Policy Manual Section 200

It is the policy of CSM that all persons in need of services this agency is eligible to provide are admitted to and discharged from programs in a timely and efficient manner appropriate to their needs in the least restrictive setting.

II. DISCUSSION

This policy applies to routine admissions and discharges of consumer to service programs. It must be stated at this point, that no staff person will confirm orally, in writing or through any other means of communication that a consumer is a receiving services from this agency and all HIPAA policies on privacy must be followed.

III. PROCEDURE

A. Upon referral by self, family, other individuals or service providers, an initial screening is conducted. Based upon the initial review and if the referred individual is willing to accept services, an intake is scheduled at the earliest possible time.

B. Identifying data is gathered at the intake necessary to complete all internal and funding source requirements.

C. The consumer is informed of charges for services at the time of intake and before any services is provided if they are not eligible for any third party payments.

D. CSM will inform consumers of all their rights during the intake process, especially confidentiality and Protected Health Information (PHI).

E. Based on presenting problems and other available information obtained during the intake process, staff will determine the need for evaluations.

F. A consumer record must be established within five (5) days of the intake.

which contains all internal and funding source requirements.

G. The intake worker shall serve as Case Manager for a consumer until a permanent Case Manager is named. The initial worker must be aware of any “high risk” factors involved with the consumer and make immediate and appropriate referrals.

Admissions and Discharges Policy

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H. There will be a written plan of individual treatment for each consumer based on the initial evaluation of the consumer’s treatment or training needs.

I. The plan is developed at the time of the intake and documented in the consumer’s record. The consumer or guardian, if appropriate, is included in the development of the initial treatment plan unless the inability or unwillingness is documented in writing. The treatment plan of each consumer must be finalized within 30 days of intake and placed in the record.

J. The consumer’s informed consent for a course of treatment specified in any treatment plan is verified by that person’s signature or the guardian’s.

K. At termination of a consumer’s treatment at the agency, a summary of care will be completed and placed in the record. Any recommendations for services will also be provided to the consumer or guardian and placed in the record.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

Section 200 Policy 202

Date of Issue: September 19, 2006

Date Revised:

CONSENT TO TREATMENT

IV. POLICY

It is the policy of this agency that consumers of services provide informed consent to treatment prior to being provided interventions.

V. DISCUSSION

No treatment can be given to a consumer without his or her written consent. Such consents are obtained on treatment plans as a part of the admission. If no informed consent is documented in the chart, the case manager must provide information indicating why such consent was not obtained.

III. PROCEDURES

The following procedures will be followed:

A. At the initiation of services, the case manager will assure documentation is maintained in the respective consumers’ records if Consumers who have been judged incompetent by the legal system shall have a court appointed committee, guardian or family member who as the authority to assert the consumer’s right to consent or refuse treatment.

B. To assure informed consent, the following will be explained to each consumer and/or guardian:

1. the nature of the consumer’s mental condition

2. the reason for proposed treatments, including the likelihood of improving or not improving with proposed treatments

3. the consent, once given, may be withdrawn at any time by stating or writing such intention to a member of the treating staff

4. the reasonable alternative treatments available, if any

5. how extra precautions shall be taken for use of medications, including the type, range of frequency and amount of proposed medications, including use of PRN orders, method (oral or injection), duration of taking proposed medications, the possible side effects of drugs known to occur commonly, and any particular side effects likely to occur to the particular consumer

6. the consumers’ rights under these procedures

Consent to Treatment Policy

Page Two

7. an explanation and discussion must b e documented and signed by staff and consumer

C. A consumer who has consented t medication or treatment may refuse specific medication or treatment at any time by stating or writing that he or she does not wish the medication or treatment. A revocation of consent shall be documented and entered in the consumer’s record.

D. Any violation of this policy will be reported immediately to the Executive Director.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 203

Date of Issue: September 19, 2006

Date Revised:

RIGHT TO REFUSE TREATMENT

VI. POLICY

It is the policy of this agency that each individual receiving treatment has the opportunity to exercise a voice in his or her treatment plan and object to, or refuse aspects of the plan.

VII. DISCUSSION

As a participant in the treatment planning process, the consumer has the right to have an opportunity to exercise his or her voice in the plan and object or refuse aspects of the plan. The right to object to or refuse treatment, in accordance with the provision of law is recognized as legitimate and should be responded to in accordance with provisions of the treatment planning process and the consumer grievance procedure if informal discussion and negotiations do not resolve the differences.

IV. PROCEDURES

The following procedures will be followed:

A. A consumer who has consented to medication or treatment may refuse medication or treatment at any time, by stating or writing that he or she does not wish the treatment intervention. A revocation of consent shall be documented and entered in the consumer’s record.

B. Consumers who have been judged incompetent by the legal system shall have a court appointed committee, guardian or family member who as the authority to assert the consumer’s right to consent or refuse treatment. This individual or these individuals must be notified whenever the Interdisciplinary Team (IDT) intends to use psychotropic medication, aversive conditioning, experimental or hazardous treatment, intrusive treatment, or involve the client in research experimentation.

C. Any violation of this policy will be reported immediately to the Executive Director.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 204

Date of Issue: September 19, 2006

Date Revised:

CONSUMER RECORDS-POLICY 204

I. POLICY

It is the policy of this agency that individual consumer’s records be maintained in a confidential manner with information appropriate to the effective and efficient delivery of consumer services.

II. DISCUSSION

State and federal statutes as well as policies of the Department of Health and Human Services are intended to ensure that every consumer’s right to privacy is protected and that all clinical records are kept confidential. At the same time, there is recognition that there are circumstances under which is necessary for certain legal or fiscal purposes, to for continuity of consumer services, that records or parts thereof may be released. The procedures listed below define circumstances in which records may be released and requirements for such release. Every employee who has access to any such record is responsible for maintaining the confidentiality of any information contained in such records.

V. PROCEDURES

The following procedures will be followed:

A. A consumer record will be maintained for every person receiving services.

B. The consumer record for non-emergency services shall contain:

1. identification data including name, date of birth, address, and consumer’s legal status

2. appropriate social and medical history concerning the consumer

3. summary of the assessment process and treatment or training recommendation

4. a record of any evaluations of the consumer

5. treatment plans and updates including the date of the next review and documentation of the consent of the consumer for treatment

6. a record of any signed and dated physician’s orders

7. a complete record of any accidents, psychiatric emergencies, seizures or illnesses occurring while the consumer is on agency premises or engaged in agency activities and treatment thereof

8. a record of any medications administered

9. copies of all consultation reports

10. a record of any dietary modifications or nutritional needs

11. a continuing record of treatment data, such as performance indicators, post-tests or progress notes which include a summary of treatment provided, progress toward goals and immediate plans for continuing treatment

12. treatment or discharge summary within thirty (30) days of termination

13. communication pertinent to the well-being of the consumer

14. the results of treatment and changes in the treatment plan

C. The record for emergency services shall include, as far as the information is available, the following:

1. For emergency telephone contacts:

a. identification data relating to the consumer or individual making the contact, such as family, friend, police, etc.

b. description of significant clinical data

c. response of professional taking the emergency call

d. record or recommendation made

e. specific instructions given for consumer

f. provision of follow-up

g. signature of staff person taking the call

h. after hours or emergency contacts that may involve the involuntary commitment process will be referred to the local mental health center with CSM staff monitoring and follow up

2. For walk-in emergencies or other emergencies where the consumer is present:

a. identification data including the consumer’s legal status

b. time of arrival and time of discharge

c. means of transportation to emergency service

d. pertinent history including emergency care given prior to the arrival at the agency

e. a description of significant clinical data

f. treatment plan

g. the condition of the individual on transfer or discharge

h. disposition, including instructions given to the individual relative to necessary follow-up care. In addition to any oral instructions given to the consumer upon discharge from

i. emergency services, written instructions shall be given which are dated and signed and documentation of providing such instructions shall be made a part of the consumer’s record

j. the signature of the staff member providing emergency service to the consumer

3. The record of emergency service provided shall be incorporated into the consumer’s record.

4. Consumer records shall be kept current, accurate, and any notations, including treatment plan, shall be signed and dated by the staff providing the service.

