INAPPROPRIATE ITEMS BROUGHT ON PREMISES: Date Revised: May 2013 Policy statement: Dangerous and inappropriate items are prohibited from all Progressions premises. Purpose: To ensure the safety of all clients, their family members, and staff. Applicability: This policy applies to all contracted and salaried employees of Progressions BHRS and OP, all clients, their family members, and all visitors on Progressions property. Procedure: All firearms, knives or another other dangerous/deadly weapons are prohibited from being brought onto Progressions property, unless carried by an officer of the law as part of his or her official duties. Should staff become aware that a client, family member, visitor, or other staff person has brought a firearm onto Progressions’ premises, staff will request that that individual leave and not return until they are no longer carrying a firearm on their person. Should the individual in question refuse, the Site Director or COO should be contacted. Should the individual in question also refuse the request to leave made by the Site Director, COO, or their designee, then the police should be called to have the individual removed. This same policy will apply to other such weapons as the Site Director may determine to apply, such as hunting knives.

All illegal drugs and alcohol are prohibited from being brought onto Progressions’ property. Should staff become aware that a client, family member, visitor, or other staff person has brought illegal drugs or alcohol onto Progressions’ premises, staff will request that that individual leave and not return until they are no longer in possession of such contraband. Should the individual in question refuse, the Site Director or COO should be contacted. Should the individual in question also refuse the request to leave made by the Site Director, COO, or their designee, then the police should be called to have the individual removed. Legally prescribed drugs may be brought onto Progressions’ premises, as long as they are kept securely on the person of the individual for whom it is prescribed, or on the person of the caregiver if the individual is a minor. Any member of Progressions staff who is found to have brought weapons, alcohol, or illegal drugs onto Progressions’ premises will be subject to disciplinary action. Depending on the circumstances and the severity of the infraction, the individual could be subject to as severe a consequence as termination of employment.

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DEMOGRAPHIC INFORMATION: Date Revised: January, 2011 Policy statement: Progressions BHRS 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 Progressions BHRS and OP 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.

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DISCHARGES: ADMINISTRATIVE OR AGAINST FACILITY ADVICE: Date Revised: January, 2010 Policy statement: All client/families are free to end treatment with Progressions BHRS or OP at any time. Further, Progressions BHRS and OP 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 Progressions’ 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 Progressions. Legal references: 28 PA Code §709.91(4); 28 PA Code §709.33(a). 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 Progressions 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 Progressions staff.) If the client/family chooses to terminate treatment against the advice of the Progressions 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 Progressions BHRS or OP choose to discontinue treatment to a client/family, the appropriate managed care corporation will be informed. Progressions 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 Progressions’ 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):

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For clients who are minors: [Date] Dear __________ (caregiver), This letter confirms your decision to discontinue (“BHRS” – or – “Outpatient”) services for (name of client) through Progressions. (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 Progressions. 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.

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DISCHARGE DOCUMENTATION: Date Revised: January, 2010 Policy statement: Progressions BHRS and OP 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 Progressions BHRS and OP. Legal references: 55 PA Code §157.22(b); 55 PA Code §157.23(a); 55 PA Code §5221.33(5)(iii); 28 PA Code §709.93(10); 55 PA Code §1101.51(e)(1)(iv). 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 BHRS cases and by the Outpatient Therapist for OP 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 BHRS services, the follow-up appointment will be made prior to the discharge of the client from BHRS services, and BHRS staff will offer to assist in this process.

Upon termination from BHRS 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 Progressions in the client’s treatment record, with a copy given to the family.

For BHRS 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

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 Anticipated problems/concerns for future compliance

 Primary Care Physician

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EMERGENCY PROCEDURES: GENERAL PREPAREDNESS Date Revised: May, 2012 Policy statement: Progressions will take seriously all potential threats to the welfare of clients, staff, and property, and will strive to anticipate effective responses to all such foreseeable threats. Purpose: To ensure that Progressions staff are adequately prepared for all foreseeable emergencies. Applicability: This applies to all Progressions sites. Procedure: The personnel responsible for health and safety plans & procedures will be identified for each site. Unannounced tests of each emergency procedure will be conducted at each site on a monthly basis, and the Site Director for each site will assess by written survey the adequacy of response and how to improve any inadequacies identified. In addition, an external authority will be formally engaged on an annual basis to conduct an inspection of all sites for health & safety issues.

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EMERGENCY PROCEDURES: EVACUATION Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats to the welfare of clients, their family members, and staff. When it is determined that all personnel need to be evacuated from Progressions’ premises, this shall be done in an orderly and efficient manner. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff. Applicability: This applies to all such occasions when it is determined that all personnel need to evacuate Progressions’ premises. Procedure: 1. If there is an alert to evacuate the building due to a fire alarm or drill, or at the direction of the Site

Director or designee, or at the direction of proper authorities, the evacuation process shall begin

immediately.

2. The COO or designee shall be notified immediately. If there is an emergency situation, the staff

member alerted to the emergency shall call 911 immediately.

3. All persons shall evacuate using the closest available Exit door.

4. The Site Director or designee shall ensure that all staff, clients, and their family evacuate the building.

5. The Site Director or designee shall designate an Assembly Area in the safest area near the building.

6. After evacuation procedures are complete and if deemed safe by the Site Director or designee or

proper authorities, all persons may return to the building. If not, staff, clients, and family members will

be sent home.

7. During the evacuation process. staff members shall always close doors and windows If time permits

and if it is safely possible.

8. All lights will be left on.

9. If staff members have already evacuated to the assembly area, no staff member shall re-enter the

building for any reason unless notified by an authorized person to do so.

10. The above procedures also apply in their entirety to safety drills, except for the passages concerning

contacting outside authorities.

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EMERGENCY PROCEDURES: FIRE Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats of fire in an orderly and efficient manner. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff, as well as Progressions’ property. Applicability: This applies to all such occasions when it is determined that a fire is occurring on Progressions’ premises. Procedure: 1. Site Director or designee is to call 911 if there is a report of a fire in the building or if the alarm

system sounds and indicates there is a fire in the facility. COO or designee shall be notified immediately.

2. Staff members shall remain calm and use common sense to model poise and composure with clients

and family members.

3. Site Director will call the building management company to alert them of the fire alarm.

4. Evacuation shall begin in the suspected area, moving away from the problem location. The local Fire

Marshall will check all fire sensors, detectors, and pull boxes in the problem area to determine where

the alarm was activated. Evacuation procedure shall be followed.

5. Staff will assemble in the designated Assembly Area near the building and the Site Director will take a

head count of staff. Stairs will be used in lieu of elevators.

S. After evacuation procedures are complete and if no evidence of fire has been found and if the Fire

Marshall or Building Management Company approves, staff, clients, and family members may return to

the building,

7. During the evacuation process, always close doors and windows if time permits.

8. Lights shall be left on.

9. Heat sources shall be turned off if time permits.

10. Staff members shall only fight a fire after the area has been evacuated and if it seems that the fire

can be extinguished safely.

11. If staff members have already evacuated to the assembly area, staff member shall not re-enter the

building for any reason unless notified by an authorized person to do so.

