Policy and Procedure Manual

Policies that apply to our provider network are indicated with a *

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

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, 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*

0100275

Definitions of Applications for Policies*

0100280

Code of Ethics*

0100285

Procuring Employment Services Providers, Independent Contractors and Network Providers*

0100290Clinical Case Review Committee
 
0100295Financial Conflict of Interest in Public Health Services Funded Research

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
0200145

Telehealth 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 Summary

02

002

60

Confidentiality and Release of Person Served Records/Subpoenas*

0200265

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*

0200375

Transportation Services to Authorized Day Activities*

0200380Residential Placements, Community Living Supports and Respite Procedures*

02

004

Clinical and Support Services

02

004

05

Suicide Calls

0200415

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

Children's Services Program

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

02

004

145

Problem Solving 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*

02004175

Substance Use Prevention and Treatment

02004180

Trauma Informed System of Care*

02004185

Recovery Oriented Systems of Care*

02004190

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

02004195

Children's Mobile Intensive Crisis Stabilization*

02004205

Habilitation Supports Waiver

02004210

Suicide and Homicide Assessments*

02004215Veteran's Care Pathway
02004220Behavioral Health Hospitalizations and Discharge Planning

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

0300150

Pharmacological Treatment for Substance Use Disorders

0300155

Narcan/Naloxone

0300160

Vivitrol® for Medication Assisted Treatment for Alcohol Use Disorder*

0300165Prescribing 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 Insurance Portability and Accountability (HIPPA)*

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*

0200265Duty 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

Employee Orientation

05

001

160

Personal Relationships in the Workplace

05

001

170

Performance Appraisals

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

05001200

Lactating or Nursing Mothers

05001205

Military Leave and Deployment

05001210

Peer Support Services Workers

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

0500340Debriefing 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*

0600265Mail 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

Billing for Services and Delinquent Accounts

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

00120Information Security*

07

001

25

Information Systems Change Management Tracking*

0700130

CareConnect360

0700135

HIPAA Breach Notifications*

0700140Remote 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)

0700235Use 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

0800350Rapid Response Team: Medical Emergency and Code Gray

0800355Mass Communications System