Policies and Procedures

Table of Contents

Rights of the Client 4

POLICY 01.001 COMPREHENSIVE INFORMED CONSENT TO TREATMENT 4

POLICY 01.002 CLIENT RIGHTS 9

POLICY 01.003 CLIENT GRIEVENCES 13

POLICY 01.004 CLIENT TELEPHONE USAGE 15

POLICY 01.005 USE OF RESTRAINTS 16

POLICY 01.006 CONTRABAND 17

POLICY 01.007 RESEARCH STUDIES 18

General Requirements/ Treatment Services 20

POLICY 02.001 ACCESS TO CLIENT RECORDS 20

POLICY 02.002 TARGET POPULATION 21

POLICY 02.003 ADMISSION AND EXCLUSION CRITERIA 22

POLICY 02.004 ASSESSMENT 24

POLICY 02.005 CLIENT TREATMENT PLANNING 26

POLICY 02.006 PROGRESS NOTES 28

POLICY 02.007 DISCHARGE PLANNING 30

POLICY 02.008 DISCHARGE SUMMARY 31

POLICY 02.009 FOLLOW-UP 32

Compliance, Privacy, & Legal 33

POLICY 03.001 CONFIDENTIALITY 33

POLICY 03.002 UNUSUAL INCIDENT REPORTING 37

POLICY 03.003 SENTINEL EVENTS 38

POLICY 03.004 INTERNAL INCIDENT REPORTS 40

POLICY 03.005 PET THERAPY 42

Environment of Care 43

POLICY 04.001 CLIENT CARE ENVIRONMENT 43

POLICY 04.002 SYSTEM INSPECTIONS 45

POLICY 04.003 HOUSEKEEPING 46

POLICY 04.004 PEST AND VERMIN CONTROL 47

POLICY 04.005 WASTE REMOVAL 49

POLICY 04.006 TOBACCO PRODUCTS 51

POLICY 04.009 AROMATHERAPY 52

POLICY 04.009 SECURITY PROTOCOLS 54

Infection Control 56

POLICY 05.001 INFECTION CONTROL PROTOCOLS 56

POLICY 05.002 UNIVERSAL PRECAUTIONS 58

POLICY 05.003 TUBERCULOSIS EXPOSURE PLAN 61

POLICY 05.004 BOIL WATER ADVISORIES 63

POLICY 05.005 NEEDLESTICK INJURIES AND MUCOUS MEMBRANE EXPOSURE 64

Medical 65

POLICY 06.001 CLIENT PHYSICAL EXAMINATIONS 65

POLICY 06.003 CLIENT TUBERCULOSIS TESTING 66

POLICY 06.004 CLIENT SUICIDE RISK 67

POLICY 06.005 LOOK ALIKE SOUND ALIKE MEDICATIONS 68

POLICY 06.006 HIGH ALERT MEDICAITONS 69

POLICY 06.007 MEDICATION MANAGEMENT AND ADVERSE DRUG REACTION 70

POLICY 06.008 PROHIBITTED ABBREVIATIONS 71

Official "Do Not Use" List 71

POLICY 06.009 APPROVED ABBREVIATIONS 72

POLICY 06.010 LABORATORY TEST RESULTS 73

POLICY 06.011 LABORATORY – URINE DRUG SCREENING AND FREQUENCY OF TESTING 74

POLICY 06.012 WAIVED TESTING 76

POLICY 06.013 SEIZURES 78

POLICY 06.014 ALLEGIES 79

Safety 80

POLICY 07.001 EVACUATION OF FACILITY 80

POLICY 07.002 FIRE ALARM AND SAFETY 83

POLICY 07.003 HEAT EMERGENCY 85

POLICY 07.004 MEDICAL EMERGENCY 86

POLICY 07.005 DEATH ON PREMISES 88

POLICY 07.006 POSS OF A CONTROLLED SUBSTANCE OR RELATED PARAPHANALIA 89

POLICY 07.007 POSSESSION OF LICIT DRUGS 90

POLICY 07.008 EMERGENCY PROCEDURES DISASTER PLAN 92

Performance Improvement 102

POLICY 08.001 PERFORMANCE IMPROVEMENT PROGRAM 102

POLICY 08.002 CLINICAL SUPERVISION 112

Information Technology 113

POLICY 09.001 ELECTRONIC INFORMATION AND COMMUNICATION SYSTEM 113

Administrative/ Human Resources 116

POLICY 10.001 POLICY AND PROCEDURE MANUAL 116

POLICY 10.002 CODE OF ETHICS 117

POLICY 10.003 ABUSE IDENTIFICATION AND REPORTING 120

POLICY 10.004 STUDENT INTERNS AND VOLUNTEERS 122

POLICY 10.005 TRANSPORTATION 126

POLICY 10.006 PRIVATE VEHICLE TRANSPORTATION OF CLIENTS 129

POLICY 10.007 USE OF COMPANY LOGOS 130

POLICY 10.008 HIRING PROCEDURES 131

POLICY 10.009 EMPLOYEE PHYSICAL EXAMINATION 133

POLICY 10.010 EMPLOYEE VACCINATION SCREENING 134

POLICY 10.011 CRIMINAL BACKGROUND CHECKS 135

POLICY 10.012 EMPLOYEE DRUG TESTING 137

POLICY 10.013 EMPLOYEE TRAINING 139

POLICY 10.014 EMPLOYEE PERSONNEL FILES 141

POLICY 10.015 NATIONAL PRACTITIONER DATA BANK 143

Rights of the Client

PURPOSE

The purpose of this policy is to detail how clients receive information regarding basic agency policies and practices at the time of admission.

POLICY

It is the policy of the organization that all clients are informed and understand agency policies and practices upon admission.

PROCEDURES

Upon admission, all clients are informed of the basic agency rules, policies, procedures, and restrictions and must agree to the following in order to receive treatment. All clients must sign this consent that they understand and will adhere to the following:

General Consent for Substance Abuse Treatment

• Clients will voluntarily consent that they will participate in a substance abuse evaluation and/or treatment by facility employees. Information will be provided to the client concerning: the benefits of the proposed treatment, alternative treatment modes and services, the manner in which treatment is administered, expected side effects from treatment, risks of side effects from medication, and probably consequences of not receiving treatment. The evaluation or treatment will be conducted by a certified addiction counselor or other qualified treatment professional.

• Clients will receive evaluation and treatment which may be administered with clinical interviews and assessment, as well as expectations regarding the length and frequency of treatment. This may be beneficial to the client in understanding the nature and cause of any difficulties affecting daily functioning, so that appropriate recommendations and treatments may be offered. Uses of the evaluation include, diagnosis, evaluation of recovery or treatment, estimating prognosis, education, and rehabilitation planning. Benefits include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.

• Clients will have any fees that are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. Clients will be responsible for any charges not covered by insurance, including co-payments and deductibles. Fees are available to clients upon request.

• Clients have the right to withdraw his/her consent for evaluation and/or treatment at any time by providing a written request to their treatment team or facility leadership.

General Program Rules Smoking

• Clients are not permitted to smoke and/or use of smokeless tobacco products, including electronic cigarettes, inside any building or vehicle. Smoking is only permitted in designated areas.

Drug Free Program

• Clients and/or visitors are not permitted to use alcohol and/or drugs on the premises or in the vicinity of the facility. In doing so, it may be grounds for immediate discharge. Clients offering alcohol/drugs to each other, making alcohol/drugs available, using alcohol/drugs together, or selling alcohol/drugs to clients in this program is grounds for immediate discharge. The local authorities will be contacted if any client is in possession of illegal substances.

• For outpatient facilities, clients and/or visitors are not permitted to show up on the premises in a mentally impaired or intoxicated state due to alcohol/drug use. If this should happen, clients will be required to provide employees with their car keys and employees will contact the person(s) he/she designated in writing as "emergency contacts" or other available family contacts/significant others and ask them to take them home. If a client chooses to drive off the premises while intoxicated, the local authorities will be notified. Should a client's behavior continue in this manner, it may be grounds for discharge. Visitors will be removed from the premises by local authorities if necessary.