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EMERGENCY PROCEDURES: FLOOD Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats to the welfare of clients, their family members, and staff, as well as to Progressions’ property. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff, and the welfare of Progressions’ property, especially including client records. Applicability: This applies to all such occasions when it is determined that Progressions’ premises are at risk of flooding. Procedure: a. All staff, clients, and family members located in the immediate area of a flood shall be moved to a

secure part of the building, if possible, and made as comfortable as possible.

b. Efforts shall be made by staff to salvage any facility property which may be in danger, such as client

records, employee records, emergency information and first aid supplies.

c. If it is not possible to control the flood and there is no safe and secure area of the building to move to,

the Evacuation Procedure shall be followed. Staff shall notify COO and keep in constant communication

for updates and direction. It can only be COO or designee’s decision for total evacuation.

Note:

None of Progressions’ current locations are in a flood plain. Hence, the risk of flood would appear to be

extremely low.

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EMERGENCY PROCEDURES: HURRICANE Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats to the welfare of clients, their family members, and staff, as well as to Progressions’ property. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff, and the welfare of Progressions’ property. Applicability: This applies to all such occasions when it is determined that Progressions’ premises are at risk of hurricane damage. Procedure: a. Staff members shall close all doors.

b. Staff members shall cover windows with drapes and blankets to protect against flying glass.

c. Site Director shall monitor emergency weather reports, such as by computer, radio, or smartphone.

d. In the event of flooding, follow the procedure listed under Flood Procedure.

e. If conditions are severe and adaptation cannot reasonably be made, the plan for total evacuation will

be followed. Staff shall notify COO and keep in constant communication for updates and direction. It

can only be COO or designee’s decision for total evacuation.

d. These procedures are primarily intended to cover staff and office closings, since hurricanes are slow

moving and our BHRS and Outpatient sites are not likely to have more than around 5 clients scheduled

or in treatment at any one time.

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EMERGENCY PROCEDURES: MEDICAL EMERGENCIES: Date Revised: June, 2013 Policy statement: Progressions staff will responsibly manage medical emergencies that may arise. Purpose: This policy is designed to ensure that staff and clients receive appropriate medical care. Applicability: This policy applies to all clients of Progressions BHRS and OP. Procedure: A medical emergency is defined as any situation in which there is reason to believe that a staff member, client, or family member might require immediate medical attention to treat a potentially serious medical condition that may have arisen. This could include but not be limited to such medical events as a suspected heart attack or stroke, profuse bleeding, fainting, or any other potentially serious medical condition. In the event that a medical emergency is believed to have occurred, staff should call 911 to arrange for emergency transport to the nearest hospital. Following the 911 call, staff should provide emergency treatment to the affected individual only to the extent that the staff are qualified. Hence, staff who have current CPR certifications may perform CPR on an individual who may have collapsed due to a suspected heart attack. An Automatic Emergency Defibrillator will be kept at each office and may be utilized by staff who have been trained in its use. Medical doctors employed by Progressions may provide additional treatment to the extent that they feel qualified.

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EMERGENCY PROCEDURES: NUCLEAR ACCIDENT Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats to the welfare of clients, their family members, and staff. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff. Applicability: This applies to all such occasions when it is determined that a nuclear accident has occurred within the affected vicinity. Procedure: 1. In the event of a nuclear accident in the area surrounding the facility, all staff, clients, and family

members are to remain inside the building. The building shall be made secure and no one will be

permitted to leave or enter the building while the emergency is in force.

2. The Site Director or designee shall call the COO and the Building Management Company and accept

any direction or updates.

3. In the event that an evacuation is determined to be necessary, all preparations shall be coordinated

with the County Emergency Services.

Note: This procedure applies primarily to our Pottstown site and secondarily to our Reading site, the closest locations to the Limerick Nuclear Power Plant.

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EMERGENCY PROCEDURES: SNOWSTORM Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats to the welfare of clients, their family members, and staff. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff. Applicability: This applies to all such occasions when it is determined that transportation has been or is at imminent risk of being severely impacted by a winter storm. Procedure: a. When it is determined that transportation has been, or is at imminent risk of being, severely

impacted by a winter storm, the Site Director or designee may choose to cancel, open late, or close early

any sessions for the day/evening.

b. The Site Director or designee will contact staff to inform them of cancellation, and all staff will be

advised to leave for their homes, as long as it is felt to be safe to do so.

c. The Site Director and COO will coordinate with each other the decision to close, open late, or close

early.

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EMERGENCY PROCEDURES: THREAT OF VIOLENCE Date Revised: March, 2012 Policy statement: Progressions will take seriously all potential threats to the welfare of clients, their family members, and staff, and respond to all such threats as appropriate. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff. Applicability: This applies to all such occasions when a threat of physical harm in any form is made to Progressions staff. Procedure: A threat of physical harm (such as by bomb, chemical or biological weapon, or shooting) may be received either by phone, a letter, a package, or by personal contact. It is important the person initially receiving such a threat remains calm and does not panic. 1. THREAT RECEIVED BY PHONE CALL. a. The person initially receiving such a threat shall alert another staff member, if possible, by whatever means possible, while keeping the phone call going. This could be by a written message, gesturing to staff or even gesturing to a client or family member to get another staff member; this second staff member shall call 911 immediately and notify the Site Director and COO or designee. b. Staff member receiving such a call shall attempt to keep the caller on the line in order to obtain as much information concerning the nature of the threat of harm, such as the time of the threatened incident, the location and appearance (if a bomb), the reasons for the attack, and the identity of the person. If there is no other staff member present, the staff member receiving call shall immediately call 911 and the COO or designee. c. The fire alarm shall be pulled to initiate an evacuation. d. Staff members are encouraged to remain calm in order to model poise and composure to clients and family members. 2. THREAT RECEIVED BY LETTER/PACKAGE/PERSONAL CONTACT a. Person initially receiving threat by letter or package or personal contact shall immediately call 911, and notify Police and COO or designee. b. The letter or package should not be handled until an inspection is performed by the proper authorities. c. A staff member receiving information through personal contact should engage the person in conversation and obtain as much information as possible concerning the time of the attack, the location of the attack, the appearance of the weapon, the reasons for the attack, and the identity of the person. The staff member will then immediately call 911 and notify the Police and COO and/or the Site Director. d. The fire alarm shall be pulled to initiate an evacuation. e. Staff members are encouraged to remain calm in order to model poise and composure to clients and family members. f. In the event that a disgruntled client, family member, visitor, or employee expresses a threat which includes even a vague reference to committing physical harm to someone or some property, the staff member receiving this information should promptly notify the Site Director and COO.

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3. ADMINISTRATIVE RESPONSE a. If a physical attack is alleged to be imminent, all staff, clients, family members, and visitors shall evacuate the building immediately. They shall congregate as far from the building as possible. b. Once the police and/or other designated authorities arrive on scene, they are then responsible for the situation and will issue necessary orders and directions. All staff shall follow whatever directions are given. c. If the Police and/or designated authorities deem an area safe after search, shelter can be sought there. d. If the Police and/or designated authorities estimate a long procedure will be involved, clients will be sent home. 4. SEARCH FOR THE WEAPON The entire facility shall be searched only by police and/or designated authorities even if a location is given or a suspected weapon has been found, in the event that more than one weapon may have been placed. 5. INJURIES a. in the event of injuries resulting from an explosion or attack, staff, clients and/or family members shall be sent to the nearest Emergency Room via ambulance. b. All available information shall accompany the client in the ambulance. 6. INQUIRIES Inquiries from the news media shall be handled only by the COO or designee.

