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 Program, Evaluation and Annual Plan

01

002

20

Legal Liability Protection

01

002

25

Fraud

01

002

30

Provider Network Maintenance and Monitoring

01

002

35

Legal Action Resulting from Unusual Incidents

01

002

40

Quality Council, Subcommittee Structure and Quality Improvement Plan

01

002

45

Behavior Treatment Plan Review Committee (BTPRC)

01

002

50

Provider Enrollment Privileging and Credentialing

01

002

55

Utilization Management Policy

01

002

60

Record Retention / Right to Audit

01

002

65

Provider Procurement and Best Value Purchasing

01

 002

70

 Freedom of Information Act Requests

01 002 75

Definitions of Applications for Policies

01 002 80

Code of Ethics

01 002 85

Procuring Employment Services Providers, Independent Contractors and Provider Network Services

01 002 90 Clinical Case Review Committee
       

02

 

 

SERVICE DELIVERY

02

001

 

Treatment

02

001

05

Psychological Testing

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

001

40

Telepsychiatry Services
02 001 45

Teletherapy Services 

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

60

Confidentiality and Release of Person Served Records/Subpoenas

02 002 65

Duty to Warn

       

02

003

 

Access to Services

02

003

05

Accessibility Plan

02

003

10

Treatment Authorization

02

003

15

Waiting Lists for Programs

02

003

25

Order Following Hearing on Petition for Admission

02

003

30

Intake Procedures

02

003

35

Involvement of Persons Served in the Development of Services and Treatment (Consumerism)

02

003

40

Least Restrictive Environment

02

003

45

Informed Consent

02

003

50

Referrals to Other Resources

02

003

55

Limited English Proficiency, Interpretation and Translation Services

02 003 75

Transportation Services to Authorized Day Activities

02 003 80 Residential Placements, Community Living Supports and Respite Procedures
       

02

004

 

Clinical and Support Services

02

004

05

Suicide Calls

02 004 15

Accessing Crisis Residential Beds

02

004

20

Pre-Screening for Inpatient Hospitalization and Alternatives

02

004

30

Emergency Services Staffing Coverage

02

004

35

Behavior Assessment, Management and Behavior Treatment Plans

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

Integrated Dual Disorder Treatment (IDDT) - Substance Use Disorder Services for Persons with Severe and Persistent Mental Illness

02

004

60

Outpatient Therapy Services

02

004

65

Child Clinical Services

02

004

70

Adult Case Management/Supports Coordination and Residential 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 Skill Building Program Participant Excursions

02

004

105

Cancellations for Stepping Stone

02

004

110

Program Participants - Illness

02

004

115

Assertive Community Treatment Program

02

004

125

Out of Office Service Provision

02

004

135

Community Benefit Activities 

02

004

140

Jail Diversion Services

02

004

145

Mental Health Court Services

02

 004

 150

Autism Benefit

02

004

155

Mobile Intensive Crisis Stabilization (MICS) for Adults

02

004

165

Children's Waiver Program

02 

 004

 170

Integrated Employment Coordination

02 004 175

Substance Use Prevention and Treatment

02 004 180

Trauma Informed System of Care

02 004 185

Recovery Oriented Systems of Care

02 004 190

Secondary Interventions for Non-responders to Integrated Dual Disorder Treatment (IDDT)

02 004 195

Children's Mobile Intensive Crisis Stabilization

02 004 205

Habilitation Supports Waiver

02 004 210

Suicide and Homicide Assessments

02 004 215 Veteran's Care Pathway
     

 

03

 

 

HEALTH/MEDICAL

03

001

 

Drugs and Medication

03

001

05

Medication Consents

03

001

10

Medication Administration and Assistance with 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

03 001 50

Pharmacological Treatment for Substance Use Disorders

 
03 001 55

Narcan/Naloxone

03 001 60

Vivitrol® for Medication Assisted Treatment for Alcohol Use Disorder

03 001 65 Prescribing Schedule II Medications for Attention Deficit Hyperactivity Disorder (ADHD)
       

03

002

 

Health Care

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 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

05

Recipient Rights System

04

001

10

Grievance and Appeals and Second Opinion 

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, Critical Incident Reporting, Risk Events & Root Cause Analysis

       

04

002

 

SUD Recipient Rights

04

002

05

Recipient Rights and Charitable Choice 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 Person Served Records/Subpoenas

02 002 65 Duty to Warn

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

05

Personnel Policies

05

001

10

Affirmative Action Plan

05

001

15

Request for Reasonable Accommodations

05

001

20

Cultural Competency and Sensitivity

05

001

25

Human Resource Services

05

001

30

Change of Name, Address and Phone Number

05

001

45

Criminal Background Checks

05

001

55

Harassment in the Workplace

05

001

60

Personal Relationships with Persons Served

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

105

Supplemental Employment

05

001

110

Physician Services

05

001

115

Dress Code

05

001

125

Salary Schedule

05

001

130

Workers' Compensation/On the Job Injuries

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

05

001

190

After-Hours Coverage Reimbursement

05

001

195

Infection Control Program

05 001 200

Lactating or Nursing Mothers

05 001 205

Military Leave and Deployment

05 001 210

Peer Support Workforce

       

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

10

Hepatitis B Vaccine

05

003

15

Universal Precautions / Standard Precautions

05

003

20

Maintaining a Safe Environment

05

003

30

Safety and Conflict Avoidance and Emergency Response Plan

05 003 40 Debriefing After a Traumatic Incident
       

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

25

Petty Cash Fund and Checking Account

06

002

30

Institutional Billing Process

06

002

40

Purchasing Procedure, Supply Requisition and Inventory Control

06

002

45

Accounts Payable

06

002

50

Accounts Payable Processing

06

002

55

Invoice Payment Processing for Contract Providers

06

002

60

Risk Management Plan

06 002 65 Mail Received
       

06

003

 

Reimbursement

06

003

75

Self Determination/Choice Voucher

06

003

80

Adult Services Authorized Payments: Title XIX Provider Enrollment Authorizations and Payment Problems

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

105

Annual Review of Rate Determination

06

003

110

Delinquent Accounts

06

003

120

Other Accounts Receivable

06

003

130

Ability to Pay Determination 

06

003

135

Internal Control: Cash Handling/Cash Deposits

       

07

 

 

INFORMATION MANAGEMENT

07

001

 

Information Systems

07

001

05

Smart Phone Usage

07

001

10

Internet and E-Mail Use

07

001

25

Information Systems Change Management Tracking

07 001 30

CareConnect360

07 001 35

HIPAA Breach Notifications

07 001 40 Remote Work and Access
       

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 the Electronic Health Record

07

002

20

Corrections, Deletions, Disclaimers in the Electronic Health Record

07

002

25

Community Electronic Health Records (CEHR)

07 002 35 Use of Social Media
       

08

 

 

FACILITIES

08

001

05

Utilities Management Plan

08

001

10

Community Use of CMH Facility

08

001

15

Room Reservations

08

001

20

Scheduling and 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

Driver License and Driving Record Monitoring

       

08

003

 

Safety

08

003

05

Health and Safety Committee

08

003

10

Equipment Safety Plan

08

003

15

Food Preparation

08

003

25

Emergency Preparedness and Response Plan

08

003

30

Severe Weather Safety

08

003

35

Fire Safety 

08

003

40

Gymnasium Safety

08

003

45

Smoking Policy

08 003 50 Rapid Response Team: Code Blue and Code Gray