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*
01	002	75	Definitions of Applications for Policies*
01	002	80	Code of Ethics*
01	002	85	Procuring Employment Services Providers, Independent Contractors and Network Providers*
01	002	90	Clinical Case Review Committee
01	002	95	Financial 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
02	001	45	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 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
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*
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

02	004	220	Behavioral 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
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*
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*
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	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			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	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	001	20	Information Security*
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
08	003	55	Mass Communications System

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