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EMERGENCY PROCEDURES: TORNADOES Date Revised: March, 2012 Policy statement: Progressions staff will respond appropriately to all potential threats to the welfare of clients, their family members, and staff. Purpose: To ensure the safety of Progressions clients, family members of clients, and staff, as well as to Progressions’ property. Applicability: This applies to all such occasions when it is determined that a tornado is in the vicinity. Procedure: a. The Site Director shall listen to emergency weather reports, such as by computer, radio, or

smartphone.

b. If a tornado is believed to be in the vicinity, staff and clients will be advised to remain indoors away

from windows until the danger has passed. Staff shall notify COO and keep in constant communication

for updates and direction.

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EMERGENCY PROCEDURES: UTILITY FAILURES: Date Revised: June, 2013 Policy statement: Progressions staff will implement emergency procedures in the event of a utility failure. Purpose: This policy is designed to ensure that treatment and services will be impacted as little as possible in the event of a utility failure. Applicability: This policy applies to all clients of Progressions BHRS and OP. Procedure: Water outage: In the event of a loss of water at an office, staff will immediately inform clients and their guardians who are present at the site at that time, indicating that they could stay for their appointment, or reschedule should they wish. Staff will also immediately call clients/guardians who are scheduled to come to the office that day, to inform them of the loss of water and offering to reschedule them should they so desire. Power outage: In the event of a loss of electric power at an office, staff will cease to perform their regular duties and clients and their families should be sent home. Should management have reason to believe that the outage will last less than an hour, then staff will be asked to wait for the power to return. If, however, the management has reason to believe that the power loss will likely last for more than an hour, then staff will be sent home and asked to use PTO time to cover the lost work hours.

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EMPLOYEE AND CONTRACTOR ABSENCES: Date Revised: September, 2015 Policy statement: In the event of an unplanned absence of direct service staff, Progressions will strive to ensure continuity of support for clients. Purpose: To ensure continuity of care for Progressions 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 Progressions BHRS and OP. Procedure: Should a member of Progressions 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 separated.

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EMPLOYEE AND CONTRACTOR ORIENTATION POLICY: Date Revised: May, 2013 Policy statement: Progressions BHRS 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 Progressions BHRS and OP. Legal references: 28 PA Code §709.26(b)(3) Procedure: All new employees will receive training by their 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 Progressions staff, to ensure that all employees of Progressions 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.

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EMPLOYEE AND CONTRACTOR REHIRE POLICY: Date Revised: September, 2015 Policy statement: Employees and contractors must have left Progressions 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 Progressions 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.

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EMPLOYEE AND CONTRACTOR SANCTIONS POLICY: Date Revised: May 2013 Policy statement: Progressions BHRS 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 Progressions. 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 Progressions BHRS. 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.

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EQUAL OPPORTUNITY EMPLOYMENT Date Revised: April, 2012 Policy statement: It is the policy of Progressions 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 hirees from all forms of discrimination on the basis of 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:

Progressions 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.

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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.

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ETHICAL CONDUCT POLICY: Date Revised: June, 2010 Policy statement: Progressions 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 Progressions staff are performed in an ethical manner. Applicability: This policy applies to all Progressions BHRS 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 is 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

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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 Progressions, 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. Progressions 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.

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HAZARDOUS WASTE POLICY: Date Revised: June, 2013 Policy statement: Progressions staff will ensure that all potentially hazardous materials are used, stored, and disposed of in an environmentally safe manner. Purpose: To ensure that no harm will occur to humans and the environment. Applicability: This policy applies to all Progressions BHRS and OP Staff. Procedure: The types of materials that could be considered hazardous (harmful) are materials that exhibit the following characteristics: ignitable (can catch fire), corrosive (acids and bases), reactive (can explode) and toxic (poisonous), as well as materials identified specifically by the Federal or State governments as hazardous. This list includes, in addition, fluorescent bulbs that have shattered, since such items are likely to contain mercury. Handling of Hazardous Materials a. Each site shall have a “spill kit” on hand as well as rubber or latex gloves for the safe handling of accidental spills of hazardous materials. b. All instances of handling and/or disposal of hazardous materials will be documented by the Site Director or designee in a manifest specifically for this purpose. c. The Safety Officer will be notified of all instances involving the handling or storage of hazardous materials at a site. Storage of Hazardous Materials a. Hazardous materials shall be stored in a compatible fashion to prevent accidental reactions, explosions, or discharges. b. An inventory of hazardous material shall be maintained at each site. c. A material safety data sheet shall be maintained on site for all hazardous material inventoried. d. All hazardous materials shall be labeled with the product identity, hazard warning, and the name and address of the manufacturer. e. No unidentified or unlabeled substance will be used, handled, or stored. f. No hazardous materials shall be used, handled, or stored at any site unless the Director has been notified and approves such activity. This includes, but is not limited to, pesticides, cleaning chemicals, and solvents. Storage of Hazardous Waste a. The Safety Officer will be notified when hazardous materials need to be discarded. The Safety Officer shall provide all materials necessary to properly store hazardous waste. All hazardous waste disposals will be coordinated by the Safety Officer. b. Keep hazardous waste containers closed when not in use. c. Store hazardous waste in proper containers (no severe rusting or apparent structural defects). If a container leaks, contact the Safety Officer for assistance. d. If more than one hazardous waste is stored in the same container, the wastes must be compatible. Contact the Safety Officer for guidance. e. Containers must be stored in a manner that prevents an accidental release to the environment. f. Staff will ensure that hazardous waste containers are properly labeled.

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g. Staff will ensure that the possibility of an unplanned release into the environment is minimized. Universal Wastes. Universal wastes are hazardous wastes that are more common and pose a lower risk to the environment. The types of wastes that could be considered universal are: mercury and mercury- containing devices (switches, thermometers, batteries, fluorescent lamps), cathode ray tubes (CRTs, TVs, computer monitors); non-empty aerosol cans (paint spray); and household batteries (rechargeable and nonrechargeable). Universal wastes must be handled as hazardous wastes using the aforementioned guidelines. Restricted Wastes. Restricted wastes are wastes that may not contain hazardous characteristics but could pose a hazard if improperly discarded into the trash, sewer, ground or air. Contact the Safety Officer for guidance. Biohazardous and Medical Wastes. Biohazardous and medical wastes are wastes that could contain bloodborne pathogens or be considered infectious and pose a health risk to people and animals. Contact the Safety Officer for guidance. Stormwater Pollution. The stormwater system is intended solely for the purpose of conveying stormwater. Generally, storm drains are located outdoors, unlike sewer drains located in buildings for conveyance of domestic waste. No substances or materials may be discharged into storm drains or stormwater conveyance systems. Recordkeeping. A manifest list shall be prepared for each incidence of hazardous waste disposal. Originals shall be filed with the Safety Officer; copies shall be retained at the generating site for three years. The Safety Officer shall receive an annual training based on Environmental Protection Agency guidelines in the handling, storage, and disposal of hazardous wastes.

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JOB OPENINGS Date Revised: February, 2012 Policy statement: It is the policy of Progressions to promote and transfer from within the organization

when feasible.

Purpose: To provide a means for employees to transfer into other positions within the organization. Applicability: This applies to all Progressions staff. Procedure: 1. When a position is vacated or is soon to be vacated, or a new position is authorized, the Site Director

will send an email to staff informing them of the opening. The email will include the job title and

number of hours per week anticipated.