5. Consumer records shall be legible, written in ink or typed. Computer printed records are acceptable.

6. Consumer records shall contain information relating only to the individual consumer’s course of care and treatment. The behavior of on other consumer who is under treatment or training shall be recorded in another consumer’s record except for such information directly affecting the care and treatment of the consumer, in which case other consumers who are not relatives shall not be identified in the consumer record by name or number.

7. The agency will maintain a system of identifying and filing consumer records to insure rapid location and retrieval of consumer records at all times.

8. Consumer records or photo copies shall be retained for a minimum of ten (10) years following termination. In the case of minors, records shall be retained until five (5) years after the consumer’s eighteenth birthday. Disposal will assure the confidentiality of information and the preferred method is shredding.

9. The agency will assure records are organized and maintained properly.

10. The agency staff procedures, sanctions, and office procedures as are necessary to protect the confidentiality of the consumers and to govern the release of such records to proper interested parties are as outlined below.

A. Records may be released without consent as follows:

a. In a proceeding under Section 4, Article 5, Chapter 27 of the WV Code to disclose the results of involuntary examination made pursuant to section 2, 3. or 4, Article 5 of Chapter 27 of the WV Code

b. In a proceeding under Article 6-A of Chapter 27 of the WV Code to disclose the results of an involuntary examination made pursuant thereto

c. Pursuant to a order of any court, based upon a finding that said information is sufficiently relevant to a proceeding before the court to outweigh the importance of maintaining confidentiality established by this section

d. To protect against a clear and substantial danger of imminent injury by a patient or client to himself or herself or other

e. For treatment or internal review purposes to staff of agency

f. Records may be released or shared with persons within the Department of Health who have a legitimate reason for access to the record

g. Whenever any physician or psychologist is required to provide testimony to any hearing relative to the involuntary commitment of any individual, all records pertaining to that individual must be taken to the hearing.

11. Consumer records may re released only with written consent of the consumer to :

A. The consumer

B. Physicians and other providers of health, social, educational or welfare services involved in caring for or in rehabilitating the consumer, provided that such information shall be kept confidential and used solely for the benefit of the consumer

C. Agencies or organizations requiring information necessary to make payment sot or on behalf of the consumer pursuant to contract or tin accordance with law, provided that only such information shall be released t third party payers as is required to certify that covered services have been provided

D. Others obtaining such consent

12. Consumer records shall be released to an attorney once verification is obtained that the attorney does represent the

13. consumer, i.e., through the consumer or through circuit clerk confirmation that the attorney is the attorney of record.

14. Upon written request of a consumer, his authorized agent or authorized representative, the agency shall make available to the

15. consumer, his authorized agent or authorized representative, within a reasonable time, a summary of the consumer’s record following termination of the treatment program.

16. There is an obligation on the part of agency staff to assure that a consumer is provided access to their record in clinically responsible manner.

17. All records relating to treatment of an individual for alcoholism or drug abuse shall be subjected to federal regulations of confidentiality of alcohol and drug abuse patient records found at Part 2 of Subchapter A of Chapter 1, title 42, Code of Federal Regulation s or to the statutory requirements of the WSV Code, whichever is more stringent.

18. Nothing in these policies shall be construed to interfere with the right of the Director of Health to examine consumer records in the course of executing her/her responsibilities to administer the licensing regulations or other appropriate state and federal regulations.

19. The agency may charge reasonable fees to cover the actual cost of copying records to be released.

20. Any violation of these procedures will be reported immediately to the E.D.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 205

Date of Issue: September 19, 2006

Date Revised:

Case Management-205

I. POLICY

The purpose of this policy is to outline the standards of this agency for case management of consumer services.

II. DISCUSSION

Case Management is a process of consumer related activities that assess, plan, link, monitor, and advocate for respective individuals receiving services. A specific individual is assigned responsibility for these consumer services. The case manager assures the consumer receives services in fulfillment of the treatment plans from entry to discharge. Case management is a problem solving activity to assure the following: system continuity, system flexibility, integrated service, proper utilization of certain resources and access to services.

Case manager maintain continuous relationship with their consumers, assisting whenever required, especially in alleviating crisis provoking situations. They convene meeting at major junctures in the consumer’s service reception. These individual’s also assure a level of service appropriate to the consumer’s needs. Consequently, consumers with multiple service needs will be provided case manager appropriate to their respective needs.

The focus of all these functions is the maintenance of each consumer’s total social support system, both natural and professional, that includes the recipient in every aspect of service delivery. The consumer’s choice must always be considered as primary,

This agency will assure all consumers will receive case management from a specifically assigned staff person.

III. PROCEDURE

A. Written policies are included in this manual designed to meet the standards of case management for all funding services.

B. Any violation of case management standards must be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 206

Date of Issue: September 19, 2006

Date Revised:

Assessment-Policy 206

VIII. POLICY

The purpose of this policy is to outline the standards of this agency for assessment of consumers for treatment planning. All services, activities and programs

II. DISCUSSION

Appropriate treatment planning and service delivery can only be accomplished when it is based on adequate assessment of each consumer’s current and potential needs, strengths, and weaknesses. In addition, to assure on-going evaluation of consumer’s needs, reassessments will be recommended and secured as indicated.

VI. PROCEDURES

A. Initial Assessment

1. The initial assessment or evaluation of each consumer’s needs, strengths and weaknesses will be entered in each record within five days of the intake.

2. The initial assessment or evaluation will include the following information:

a. presenting problems

b. background history, including social and medical information

c. interview information

d. recommendations for further evaluation and initial treatment prior to finalization of the treatment plan.

3. The initial assessment may include the following:

a. background history including social and medical information which may include environment, home, religion, childhood history, military service, financial status , the social peer group, environmental setting from which the consumer comes, the consumer’s living situation, and social, ethnic, cultural, emotional, and health factors

Assessment Policy

Page Two

b. history of physical exams

c. mental status examinations which may, where appropriate, include psychological testing.

4. Each individual served with a developmental disability for period of one year, shall be provided a complete physical and dental review annually, or referred for a physical and dental review annually and assisted in receiving these services, if necessary.