Abstinence

• Clients are expected to abstain from the use of alcohol and all other mood-altering chemicals during their participation in the program. While the company recognizes that relapses sometimes do happen along the road to recovery, clients who are unable to remain consistently abstinent may have to be referred to a higher level of care.

Weapons

• Clients are not permitted to possess any weapons within the facility, in any parking lot, or within the immediate vicinity of any facility is grounds for immediate discharge. The local authorities will be contacted if anyone is in possession of a weapon.

Removal of Company Property

• Clients are prohibited from removing company property off of the premises at all times.

Safety

• Clients are prohibited from engaging in any acts of violence and/or threats of violence towards employees or peers. This is grounds for immediate discharge and local authorities will be contacted.

Personal Valuables

• Clients may not hold the organization liable for the loss or damage to any money, jewelry, eyeglasses, contact lenses, dentures, documents, cell phones, laptops, or other articles of value.

Communication

• Clients are prohibited from using profanity or verbal abuse towards employees or others.

Confidentiality

• Clients agree to protect the anonymity and confidentiality of his/her peers. Clients are recommended to not divulge the identity of another client or the content of any group sessions to persons outside of the group, including to their spouse/mate or parents. Clients are to remember that 1) group issues are not to be discussed with others outside group; 2) group issues are not to be discussed with roommates, unless he/she is in the same group; and 3) group issues are not to be discussed in outside meetings or places where others may overhear.

• Clients agree to additional prohibitions which include the taking any pictures of other clients on cell phones, voice recording any group counseling sessions, individual counseling sessions, or medical appointments, or posting such content on any social media website. Any suspected violations of confidentiality may result in immediate discharge from program.

• Clients agree not to disclose any information identifying a client as an abuser of drugs, alcohol, or diagnosed with an eating disorder unless 1) the client consents in writing; 2) the disclosure is allowed by a court order; or 3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

• Clients understand that federal regulations prohibit making any record disclosures unless expressly permitted by written consent of the person whom it pertains or as otherwise permitted by 42 C.F.R. Part 2.

Personal Boundaries

• Clients agree to refrain from becoming involved romantically, sexually, or financially with another peer while in treatment. Clients are strictly prohibited from providing any professional (medical, legal, etc.) or business services to one another, from loaning or gifting money to one another, from entering into any employer-employee relationships, and from entering into any formal or informal business partnerships and/or investment transactions with one another.

Clients agree to not engage in any physical contact between other peers. This includes kissing, hugging, sitting too close, massaging, etc.

Drug Screens

• Clients agree to give a random urine drug sample for drug testing or take a breathalyzer test whenever the clinical team deems appropriate and as required by state licensing regulations.

• Clients agree that the refusal of any scheduled drug screen or leaving group without providing a drug screen will automatically be considered positive and this information will be documented in client chart.

Medical Treatment

• Clients agree to be placed under the care of their attending physician, or the physician assigned by the facility to examination and laboratory procedures.

• Clients agree that while receiving care, the need for emergency treatment and/or transfer to a hospital may become necessary and appropriate by his/her attending physician, their assistants, and designees. Clients agree that such emergency treatment and/or transfer to a hospital may be deemed necessary and appropriate.

Electronic Devices

• Clients agree that in order to safeguard the privacy of others and to avoid disruption of groups, the use of all electronic devices is strictly prohibited during treatment services.

Dress Code

• Clients agree to adhere to a standard dress code while attending treatment which includes at a minimum no bare feet, no bare midriffs, no low­cut or revealing attire, no sunglasses, and no logos on clothing that are sexually suggestive, gang, drug, and/or alcohol related.

• Clients agree that facility employees will always be the final judge of what is or is not appropriate.

Legal Rights

• Clients agree to not take any action or fail to take any action which would cause harm to others (e.g. self-mutilation, drug or alcohol overdose, suicide attempts through any means, or others).

• Clients agree that any minor children are the client's responsibility and that the foregoing release extends to all such minor children.

• Clients understand that the participation may involve risk of injury, harm, danger to personal property, or death and agrees that such risk shall be fully assumed by the client. In addition, clients hereby release and agrees to hold the organization and affiliated individuals harmless for, from, and against all liability, damages, and claims of any kind, known and unknown, which may be connected with, result from or arise out of the participation in Facility, including without limitation, all claims resulting from transportation, contingent upon lack of gross negligence.

Health Information

• Clients understand that the organization is required to collect "protected health information" (PHI). Facility reserves the right to use PHI in its facilities to decide on what treatment is best for the client. This information may also be shared with others to arrange payment for the client's treatment, to help carry out certain business or government functions, or to help provide other treatment to the client.

• Clients agree that if he/she is concerned about their PHI, he/she may ask Facility, in writing, not to use or share some of it for treatment, payment, or administrative purposes writing. However, clients understand that Facility is not required to accept these limitations. If the agency does agree, it will do as the client asked.

• Clients agree that Facility may take a client's picture for the sole specific purpose of having it as a means of identifying the client within is/her electronic medical record. This picture will not be distributed or used in any other fashion.

Attendance and Punctuality

• Clients understand that attendance and participation are necessary for therapeutic success, and thus if expected to be absent, he/she must notify their primary therapist no later than 24 hours prior to a scheduled session or appointment. Facility reserves the right to impose cancellation or no-show fees for those clients who are absent from individual counseling sessions or medical appointments.

• Clients understand that they are expected to consistently arrive to group 15 minutes before the scheduled start time, allowing employees to conduct urine drug screens. This may require them to rearrange other obligations while participating in the program.
• Clients understand that groups start on time and if he/she arrives 15 minutes after the scheduled start time, he/she will not be allowed in group and will be considered absent.

• Clients understand that he/she will only be allowed late into groups if they have previously called to inform employees and given a legitimate reason.

• Clients agree to remain in the group until instructed by his/her therapist or the group facilitator. If a client is to leave prematurely without the consent from his/her therapist or group facilitator, he/she will be considered non-compliant with treatment.

PURPOSE

The purpose of this policy is to outline and safeguard the rights of all clients.

POLICY

It is the policy of the organization that all clients are informed of their rights upon admission, that they are protected at all times while they are receiving treatment, and that they are conspicuously posted in all facilities. In addition, it is policy that all employees are educated on client rights and that client rights as defined by law and regulation for each program element.

PROCEDURES

Information Dissemination

• Upon admission, all clients will receive a copy of the Client Bill of Rights.

• The Client Bill of Rights will be posted in a conspicuous place within the facility.

• The Client Bill of Rights will be reviewed with all employees, interns, and volunteers at least annually through in-service trainings.

Bill of Rights - Substance Abuse Programs

• The right to be informed of these rights, as evidenced by the client's written acknowledgment or by documentation by staffing the clinical record that the client was offered a written copy of these rights and given a written or verbal explanation of these rights in terms the client could understand.

• The right to be notified of any rules and policies the program has established governing client conduct in the facility.

• The right to be informed of services available in the program, the names and professional status

of the staff providing and/or responsible for the client's care, and fees and related charges, including the payment, fee, deposit, and refund policy of the program and any charges for services not covered by sources of third-party payment or the program's basic rate.

• The right to be informed if the program has authorized other health care and educational institutions to participate in his or her treatment, the identity and function of these institutions, and to refuse to allow their participation in his or her treatment.

• The right to receive from his or her physicians or clinical practitioner(s) an explanation of his or her complete medical/health condition or diagnosis, recommended treatment, treatment options, including the option of no treatment, risks(s) of treatment, and expected result(s), in terms that he or she understands. If, in the opinion of the medical director or director of substance abuse counseling, this information would be detrimental to the client's health, or if the client is not capable of understanding the information, the explanation shall be provided to a family member, legal guardian or significant other, as available, a release of information to a family member, legal guardian or significant other, along with the reason for not informing the client directly, shall be documented in the client's clinical record; and all consents to release information shall be signed by client or their parent, guardian or legally authorized representative.