2. Interested employees may apply by responding to the Site Director’s email.

3. The Lead Case Manager may interview potential TSS and CM candidates. The Site Director will

interview potential BSC, MT, and OP candidates. The Site Director will make a formal job offer to

qualified candidates.

4. The COO and Regional Director will interview Site Director and Psychologist openings. The Clinical

Director will be consulted on Psychologist openings.

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MANAGEMENT OF ESCALATION POLICY: Date Revised: January, 2010 Policy statement: Progressions BHRS and OP will promote the use of constructive and nonviolent techniques to de-escalate potentially volatile and dangerous situations with clients and/or their families. Purpose: This policy is designed to ensure the safety of all clients, families, and staff associated with Progressions BHRS and OP. To ensure a safe environment for Progressions staff and clients, it is imperative that all staff are competently trained to appropriately manage aggressive client behavior in a safe, effective, and least restrictive manner. Applicability: This policy applies to all staff who are in clinical contact with clients and their families. Procedure: It is the policy of Progressions to mandate all staff, clinical and non-clinical, to receive training and demonstrate competency in the management of verbal or physical aggression on this site. Training will be given during the orientation process and yearly thereafter. Trainees will receive certificates of completion which will be placed in their personnel files. This training will emphasize the crucial importance of identifying escalation by clients and/or their family members, and offer strategies to de-escalate such situations, through dialogue as well as through careful attention to nonverbal cues. At no time should physical contact be used by Progressions staff to restrain clients. Should a client appear to be out of control and a danger to self or to others (outside of school hours), then the parent/legal guardian will be consulted. However, while the client is attending school, the school’s policy on such conduct will prevail.

Training:

1. All staff will be required to attend a Management of Escalation workshop. Workshops will be conducted on site or at a location designated by trainers. Training will be given by qualified Progressions staff.

2. Training will be didactic and experiential. Pre-test and post testing will be done. Scope of Training: All staff must master the following techniques for de-escalation and managing verbal aggression.

1. Clear the area of bystanders and avoid becoming a spectator when someone is in the vulnerable stage of crisis, in order to minimize the emotional contagion associated with aggression/violence.

2. Adjust the personal space between yourself and the client as the client’s anxiety level increases/decreases. Give the client an opportunity to de-escalate on his or her own by giving the person space. Three feet is considered a neutral zone.

3. Stay relaxed. If you are tense, you will need to relax before you can intervene effectively.

4. Proactively utilize your body language (eye contact). Neutral facial

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expression, open posture, and minimal physical gestures/movements. Avoid reactivity, communicating negative attitudes or emotions such as intolerance or anger.

5. Control your tone of voice including the rate of your speech, the cadence, pitch, volume, and modulation. You need to communicate that you are maintaining control.

6. Self-awareness – be aware of verbal and non-verbal communication and messages sent to clients.

7. Be specific and clear (verbal). 8. State exactly what the inappropriate behavior is. State exactly what is acceptable. 9. Don’t argue with clients, set limits firmly, and the follow it through. 10. Keep your tone of voice calm and even to help the client reduce anxiety and fear.

Whispering disarms a client who is yelling. 11. Do not make unrealistic promises or give confusing or disingenuous answers. 12. Follow through each time you make agreements. 13. Actively listen. 14. Ask questions that will help you help them. Who, what, where, and when. 15. Ask specifically what it is that you can do to help them. 16. Honor reasonable requests. If you cannot do something immediately, let them

know this. 17. Be sensitive to cultural/status differences between you and the client. Extreme

dissimilarities in the use of language, appearance, dress, or social status can prohibit communication, foster dissension, and/or incite conflict. Be aware that different cultures interpret eye contact and physical gestures to mean vastly different things. Attempt to be sensitive to these subtleties.

18. Control the environment. Scan the office environment for potentially dangerous furnishings/objects that could be used as a weapon (a letter opener, paperweight, small table).

19. Assure yourself of an escape route in the event that the interventions you attempt are not effective in de-escalating the client. Avoid putting yourself in a corner. Minimize the risk of being “cut off.” Consider the arrangement of furniture, the configuration of walls/doors, your distance from the egress point and the person.

20. If all efforts at de-escalation fail, call 911.

The following procedures will be followed during a crisis:

 Immediately contact the site supervisor or designate a person responsible for assessing the situation.

 Follow the de-escalation policy as per training.

 Prepare an incident report within 3 hours of the incident and give it to the Site Director.

 The circumstances surrounding the event will be fully documented afterward in the client’s chart.

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MEDIA RELATIONS & PUBLICITY: Date Revised: October, 2015 Policy statement: Progressions staff will seek to present Progressions 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 Progressions. Applicability: This policy applies to all staff affiliated with Progressions. Procedure: Public Relations/Marketing staff members, through their many contacts, will provide input with regard to needed services and community or media concerns.

Progressions strives to assure responsiveness to the community by designating the Director of Marketing as Progressions’ 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 Progressions’ 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 Progressions are answered 24 hours/day, 7 days/week.

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MEDICAL INFORMATION POLICY: Date Revised: January, 2012 Policy statement: Progressions BHRS and OP will collect and document all essential medical information as it pertains to the provision of BHRS services. Purpose: This policy is designed to ensure that Progressions BHRS and OP staff acquire a thorough understanding of all of the factors that impact on a client, including medical/biological factors. Applicability: This policy applies to all clients of BHRS and OP services. Procedure: Progressions staff will inquire regarding all pertinent medical and health-related information, and document that information in the client’s treatment record. For BHRS 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

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METABOLIC SYNDROME SCREENING: Date Revised: April, 2015 Policy statement All clients being prescribed an Antipsychotic medication by a Progressions psychiatrist will be periodically screened for the possible development of Metabolic Syndrome. Purpose: To prevent the development of the medication side-effects of hyperglycemia and diabetes. Applicability: All clients being prescribed Antipsychotic medication by a Progressions psychiatrist. Procedure: Clients who are prescribed a Second Generation Antipsychotic by a Progressions psychiatrist are screened on a periodic basis for Metabolic Syndrome. Metabolic screening should be performed according to the following schedule, based on the initiation of the Antipsychotic:

Baseline 4 weeks post-baseline

8 weeks post-baseline

12 weeks post-baseline

Quarterly Annually

Personal/ Family History

X X

Body Mass Index

X X X X X

Waist Circumference

X X

Blood Pressure

X X X

Fasting plasma glucose

X X X

Fasting lipid profile

X X X

Metabolic Syndrome will be considered to be present if at least 3 out of 5 of the following criteria are present: (1) fasting plasma glucose ≥5.6 mmol/L (100 mg/dL) or taking anti-hyperglycemic medication, (2) triglycerides ≥1.7 mmol/L (150 mg/dL), (3) high density lipoprotein (HDL) cholesterol <1.0 mmol/L (40 mg/dL) for males and <1.3 mmol/L (50 mg/dL) for females, (4) systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥85 mm Hg or taking antihypertensive medication, and (5) a body mass index (BMI)≥30 for clients age 20 or older, or a BMI percentile of 95 or greater if less than 20 years old. If a client warrants a diagnosis of Metabolic Syndrome, it will be added to the client’s current diagnosis on record, and will be referred to their Primary Care Physician (PCP). The psychiatrist will give strong consideration (and document such consideration) to reducing the dose of the Antipsychotic, or of prescribing an alternative medication with less propensity to cause Metabolic Syndrome.