5. Based on information obtained during the intake interview and subsequent assessments of the consumer’s current and potential needs, strengths, and weaknesses, the need for each of the following evaluations shall be determined and recommendations made for any additional evaluations needed. Evaluations shall be conducted and entered in the record and may include the following:

a. psychiatric evaluation

b. psychological evaluation

c. physical evaluation

d. laboratory tests

e. neurological examination

f. occupational therapy

g. physical therapy evaluation

h. rehabilitation and vocational evaluation

i. adaptive behavior evaluation or direct observation of behavior

j. specific needs, i.e., nutrition or dietary modifications

k. financial needs assessment

l. residential needs assessment

m. speech/language assessment

n. audiological assessment

o. opthamological assessment

p. dental assessment

q. transportation needs assessment

6. Upon review of the treatment plan, the Interdisciplinary Team (IDT) will determine the adequacy of the evaluations conducted and assure that all appropriate evaluations are conducted

7. When diagnoses are rendered, they shall be:

a. written in standard nomenclature as provided in either the American Psychiatric Association’s latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the latest edition of the International Classification of Diseases or the latest Classification for Mental Retardation of the American Association for Mental Deficiency

b. substantiated by valid and reliable data based upon accepted professional standards of examinations and tests

Assessment Policy

Page Three

c. indicated by factual description of consumers’ symptoms and problems

8. Any violation of these procedures will be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 207

Date of Issue: September 19, 2006

Date Revised:

Treatment Planning

IX. POLICY

The policy of this agency is to provide that individual treatment plans are developed and implemented for each consumer which addresses all current and potential needs, strengths and weaknesses.

X. DISCUSSION

In order to assure to the greatest extent possible that all current and potential needs, strengths and weaknesses are considered in developing a treatment plan, all treatment plans will be developed and reviewed by an Interdisciplinary Team which may, in some cases, involve interagency involvement.

VII. PROCEDURES

The following standards for Treatment Planning will be followed:

A. There shall be a written plan of treatment for each consumer, based on the initial assessment of the consumer’s treatment or training needs and the resources of the agency. The plan shall be developed and implemented within seven (7) days of the intake interview and finalized within thirty (30) days.

B. The Treatment Plan, as developed and implemented within seven (7) days of the intake, shall contain at least the following:

1. Immediate needs and interventions

2. Data/assessment needed to finalize the treatment plan

3. Documentation of persons or services responsible for collecting information necessary to finalize the treatment plan and for implementing immediate interventions

4. Specific goals the consumer is to achieve for improvement or maintenance of mental health or optimal adaptive functioning

5. Specific objectives that relate to the goals

6. Expected achievement dates of the objectives

7. A description of the services, activities, and programs initially planned for the consumer

Treatment Planning Policy

Page Two

8. A statement of persons or services responsible for each objective

C. The treatment plan, as finalized within thirty (30) days of the intake, shall contain the following:

1. Specific goals the consumer is to achieve for improvement or maintenance of behavioral or adaptive functioning

2. Specific objectives, written in measurable terms, that relate to the goals

3. Methods for achieving the objectives

4. Expected achievement dates of each objective

5. A description of services, activities, and programs planned for the consumer

6. A statement of persons or services responsible for each objective

7. A date for review of the individual program plan

8. Documentation of the consent of the consumer for treatment

9. The extent of consumer and family participation in the program planning

10. Signatures and titles of all participants in the planning process, including the consumer and/or guardian

D. The consumer and/or guardian shall participate in the development of the treatment plan and reviews. If a consumer is unable or unwilling to participate, and such inability is documented in writing, then planning can be done without participation by the consumer. The consumer’s informed consent for a course of treatment specified in the treatment plan or updates shall be verified by his or her signature or the guardian’s signature.

E. An Interdisciplinary Team (IDT) shall be organized for each consumer and with membership based on that consumer’s current and potential needs, strengths and weaknesses.

1. The IDT shall include:

a. the consumer and/or guardian

b. the consumer’s case manager

2. The IDT may include, depending upon the consumer’s level of need:

a. family or significant others from the consumer’s natural support system, if relevant

b. representatives of each discipline relevant to the consumer’s needs

c. service provider with specific knowledge of the consumer, both intra and inter-agency

d. providers of services for which the consumer is being considered

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Page Three

3. Severely impaired and/or chronic populations with multiple service needs shall be provided comprehensive case planning by an IDT composed of all the above parties

4. Reasons for lack of participation of any of these parties in the IDT shall be documented

F. The treatment plan shall be reviewed and modified by the consumer’s Interdisciplinary Team at each major juncture of the treatment process. The major junctures are:

1. at least every 90 days except that where longer intervals between consumer contacts are part of an approved treatment plan, such reviews shall occur at least every 180 days

2. crisis points

3. transfer among services or responsible staff

4. planned discharge from the agency

G. Reviews of the treatment plans by an appropriated Interdisciplinary Team shall :

1. summarize the amount of treatment or training provided

2. indicate progress toward the objectives

3. indicate problems which impede treatment progress whether consumer or agency based

4. indicate whether the timelines designed for the completion of activities were met

5. provide a decision either to:

a. continue the treatment plan because of acceptable levels of progress

b. modify the treatment plan

H. At termination of services, a summary of care shall be set forth clearly in the clinical record and shall include at least the following:

1. reason for termination

2. summary of assessments

3. course of treatment

4. final outcomes

I. Any deviations from these procedures will be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

Date of Issue: September 19, 2006 Section Number: 200-Policy 208

Date Revised:

SECTION 200-POLICY-CONSUMER RIGHTS-208

I. POLICY

It is the policy of the Council of the Southern Mountains (CSM) to provide treatment and services under conditions that support each consumer’s civil liberties and self-determination. Restrictions on individual liberties and personal choices will only be imposed as necessary to comply with the interdisciplinary treatment process and the respective needs of the consumer. This agency will enforce this Policy and assure procedures are maintained that honor and enforce consumer rights throughout the course of treatment.

II. DISCUSSION

CSM will assure the rights and welfare of each consumer receiving services from this agency are protected at all times. A Human Rights Committee will be an active component of consumer services and will serve to maintain the fair and honorable treatment of all program participants.

III. PROCEDURES

A. The Center will maintain a Human Rights Committee whose role will be to assure the protection of consumer rights within all service areas of the facility.

1. The Human Rights Committee membership is established as follows:

a. there will be minimum of six members

b. at least one third (1/3) of the members will be consumers of behavioral health services

c. no more than one third (1/3) of the members will be Center staff

2. The Human Rights Committee will be convened upon the filing of a consumer grievance, written or verbal and to review behavior intervention treatment plans that may in some aspect limit individual rights or choices.

3. The Human Rights Committee will keep written minutes of all meetings that includes the names and titles of all members and guests present with members absent. Guests present must have any consumer’s or their legal representative’s written permission to attend a meeting where confidential matters are discussed. The chairperson of the Committee will assure this requirement is fulfilled with the consumer’s or their legal representative‘s consent maintained in their clinical record. All meetings are to be conducted with consumers only identified by case number.

4. The Human Rights Committee will hear all consumer issues presented by CSM staff, consumer grievances and treatment plan strategies that could possibly affect consumer rights. The Committee Chairperson will assure a report is issued of findings and recommendations to the Executive Directed within ten (10) calendar days.

5. To review consumer services and provide analysis of the results of reports by the Human Rights Committee, the Project Directors Committee will evaluate all findings within fourteen (14) days of the reports’ submission to the Executive Director. Written minutes will be maintained of this analysis and maintained by the Executive Director. This analysis will be utilized in the Executive Director’s written report to the Human Rights Committee of the investigation findings, conclusions and actions taken to prevent further occurrences of violations within seven (7) calendar days. A notation of the incident and the effect of the incident on a consumer’s illness or treatment will be documented in the consumer’s clinical record.

B. Consumers’ basic rights include the following listing with the understanding that staff must always respect the basis human dignity of all individuals served by the Center, whether every right is delineated below or not. Consumers, parents or guardians will sign CSM form #, Consumer Rights Acknowledgement, at intake into services.

1. The right to treatment and services that support a consumer’s liberty and result in positive outcomes to the maximum extent possible.

