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Policy and Procedure Manual

Chapter  

Section  

Subject  

Description

01

  

Administrative

01

001

 

Governance/Leadership

01

001

05

Policy Manual

01

001

10

Mission Statement, Vision, Values, and Strategic Plan

01

001

15

Channels of Internal Communication

01

001

20

 Input from Persons Served/Satisfaction Surveys

01

001

25

Public Relations, Press Releases and Publications

01

001

30

Notice of Board Meetings

01

001

35

Board Meeting Preparations and Meeting Minutes

01

001

40

CMH Board Meeting Attendance Requirements

01

001

45

CMH Board member Orientation

01

001

50

Per Diem for Board Members

01

001

55

CMH Board Conflict of Interest

01

001

60

CMH Board/Management Rights

01

001

65

CMH Board Distribution of Resolutions Adopted by the Lapeer County Community Mental Health Services Board

01

002

 

Operations

01

002

05

Corporate Compliance Compliant, Investigation and Reporting Process

 01

002

10

Corporate Compliance Program

01

002

15

Corporate Compliance Risk Assessment & Annual Plan

01

002

20

Legal Liability Protection

01

002

25

Fraud

01

002

30

Network Management

01

002

35

Legal Action Resulting from Unusual Incidents

01

002

40

Quality Council, Subcommittee Structure and Quality Improvement Plan

01

002

45

Behavior/Risk Management Committee; Behavior Treatment Plans

01

002

50

Provider Enrollment Privileging and Credentialing

01

002

55

Utilization Management Policy

01

002

60

Record Retention

01

002

65

Procurement, Best Value Purchasing Guidelines

01

 002

 70

 Freedom of Information Act Requests

02

  

SERVICE DELIVERY

02

001

 

Treatment

02

001

05

Specialty Assessment Services

02

001

10

Services Suited to Condition

02

001

15

Person Centered Planning

02

001

20

Housing Policy

02

001

25

Continuity of Care

02

001

30

Family Planning and Health Information

02

001

35

Active Treatment Standards

02

002

 

Records

02

002

05

Advanced Directives: Medical and Psychiatric

02

002

30

Authorized Abbreviations and Symbols

02

002

40

Record System, Management and Storage

02

002

45

Case Record Organization

02

002

50

Discharge Summaries

02

002

55

Legal Error Correction

02

002

60

Confidentiality and Release of  Records/Duty to Warn/Subpoenas

02

003

 

Access to Services

02

003

05

Accessibility

02

003

10

Treatment Authorization

02

003

15

Waiting Lists for Programs

02

003

20

Reception Desk Procedures and Appointment Scheduling

02

003

25

Order Following Hearing on Petition for Admission

02

003

30

Intake Procedures

02

003

35

Consumerism (Persons Served)

02

003

40

Least Restrictive Environment

02

003

45

Informed Consent

02

003

50

Persons Served Referrals to Other Resources

02

003

55

Interpretation and Translation Services (Limited English Proficiency)

02

003

60

Limited English Proficiency

02

003

65

Text Telephone TTY "Deaftele"

02

003

70

 Waiting List for Substance Use Disorder Services

02

004

 

Clinical and Support Services

02

004

05

Suicide Calls

02

004

20

Pre-Screening Services for Inpatient Hospitalization and Alternatives

02

004

25

Accessing Adult Crisis Residential Beds

02

004

30

Emergency Coverage

02

004

35

Behavior Management

02

004

40

Case Management/Supports Coordination in Residential Setting

02

004

45

Family Support Subsidy

02

004

50

Property and Funds of Persons Served

02

004

55

Substance Use Disorder Services for SPMI

02

004

60

Outpatient Clinic (OPC)  Adult Clinical Services

02

004

65

Child Clinical Services

02

004

70

Adult Case Management/Supports Coordination Services

02

004

75

Children's Home Based Services

02

004

80

Currently Approved Therapies and Plan for Evaluation/Introduction of Other Therapies