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ON-CALL EMERGENCY PROTOCOL POLICY: Date Revised: January, 2011 Policy statement: Progressions BHRS 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. Legal references: 55 PA Code §5221.23(a) Procedure: During the initial orientation of new clients/families, the Case Manager (for BHRS 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:

 Berks County Crisis Center is Service Access Management (SAM). The phone number is 610- 236-0530.

 Bucks County Crisis Center is Lower Bucks Hospital. The phone number is 215-785-9765.

 Delaware County Crisis Center is Crisis Intervention Unit. The phone number is 610-494-7600.

 Lehigh County Crisis Intervention is 610-782-3127.

 Philadelphia County Crisis Center is Albert Einstein Hospital. The phone number is 215-456- 7890.

 Pottstown/ Montgomery County Crisis Center is Montgomery County Emergency Services (MCES). The phone number is 610-279-6100.

In addition, Progressions’ after-hours phone message consists of the following: “Thank you for calling Progressions of ______ County. 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 voicemailbox after the tone.”

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OUTCOME MEASUREMENT: Date Revised: February 23, 2014 Policy statement: Specific structured tools will be periodically utilized to track clinical progress of all clients. Applicability: This applies to all clients of Progressions 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 provides 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 systemwide 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.

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PERFORMANCE EVALUATIONS: Date Revised: May 2013 Policy statement: Progressions BHRS 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 Progressions BHRS and OP. Legal references: 28 PA Code §709.26(b)(3) 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. 6. 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.

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PHYSICAL PLANT STANDARD POLICY: Date Revised: January, 2010 Policy statement: Progressions BHRS and OP will maintain a safe, secure, and comfortable treatment setting. Purpose: This policy is designed to specify the minimum steps necessary to ensure that a suitable environment is provided for clients, families, and staff at the offices of Progressions. Applicability: This policy applies to all offices rented, leased, or owned by Progressions BHRS and OP. Legal references: 28 PA Code §709.27 Procedure: Progressions BHRS and OP will maintain a safe, secure, and comfortable treatment setting in which to serve its members. The Site Director for each office will be responsible for assessing compliance with the standards of Progressions BHRS and OP, and will ensure improvements when necessary. Progressions will comply with all regulatory requirements for safety, cleanliness, hygiene, and other issues as mandated by applicable governmental, licensure, and accreditation agencies. The areas to be regularly reviewed for physical plant safety includes, but is not limited to:

 Poison control number is posted in all clinical areas.

 Medical reference material is readily available.

 Emergency equipment accessibility to all staff.

 Fire safety exits are labeled, freely accessed and well-lit, as well as fire safety maps posted in appropriate areas.

 Smoking rules are posted.

 All paints, solvents, flammable solutions, and sharps are monitored and used with supervision.

 General use client/consumer areas are available and have comfortable, safe furniture in good repair. Lighting is adequate for reading. All general use areas must be clean and orderly (e.g., no holes in walls, paint chips, graffiti, mold/mildew).

 Clocks are visible in public areas; bulletin boards are used to communicate information.

 The Bill of Rights and Grievance policies are clearly posted in all clinical areas.

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PREVENTATIVE AND DIAGNOSTIC HEALTHCARE: Date Revised: February, 2014 Policy statement: Progressions staff will encourage clients to receive periodic healthcare screening as appropriate. Purpose: To provide a holistic perspective on the client’s needs. Applicability: All Progressions clients. Procedure: At the time of admission, the assigned Progressions 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. Progressions 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.

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PROGRESS NOTES POLICY: Date Revised: January, 2010 Policy statement: All Progressions BHRS 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 Progressions BHRS and OP staff. Legal references: 28 PA Code §709.93(a)(5); 28 PA Code §709.84(9); 28 PA Code §709.93(5)(9); 55 PA Code §5200.41(b)(1)&(4); 55 PA Code §1101.51(e)(1)(i); 55 PA Code §5221.33(4)(i)(a). 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 Progressions BHRS 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.

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PSYCHIATRIC PRESCRIBING AND DOCUMENTATION: Date Revised: July, 2012 Policy statement: All psychiatrists affiliated with Progressions BHRS 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 Progressions 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 Progressions BHRS and OP, in their professional contact with clients. Legal references: 28 PA Code §709.93(a)(5); 28 PA Code §709.84(9); 28 PA Code §709.93(5)(9); 55 PA Code §5200.41(b)(1)&(4); 55 PA Code §1101.51(e)(1)(i); 55 PA Code §5221.33(4)(i)(a). Procedure: Psychiatrists affiliated with Progressions 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

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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. Progressions 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.

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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, in the event that 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.

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— 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 Progressions’ premises. (In some cases of financial hardship, Progressions 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 Progressions psychiatrists. (See policy on “Quality Assurance”.)

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QUALITY ASSURANCE POLICY: Date Revised: February, 2015 Policy statement: Progressions BHRS 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 Progressions BHRS and OP staff. Legal references: 55 PA Code §1151.31(3); 55 PA Code §5200.44. Procedure: Quality assurance will be conducted in a variety of ways, supervised by the Director of Quality Assurance. All new Masters Level staff are required to receive 1:1 mentoring from a licensed psychologist, for an hour session once per week for at least four weeks. Staff who demonstrate satisfactory performance after a month of such mentoring will be transitioned to normal status, requiring only monthly group or individual supervision from a licensed psychologist; staff who consistently fail to demonstrate satisfactory performance during this initial period will be terminated. For BHRS cases, the Case Managers review every billable note entered (e.g., evaluations, treatment plans, BSC notes, MT notes, TSS notes), to assess adherence to Progressions BHRS 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 Progressions 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 Progressions BHRS 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 Progressions BHRS and OP will continuously improve its delivery of services.

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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 Progressions. 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 Progressions. 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 Progressions BHRS 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.

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RECORD MAINTENANCE AND DESTRUCTION: Date Revised: January, 2012 Purpose: It is the policy of Progressions 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 Progressions Behavioral Health Services,

Inc. (“Progressions”) in connection with the transaction of Progressions 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 Progressions' operations by promoting efficiency and freeing up valuable storage space.

Document Retention: Progressions 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 Progressions’ e-mail policy.

Emergency Planning: Progressions' records will be stored in a safe, secure and accessible manner.

Documents and financial files that are essential to keeping Progressions operating in an emergency will

be regularly duplicated or backed up.

Document Destruction: Progressions' 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 Progressions’ 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 Progressions and its employees and possible disciplinary action against

responsible individuals. The Progressions 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.

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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, Progressions 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

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Invoices Sales Records (box office, concessions, gift shop) Petty Cash Vouchers Cash Receipts Credit Card Receipts

5 years 3 years 3 years 3 years

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

Health System Administration Records:

QUALITY IMPROVEMENT:

Quality improvement outcome database, except peer review Permanent

Quality improvement records—peer review 7 years

Medical staff records 75 years

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Impaired physician/clinician records 75 years

REGULATORY RECORDS:

Accreditation records Permanent

Health System Treatment Records:

Inpatient and outpatient medical records/charts

4 years from date of last treatment; for minors, 2 years from age 18

Documentation regarding required request/organ donation 7 years

Transfer and discharge planning records (except those that are part of the inpatient or outpatient medical record/chart)

7 years

Utilization review (UR) records 4 years

Federal Safe Medical Device Act reporting and compliance records Permanent Peer Review Organization QA reviews and correspondence 4 years

Records of reports of suspected cases of child abuse 3 years after minor reaches age of majority

Tests concerning ability to drive 4 years

Notification of injuries arising from use of firearms 4 years

Reports of contagious or communicable disease Permanent

Abortion statistics Permanent

Cancer registry reports Permanent

Fetal birth and death reports Permanent

In vitro fertilization reports Permanent

Maternal death reports Permanent

Records required to be kept by the Health Insurance Portability and Accountability Act

8 years

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REFERRAL SYSTEM POLICY: Date Revised: August, 2011 Policy statement: Progressions BHRS and OP 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 Progressions BHRS and OP. Legal references: 55 PA Code §157.42(a)(4) Procedure: Case Managers (for BHRS clients) or the Supervisor (for OP 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 BHRS 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 Progressions Consent for Treatment.