2. The right to an individualized, written treatment plan to be developed promptly after admission; treatment based on the plan; periodic review and reassessment of needs, and appropriate revisions of the plan including a description of the services that may be needed for follow-up (see Policy).

3. The right to treatment and services in the least restrictive, most appropriate and potentially most effective setting.

4. The right to ongoing informed participation in the treatment plan process.

5. The right to refuse treatment at any time, except during an emergency situation where harm to self or others is likely or as permitted under West Virginia state law in the case of a person committed involuntarily for treatment.

6. The right to a legal representative when the consumer is unable to act on his or her own behalf.

7. The right to be free from involuntary experimentation.

8. The right to freedom from restraint or seclusion. Restraint and seclusion shall only be used in situations where there is imminent danger to the consumer or others and all less restrictive methods of control have been used.

9. The right to a humane treatment environment in which personal dignity and self-esteem are promoted.

10. The right to confidentiality of records, as provided by rules established by the WV Department of Health and Human Resources.

11. The right to access his or her own consumer records in accordance with State law.

12. The right to assert grievances, orally or in writing, with respect to the infringement of all rights, including the right to have all grievances considered in a fair, timely and impartial procedure.

13. The right of access to an available advocate in order to understand, exercise and protect his or her rights.

14. The right to be informed in advance of any charges for services.

15. The right to all available services without discrimination because of race, religion, color, sex, sexual orientation, disability, age national origin, or marital status.

16. The right to exercise his or her civil rights.

17. The right to referral, as appropriate, to other providers of behavioral health services.

18. The right to be free from physical, verbal, sexual or psychological abuse or punishment.

19. The right to be free from unnecessary or excessive medication.

20. The right to medication that is not used as punishment, for the convenience of staff, as a substitute for programming, or in quantities that interfere with the treatment program.

21. The right to be free from uncompensated labor, except for consumers in residential facilities who perform housekeeping tasks.

22. The right to be informed orally, in writing and in appropriate language and terms, of the rights described in this Policy.

23 Rights and personal liberties may be limited by established policies and procedures when the limitation of the right is clinically appropriate and clearly justified in writing.

24. A consumer’s rights and responsibilities shall devolve only to a legal representative and to the extent that the legal representative’s acts are not hostile or adverse to the best interests of a consumer. This provision does not relieve this agency of the responsibility of informing a consumer , to the extent that a consumer is capable of understanding the matter, nor does it in any way deprive a consumer of his ho her legal rights granted under State or federal law.

BASIC RIGHTS OF RESIDENTIAL CONSUMERS

1. The right to be housed with consumers of the same approximate ages, developmental levels and social needs.

2. The right to unimpeded access to his or her attorney or religious advisor.

3. The right to constant access to his or her personal possessions unless contraindicated by treatment needs.

4. The right to private communication with others by mail, in person and by telephone.

COUNCIL OF THE SOUTHERN MOUNTAINS

P.O. Box 85

Northfork, WV 24868

1-304-862-3144

CONSUMER RIGHTS ACKNOWLEDGEMENT

I have been provided a copy of CSM’s Consumer Rights Policy

as a way of informing me of my rights and treatment I should expect from staff as a consumer of the Council of the Southern Mountains.

_______________________________________________________

Consumer/Parent/Guardian Signature of Acknowledgement-Date

_______________________________________________________

Witness Signature-Date

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 209

Date of Issue: September 19, 2006

Date Revised:

Consumer Rights Pertaining to Freedom From Physical and Verbal Abuse-Policy 209

I. POLICY

It is the policy of this agency that individuals receiving services be protected from physical and verbal abuse.

II. DISCUSSION

It is the responsibility of this agency to insure protection of all consumers’ rights to be free from physical and/or verbal abuse and other infringements on civil rights, human or legal rights, while in the course of receiving services.

Any employee witnessing abuse or having abuse reported to him/her must report same to the Executive Director or designee immediately.

III. PROCEDURES

Freedom from physical abuse includes but is not limited to the following:

a. Unnecessary physical restraint

b. Improper use of physical restraint

c. Placement in seclusion without proper orders or cause

d. Use of unnecessary force in dealing with an acting-out consumer

e. Slapping, kicking or hitting

f. Inappropriate physical horseplay with consumers

g. Inappropriate removal from treatment programs, restriction of communications and withdrawal of privileges for punitive purposes

h. Withholding of meals

i. Corporal punishment of any kind

j. Sexual abuse, physical advances, caressing, intercourse, kissing

Verbal abuse shall be defined to include but is not limited to the following:

A. Yelling and using derogatory, vulgar, profane or abusive language

B. Threatening, abusive tone in speaking to consumers

C. Teasing, pestering, molesting, deriding, harassing, mimicking or any other way of humiliating a consumer

Freedom from Abuse Policy

Page Two

D. Sexual abuse, any sexual innuendo physical advance, or verbal suggestion (see Chapter 27-12-3, WV Code)

E. Verbal threats

F. Derogatory remarks about consumer or family

IV. When verbal or physical abuse of a consumer ahs been observed or alleged by staff or consumer, the grievance procedure will be followed. All mandatory reporting procedures will be followed.

A. Any violation of these procedures will be reported immediately to the Executive Director

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 210

Date of Issue: September 19, 2006

Date Revised:

Consumer Rights to Communicate-Policy 210

I. POLICY

It is the policy of CSM that all persons receiving services from this agency will have the right to communicate with any person or agency of their own choosing.

II. DISCUSSION

The availability for free and open communication with person outside this agency is basic right. Communication is encouraged for it is clinically important for consumers to maintain community contacts to facilitate their individual choices of residential settings.

III. PROCEDURES

A. Written correspondence shall not be opened or read by staff, unless the consumer gives permission for this to be performed.

B. Staff will assist consumers with communication and will provide necessary materials to facilitate appropriate the form of messaging chosen.

C. Any mail that may be returned or sent to the agency for the consumer will be given to the consumer unopened.

D. Consumers will have access to a public telephone during normal hours while at the agency.

E. Consumer will be allowed privacy in regard to communication.

F. Any restriction to mail, telephone calls or other forms of communication, will be based on clinical considerations and documented on the treatment plan which will verify treatment team approval.

G. Access to attorneys, religious advisors or advocates will not be restricted.

H. In situations where access is clinically contraindicated, counsel, religious advisors and advocates will be advised by consumer’s case manager of the reason for such contraindications, that it was approved by the treatment team and the persons will be allowed to observe the consumer, if they so desire. However, counsel or religious advisors must be allowed to visit the consumer, if they insist.

I. Any violations of this policy will be reported to the agency Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 211

Date of Issue: September 19, 2006

Date Revised:

MANDATORY REPORTING OF CHILD OR ADULT ABUSE, NEGLECT OR EMERGENCY SITUATIONS-POLICY 211

I. POLICY

It is the policy of this agency to report all known or alleged adult or child abuse, neglect or emergency situations in compliance with the Protective Services Law of the State of West Virginia.

II. DISCUSSION

Employees of this agency are required to with all requirements of the Child Protective Services Law. It is understood that the “privileged status of communication” or the rights or duties of a person to keep information confidential is abrogated (abolished) between consumer and clinician in circumstances involving known or suspected cases of abuse, neglect or emergency situations. Only privileged communications between an attorney and his/her client are exempt from abrogation. Please refer to HIPAA policy.

III. DEFINITIONS

“Adult Protective Services Agency” – Any public or nonprofit private agency, corporation, board or organization furnishing protective services to adults.

“Abuse”- The infliction of or threat to inflict physical pain or injury on or the imprisonment of any incapacitated adult.