• The right to participate in the planning of his or her care and treatment, and to refuse

medication and treatment. A client's refusal of medication or treatment shall be documented in the client's clinical record.

• The right to participate in experimental research only when the client gives informed, written consent to such participation, or when a guardian or legally authorized representative gives such consent for an incompetent client in accordance with law, rule and regulation.

• The right to voice grievances or recommend changes in policies and services to program staff, the governing authority, and/or outside representatives of his or her choice either individually or as group, free from restraint, interference, coercion, discrimination, or reprisal.

• The right to be free from mental and physical abuse, exploitation, and from use of restraints. A client's ordered medications shall not be withheld for failure to comply with facility rules or procedures, unless the decision is made to terminate the client in accordance with applicable state law. Medications may only be withheld when the facility medical staff determines that such action is medically indicated.

• The right to confidential treatment of information about the client. Information in the client's clinical record shall not be released to anyone outside the program without the client's written approval to release the information in accordance with Federal statutes and rules for the Confidentiality of Alcohol and Drug Abuse Client Records., and the provisions of the Health Insurance Portability and Accountability Act (HIPAA) at 45 CFR Parts 160 and 164, unless the release of the information is required and permitted by law, a third-party payment contract, a peer review, or the information is needed for statutorily authorized purposes; and the program may release data about the client for studies containing aggregated statistics only when the client's identity is protected and masked.

• The right to be treated with courtesy, consideration, respect, and with recognition of his or her dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy. The client's privacy also shall be respected when program staff are discussing the client with others.

• The right to exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at religious services, shall be imposed upon any client. Clients receiving care or treatment under section 7 of the act shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.

• The right to not be discriminated against because of age, race, creed, religion, sex, ethnicity, color, marital status, national origin, sexual orientation, handicap (including, but not limited to, blind, deaf, hard of hearing), or ability to pay; or to be deprived of any constitutional, civil, and/or legal rights. The program shall not discriminate against clients taking medications as prescribed.

• The right to be transferred or discharged only for medical reasons, for the client's welfare, that of other clients or staff upon the written order of a physician or other licensed clinician, or for failure to pay required fees as agreed at time of admissions (except as prohibited by sources of third-party payment). Transfers and discharges, and the reasons therefore, shall be documented in the client's clinical record.

• The right to be notified in writing, and to have the opportunity to appeal, an involuntary discharge.

• The right to have access to and obtain a copy of his or her clinical record, in accordance with the program's policies and procedures and applicable Federal and State laws and rules. Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.

• The right to appeal a decision limiting access to their records to the director.

• The right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.

• Clients have the right to submit rebuttal data or memoranda to their own records.

Bill of Rights Mental Health Programs

All clients have the right to be treated with dignity and respect.

All clients retain all civil rights that have not been specifically curtailed by order of court.

All clients have the right to unrestricted and private communication inside and outside this facility including the following rights:

a. To a peaceful assembly and to join with other patients to organize a body of or participate in patient government when patient government has been determined to be feasible by the facility.

b. To be assisted by any advocate of your choice in the assertion of your rights and to see a lawyer in private at any time.

c. To make complaints and to have your complaints heard and adjudicated promptly.

d. To receive visitors of your own choice at reasonable hours unless your treatment team has determined in advance that a visitor or visitors would seriously interfere with your or others' treatment or welfare.

e. To receive and send unopened letters and to have outgoing letters stamped and mailed. Incoming mail may be examined for good reason in your presence for contraband. Contraband means specific property which entails a threat to your health and welfare or to the hospital community.

f. To have access to telephone designated for patient use.

2. To practice the religion of one's choice or to abstain from religious practices.

3. To keep and to use personal possessions, unless it has been determined that specifi-c personal property is contraband. The reasons for imposing any limitation and its scope must be clearly defined, recorded and explained. Clients have the right to sell any personal article you made and keep the proceeds from its sale.

4. To handle one's personal affairs including making contracts, holding a driver's license or professional license, marrying, or obtaining a divorce and writing a will.

5. To participate in the development and review of the treatment plan.

6. To receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals.

7. To be discharged from the facility as soon as the individual no longer needs care and treatment.

8. To not be subjected to any harsh or unusual treatment.

PURPOSE

The purpose of this policy is to outline the procedures in which client grievances are addressed, investigated, and resolved.

POLICY

It is company policy that if a client is dissatisfied with any aspect of their treatment at any time, he/she has the right to voice their complaints. In addition, the organization will ensure that its employees always abide by client grievance protocols.

PROCEDURES

The organization shall provide notice to all clients that a grievance mechanism exists within the agency to process complaints and grievances related to the Client Bill of Rights. If requested, a written response will be provided to clients regarding a particular grievance and complaint.

Clients are to follow these procedures when he/she wishes to file a grievance:

• Complete a "Client Grievance Form" and provide it to their primary therapist. The primary therapist has three business days to meet with the client, evaluate the problem, and discuss the resolution.

• If the client is dissatisfied with the solution, or if the primary therapist cannot resolve the matter, the client will meet with the program director. The program director has three business days to meet with the client, evaluate the problem, and discuss the resolution.

• If the client is dissatisfied with the solution, or if the program director cannot resolve the matter, the client will meet with the Chief Clinical Officer. The Chief Clinical Officer has three business days to meet with the client, evaluate the problem, and discuss the resolution.

• If the client is dissatisfied with the solution, or if the Chief Clinical Officer cannot resolve the matter, the client will meet with the Chief Operating Officer. The Chief Operating Officer has three business days to meet with client, evaluate the problem, and discuss the resolution. A resolution will be completed by the Chief Operating Officer and considered final.

• If the client is dissatisfied with the solution, the client has the right to contact the following agencies:

For clients in Indiana:

Indiana Division of Mental Health and Addiction

402 W Washing St, Indianapolis, IN 46204

Telephone: (800) 901-1133

Clients also have the right to contact: 

The Joint Commission

Office of Quality and Patient Safety 1 Renaissance Blvd

Oakbrook Terrace, IL 60181 Telephone: (630) 792-5000

• Clients may also contact these agencies at any time while they are receiving treatment at the facility. All clients will be afforded the opportunity to contact any of these agencies without fear of retaliation or barrier to services. The company will provide access to advocates or other assistance if necessary for the client reporting the grievance.

• Facility staff shall maintain documentation of all grievances. This policy will be communicated to clients upon admission and will be posted throughout the facility.

PURPOSE

The purpose of this policy is to establish procedures for clients to follow regarding telephone usage.

POLICY

It is company policy that clients are to only use the telephone when deemed appropriate. The organization reserves the right to revoke this client privilege, with cause, at any time.

PROCEDURES

• Clients are permitted to bring cell phones into outpatient facilities, but must turn off cell phones during all groups, individual counseling sessions, and medical appointments. A client's refusal to comply will result in the confiscation of the cell phone by employees while in facility. If a client repeatedly refusals to comply, it may result in the client being administratively discharged.

• Outpatient clients are prohibited from voice and/or video recording on their cell phones while within any facility.

• If a client's cell phone is confiscated, it must be documented in the client's record. Employees are prohibited from confiscating a client's cell phone as a tool to punish or coerce.

• At any time, clients are permitted to telephone to the local police/fire department for an emergency.

• Clients in Indiana have the right to call the Indiana Division of Mental Health and Addiction.

PURPOSE

The purpose of this policy is to outline the organization's position concerning on the use of restraints.

POLICY

It is company policy that the use of any restraints be prohibited from its facilities. All employees will be educated on this policy upon hire and annually through in-service trainings.

PROCEDURES

The organization will not utilize the use of restraints (pharmacological, medical, or physical) at any of its facilities.

PURPOSE

The purpose of this policy is to outline which items are prohibited from being brought into treatment.

POLICY

It is company policy that its employees are aware of what items are prohibited from being brought to any facility by clients, employees, or visitors.