When a client’s discharge from Progressions 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 BHRS 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 BHRS services, the Case Manager is responsible for assuring that this process occurs; for OP 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”.

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Progressions BHRS and OP will enter into formal cooperative arrangements with other appropriate agencies, from whom referrals can be received and/or to whom aftercare referrals can be made. These formal arrangements must be renewed every two years. The sharing of information with these organizations for incoming referrals and for aftercare must conform to HIPAA standards.

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RELEASE OF INFORMATION POLICY: Date Revised: January, 2010 Policy statement: Progressions BHRS and OP will utilize an appropriate and comprehensive Release of Information when necessary, and will utilize appropriate procedures consistent with HIPAA to obtain a valid release from a client (if age 14 or older) or parent/legal guardian. Purpose: This policy is designed to ensure that clients/parents/legal guardians are fully apprised of the nature of the consent that they may be asked to approve for release of personal information. Applicability: This policy applies to all clients and their parents/legal guardians. Legal references: HIPAA; 35 P.S. §7607(c); 28 PA Code §701.1; 55 PA Code §5100.34; 28 PA Code §709.28(c)(1-6); 28 PA Code §709.28(d)&(e); 55 PA Code §5100.33(a)(b)(c)(1)(2). Procedure: When a client (if age 14 or older) or parent/legal guardian is requested to approve the release of information, the document on which such a release is obtained will contain the following information:

 The name of the consumer.

 The name or title of the individual or organization permitted to disclose the requested information.

 Identification of the person, agency, organization to whom the disclosure will be made.

 Statement identifying the specific information requested.

 Statement of the specific purpose(s) for which the disclosure is to be used.

 An established time limit on the validity of the consent that shows starting and ending dates, or the event or condition on which the consent will expire, if not earlier revoked.

 A statement that the consent is subject to revocation at any time except to the extent that the person who is to make the disclosure has already acted in reliance on it. This revocation can either be oral or in writing.

 A dated signature of the consumer or parent/guardian/legally qualified representative, following a statement that the person understands the nature of the release.

 Place for signature of staff member obtaining consent, and the date (or to record oral consent, place for signatures of two (2) witnesses).

 Written notice of prohibition of re-disclosure.

The parent/guardian of children under fourteen (14) years of age, as well as clients who are fourteen (14) years of age and older, have the right to access the client treatment records, and have control over the release of such records. Parent/guardians, or clients if at least 14 years of age, may revoke a Release of Information at any time. Each time a Release of Information is requested of a client/parent/legal guardian, a qualified staff person of Progressions BHRS or OP will discuss with the client on a 1:1 basis the specific purpose for which the released records are to be used, the nature of the information that is to be released, the specific person/agency requesting the disclosure, the right the consumer has to revoke a release of information at any time, and the duration of the release of information. The client/parent/legal guardian’s signature on a Release of Information must clearly indicate that he/she has understood the above information contained within a Release of Information

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document. A copy of the Consent for Release of Information will be offered to the client/parent/legal guardian, and the original shall be maintained in the treatment record. Any written or oral disclosures must be accompanied by this notice of prohibition of disclosure on all outgoing information: “This information has been disclosed to you from records whose confidentiality is protected by State and Federal statute. State regulations limit your right to make further disclosure of this information without prior written consent of the person to whom it pertains.” Regarding release of information pertaining to H.I.V., the following information must always be included in writing: “This information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is authorized by the Confidentiality of HIV-Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.”

A Release of Information to CBH, MBH, or CCBH (as appropriate) will be included within the clinical chart.

Any correspondence with an agency or individual about a consumer, attained through an authorized Release of Information, shall be documented within the clinical chart. (As per HIPAA, this element is necessary in the case of future requests by clients/parents/legal guardians for an “accounting of disclosures”.)

A Consent for Release of Information should be sought, but need not be obtained, in the event that an emergency exists. Information crucial for the imminent physical welfare of the client may be shared with another individual/agency, to the extent that it is believed that such information can prevent imminent physical harm to the client or others. If such release of information is made, it must be fully documented in the treatment record, including to whom the information was provided and the justification for such release. The parent/guardian (or client if 14 or older) must be informed as soon as possible if information was released on an emergency basis, and they must be informed as to the exact nature of the information released and the justification for the release.

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RISK MANAGEMENT ASSESSMENT: Date Revised: March, 2012 Policy statement: Progressions will periodically assess all potential threats to its functioning and its ability to provide service to its clients. All such foreseeable threats will be addressed through an annual action plan. Purpose: To ensure that Progressions anticipates and seeks to remedy all foreseeable obstacles to its functioning. Applicability: This applies to all Progressions staff. Procedure: Potential areas of loss exposure for Progressions will be assessed through periodic staff trainings. In addition, Progressions’ loss exposure will be assessed through a comprehensive annual review by the Directors, who will devise an action plan to address any perceived shortcomings. Input from all levels of staff will be sought for this purpose, which will be performed by June of every year and then implemented. In the same vein, on an annual basis Progressions’ insurance package will be reviewed for adequacy by June of every year.

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STAFF CREDENTIAL POLICY Date Revised: July, 2012 PURPOSE: To ensure that all staff are treated consistently with regard to the expiration of their professional credentials. To try to ensure coverage of cases and avoid lapses in staff credentials. POLICY: Staff who have a clearance that expires must stop working and will not be paid from the date of the credential’s expiration. Staff will be given 30 days from the clearance’s expiration to obtain the updated clearance or be separated from Progressions. If a clearance (FBI, Child Abuse or Criminal Clearance) is returned that shows a conviction that prevents staff from working with children based upon the Pennsylvania child protective services law (Title 23 PA C.S.A. Chapter 63), that staff member will be immediately terminated. PROCEDURES:

 HR sends an email to the Progressions email address of all staff both 60 and 30 days prior to any clearance about to expire. Directors will be copied on the 30-day notice.

 All communication with staff will be through their Progressions email accounts or through Credible. It is the staff’s responsibility to check their Progressions email and Credible on a regular basis and to respond to messages accordingly. Staff should also make sure that their local site, HR, and Payroll have their updated contact information, including address and phone number if changes occur.

 The HR manager sends a reminder to the Directors any time a staff member has a credential about to expire within the upcoming week.

 If the staff member is not able to provide evidence that the credential has been renewed prior to expiration, the staff member is taken off any cases or suspended from work until they submit their clearance.

 If a time period of 30 days transpires and the staff member still hasn’t turned in their 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 staff member will be terminated.