“Neglect”- The failure to provide the necessities of life to an incapacitated adult with intent to coerce or physically harm such incapacitated adult or the unlawful expenditure or willful dissipation of the funds or other assets owned or paid to or for the benefit of an incapacitated adult.

“Incapacitated Adult”- Any person who by reason of physical, mental or other infirmity is unable to independently carry on the daily activities of life necessary to sustaining life and reasonable health.

“Emergency Situation”- An incident or set of circumstances which presents a substantial and immediate risk of death or serious injury to an incapacitated adult.

VIII. PROCEDURES

The following procedures will be followed:

A. A report of neglect or abuse of an incapacitated adult or of an emergency situation involving such an adult will be made immediately by telephone to the local Adult Protective Services agency and must be followed by a written report within forty-eight hours. Local numbers are to be posted at all sites and the attached reporting form must be completed.

B. During employee orientation, all staff will receive a copy of this Policy and the attached reporting form regarding:

1. Who is required to report by law

2. Where are reports made

3. What should be included in reports

4. Confidentiality of reports

5. Reporting person’s immunity from liability

6. Abrogation of privileged communication

Agency staff will sign a statement verifying they have reads and understand the Policy and agree to abide by its mandates and WV State law.

C. When any medical, dental or mental health professional, Christian Science Practitioner, religious healer, social service worker, peace officer or law enforcement officer, employees of any nursing home or residential facility, and state or regional ombudsman has reasonable cause to believer hat a incapacitated adult is neglected, abused or in an emergency situation, or if such person observes an incapacitated adult being subject to condition stat are likely to result in abuse, neglect or an emergency situation, the person will immediately report the circumstances or cause a report to be made to the local protective services agency.

D. Nothing in this Policy is intended to prevent individuals from reporting on their own behalf.

E. Any person, other than those listed within Section 3 above, may report situations involving suspected abuse or neglect of an incapacitated adult or the existence of an emergency situation.

F. When serious injury, sexual abuse or sexual assault is suspected or witnessed, the situation will be reported to the Department of Public Safety (State Police) and any law enforcement agency having jurisdiction to investigate the report. Documentation will be made in the respective consumer’s clinical record of any such reporting.

G. Failure of any agency employee to make protective services reports involving suspected abuse, neglect or emergency situation is a misdemeanor and punishable by fine and/or imprisonment as established by WV State law. In addition, any employee failing to make such reports is subject to immediate termination from employment. All employees will sign an acknowledgement that they have read, understand this policy and will abide by its directives.

H. In the event any staff person becomes aware of or suspects a situation of neglect or abuse within any area of this agency, that employee must also report the situation immediately to the E.D.

I. The Executive Director will report or assure a designated staff reports to the local Department of Health and Human Resources offices all reports of suspected or known cases of neglect, abuse or emergency situations. The E.D. will then begin an internal investigation of all reports. Results of all investigations and actions taken will be reported to the Human Rights Committee.

J. All reports of known or suspected cases of abuse, neglect, exploitation or emergency situations involving agency consumers will be reported on the standardized WV DHHR Adult Protective Services Report Form. The form will be forwarded to all listed parties and will be filed within 48 hours. A copy of this form is attached.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 212

Date of Issue: September 19, 2006

Date Revised:

Advocacy-Policy 212

I. POLICY

It is the policy of this agency for case managers will influence the human service system and natural support systems to respond to individual consumer needs.

II. DISCUSSION

In order to provide effective case management services, it is imperative that case managers provide case-specific and class specific advocacy. Case specific involves influencing the human service systems and natural support systems to respond to individual case needs, while class specific advocacy is the process of influencing human service systems and natural support systems to change in response to documented deficiencies in the their capacities to serve and nurture. Advocacy is the manner in which case managers insure continuity of services, system flexibility, integrated service, proper utilization of facilities and resources and accessibility.

III. PROCEDURES

The following standards for Treatment Planning will be followed:

IV. the agency will provide case specific advocacy as needed with documentation of this support maintained in respective consumer clinical records

V. the agency will provide class specific advocacy through community support of targeted consumers with staff training records

VI. Any violation of this policy will be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 213

Date of Issue: September 19, 2006

Date Revised:

Psychiatric Emergency-Policy 213

I. POLICY

It is the policy of this agency that psychiatric emergencies will be dealt with in an effective and timely manner.

II. DISCUSSION

A psychiatric emergency exists when a consumer loses control and acts in a manner that poses substantial likelihood of physical harm to himself or others. On these occasions, when less restrictive measures such as talking with the person are not effective, or where the consumer is actively dangerous to himself/herself or others, the agency may utilize intrusive measures, such as:

1. Physical/Mechanical Restraint

2. Seclusion

3. Initiation of the involuntary commitment process under Chapter 27 of

the West Virginia Code.

Any intrusive measure may only be used until the crisis is resolved or the consumer can be transported to an inpatient facility, as prescribed by Chapter 27 of the WV Code.

III. PROCEDURES

The following standards for psychiatric emergencies will be followed:

K. Staff shall immediately notify the appropriate supervisor of any psychiatric emergency and clear other consumers from the immediate area.

L. Unless the consumer is immediately dangerous to himself or others as, for example, the consumer is actually attempting suicide or attacking others, staff will perform less restrictive methods of crisis management, such as one-to-one verbal rapport.

M. In the consumer is immediately dangerous to himself or others and less restrictive methods do not work, staff may intervene with more intrusive methods until the crisis is resolved or the consumer is transported to an inpatient facility.

N. Seclusion or restraint may be used as an extreme last resort to control dangerous behavior. Such seclusion or restraint shall not be used for a period that exceeds three (3) hours.

O. A consumer may be placed in seclusion only with the dated and signed approval of a physician, the Executive Director or designee, and written in the consumer’s record.

P. The staff person in charge shall be responsible for assuring that each consumer in seclusion shall be monitored continuously with a log maintained of the consumer’s actions.

Q. All harmful objects will be removed from any area utilized for the purpose of seclusion.

R. Restraints may be used when seclusion is inappropriate because the consumer is actively suicidal or requires constant observation.

S. Restraints may be applied to a consumer only with the dated and signed approval in the consumer’s record by a physician, the Executive Director or designee. The Executive Director will be notified immediately when restraints are used.

T. Supervision of consumers in restraints shall be on a one-to-one basis for the duration of the time the restraints are in place.

U. In cases where the crisis abates before it is necessary to transport the consumer to an inpatient facility, a physician, the Executive Director or designee, may approve the consumer’s release from seclusion or restraints.

V. A complete description of the emergency shall be immediately entered in the consumer’s record and include:

1. a report of the incident

2. physician’s orders as needed

3. staff actions and rationale for each method employed

4. a continuing description of the consumer’s response to staff actions

5. all approvals by a physician, the Executive Director or designee to utilize obtrusive measures

6. seclusion checks and restraint reports at least every five (5) minutes

7. the resolution of the emergency

8. plans to continue services to the consumer

W. Any violation of this policy will be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 214

Date of Issue: September 19, 2006

Date Revised:

Linking-Policy 214

I. POLICY

It is the policy of this agency that all assessed needs of consumers be addressed by direct service on the part of the agency or by linkage with other service providers.

II. DISCUSSION

Some consumers, particularly those who are seriously impaired and/or chronic, require a variety of services and programs to meet their needs. These services and programs may be available within the agency, or may need to be provided through referral or transfer to other service agencies. This referral, if appropriate, may also be made to the natural support system.

It is the responsibility of the case manager to assure linkages to all indicated internal and external services and to monitor the delivery of these services.