PROCEDURES

• Contraband includes, but is not limited to:

o Weapons (firearms, explosives, knives, scissors, box cutters, blunt objects, etc.)

o Controlled substances, unlawful licit drugs, and alcohol

o Outdated medications (any medication will be held onto by employees)

o Laptops/tablets

• Any confiscated items are to be confiscated by employees and the Program Director is to be contacted immediately. Confiscated items must be returned to the client upon the conclusion of the group, session, or appointment.

PURPOSE

The purpose of this policy is to outline how the organization conducts and permits research involving clients.

POLICY

It is company policy that all research protocols protect and respect the rights of its clients.

PROCEDURES

Review and Approval of Research

The organization and its leadership shall review and approve all research projects conducted within the agency in the following manner:

• The Performance Improvement Committee, consisting of members of the agency's corporate leadership and various program specific personnel, shall review and approve all research proposals.

• The organization reserves the right to require modifications to any proposal prior to approval, as well as denying any research projects.

Requirements for Research

It shall be guaranteed that any client who participates in any research, investigations, and clinical trials conducted within the organization that:

• All participation in new interventions is voluntary.

• Confidentiality of client records and research data is assured.

• Written, informed consent is obtained and documented within the client's electronic medical record.

• The risks/benefits of participation are explained to those participating in the research.

• Participation shall not jeopardize ongoing treatment.

• The research does not impose an undue burden to those participating in the research.

Research Consent Form

Clients participating in all research projects are required to complete and sign a Research Consent Form which must detail the following:

• Project title and purpose

• Expected duration of the individual's participation

• Description of procedures to follow

• Description of the risks, benefits, discomforts, and side effects

• Alternative treatment services available to the participant that might prove advantageous

• Statement that participation is voluntary and participants may leave the project at any time

• Statement that refusal to participate or discontinue participation at any time will not jeopardize his/her treatment or services being received at the facility

• Statement that all reasonable measures to protect the client's confidentiality will be undertaken

• Statement of revocation of consent.

General Requirements/ Treatment Services

PURPOSE

Only authorized staff will have access to client records. Authorization will be predicated on who and who is not actively involved in the client's care.

POLICY

Maintain security of protected/confidential information

PROCEDURES

• In most instances the Program Director, and any necessary staff will only have access to client's records. 

• The facility policy strictly prohibits anyone from removing and/or altering any information that is in a client record. Any such violation of this policy will be grounds for immediate dismissal and could lead possibly lead to civil and/or criminal action. 

• The Program Director shall be responsible for ensuring this policy is adhered to. 

• Finally, a client record log shall be developed and stored with the medical records cabinet. Any person removing a client record will be obligated by this policy to sign the record out, and conversely upon returning the client record will be responsible to sign the client record log noting its return.  Under no circumstance shall a record remain out overnight. All records shall be returned to the locked storage area daily by all. Lastly, no person shall ever remove a client record from the project unless specifically authorized by the Executive Director. Violations of this policy will result in immediate termination. 

PURPOSE

At This facility, we serve individuals from the age of 18 years to those in their senior years.  Our clients represent all socioeconomic levels, race, genders, religious backgrounds, and sexual orientations. The served population will include the surrounding areas of Kennett Square, PA and beyond. 

PROGRAM STRUCTURE

 Prospective clients will have to meet diagnostic criteria for ASAM 2.1 or 1.0 levels of  care to be eligible to receive services. Special attention will be given to pregnant women, veterans, elderly (65+) and individuals who have a significant history of relapse and recidivism. 

 PHILOSOPHY

This facility views chemical dependency as a primary disease, which is progressive and potentially fatal.  It may severely impair functioning in all major life areas.  The company provides programs that deliver a comprehensive individualized care for chemically dependent persons and/or their family members who have been affected by the disease of alcoholism and/or drug abuse/dependence. The philosophy applies to all programs and services provided.

 SPECIAL POPULATIONS

 The facility is wheelchair accessible. 

HOURS OF OPERATION

 The company will provide treatment services Monday through Saturday with both morning and evening group and individual therapy to accommodate client schedules. 

PURPOSE

To provide outpatient treatment to individuals experiencing difficulties in their lives as a result of substance use and to ensure all potential clients obtain the treatment they need at the appropriate level of care.

POLICY

It is the policy of this facility to evaluate individuals for outpatient treatment on the basis of their needs. Admission is not denied due to any of the following characteristics: race, religion, age (over 18), sex, sexual orientation, color, ethnicity, handicap or handicap condition, HIV/AIDS diagnosis, history of criminal conviction, or medication prescribed by a physician outside of the facility.

PROCEDURES

Exclusionary Criteria:

Some patients will be excluded from admission to the facility’s outpatient programs. If a potential client meets any of the criteria listed below, the client may not be admitted to the facility:

• Individuals under the age of 18.
• Individuals presenting with medical or unstable psychiatric conditions that would preclude the consumer's participation in this level of treatment. 
• Individuals assessed at a more or less intensive level of treatment than the services offered.

Admission Criteria:

During the initial assessment, the assessor will ensure that the client can benefit from outpatient treatment and that this is the best setting to address their concerns. The decision to admit an individual lies solely with the facility. The facility is not bound by any contract or other obligation to accept an individual into treatment who is inappropriate by virtue or medical or psychiatric diagnosis.

Potential clients shall meet the following minimum criteria for admission to the facility:

• The client has a documented history of current excessive use of alcohol or other drugs.
• The client is experiencing significant functional impairments in one of the following areas:
• Activities of daily living,
• Interpersonal functioning,
• Psychological functioning,
• Ability to live without recurrent use or abuse of alcohol or other drugs.
• The facility will consider whether the consumer has adequate support systems to foster recovery.
• None of the above exclusionary criteria are met.

The determination will be made according to the ASAM PPC-2 Patient Placement Criteria, which include six dimensions in determining level of care.

The following dimensions are the basis for this determination:

• Dimension 1: Intoxication/withdrawal:  The client is not at risk for severe withdrawal.
• Dimension 2: Biomedical conditions and complications:  The client does not have any physical conditions affecting his/her ability to participate in treatment.
• Dimension 3: Emotional behavioral or cognitive conditions and complications:  The client is emotionally and thoroughly capable of participating in and benefiting from outpatient treatment.
• Dimension 4: Readiness to change:  The client is able and willing to develop and follow through with treatment goals.
• Dimension 5: Relapse, continued use or continued problem potential:  The client is experiencing a substance use related problem which is causing difficulties in major life areas.
• Dimension 6: Recovery/family environment:  The client has or is able to develop a recovery network.

It is the goal of this facility to treat clients with the most appropriate level of care possible.

The facility shall refer the client to the appropriate treatment or link to another program with special expertise if:

• there are medical or unstable psychiatric conditions that would preclude the client’s participation in this level of treatment; or
• a more intensive level of treatment is indicated from the assessment.

PURPOSE

To identify the individual’s principal reasons for seeking services, to clarify needs and preferences and to identify conditions that shall constitute the focus of the services provided. 

POLICY

It is the policy of this facility to provide a comprehensive biopsychosocial assessment upon admission to any service program. The purpose of the biopsychosocial assessment is to identify the individual's principal reasons for seeking services, to clarify needs and preferences, and to identify conditions that shall constitute the focus of the services provided. 

PROCEDURES

•  A comprehensive biopsychosocial assessment will be completed for all individuals served at this facility regardless of the level of care, or the type of program in which the individual is enrolled. 

• The results of the initial biopsychosocial assessment process will be used to assist in the development of the individual treatment plan for all persons served. 

• Initial assessments will be completed within 2 weeks of first contact. 