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STAFF EXCLUSIONARY SANCTIONS POLICY: Date Revised: May, 2015 Policy Statement: Progressions will screen all potential hires to ensure that no sanctioned individuals are hired.’ Purpose: To prevent the hiring of individuals who have been sanctioned. Procedure: Before hiring any potential staff, Progressions Companies performs an initial exclusion screening on the website of the Office of the Inspector General of the U.S. Department of Health and Human Services (http://exclusions.oig.hhs.gov/). In addition, Progressions Companies runs a monthly Exclusions Sanctions Report on all current staff to make sure that current staff have not come up on the exclusions list since being hired.

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STAFFING: Date Revised: June, 2015 Policy Statement: Progressions will work to staff each case with the most qualified staff for the situation. Purpose: This policy is designed to ensure that the highest quality of professional standards are applied to staffing in a timely and appropriate manner. Procedure: When a case is accepted by Progressions BHRS either through initial evaluation or transfer, the lead case manager will review the recommendations and seek to staff each role quickly and efficiently. Lead case manager will contact available staff and provide basic demographic information. Each staff member has the right to accept or decline an assignment as they see fit. Once staff has been identified the case manager will notify the family and give all parties the necessary contact information. It is the staff’s responsibility to make contact with the family or school to set up an acceptable schedule. In the event that either the family or the staff feels this is not a good match, they will notify the case manager and the process will begin again. In the event that a staff member becomes unavailable to continue with a case for any reason, the case manager will notify the family with as much notice as is possible. The lead case manager will again search for staff either internally, through a staffing agency or via the transfer list. If a staffing agency employee/contractor is needed to provide coverage, it is to be temporary until an internal staff can be provided. The COO and director’s approval is needed for any overtime. Overtime can be approved if no other staff is available and the overtime does not affect quality of services provided. This is to be temporary until another staffing option is available.

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STRATEGIC PLANNING: Date Revised: June, 2012 Policy statement: Progressions will periodically develop a strategic plan for improvement, based on input from clients, staff, and other stakeholders. Purpose: To ensure that Progressions engages in continuous quality improvement in as meaningful and productive a manner as possible. Applicability: This applies to all Progressions staff. Procedure: Data will be regularly collected regarding the needs of persons served, other stakeholders, and the organization as a whole for comparative analysis. As part of this effort, comprehensive data will be systematically collected to track client characteristics and clinical progress at the start of treatment, at periodic intervals, and at end of treatment, to be assessed against previously set performance goals. In addition, input will be sought on at least an annual basis from clients, personnel, and other stakeholders through administration of structured surveys (appropriate for each type) that will include open-ended questions on ways to improve service. For business function improvement, performance will be measured utilizing data from accessibility, surveys, risk analysis, human resources, technology analysis, environmental health and safety, field trends, and the service delivery system. Needs assessment issues of data validity, reliability and accuracy will also be addressed and documented. Using all of the above data, an annual company-wide analysis will be conducted to assess performance of each program relative to goals set for efficacy, efficiency, access, and satisfaction of clients and other stakeholders. Deficiencies will be identified and result in an action plan. Information gathered for the performance analysis will be used to review the mission and core values, improve program quality, and facilitate strategic planning. Information from this analysis and the strategic plan derived from it will be shared with clients and other stakeholders, including on a bulletin board in the waiting rooms and on the public website.

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SUBPOENAS, WARRANTS, AND GOVERNMENT INVESTIGATIONS Date Revised: January, 2012 Policy statement: Progressions 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 Progressions staff. Procedure: 1. Progressions is committed to ensuring the privacy and security of client records. Under Pennsylvania laws and regulations, Progressions 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 Progressions to comply with Pennsylvania laws and regulations regarding the release of client records of individuals currently receiving or who have received treatment by Progressions. Progressions 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 Progressions 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 Progressions staff are reviewed with Progressions’ corporate counsel for consultation and guidance. 3. Progressions is allowed to disclose a client’s record without a valid authorization under the following circumstances:

(a) to those Progressions 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 Progressions 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.

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SUBPOENAS 1. Every Subpoena received should be given to the Site Director. 2. Pennsylvania law requires that Progressions 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 Progressions with a signed release authorizing it to disclose his or her records and/or to testify pursuant to the Subpoena, Progressions is required to abide by the terms of the client’s release. The following procedures will apply; .

(a) Progressions 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 Pennsylvania 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 Progressions 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 Progressions from the Subpoena, Progressions’ 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 Progressions 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

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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 Progressions or the homes of present or former employees and seek interviews and documentation concerning services rendered by Progressions employees. 2. Progressions will cooperate with any appropriately authorized government investigation or audit; however, Progressions 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 Progressions 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. Progressions 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. Progressions employees and staff members must not alter, remove, or destroy permanent documents or records of Progressions. 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.

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3. If the investigators present a search warrant, the investigators have the authority to enter Progressions’ 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 Progressions. 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 Progressions' 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) Progressions objects to the search. (ii) The search is unjustified because Progressions is willing to voluntarily cooperate with the government; and (iii) The search will violate the rights of Progressions 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 Progressions 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 Progressions 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 Progressions staff members.

(a) Progressions 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 Progressions' counsel to monitor the search. (c) Investigators should never be left alone on Progressions’ 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.

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(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 Progressions' 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 Progressions.

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SUICIDE ASSESSMENT POLICY: Date Revised: November, 2011 Policy statement: Progressions BHRS and OP 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 Progressions BHRS. Procedure: All Progressions BHRS 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., BSCs, MTs, TSSs, OP Therapists) are responsible for recognizing suicidal feelings and observing suicidal behavior in clients. Any clinical staff member of Progressions 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 BHRS 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 OP 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.

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TARDIVE DYSKINESIA SCREENING: Date Revised: February, 2014 Policy statement: All clients being prescribed an Antipsychotic medication by a Progressions psychiatrist will be periodically screened for the possible development of Tardive Dyskinesia. Purpose: To prevent the development of a potentially permanent and disabling medication side-effect. Applicability: This applies to all clients being prescribed an Antipsychotic medication by a Progressions psychiatrist. Procedure: Clients who are being prescribed Antipsychotic medication by a Progressions psychiatrist are screened on at least a semiannual basis for signs of Tardive Dyskinesia (TD). The Med Check progress note includes a question, “Is client being prescribed an Antipsychotic?”, with a “Yes/No” check box for the psychiatrist to answer. If the psychiatrist checks “Yes” the note prompts, “If the last AIMS was performed over 6 months ago, a new AIMS needs to be performed.” To assess for TD, the prescribing psychiatrist administers the electronic medical record form entitled, “Abnormal Involuntary Movement Scale (AIMS)”. A rating of 2 or higher on the AIMS scale is evidence of Tardive Dyskinesia. If the client has mild TD in two areas of the AIMS scale or moderate movements in one area, then he or she is given a diagnosis of TD at which point the psychiatrist considers whether the client still needs to be on an Antipsychotic medication. This question is discussed with the client and his or her family. If the client requires ongoing treatment with Antipsychotic drugs, the dose may be lowered, which often results in a lower level of TD symptoms, or a total medical change may be in order.

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TECHNOLOGY AND ASSISTIVE DEVICES: Date Revised: January, 2012 Policy statement: Progressions 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 Progressions. 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 Progressions will be able to provide assistive technology to facilitate the functioning of such individuals.