III. PROCEDURES

The following standards for Treatment Planning will be followed:

a. All consumers shall be referred or transferred to all services and programs recommended in the treatment plan according to the timelines indicated in the plans

b. Any violation of this policy will be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 215

Date of Issue: September 19, 2006

Date Revised:

Monitoring-Policy 215

I. POLICY

The policy of this agency is to provide monitoring of progress of all agency consumers and that the reassessment and/or revision of treatment plans is accomplished whenever indicated by a change in the consumer’s status.

II. DISCUSSION

Progress of all consumers must be continually evaluated to eliminate the possibility of inappropriate placement in services and programs. The monitoring of consumer status is the responsibility of the case manager, utilizing information provided by all services and programs working with the consumer.

III. PROCEDURES

The following standards for Monitoring will be followed:

a. At each major juncture in the treatment process, an in Interdisciplinary Team (IDT) conference shall be convened for the purpose of planning and evaluation

b. Relevant materials and information shall be gathered prior to an Interdisciplinary Team conference

c. A continuing record of treatment data, such as performance indicators, post-tests, or progress notes which include a summary of the treatment provided, progress toward goals and immediate plans for continuing treatment be mentioned

d. Any deviation from or violation of this policy will be reported immediately to the Executive Director.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 216

Date of Issue: September 19, 2006

Date Revised:

CREDENTIALING PR0CEDURES-Policy 216

I. POLICY

CSM will review all staff hired for appropriate credentials and experience to comply with the current funding source requirements for service provision. This review will take place at hiring, critical junctures for staff, i.e. obtaining additional degrees or certifications, and annually.

A Credentials Committee made up of the Project Directors Staff will review all documentation presented to the Executive Director for sign-off.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 217

INFECTION CONTROL POLICY-217

Date of Issue: March 16, 2005

Date of Revision:

I. Policy

This policy is initiated to:

- Ensure the use of proper procedures in the handling of consumers in order to prevent the introduction or the spread of infection.
- Ensure the infection control procedures of the agency have been established to protect consumers and personnel during all aspects of service provision. These procedures are reviewed and revised as necessary. Employees are notified of all revisions and must be aware of all infection control procedures.
- Initiate sound principles of infection control shall be integrated into all procedures, processes, techniques, and methods utilized in direct and indirect consumer services.

II. Discussion

- Infection control procedures are the responsibility of all personnel. These policies will minimize the hazard of infection for both consumers and staff.

III. INFECTION CONTROL PROCEDURES

- All staff shall use Standard Universal Precautions for consumer care and for contact with blood or body fluids to reduce exposure to bloodborne pathogens by using personal protective equipment.
  - Any employee with a contagious disease, i.e. elevated temperature, draining lesion, etc., should not have direct consumer contact. If an employee is found to have an infectious disease, he/she is restricted from working with patients and must report to Human Resources. Employees will be required to stay at home.
  - Employees who have been or suspect they have been exposed to an infectious disease should notify their immediate supervisor.
  - For exposures, including needle sticks, the employee shall wash area immediately. Then notify supervisor. (This is for agency staff qualified to give injections.)
  - Eating and drinking will be restricted according to agency policy.
  - Post Exposure Protocol - If blood and/or body fluid exposure occurs, such as needle stick, direct skin contact, or splash to eyes, mouth or nose, wash/flush area as appropriate immediately. Report incident to supervisor. If post exposure prophylaxis is indicated for possible HIV exposure, it is optimal for treatment to begin within 1-2 hours after incident.
- Education: Infection Control training is included in the agency orientation for all new staff. This includes training employees on their responsibilities and the importance of infection prevention and control. All health related personnel will be required to read this policy and recommend any revision to the policies throughout the year.
  - - Shoes worn by staff should be made of leather or leather type material. Sandals and cloth shoes are not acceptable in the interest of safety. Clogs are worn at your own risk and are not recommended. Shoes shall be kept clean when worn.
- Equipment: To minimize the risk of infection, direct staff may not handle or in any way be involved with medical equipment utilized by consumers without the direct order of qualified medical staff.
  - - To be sterilized, equipment is to be rinsed with a disinfectant and dried. If it is contaminated with blood or body fluids it is to be cleaned with a 1:5 solution of chlorine bleach and water then rinsed and dried.

- INFECTED CONSUMERS
  - If a consumer is found to have any possible contagious disease, universal precautions will be followed.
- EQUIPMENT AND MATERIALS
  - All equipment or activity supplies used by staff or consumers should be cleaned after each use with a disinfectant.
  - Storage and Stock Checking:

- 1. - Manufactured disposable items and items with an expiration date shall be stored in a specified location. All items, including disposable items with a manufacturer expiration date, will be checked on a quarterly basis (with user sign off) to insure that they are current. All packages which will expire before the next scheduled check will be identified in a manner to assure use prior to expiration date.
    - Shelf Life: Shelf life is event-related, not time related. An event can compromise or destroy the bacterial barrier effectiveness of the packaged material (e.g., package is torn or wet). Items should be routinely inspected for evidence of moisture, soilage and/or tears that may have occurred during transit or storage by the user prior to use. Packages will be considered contaminated if they are damaged, wet or stained.

- HOUSEKEEPING: Janitorial staff is responsible for emptying trash, mopping the floors and vacuuming the carpets in the office area. The workrooms and lounge areas are to be cleaned at least once a day. All staff are responsible for infection control and cleanliness. If there is no janitorial staff at a particular site, then staff will ensure all precautions are maintained.

Any violations of these procedures will be reported to the immediate supervisor or Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

Date of Issue: September 19, 2006

Date Revised:

UTILIZATION MANAGEMENT

XI. POLICY

The policy of this agency is to all consumers with access to appropriate and medically necessary services by qualified, certified staff.

XII. DISCUSSION

Utilization Management operates to ensure that CSM provides high quality services with desired outcomes for service recipients. UM is the responsibility of management staff to determine if services provided are appropriately implemented through a comprehensive interdisciplinary treatment plan based on a thorough assessment process.

XIII. PROCEDURE

A. Determine Appropriate Level of Care

i. Evaluation of the consumer’s needs for services will be based on documented assessments and evaluations after review by the Interdisciplinary Treatment Team.

ii. The Service Coordinator is responsible for ensuring all assessments are maintained in the appropriate clinical records.

And submission of all required documentation to the authorization of services agency (APS).

iii. Upon receipt of service authorizations from APS, the Service Coordinator will notify the Program Director of any problems by the end of that work day.

iv. At the time of the writing of this Policy, the Service Coordinator is the liaison with the Administrative Service Organization. When there area problems with the service authorization for their respective consumer, the Coordinator is responsible for rectifying the problem through the APS Utilization Management guidelines.

