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    
           

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  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

65

Text Telephone TTY "Deaftele"

   

02

003

70

 Waiting List for Substance Use Disorder Services

   
           

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 Day Activity Program Participant Excursions

   

02

004

105

Cancellations for PSR and Stepping Stones

   

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

 175

 SUD Services for Persons with Mild to Moderate MI

   
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)    

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

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, Risk Event & Event Reporting and Root Cause Analysis

   
           

04

002

 

SUD Recipient Rights

   

04

002

05

Recipient Rights and Charitable Choice in Substance Use Disorder Services

   

04

002 

 10

Substance Use Disorder Grievance and Appeal Process

   
           

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 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

Plan for Human Resource Services

   

05

001

30

Employee Change of Address

   

05

001

45

Criminal Background Checks

   

05

001

50

Code of Ethics

   

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

100

Contractual Service Providers

   

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

185

Long Distance Telephone Calls

   

05

001

190

After-Hours Coverage Reimbursement

   

05

001

195

Infection Control Program

   
           

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 Imprest Checking  Account

   

06

002

30

Institutional Billing Process

   

06

002

35

Postage

   

06

002

40

Inventory Purchasing Procedure/Supply Requisition and Inventory Control

   

06

002

45

Accounts Payable

   

06

002

50

Audit Procedures

   

06

002

55

Invoice Payment Processing for Specialized Residential Services

   

06

002

60

Financial Planning and Risk Management

   
           

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

   

06 

 003

140 

 Ability to Pay Guidelines for SUD Services

   
           

07

 

 

INFORMATION MANAGEMENT

   

07

001

 

Information Systems

   

07

001

05

Cellular Telephone Usage

   

07

001

10

Internet and E-Mail Use

   

07

001

15

Mail Received

   
07 001 20 Informaion Security    

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 Electronic Record: OASIS

   

07

002

20

Corrections Deletions Disclaimers: OASIS

   

07

002

25

Community Electronic Health Records

   

 07

002 

 30

 Use of Social Media, Texting, Email

   
           

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

Safe Driver

   
           

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