02

004

85

Stepping Stone/Skill Building Assistance Program

02

004

90

Psychosocial Rehabilitation Program (PSR)/Clubhouse

02

004

95

Activity Money Procedure for Day Activity Program Participant Excursions

02

004

105

Cancellations for PSR and Stepping Stones

02

004

110

Stepping Stone: Ill Participants

02

004

115

Assertive Community Treatment Program

02

004

120

Assertive Community Treatment Program: Payee Accounts

02

004

125

Out of Office Service Provision

02

004

135

Community Education and Prevention 

02

004

140

 Jail Diversion and Emergency Jail Services

02

004

145

 Mental Health Court Services

02

 004

 150

 Autism Services Benefit

02

004

155

Mobile Intensive Crisis Stabilization Services (MICSS)

02

004

165

 Children's Waiver Program

02 

 004

 170

 Integrated Employment Coordination

02 

 004

 175

 SUD Services for Persons with Mild to Moderate MI

03

  

HEALTH/MEDICAL

03

001

 

Drugs and Medication

03

001

05

Medication Consents

03

001

10

Medication Assistance with Administration and Self-Administration

03

001

15

Medication Errors

03

001

20

Psychotropic Medications

03

001

25

Schedule II Drugs and Safeguards for Drugs of Risk

03

001

30

Clozapine (Clozaril®)

03

001

35

Disposal of Syringes Used for Intramuscular Injections

03

 001

 40

 Medication Disposal

 03

 001

 45

 Sample Medications

03

002

 

Health Care

03

002

05

Medical Emergencies

03

002

10

Automated External Defibrillators

03

002

15

Coordination with Health Care

03

002

20

Physical Examinations

03

002

25

Health Care Guidelines for Surveillance and Prevention of Tuberculosis, Hepatitis and Other Communicable Diseases for Persons Served

03

002

30

Exposure Control and Post Exposure Plan/ Hepatitis B Virus and Human Immunodeficiency Virus

04

  

RECIPIENT RIGHTS

04

001

 

Recipient Rights

04

001

05

Recipient Rights System

04

001

10

Grievance and Appeals and Second Opinion Process

04

001

15

Investigation of Complaints/Appeal Process

04

001

20

Report and Review of Deaths

04

001

25

Rights of Family Members/Respect and Dignity

04

001

30

Reporting  Abuse and Neglect

04

001

35

Incident Reporting, Sentinel Events and Root Cause Analysis

04

002

 

SUD Recipient Rights

04

002

05

Recipient Rights in Substance Use Disorder Services

04

003

 

Individual Rights

04

003

05

Fingerprinting, Photographing, Audio and Videotaping of Persons Served, and Use of One-Way Glass

04

003

10

Freedom of Movement

04

003

15

Right to Access Communication/Mail/Telephone/Visits/Entertainment Materials/Information and News

04

003

20

Performance of Labor by Persons Served             

04

003

25

Restraint, Seclusion and Physical Management

04

003

30

Treatment by Religious/Spiritual Means

04

003

35

Change in Type of Treatment

04

003

40

Health Information Privacy

04

 003

 45

 Emotional Support Animals

04

003

50

 Service Animals

04

003

55

 Therapy Dogs

04 

 003

 60

 Research Guidelines and Ethical Standards

   

Additional Rights Policies

02

001

10

 Services Suited to Condition

02

001

30

 Family Planning and Health Information

02

002

 60

Confidentiality and Release of Records/Duty to Warn/Subpoenas

02

003

40

Least Restrictive Environment

02

003

45

Informed Consent

02

004

50

Property and Funds of Persons Served

03

001

20

Psychotropic Medications

03

002

20

Physical Examinations

05

  

HUMAN RESOURCES

05

001

 

Personnel

05

001

05

Personnel Policies

05

001

10

Affirmative Action Plan

05

001

15

Michigan Persons with Disabilities Civil Rights Act

05

001

20

Cultural Competence

05

001

25

Plan for Human Resource Services

05

001

30

Employee Change of Address

05

001

45

Criminal Background Checks

05

001

50

Code of Ethics

05

001

55

Sexual Harassment

05

001

60

Personal Relationships with Persons Served

05

001

65

Staff Identification Cards

05

001

75

Time Sheets/Absence from Scheduled Work

05

001

80

Work Schedules and Breaks

05

001

85

Work Adjustment Time (Compensatory Time)