Utilization Management Policy

Page Two

B. Continuation of Services

i. Service Coordinators develop consumer budgets for Title XIX Waiver services according to funding source and other regulatory standards.

ii. All approved consumer budgets with units of service, and not just Service Coordination consumers, copies will be forwarded to the Administrative Assistant. This individual, at this writing, is responsible for Waiver billing.

iii. The Service Coordinator will also inform the Administrative Assistant of any changes in budgets or units of service for each consumer after 90 day or critical juncture meetings that change units of service for consumers, once approved by APS.

iv. The Administrative Assistant will enter the approved units of service for each consumer on a spreadsheet.

v. CSM, at present, bills Waiver services weekly. Only services with completed documentation will be billed. The Administrative Assistant will contact the Service Coordinator immediately when a Service Activity Log is submitted for billing without documentation. Disciplinary action may be taken against staff with this occurs.

vi. The Administrative Assistant will subtract the unit of services billed each week from the monthly allowable billing allocation. (Allocations are made for a year at a time but for control purposes, monthly monitoring will be standard)

vii. As a rule, but according to utilization, the Administrative Assistant during the last week of the month will notify staff when possible billing for that week could exceed allowable allocations.

viii. The Administrative Assistant will complete a Utilization Management Form (attached) at each review of billed units of service. Unbilled units will also be reviewed to determine why services are not being implemented.

ix. The Administrative Assistant will complete a Utilization Management Form each time the billing summary is received from Unisys (or other State approved payment agency) to analyze errors and to improve billing practices.

x. Service Coordinators reviewing billing results or analyzing billing practices will complete the U.M Form (attached) and file with the Administrative Assistant. This is required for staffs’ daily documentation for correct billing and utilization of approved services.

xi. U.M. information will be shared with the Executive Director and Director of Finance to verify documentation is utilized to review the agency’s billing practices as related to efficient and effective utilization of each consumer’s Individualized Waiver Budget.

xii. The Administrative Assistant will evaluate through a U.M review to ensure authorization requests to APS are appropriate, after consulting with the Service Coordinator, i.e., Environmental Accessibility Adaptation, services requested in excess of limits, etc.

xiii. CSM will complete self Utilization Management reviews and submit the results to APS and the BHHF Waiver office according to established timelines.

xiv. The Service Coordinator will notify the Director of all problems regarding authorization of services for consumers immediately. The Service Coordinator is responsible for ensuring that service authorizations are current.

xv. Staff providing services without authorization will be subject to disciplinary action.

C. Continuous Improvement

i. Waiver services reviews will be conducted by administrative staff on a weekly basis. The results of the reviews will be discussed with all relevant staff and staff training with need procedures changes will be determined.

ii. Administrative staff will communicate to all direct care staff changes regarding procedures or regulations from APS, BHHF or any other regulatory entity.

iii. All denied or pending requests for services will be investigated to ensure accuracy of information submitted. Staff will be notified of any breaks in services.

iv. Any reduction of services based on utilization management or APS action will be discussed with the consumer and family, if appropriate, by the staff person assigned to the consumer.

v. Any denial of services based on APS action will be discussed with the consumer by the clinician assigned to the consumer according to regulatory procedures established at the time.

COUNCIL OF THE SOUTHERN MOUNTAINS

TITLE XIX WAIVER PROGRAM

UTILIZATION MANAGEMENT REVIEW

STAFF:____________________________________DATE:_______________________

FINDINGS:______________________________________________________________

________________________________________________________________________

RECOMMENDATIONS:

________________________________________________________________________

__________________________________________

SIGNATURE DATE

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 219

Date of Issue: September 19, 2006

Date Revised:

QUALITY ASSURANCE-POLICY 219

I. POLICY

This agency accepts the responsibility to its consumers, funding sources and to the community of providing the best care and treatment possibility available. It is the duty of the administration of this agency to develop procedures that are necessary to fulfill our responsibility of quality services for our consumers.

II. DISCUSSION

Title 64, Series 11 of the WV Legislative Rules of the Department of Health mandates that all behavioral health providers have and implement a systematic review of the appropriateness and efficacy of consumer services. This agency recognizes that quality assurance also extends to compliance with other mandates relating to documentation of services that demonstrate accountability.

III. PROCEDURE

a. Administrative Review

The purpose of administrative reviews is to assure that agency management is fully cognizant of the level of compliance with agency requirements regarding the physical integrity of each consumer’s clinical record.

i. Each month a minimum of one-sixth of all active records will be reviewed for compliance with documentation requirements.

ii. A report of the deficiencies found during that review will be given the supervisor who will distribute it to the appropriate clinician. The clinician has seven (7) working days to correct any instance of noncompliance noted or to develop a corrective action plan. Such corrective action plans shall be reviewed by the clinician’s supervisor.

iii. If the clinician fails to respond with a corrective action plan, the supervisor may elect to issue a written warning and implement disciplinary action. If the corrective action plan has not been followed by the next review, disciplinary action will be taken.

iv. If the discrepancy cannot be corrected, the supervisor will approve this finding by signing off on the documentation. Once the supervisor has signed the discrepancy, it will be counted as a deficiency in future reviews.

The reviews will be filed in alphabetical order separate from the consumer record in the administrative offices in compliance with all confidentiality requirements.

b. Clinical Review

Please refer to HIPAA Policies for uses and disclosures of Protected Health Information (PHI).

i. The main objective of clinical reviews is to assure that quality services are provided. It should be utilized by supervisors and staff as a learning experience.

ii. Each month the clinical supervisor will meet with respective staff to discuss services delivered. At the supervisor’s discretion or employee’s request, reviews may be either individual or in a group setting (peer review).

iii. Documentation regarding the content of the supervision, the number of cases discussed and the time spent will be maintained in the staff member’s personnel file to comply with Medicaid regulations.

c. Service Review

To ensure that services billed are documented in the progress notes or other required documents, that units of services are documented appropriately, that services are authorized by the IDT, and services were provided according to licensing regulations.

i. Each month a random sample of at least 10 percent of the cases receiving services the preceding month will be reviewed.

ii. Each case will be reviewed to ensure compliance with existing regulations.

iii. A copy of the findings of each case will be given to the appropriate supervisor and then shared with the case manager for comments. The report will then be filed in alphabetical order in the administrative offices, in compliance with all confidentiality requirements.

iv. A summary report will be given to the Executive Director each month with recommendations for further action.

v. If corrective action is required to billings already submitted, the finance manager will be informed to initiate proper remediation.

vi. A summary report of findings of the audits will be submitted to the appropriate regulatory body as required.

d. Non-compliance with this Policy must be reported to the Executive Director.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

SECTION 200-POLICY 220

Date of Issue: September 19, 2006

Date Revised:

Medical Emergency-Policy 220

I. POLICY

It is the policy of this agency that medical emergencies involving threat of death or serious physical harm requiring immediate treatment be dealt with in an effective and timely manner.

II. DISCUSSION

Medical emergencies are those which involve a threat of death and serious physical harm requiring immediate treatment. In order to assure prompt and effective provision of emergency medical services, the agency will refer all consumers as quickly as possible to the most appropriate medical facility available to provide for the consumer’s needs.

III. PROCEDURES

The following standards for medical emergencies will be followed:

A. Upon a medical emergency, as defined above, 9-1-1 will be called immediately. Until the arrival of emergency medical personnel, basic first aid and CPR will be preformed by certified agency staff, targeted consumers with the staff training records

B. A complete description of the emergency and the staff course of action taken will be entered into the consumer’s record. Such documentation will include:

1. an Incident Report

2. a full description of the event, problem action taken, staff involved and witnesses and the results of the incident

3. time of events

C. The consumer’s family or significant others, as pre-determined, will be notified as soon as possible and informed of all the incident events.

D. The agency will arrange for the necessary support services for area medical facilities and transportation as necessary for individual consumers

E. All direct care staff will be trained in first aid, CPR and How to Handle Emergency Situations on an on-going basis with documentation in personnel files.

F. Any violation of this policy will be reported to the Executive Director immediately.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURES MANUAL

SECTION 200-POLICY 221

Date of Issue: September 19, 2006

Date Revised:

CONSUMER GRIEVANCE PROCEDURE-POLICY 221

I. POLICY

It is the policy of this agency that consumer’s complaints be investigated in a timely and effective manner leading to conflict resolution.