• Assessments will contain, at a minimum, the following Information: 

• Presenting problems 
• The individual's strengths, abilities, needs, preferences, attitudes, interests and skills 
• Psychosocial history
• Previous behavioral health history or co-occurring disorders
• Use of alcohol, tobacco, and/or other drugs 
• Physical health history and current medical conditions
• Any psychiatric or medical diagnoses
• Mental status, cognitive functioning, emotional functioning, and behavioral functioning. 
• Current and historical life information including age, gender, employment history, legal involvement, family history, history of abuse and relationships 
• Need for, and availability of, social supports 
• Risk taking behaviors 
• Level of educational functioning 
• Advance directives, when applicable 
• Current or past medications 
• Medication allergies or adverse reactions to medications 
• Adjustment to disorders/disabilities 

• Requests for previous diagnostic reports and relevant records will be made at the time of the initial assessment.  All copies of previous records will be placed in the current individual record and will be integrated into the assessment process. 

• The initial and primary assessment shall result in an interpretive summary that serves the following purposes: 

• Utilizes the assessment data to integrate and interpret the information in a manner that provides an emphasis on the interrelationships between the sets of findings, contains clinical judgments regarding both positive and negative factors likely to affect the person's course of treatment and clinical outcomes, and provides the central themes - present throughout the information gathered. 
• Is utilized in the development of the Individualized Treatment Plan. 
• Identifies any co-occurring disorders that should be addressed in the development of the Individualized Treatment Plan. 
• All persons served who require additional assistance to complete the assessment process, due to disability or limitations, will be provided with the necessary support to do so within this facility's capacity to accommodate the special needs. 

PURPOSE

To outline guidelines to be followed during client assessment. 

POLICY

A client treatment plan shall be developed for every client based on the assessment of the client.  

PROCEDURES

• The program shall initiate the development of the client’s individualized treatment plan upon the client's admission and shall enter the client's treatment plan in the client record by the third session following admission.

• The program shall address each problem within the treatment plan. All problems should be appropriate for the assessed level of care and reflects the assessed strengths, needs, abilities, and preferences. All assessed problems should be addressed either through direct provision or referral to appropriate services, and shall include at least the following: 

• Client substance use and a plan to reduce symptoms, severity and improve treatment outcomes; 
• Integrated treatment of co-occurring mental health disorders, either on-site or through the coordination of treatment services with an appropriate mental health facility; 
• Treatment of medical conditions, either on-site or through the coordination of treatment services with outside medical providers.  
• The provision of vocational and educational services if needed, either onsite or by referral to community resources; 
• Client participation in self-help or other support group meetings during treatment and after discharge from treatment; 
• Family and social support services; 
• If a problem has been referred to another provider or otherwise deferred, a rationale should be provided.

                     In completing the treatment plan, the following elements must be included:

• Specific goals written in terms of measurable criteria for proposed outcomes of each identified problem, expressed in a manner that captures the individual’s words or ideas; goals should include expected timeframes for achievement;
• Objectives based on the identified goals that identify steps to achieve the goal, are sufficiently specific to assess the progress of the individual, and are expressed in terms that provide indicators of progress;
• Interventions or therapeutic activities provided by the program, their frequency, and their expected duration;
• The staff responsible for interventions and implementation of the treatment plan;  
• Evidence of client participation in development and implementation of the treatment plan, including, but not limited to, dated signatures of the client as well as signatures of participating multidisciplinary team members; 
• The use of a standardized tool to monitor the individual’s progress in achieving the listed goals;
• Discharge/ transfer plans and planning needs;
• According to appropriate timeframes, the plan will be reevaluated and revised as needed based on changes in the individual’s needs and the individual’s response to care; this includes documentation of the effectiveness of, and client satisfaction with treatment services, including assessments of client adherence to and engagement with treatment and recovery support services; 

• Practitioners in each of the services providing care to a client shall participate in the development of the client treatment plan. 

• The client, and his or her family, if indicated and clinically appropriate, shall participate in the development of the client's treatment plan, including the discharge/ transfer plan; this will include a client signature, indicating that the client has reviewed and understands the contents of the treatment plan and any revisions thereafter; participation shall be documented in the client's clinical record. All participation will be documented in the client’s chart.

• The multidisciplinary team shall review the treatment plan, address attainment of goals, and document the client's progress as appropriate but at least every 60 days, with such review and revisions, if any, documented in the client's clinical record.

• Results of random drug and alcohol screening shall be incorporated into therapeutic interventions and the treatment planning process. 

PURPOSE

The purpose of this policy is to ensure each patient’s record is documented with all services provided to the patient.

POLICY

It is the policy of this facility to document all services provided to the patient to include information regarding attendance at therapeutic sessions, assessment of the patient’s progress towards meeting those objectives established in the treatment plan and all supportive or ancillary services received by the patient. Progress notes will relate to goals and objectives identified in the Treatment Plan.

PROCEDURES

• A consumer record shall be completed for each therapeutic activity and its relationship to the service plan.
  
• Each entry in the clinical record must be signed and dated by the person making the entry.  The writer's credentials and/or title must be specified.

• Progress notes will be recorded immediately following the session or interaction. If a delay is unavoidable, the progress note must be recorded by the end of the shift.

• Each progress note must document:

• Achievement of objectives and goals
• Significant events
• The provision of services prescribed in the treatment plan 
• Any movement to another level of care

• The progress note heading must identify the type of service provided (e.g., individual, group, specialty group, family, phone call, etc.).

• If a patient misses a session, a progress note will document the missed session and any contact by phone or in person by the patient and/or family member, regarding the reasons for the missed session.

Procedure for Group Session notes:

1. Group therapy notes may be documented by writing a single progress note discussing the session activity that describes the goal of the group and what specifically was worked on in that session.  Once the session activity is documented an individual note will be written to describe the members functioning and observable behavior.  The note will include measurable outcomes and how any identified treatment plan goals were identified in the group session. 

PURPOSE

To ensure each client receives complete and appropriate Discharge planning assuring a smooth transition into the community.  

POLICY

The facility shall establish and implement written policy and procedures for discharge planning

PROCEDURES

• Upon admission, the Primary Counselor will ask the client what his or her goals and plans for discharge are and will reflect that information in the progress note;

• The client's primary counselor will provide and/ or coordinate the individualized discharge plan; 

• The primary counselor will utilize  the  referral sources, family members, clinical team and client interview in determining client's needs and the  development of goals for aftercare services; .

• In developing a client's discharge plan, the plan will be reviewed by the client.

• Client and family will receive education and be provided with information regarding symptoms, effects,  and treatment of substance abuse; co-dependency and  its effect on substance abuse treatment; the  implementation of self-care   rehabilitation (including, but  not limited  to, Alcoholics Anonymous,  AI-Anon, Narcotics  Anonymous, Nar-Anon,  Alateen)  and/ or information about mental health issues and  medications upon  discharge from facility; and  community agencies/resources available for aftercare Services.  

• When a client chooses to terminate treatment of his/her own volition, or is involuntarily discharged, appropriate referrals will be offered (including alternative client care, housing and support group contact); 

PURPOSE

To summarize the treatment process, prognosis, and reason for termination of treatment. 

POLICY

Upon the client's discharge from the program, a discharge summary is completed indicating the identified client goals and the client's response to treatment interventions and reason for discharge. 

PROCEDURES

• Within 30 days of discharge, the primary counselor will initiate the completion of a discharge summary. 
• The Discharge Summary will include, but is not limited to: 

• Identifying Information 
• Admission and Discharge Date 
• Strengths, needs, abilities and preferences of the client. 
• Client’s progress in achieving outcomes for each goal of the treatment plan
• A final evaluation
• Recommendations for care after discharge 
• Status of any referrals and continuing care participation 

7.      Within 30 days of discharge, the primary counselor will initiate the completion of a discharge summary. 

• The Discharge Summary will include, but is not limited to: 

a.      Identifying Information 

b.      Admission and Discharge Date 

c.      Strengths, needs, abilities and preferences of the client. 

d.      Client’s progress in achieving outcomes for each goal of the treatment plan

e.      A final evaluation

f.       Recommendations for care after discharge 

g.      Status of any referrals and continuing care participation 

PURPOSE

To ensure each client receives timely and ongoing outreach from staff to ensure client is actively engaged in treatment process and can provide any feedback for improvement of clinical services to our multi-disciplinary team.

