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	Network 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	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	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	Stepping Stone: Ill Participants
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	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

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 Process (non-SUD)
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	05	Tuberculosis Screening and Testing for Staff
05	003	10	Hepatitis B Vaccine
05	003	15	Universal Precautions / Standard Precautions
05	003	20	Maintaining a Safe Environment
05	003	25	Personal Safety and Security
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	35	Postage
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

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