01 |
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| 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 | 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 theLapeer 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 |
01 | 002 | 95 | Financial Conflict of Interest in Public Health Services Funded Research |
02 |
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| 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 | 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 | 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 |
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03 |
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| 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 |
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| 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 |
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| 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 |
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| 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 | Personal Relationships in the Workplace |
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 |
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| 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 | 130 | Ability to Pay Determination |
06 | 003 | 135 | Internal Control: Cash Handling/Cash Deposits |
07 |
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| 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 |
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| 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
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08 | 003 | 55 | Mass Communications System
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