POLICY

The facility shall establish and implement written policy and procedures for outreach to clients enrolled in the program.

PROCEDURES

• All patients will receive text/email/or call reminder of scheduled appointments.
• In the event that a client does not show for their scheduled appointment, administrative staff will call client in attempt to ensure attendance.  The call will be documented in the client’s EHR.  If there is no response from the client on the day of scheduled appointment, the client’s primary therapist will make follow-up call to the client at end of day of missed appointment.  If the client is unreachable by phone, the primary therapist will leave a voicemail for the client.  Additional outreach will be made by staff to ensure engagement of the client and continued attendance to programming.
• In the event that the client has missed 3 consecutive sessions and has not been responsive to outreach, a letter will be mailed to the client that unless they contact the program, they will be terminated within 7 days.  The letter will provide additional community resources, treatment providers and emergency services contact information.  The counselor and/or administrative staff will continue to attempt contact with the client during this time period and all contact attempts and any associated correspondence will be documented in the client’s EHR.
  

Compliance, Privacy, & Legal

PURPOSE

The purpose of this policy is to establish procedures for accessing client records while maintaining the confidentiality of clients.

POLICY

It is company policy to adhere to all federal and state guidelines regarding client confidentiality. The organization is mandated to follow procedures outlined by the Health Insurance Portability and Accountability Act of 1996 and Federal Regulation, 42 C.F.R. Part 2, which protects client identifying information. This information includes any information, whether oral or written, that would directly or indirectly reveal an individual's status as a current or former client.

PROCEDURES

Protected Health Information (PHI)

All information contained in client records that is individually identifiable health information is protected health information (PHI). PHI includes, but is not limited to:

• Name
• Address
• Birth date
• Social Security number
• Contact information
• Information about an individual's physical or mental health
• Treatment services an individual is receiving
• Billing records
• Claim information
• Referral authorization
• Research records
• Explanation of benefits forms
• Any other information that connects the individual to their medical record or could reasonably be used to identify an individual

TWO PATIENT IDENTIFIERS MUST BE PROVIDED IN ORDER FOR ANY PATIENT INFORMATION IS TO BE RELEASED FROM A RECORD.

Client Consent

Upon admission, clients will be able to complete consent forms as needed which will dictate how the client authorizes the company and/or staff to release specific information in their clinical record. All consents will be maintained in the client's record.

To obtain a client's consent, the following conditions must be met:

• The client is informed in a manner to assure his/her understanding, of the specific types of information that have been requested, and the benefits and disadvantages of releasing the information as it is known.

• The client gives consent freely and voluntarily.

• The client is informed that treatment services are not contingent upon the client's decision concerning the release of information.

• A valid consent form must contain the following:

• The name of the program that is to release information
• The name of the client
• Name/address of the person
• Specific items from the record to be released
• Specification of the time limit of the authorization
• The dated signature of the client
• The dated signature of a witness
• A statement of the client's right to revoke the consent

General Disclosures

If the company receives a request for a disclosure of a client's records that is not permitted by the regulation, staff receiving the request must refuse to make the disclosure. It must be done in a way that does not reveal that the client has ever been diagnosed or treated for an alcohol or drug problem.

Client identifying information may be disclosed with written authorization. Limited disclosures are permitted in the following circumstances:

• Internal communications
• Any information not classified as PHI
• Medical emergency
• Court order
• Crime at the facility or against company personnel
• Research
• Audit and evaluation
• Child abuse and neglect
• Qualified Service Organization/Business Associate Agreement

Employees are required make reasonable efforts to limit the information, being shared to the minimum necessary to accomplish the intended purpose. Employees have access to all protected health information within the programs. Therapists have access to protected health information of clients on their caseload. Other employees may have access to protected health information that is needed for the purpose of consultation and case management.

Administrative employees will only have access to specific protected health information based on their position in the agency.

Therapists must document an accounting of disclosures made without client consent. Accountings must include the date of disclosure, the name and address of the person who received this information, description of the disclosed information and a statement of the purpose of the disclosure. This information must also be disclosed to the Director of Corporate Compliance.

Clients have the right to receive an accounting of disclosures of their own protected health information made prior to the date of the request. This accounting does not have to include disclosures made with client authorization.

Specialized Disclosures

Judiciary, Insurance Companies, and Hospitals

Only those portions of the client's record specifically requested will be released and only if those portions fall under the federal and state guidelines of information allowed to be released.

Requests from insurance companies will be honored only if their company is named on the face sheet of the record and there is consent. The information to be released is restricted by the federal and state guidelines.

Attorney Requests/Subpoenas

Attorney requests for records must be accompanied by valid client consent. Additionally, a subpoena is not sufficient for record release. Unless there is a valid client consent, a court order, signed by a Judge of Court of Common Pleas or higher, is required to release the records.

Upon receipt of an attorney's request or subpoena, the Chief Operating Officer will retrieve the record and place it in a locked file for security. If the record is required for internal purposes, a copy of the record will be made for that use, and the original will remain secured and accessible only to the Chief Operating Officer.

Search/Arrest Warrants

In the event an employee must respond to a search/arrest warrant, the following procedures are to be followed:

• Kindly explain to the law enforcement officer that the organization cannot cooperate with a search or arrest warrant without an appropriate court order, one that has been issued in accordance with the regulations. Law enforcement officers are not permitted to search inside the facility.
• Immediately notify the Chief Operating Officer so that the situation may be resolved in a manner that either the client's rights or the company's position are not compromised.
• If the officer insists on entry, do not forcibly resist. Obtain the officer(s) identification, and allow the officer(s) into the facility. Refusing to obey the orders of a law enforcement officer may constitute a crime, even though the officer's orders may later be shown to be erroneous or illegal.
• Once the officer(s) are inside the facility, employees are to escort them to an empty conference room/office where they are to wait for the Chief Operating Officer or any other member of executive management and/or Program Director (if no member of executive management is available). Any assistance permitted
• by federal and state law, as well as policies, will be provided to the officer(s). If necessary, the Chief Operating Officer will contact the agency's legal representatives for means of a resolution if the officer(s) demands would violate federal and state law.
• Complete an Incident Report with the officer(s) identification information (e.g. name, police department, badge number).
• If possible, employees should speak to the client and convince him/her to surrender to the officer(s).
• The above procedures do not apply if the officer has an arrest warrant for a particular client who committed or threatened to commit a crime on the premises of the program or against an employee. Employees are permitted to release client identifying information to assist law enforcement authorities in apprehending a client who commits or threatens to commit a crime on the property

Refusal to Honor a Written Consent

Staff will refuse to honor a written client consent form if there is:

• Reasonable doubt as to the identity of the person presenting the authorization, or evidence that the person requesting the information is not the person named in the authorization or refusal to offer reasonable proof of identity, such as a driver's license.
• Evidence that the client is not legally authorized to disclose the information or if there is a serious question regarding the client's mental capacity to understand what they have authorized by their signature.
• Evidence that the person signing for a minor or incompetent client is not legally qualified to do so.
• Reason to suspect the client's signature is not authentic.
• Reason to question the current validity of an authorization because it is general in nature and does not specifically identify the type of records to be released or the specific items to be released.

Death of a Client

In the case of a client's death, consent to release information from the record must be signed by the following, in this order:

• Court appointed executor of the estate.
• If there is no court appointed executor, the spouse (if the client was married).
• If the client was unmarried, the parents.
• If the client's parents are deceased, the remaining siblings.
• If the client was a minor, the parents or guardian.

Release of information requests for a deceased client's records must be forwarded to the Chief Operating Officer for review and approval. Refer to the 'Death on the Premises policy' for protocols on the discovery of a deceased individual.

PURPOSE

The purpose of this policy 1s to establish procedures for reportable events.

POLICY

It is company policy that all reportable events be reported to the applicable state licensing entity in a timely and sufficient manner.