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TOBACCO POLICY: Date Revised: June, 2013 Policy statement: No individual will smoke cigarettes or other forms of tobacco within or near Progressions offices, and staff will not smoke while working with clients to whom they have been assigned. Purpose: To promote the health of staff and clients. Applicability: This policy applies to all staff and clients. Procedure: No tobacco products may be smoked by staff or clients inside Progressions offices. In addition, individuals who wish to smoke tobacco products must do so outdoors, at least 15 feet away from entrances to the office. Staff shall not use tobacco products while working with clients to whom they have been assigned.

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TRAINING POLICY FOR EMPLOYEES AND CONTRACTORS (STAFF): Date Revised: September, 2015 Policy statement: Progressions BHRS, STS, and OP will continuously strive to improve the quality of its services through a variety of training modalities. Purpose: This policy is designed to regularly improve the quality of clinical skills of Progressions staff who provide treatment to clients. This will be achieved through a combination of live training, home study, web-based and non-traditional training approaches. This policy is also to ensure that all employees and contractors (staff) are treated consistently with regard to their need to complete trainings, and to ensure that employees and contractors do not lapse in completing their training hours within the time-frame requirements. Applicability: This policy applies to all Progressions BHRS and OP staff. Legal references: 28 PA Code §709.26(c)(1)(2)(3)(4); 28 PA Code §704.11(a). Procedure: Progressions staff are required to be compliant with the yearly training hour requirements set forth by the State of Pennsylvania. This comprises a minimum of 10 hours/year for Outpatient Therapists, BSCs, MTs, GMTs, and LCs and 20 hours/year for experienced TSSs and BHWs. Newly hired TSSs and BHWs are required to take 15 hours of orientation training. TSSs and BHWs with limited experience are required to take an additional 24 hours of training prior to their first 6 months. Employees and contractors (staff) who have training hours that need to be completed by a certain date will be separated from Progressions if they haven’t attained the required hours within the required time-frame. Employees and contractors will be given a 60-day IM message through the Credible electronic medical record system regarding the training hours needed prior to the deadline, and an email will be sent to them and copied to their Director 30 days from the deadline, to notify them of the need to get their training hours completed by the deadline. All communication with employees and contractors (staff) will be through their Progressions email accounts or through Credible. It is the employee’s and contractor’s responsibility to check their Progressions email and Credible on a regular basis and to respond to messages accordingly. Employees and contractors should also make sure that their Progressions office/HR/and payroll have their updated contact information, including address and phone number if changes occur. If the employee or contractor doesn’t complete their trainings within the required time limit, the employee or contractor will be separated from their employment. Employees and contractors who are separated will be allowed to re-apply for positions within Progressions if they are separated for this reason, per the Director’s decision and any stipulations the Director may wish to create for re-employment. All Progressions Outpatient, BHRS, and STS staff are required to complete the following mandatory trainings, which are provided and documented by Progressions:

 Fire Safety & Prevention

 Suicide Precautions

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 Management of Escalation

 Infection Control/Universal Precautions/Blood-Borne Pathogens

 Cultural Awareness

 Disaster Training

 CPR

 First Aid

 Identification and Reporting of Critical Incidents

 HIPAA Requirements (These can be found on our website at www.PBHSI.com). These are to be completed prior to hire and must be completed every two years. These do NOT count towards the minimum State mandated requirement referred to above. All Progressions OP Therapists are required to receive 2 hours of trauma-related training each year. All Progressions OP Therapists, BHRS staff, and STS staff are required to attend a minimum of 2.5 hours of training each year on LGBTQI issues. In addition, all staff may be referred for specific training based on identified professional development needs, agency corrective action plans, or organizational efforts to change the culture of treatment. Examples of training that all staff are expected to take are as follows:

 Intro to Trauma Informed Treatment

 Best Practices in Assessment/Treatment Planning/Progress note writing

 Ethics and Clinical Boundaries

 Crisis Intervention/Prevention

 Compliance

 Protecting Children and Confidentiality

 Use of the CANS, ATEC, and other structured tools used by Progressions

 Affirming Practice with LGTBQI

 Using and Providing Clinical Supervision All staff (including administrative staff, office staff, and staff who have direct contact with children) are required to take a Mandated Reporting training. This is also referred to as “Act 31 Training”. In addition, all Behavior Specialist Consultants and Lead Clinicians who work with Community Behavioral Health (CBH) clients are required to take 8 hours of Behavior Modification per year. This is in addition to any training taken as part of the Licensed Behavior Specialist requirements by the state and does NOT count towards the minimum State mandated requirements. (On the other hand, the Behavior Mod training can count for all staff who do not have CBH clients.) Clinicians who are assigned to Magellan clients are required to complete an online CANS (Child and Adolescent Needs and Strengths) training through Magellan’s website. The CANS assessment is required at every evaluation for clients who are NOT in the Autistic Spectrum. Clinicians will only be able to complete the CANS if they are credentialed through Magellan’s site. Behavior Specialist Consultants who perform Functional Behavioral Assessments are required to take a 2-day training on this specialized assessment. In addition, there is a State competency test for the FBA that must be passed. (This does not count towards the State minimum requirement.)

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The above listing of required trainings is by no means exhaustive. Progressions accepts training from outside entities, provided that the following is furnished to the Site Director: a copy of the certificate listing the time (clock hours), learning objectives, and a copy of the PowerPoint or other handouts. Progressions allows a percentage of training to be completed online and provides a list of approved and vetted sites which generate documentation when content is completed. Either the Site Director or Training Director will provide staff with a list of applicable websites. These may also be found on our website, www.PBHSI.com. Progressions encourages home study and provides a series of training DVDs to staff (lending library style) along with a post-test. A minimum score of 80% will be required to pass the post-test and obtain credit for all unproctored showings of the training DVDs. Credit for the length of the training will be added to the clinician’s training record when the DVD and post-test with a passing score are returned. Progressions encourages staff to keep track of their training hours (certificates should be kept and can be scanned and attached to the employee file in Credible). In addition, training is tracked at each office as the information is often requested at compliance/quality audits. Staff are regularly encouraged to check to make sure that their records match those of the organization. The Site Director will monitor staff’s adherence to the above training requirements. Failure of a staff person to meet the above training requirements could result in disciplinary actions as described in the Employee Sanctions Policy.

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TREATMENT AND TRANSITION PLAN POLICY: Date Revised: January, 2010 Policy statement: Progressions BHRS clinical staff will utilize a Treatment Plan and a Transition Plan (or Discharge Criteria, in the case of OP 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 BHRS 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 Progressions BHRS and OP. Legal references: 28 PA Code §709.92; 55 PA Code §5200.31(5); 55 PA Code §1223.42(b)(1). 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. BHRS 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 BHRS 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

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whenever possible, except in those rare instances where involvement of one parent would be clinically contraindicated. 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 BHRS 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.

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WITNESSING OF DOCUMENTS: Date Revised: October, 2015 Policy statement: Staff are required to sign as witnesses for clinical documents utilized by Progressions. They may not sign as witnesses for non-Progressions documents. Purpose: To clarify the legal limits of staff as signatory witnesses for their clients and their caregivers. Applicability: This policy applies to all staff of Progressions BHRS and OP. Procedure: For all clinical documents utilized by Progressions that require the witnessing of a client’s or caregiver’s signature, Progressions staff are expected to sign as witnesses. For non-Progressions documents, staff may not sign as a witness, unless approved by the corporate compliance officer, who may consult with corporate counsel if necessary.