05

001

90

Family Medical Leave

05

001

95

Jury Duty

05

001

100

Contractual Service Providers

05

001

105

Supplemental Employment

05

001

110

Physician Services

05

001

115

Staff Dress Code

05

001

125

Salary Schedule

05

001

130

On the Job Injuries/Workers Compensation

05

001

135

Healthcare Insurance and Life Insurance

05

001

140

Letters of Reference

05

001

145

Pre-Employment Physical Examinations

05

001

150

New Employee Procedures

05

001

155

New Employee Orientation

05

001

160

Employment of Relatives

05

001

170

Employee Evaluations

05

001

175

Standards for Non-Licensed Staff

05

001

180

Volunteers, Students, Interns, Aides

05

001

185

Long Distance Telephone Calls

05

001

190

After-Hours Coverage Reimbursement

05

001

195

Infection Control Program

05

002

 

Training and Travel

05

002

05

Training Registration/Overnight Travel

05

002

10

Staff Development/Ongoing Training

05

002

15

Staff Development Program for Paraprofessional Staff

05

002

20

Travel Reimbursement

05

003

 

Health and Safety

05

003

05

Tuberculosis Control for CMH Staff

05

003

10

Hepatitis B Vaccine

05

003

15

Universal Precautions

05

003

20

Safe and Drug-Free Workplace

05

003

25

Personal Safety and Security

05

003

30

Safety and Conflict Avoidance, and Emergency Response Plan

06

  

FISCAL MANAGEMENT

06

001

 

Budget

    

06

002

 

Accounting

06

002

05

Independent Financial Audit

06

002

10

Contributions to the Agency

06

002

15

Contract Management

06

002

20

Cash Balance

06

002

25

Petty Cash Fund and Imprest Checking  Account

06

002

30

Institutional Billing Process

06

002

35

Postage

06

002

40

Inventory Purchasing Procedure/Supply Requisition and Inventory Control

06

002

45

Accounts Payable

06

002

50

Audit Procedures

06

002

55

Invoice Payment Processing for Specialized Residential Services

06

002

60

Financial Planning and Risk Management

06

003

 

Reimbursement

06

003

75

Self Determination/Choice Voucher

06

003

80

Adult Services Authorized Payments: Title XIX Provider Enrollment Authorizations

06

003

85

Adult Services Authorized Payments Definitions

06

003

90

Adult Services Authorized Payments: Title XIX Training

06

003

95

Adult Services Authorized Payments: Title XIX Establishing the Need for Personal Care Services and the Payment Process

06

003

100

Medicare Billings

06

003

105

Annual Review of Rate Determination

06

003

110

Delinquent Accounts

06

003

115

Insurances Other than Blue Cross, Medicaid, and Medicare

06

003

120

Other Accounts Receivable

06

003

130

Ability to Pay Determination

06

003

135

Internal Control: Cash Handling/Cash Deposits

06 

 003

140 

 Ability to Pay Guidelines for SUD Services

07

  

INFORMATION MANAGEMENT

07

001

 

Information Systems

07

001

05

Cellular Telephone Usage

07

001

10

Internet and E-Mail Use

07

001

15

Mail Received

07

002

 

Data Management

07

002

05

Electronic Health Record: OASIS

07

002

10

Integrity of Electronic Data:OASIS

07

002

15

Request to Amend Electronic Record: OASIS

07

002

20

Corrections Deletions Disclaimers: OASIS

07

002

25

Community Electronic Health Records

 07

002 

 30

 Use of Social Media, Texting, Email

08

  

FACILITIES

08

001

 

Building

08

001

05

Utilities Management Plan

08

001

10

Community Use of CMH Facility

08

001

15

Scheduling of Group Therapy, Family Therapy and Community Rooms

08

001

20

Use of Play Therapy Room

08

001

25

Building Keys

08

001

30

Building and Grounds Maintenance

08

002

 

Transportation

08

002

05

Distracted Driving

08

002

10

Vehicle Operations and Maintenance

08

002

15

Vehicle Incident/Accident Reporting

08

002

20

Safe Driver

08

003

 

Safety

08

003

05

Safety Management Plan and Health and Safety Committee

08

003

10

Equipment Safety Plan

08

003

15

Food Preparation

08

003

20

Bomb Threat

08

003

25

Emergency Preparedness Plan

08

003

30

Severe Weather Safety

08

003

35

Fire Safety Plan

08

003

40

Gymnasium Safety

08

003

45

Smoking Policy