PROCEDURES

Staff will report any event to State of Indiana Division of Mental Health and Addiction which jeopardizes the health, safety, or welfare of clients or employees, including, but not limited to, the following:

• All fires, floods, disasters (natural or manmade), accidents, or other unanticipated events resulting in a significant disruption of services.
• All alleged or suspected crimes that jeopardize the safety of clients and employees including physical assault by a client, selling of drugs on the facility premises, theft, burglary, break-in or similar incident at the facility.
• Complaints of physical, verbal, sexual, or emotional client abuse.
• Acts that result in client death or serious injury due to trauma, suicide, medication error, or unusual circumstances.
• Any other events that warrant documentation with the State.

Crimes on the Premises

In the event any client or employee are alleged for suspected of a crime, the following shall occur:

• The client or employee will be advised of his or her right to report the incident to the local police.
• Notification, or the refusal to notify police authorities, shall be documented in writing in the client's clinical file or in the employee's personnel file, and the administrator shall be notified.
• The governing body shall be notified.

PURPOSE

The purpose of this policy is to establish procedures for how sentinel events are reported, managed, and reviewed to the Joint Commission to understand the factors that contribute to an event and to reduce risks.

POLICY

It is company policy to have a positive impact in improving its care, treatment, and services to individuals served, to understand the factors that contribute to a sentinel event and processes to reduce and prevent the probability of a similar event in the future, and to maintain the confidence of the general public.

PROCEDURES

Definitions

• A sentinel event is an unexpected occurrence involving the death or serious physical or psychological injury, or the risk thereof, which signals the need for an immediate investigation and response. Serious injury specifically includes the loss of a limb or function.

• A root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not on individual performance.

• An action plan is the product of a root cause analysis that identifies the strategies that the organization intends to implement in order to reduce the risk of similar events in the future.

Reporting

• Joint Commission accredited programs are mandated to immediately notify Joint Commission of the following events:
• The unanticipated death or major permanent loss of function not related to the natural course of the individual's condition (including falls and medication errors resulting in paralysis or a coma).
• Any elopement of a client from a staffed around-the-clock setting leading to the death, permanent harm, or severe temporary harm of the client.
• Suicide of any individual served that is receiving care, treatment, services in an accredited residential program or within 72 hours of discharge from an around the clock staff setting.
• Abduction of any individual served receiving care, treatment, and services in any accredited program.
• Rape, assault (leading to the death or permanent loss of function), or homicide of any individual served.
• Rape, assault (leading to the death or permanent loss of function), or homicide of any employees, licensed independent practitioner, visitor, or vendor while at the facility.
• Flame or unanticipated smoke, heat, or flashes during an episode of client care.
• Executive leadership will immediately contact Joint Commission by accessing the Joint Commission Connect extranet site and completing a "Self-Report Sentinel Event" form.

Client Safety Event

• Sentinel events are one category of client safety events. A client safety event is an event, incident, or condition that could have resulted or did result in harm to an individual served. A client safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Client safety events also include adverse events, no-harm events, close calls, and hazardous conditions, which are defined as follows:
• An adverse event is a client safety event that resulted in harm to an individual served.
• A no-harm event is a client safety event that reaches the individual served but does not cause harm.
• A close call (or "near miss" or "good catch") is a client safety event that did not reach the individual served.
• A hazardous (or "unsafe") condition is a circumstance (other than an individual's own disease, process, or condition) that increases the probability of an adverse event.
• The organization will determine how it will respond to a client safety event that does not meet the definition of sentinel event. Adverse events shall prompt notification of corporate
• leadership, investigation, and corrective actions, in accordance with the organization's process for responding to client safety events that do not meet the definition of sentinel event. An adverse sent may or may not result from an error.
• No-harm events, close calls, and hazardous conditions are tracked and used as opportunities to prevent harm, in accordance with the company’s process for responding to client safety events that do not meet the definition of sentinel event.

Response to a Reviewable Sentinel Event

• Once the Joint Commission becomes aware of the sentinel event, executive leadership and/or designee will complete the following:
• Prepare and submit a thorough and credible root cause analysis and action plan within 45 calendar days of the event or of becoming aware of the event along with a detailed action plan that describes risk-reduction strategies and measures for evaluating their effectiveness.
• Participation of executive leadership, along with employees that are most closely involved in the process and systems under review, is required in the completion of the root cause analysis.

Follow-Up Activity

• Once the Joint Commission determines the root cause analysis and action plan to be thorough and credible, it will assign one or more Sentinel Event Measures of Success (SE MOS) to complete.
• Executive leadership and/or designee will complete the SE MOS no later than 120 calendar days after the root cause analysis and action plan are determined to be acceptable by the Joint Commission. If the Joint Commission is submitted on time, but does not meet the determined levels of compliance, the organization will have no later than an additional 120 calendar days to comply.

Reportable Events

• The organization will concurrently comply with applicable state licensing guidelines regarding reportable events

PURPOSE

The purpose of this policy is to detail how and when incident reports will be completed.

POLICY

It is company policy that all employees complete an incident report in a timely and sufficient manner when certain events occur in the agency.

PROCEDURES

Completion of Incident Reports

All employees are required to complete an incident report when the following occurs within the agency:

• Verbal/physical altercations
• Threats of violence
• Trespassing
• Medical emergencies resulting in injuries or illnesses
• Psychiatric emergencies
• Property losses or damages
• Vehicle accidents
• Procedural breaks/rule violations
• Pharmacy errors
• Weapons/contraband brought onto the premises
• Alcohol/drug use on the premises
• Equipment failure (safety related)
• Bio-hazardous spills/accidents
• Clients leaving against medical advice/clinical advice (if the client disengages from treatment with no-follow up on behalf of the client, an incident report does not have to be completed).
• Client elopement
• Abuse/neglect

Incident reports must include the following:

• Date of the incident
• Names of those involved (for incidents involving two or more clients, the clients' first name, last initial, and medical record number are to be used).
• Type of incident
• Location of incident
• Details of the incident
• Details of all follow up measures completed

High Risk Incidents

A high-risk incident is any incident that would be considered hazardous, or potentially jeopardizing the health and safety of individuals, and/or is considered a threat to the continuity of operations. A debriefing amongst those who are notified of the incident is to occur within 24 hours to discuss what occurred and what immediate steps are to be taken to prevent a future incident from occurring.

Submission of Incident Reports

All incident reports must be completed and submitted by the employee. The incident report will then be sent, via email, to the program director, and executive leadership.

Program directors will then document any follow-up measures and/or comments that he/she wishes to document.

Incident reports must be completed on the same day of the incident.

Performance Improvement

Annually, the Director will conduct a written analysis of all incident reports to identify and report on the following:

• Causes
• Trends
• Actions for improvement
• Results of improvement plans
• Need for further education/training of personnel
• Prevention

PURPOSE

Pet therapy is part of the Holistic approach to treatment. The purpose of this policy is to establish procedures for pet therapy provided at the facility.

POLICY

It is company policy that all pet therapy is provided within the parameters specified in this policy in order to achieve maximum benefit and maintain patient safety at all times.

RATIONALE

• Therapy animals may render group and individual therapeutic settings more inviting and calm.
• Pet therapy may stimulate withdrawn clients to engage in the therapy process, facilitate interactions, and substantially alter the therapeutic environment positively.
• Pet therapy provides physical, social, physiological & psychological health benefits for clients and staff.
• Pet therapy has been shown to assist in ego and overall development, reduce blood pressure, and decrease anxiety.
• Pet therapy may aid in developing responsibility, competence, self-esteem, trust, and encouraging feelings of empathy.

