Policy and Procedure Manual

Table of Contents

Chapter/

Section/

Subject/

Description

PN

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

 
01 002 75 Definitions of Applications for Policies  
01 002 80 Code of Ethics  
01 002 85 Employment Services Providers, Independent Contractors and Provider Network Services  
         

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

001

40

Telepsychiatry 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

55

Legal Error Correction

 

02

002

60

Confidentiality and Release of Person Served 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 75 Transportation Services to Authorized Day Activities  
         

02

004

 

Clinical and Support Services

 

02

004

05

Suicide Calls

 
02 004 15 Accessing Childrens Crisis Residential Beds  

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 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

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

 
02 004 180 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 (IDDT)

 
02 004 195 Children's Mobile Intensive Crisis Stabilization  

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

 
03 001 50 Pharmacological Treatment for Substance Use Disorders    
03 001 55 Narcan/Naloxone  
         

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

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/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

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

Human Resource Services

 

05

001

30

Employee Change of Address

 

05

001

45

Criminal Background Checks

 

05

001

55

Harassment in the Workplace

 

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

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

190

After-Hours Coverage Reimbursement

 

05

001

195

Infection Control Program

 
05 001 200 Lactating or Nursing Mothers  
         

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 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

Financial Planning and Risk Management

 
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

 

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 (non-SUD)

 

06

003

135

Internal Control: Cash Handling/Cash Deposits

 
         

07

 

 

INFORMATION MANAGEMENT

 

07

001

 

Information Systems

 

07

001

05

Smartphone and Cellular Data Device Usage

 

07

001

10

Internet and E-Mail Use

 

07

001

15

Mail Received

 

07

001

25

Information Systems Change Management Tracking

 
         

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

 

07

002 

30

Use of Texting

 
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

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