II. DISCUSSION

This policy applies to the investigation of any consumer complaint. This policy is designed to provide uniformity in the conduct of an investigation, to clarify roles and responsibilities of participants, to insure that the due process is afforded both consumers and staff in the investigation process and to assure prompt resolution of complaints.

III. PROCEDURES

The following procedures will be followed:

A. Agency staff shall inform each consumer at the point of entry into the system of consumer rights, the existence of consumer grievance procedures and the process for using the procedure. Written documentation and the consumer’s acknowledgement of having received the information should be made in the consumer’s record.

B. The agency consumer’s grievance procedure, a statement of consumer’s rights and the name and telephone number of the available advocate will be posted for ready access by consumers.

C. The agency grievance procedure will include the following:

1. A report shall be made within 24 hours to the Executive Director or designee of all violations or suspected violations of a consumer’s rights, expect immediate notification should be made incase of physical abuse. A complaint may be made by a consumer, employee, or other individual.

2. A complaint shall be put in writing on a designated format. Persons unable to write shall be assisted by a case manager or other advocate who shall assure that the written complaint is a fair and accurate representation of the allegation.

3. The Executive Director shall initiate a thorough investigation within 24 hours after receiving a report of a complaint. This investigation may utilize the Human Rights Committee or be accomplished by some other means at the director discretions.

4. When the Human Rights Committee is designated as the investigating body, the committee shall meet, take testimony and conduct meeting to ascertain the facts in the case. The committee shall conclude its investigation and make a written report and recommendation to the Executive Director no later than 21 days following the request for investigation:

a. This report shall contain:

1. A restatement of the complaint

2. A summary of the investigation

3. Conclusions

4. Recommendations

b. The Executive Director shall receive the report and recommendations of the committee and make a decision within 72 hours of receipt to the committee report.

c. The complaint, the consumer’s case manager or other advocate, members of the Human Rights Committee, involved employee are to receive written notification of the Executive Director’s decision.

5. When the Human Rights Committee is not the investigating entity, the committee will receive a report from the executive director of the finding and actions taken.

a. The committee will review the report, make further investigation when appropriate and then give written recommendations to the Executive Director within 21 days of receipt to the report.

b. The E.D. shall review the report and recommendations of the committee and make a decision within 72 hours of receipt to the committee report.

c. The Human Rights Committee will be given written notification of the actions taken be the ED in response to their recommendations with action to be taken to prevent further occurrences. The consumer or consumers shall be indentified by case number only.

6. The agency is prohibited from discriminating against a consumer by whom or on whose behalf such a complaint has been

7. Submitted or who haw participated in a complaint related investigation for the reason of such submission or assistance.

8. Notation of the incident and the effect of the incident on the conumer’s treatment shall be documented in the consumer’ record.

9. If the action of the ED taken on behalf of the consumer regarding the violation of the consumer’s rights is unfavorable, insufficient, or not forthcoming within a reasonable period of time (15) days, the consumer or his/her representative may appeal to the Center’s Board of Directors, of the state licensure body (OHFLAC), the WV Advocates, or the Secretary of the Department of Health and Human Resources.

10. Provision will be made for suspension or reassignment of staff when the ED believes the continued presences of the employee assumed of abuse would pose danger to the health and safety of the consumer.

11. All persons involved in grievance investigations will conduct them with respect of consumer’s or other employee’s right to confidentiality, No agency employee will discuss investigation of violation of consumers’ rights with any unauthorized persons.

12. The duty of the agency to conduct an administrative investigation under these guidelines is independent of any investigation conducted by the police or prosecuting attorney whether there has been or has not been a violation of criminal law. The ED of the agency has not been a violation of criminal law. The ED of the agency has not fulfilled the obligation to protect consumers by referring the matter to legal authorities for investigation. Complaints of violations of consumer rights, once filed, require an administrative response. The agency may delay or defer its investigation until law enforcement authorities have completed their investigation only if the administrator concludes that a delay will not adversely affect the health and safety of the consumers.

13. Any violation of these procedures will be reported immediately to the ED.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

Section 200 Policy 222

Date of Issue: May 7, 2008

Date Revised:

Handling Consumer Money-Policy 222

I. The Council of the Southern Mountains will by this policy ensure all consumers of agency services have their funds safeguarded.

II. Discussion

All consumers must have their rights and property respected and safeguarded so their assets may be used to maintain their standards of living and community choices.

III. Procedures

A. Participant money collected for special events such as community trips, special events, etc., will be collected and handled by a designated employee assigned to each consumer. This employee will be responsible for reporting and tracking and the provision of receipts for these funds.

B. Member money is kept in a secure, safe area or on the staff person if necessary during community services.

C. Consumers are encouraged to safeguard their own funds.

D. Employees of CSM are prohibited from handling members’ money except as noted above. Handling money includes, but is not limited to: reconciling checkbooks, writing checks for members, using bank cards, Automated Teller Machines (ATM’s) or providing banking services.

E. At no time shall a CSM staff person borrow money from a consumer.

F. Service Coordinators will monitor funds of appropriate consumers on a monthly basis. Each consumer this agency serves as representative payee will have an annual budget with monthly financial statements.

COUNCIL OF THE SOUTHERN MOUNTAINS

POLICY AND PROCEDURE MANUAL

MANAGEMENT OF INAPPROPIATE BEHAVIOR

Section 200 Policy 223

Date of Issue: May 7, 2008

Date Revised:

I. POLICY

It is the policy of the Council of the Southern Mountains to assure that inappropriate behavior manifested by a consumer is treated by the Center in the most appropriate, least restrictive fashion that honors consumer rights and dignity. The only time physical restraint may be utilized is when verbal intervention techniques have been exhausted and the when the consumer in crisis presents a danger to self to others.

II. DISCUSSION

The management of inappropriate behavior within the Center refers to efforts to notify maladaptive or problem behaviors and to replace them with behaviors that are adaptive and appropriate. Inappropriate behavior is defined as consumer behavior that is disruptive to others consumers, clinics operations, or the treatment process itself such as persistent yelling, fighting, excessive vocalizations that deprive others from participation, and temper tantrums. An example within a group services environment is hostile behavior that disrupts the group to the extent that the purpose of the treatment is frustrated.

An example of inappropriate behavior within the context of individual therapy may include any behavior which is hostile, such as persistent threats to the therapists or efforts to strike or otherwise harm the therapist. Also, behavior which is disruptive to the therapy process such as persistently leaving the treatment location, disrupting other consumers in the clinic, disrobing, etc...

III. PROCEDURE

The least Restrictive Programming Hierarchy for Behavior Modification Techniques is to be followed consistently by all staff. This hierarchy is based on the fundamental legal principle that that least intrusive means which can accomplish treatment objectives must be utilized. At orientation, staff must read and be familiar with this scale.

The procedural steps or “scale of alternatives” of this hierarchy are:

A. STRUCTING THE ENVIROMENT

Structuring the environment, or setting up the antecedent conditions, to achieve the desired behaviors is the least restrictive from of behavioral programming. The environmental changes may mean anything from recording verbal request of rearranging furniture to more formal and complex structuring of training sessions any analyzing staff behavior.

Structuring the environment may aloes mean that a quiet area may be utilized to allow a consumer to regain composure, however? Staff must monitor the consumer when allowed to access this alternative, which is not to be any form is isolation.

B. EXTINCTION PROCEDURES

This procedure includes no external reaction by staff, such as ignoring behavior, up to eliminating systematically all possibility of