PROCEDURES

• Pet therapy is scheduled, organized and supervised by the Clinical Director.
• Sessions are conducted separately for the adult and adolescent clients.
• Services are provided by certified therapy animals and their handlers who have documentation of required obedience training and pet vaccinations.
• Staff and clients are informed of the scheduled sessions.
• Only clients who have signed the Pet Therapy Participation Consent may participate.
• Participation is optional and clients may decline at any time.
• For clients who decline, an alternative activity is provided.
• Clinical staff will confer with the Clinical Director regarding any client with a history of animal abuse, fears, animal associated trauma or allergy, and the appropriateness of their participation in pet therapy sessions.
• Guests, vendors, and visitors are informed when a therapy pet is in the building.
• Groups are facilitated by clinical staff. The pet handler may not facilitate groups without a clinician present.
• Therapy animals are to be on-leash at all times.
• Directions and commands are provided by the handler only.
• No food or treats are to be provided to the pet without the permission of the handler.
• Any animal may be disallowed from the facility at the discretion of the Clinical Director.

Environment of Care

PURPOSE

The purpose of this policy is to outline standards for the client care environment and to maintain a safe 

POLICY

It is company policy to maintain clean and safe facilities for clients, employees, and visitors.

PROCEDURES

The following sanitation conditions shall be met to develop and maintain policies that reflect such conditions.

• The organization shall maintain its facilities clean to sight and touch and free of dirt and debris.
• All rooms shall be free of condensation, mold growth, and noxious odors.
• All equipment and materials necessary for cleaning, disinfecting, and sterilizing (if applicable) shall be always available to employees.
• Thermometers, which are accurate to within 3 degrees Fahrenheit shall be kept in a visible location in refrigerators, freezers, and storerooms used for perishable and other items subject to deterioration.
• Articles in storage shall be elevated from the floor and away from walls, ceilings, and air vents.
• Aisles in storage areas shall be kept unobstructed.
• Facilities shall utilize safeguards to minimize and eliminate the presence of rodents, flies, roaches and other vermin, and to prevent the breeding, harborage or feeding of vermin. All openings to the outer air shall be effectively protected against the entrance of insects and other vermin.
• Toilet tissue, soap and disposable towels or air driers shall be always provided in each bathroom, with soap and disposable towels or air driers provided at each hand washing sink. Bathrooms with multiple hand washing sinks shall provide at least one soap dispenser and one disposable towel dispenser or air drier for every two hand washing sinks. A soap dispenser and towel dispenser shall be provided by each hand washing sink and utility sink throughout the facility.
• Mattresses, pillows, blankets, draperies, upholstery and other fabrics or decorations shall be fire-resistant and flameproof (this does not apply to an outpatient setting). Latex foam pillows shall be prohibited.
• Equipment requiring drainage shall be drained to a sanitary connection, in accordance with state and local codes.
• The temperature within client areas shall be maintained at a minimum of 72 degrees Fahrenheit and shall not exceed 82 degrees Fahrenheit.
• The facility shall maintain adequate ventilation in all areas used by clients and employees.
• All wall decor that is placed in areas that services clients must be approved by the Director.

The facility shall meet the following safety conditions:

• Non-skid wax shall be used on all waxed floors.
• Throw rugs or scatter rugs shall not be used.
• All equipment shall be located m an unobstructed space that has been provided for operation.
• Pesticides shall be applied in accordance with the state regulations.
• All household and cleaning products shall be identified, labeled, and securely stored in a cabinet, closet or room that is inaccessible to clients.
• Combustible materials shall not be stored in heater rooms or within 18 feet of any heater located in an open basement.
• Paints, varnishes, lacquers, thinners and all other flammable materials shall be stored outside buildings in which clients are housed or otherwise have general access to, except those minimum supplies may be kept in such buildings in a locked storage room or in closets, locked metal cabinets or containers in a non-client area.
• All furnishings shall be clean and in good repair, and mechanical equipment shall be in good working order. Equipment shall be kept covered to protect from contamination and accessible for cleaning and inspection. Broken or worn items shall be repaired, replaced or removed promptly.

For children present within the facility the following safety conditions will be met:

• No poisonous plants shall be present within the building.
• Toxic chemicals including cleaning agents shall be stored in locked cabinets or enclosed in areas not accessible to the children.
• All fluorescent and incandescent light bulbs shall have protective covers or shields.
• All windows and other glass surfaces that are not made of safety glass and that are located within three feet above the floor shall have protective guards.
• Non-permanent safety barriers (such as safety gates) shall be installed if the facility has stairs, ramps, balconies, porches or elevated play areas.
• Materials and furniture for indoor and outdoor use shall be of sturdy and safe construction, be easy to clean and free of hazards.
• Children shall be kept away from hot stoves, irons and ironing boards, knives, glassware and other equipment that may cause injury.
• Poisons, insect traps, rodent traps and similar products shall be kept out of reach of children.
• All indoor and outdoor areas shall be maintained in a safe and sanitary manner.
• All smoke detectors shall be fully operational.
• Children will not have access to medications.
• Electrical outlets in common areas will have protective covers.

PURPOSE

The purpose of this policy is to ensure that the environment of care is safe and to maintain ongoing inspections and maintenance of its safety and environment of care systems.

POLICY

It is company policy to establish and maintain ongoing inspection of its emergency and environment of care systems.

PROCEDURES

The organization will ensure that all its emergency and environment of care systems are inspected regularly to meet state licensing standards. Employees will maintain documentation of the following inspections:

PURPOSE

The purpose of the policy is to outline housekeeping procedures for the facility.

POLICY

It is company policy to maintain clean and safe facilities for clients, employees, and visitors.

PROCEDURES

Clean and Safe Environment

All employees are encouraged to maintain a clean and safe environment for clients, co-workers, and visitors. To achieve this, employees are expected to follow all standards listed in the Environment of Care policy.

Housekeeping Services

All outpatient facilities will have regularly scheduled housekeeping services, by an external vendor, which will be responsible for maintaining clean and sanitary facilities. Responsibilities of the housekeeping services include:

• Cleans and sanitizes all restroom facilities.
• Ensures that all restrooms are adequately supplied with a sufficient amount of sanitary products.
• Mopping, sweeping, and vacuuming all floors.
• Dusts all horizontal surfaces.
• Removing all trash from wastebaskets.
• Cleaning and sanitizing all water dispensers.

Refrigerators

The following activities shall be conducted by employees to ensure that all refrigerators are sanitary:

• All refrigerators will be cleaned out and discarding all open food containers except for food stored in closed bottles on a weekly basis.
• Maintaining a daily temperature log and reporting any problems to the Program Director.
• Food, specimens, and medications must be kept in separate refrigerators.

PURPOSE

The purpose of the policy is to provide guidelines on how to minimize the spread of existing pest and vermin infestations and possibly prevent future infestations.

POLICY

It is company policy to maintain clean and safe facilities for clients, employees, and visitors.

PROCEDURES

The facility and contractors are responsible for performing routine, scheduled surveillance to identify, monitor, prevent, and control infestations.

Preventive Measures

The following preventive measures will be always adhered to at all facilities:

• All facilities shall be clean to sight and touch and free of dirt and debris.
• All openings to outer air (i.e. window screens, openings to the outside) shall be effectively protected against the entrance of pests and vermin.
• All trash cans will be lined with fitted garbage bags. Garbage bags will be replaced on a regularly by housekeeping personnel.
• Safety inspections will be conducted to ensure that any cracks and crevices identified that could harbor insects are repaired as quickly as possible.
• Regularly scheduled extermination inspections will also take place. Pesticides that are compliant with licensure regulations will only be applied in all facilities.

If there is a suspicion and/or confirmation of an infestation of pest or vermin, the following procedures will be followed:

• The Program Director and building property management are to be notified (program director should refer to their individual lease to determine if and how often building management inspects and treats for pest and vermin).
• The infested area(s) will be sectioned off to everyone in the facility.
• An exterminator will be brought to the facility within 1-2 days to identify and treat the infestation.
• If necessary, monitoring traps will be placed in infested areas after all pesticides have been applied. Any other post-treatment protocols from the exterminator will be followed by employees.
• No immediate cleaning will take place in the area(s) that the exterminator applied pesticides to avoid erasing the residual effects of the chemicals.
• If necessary, the exterminator will conduct a follow-up visit to inspect monitoring traps and reapply any pesticides as need ed. This process is to be repeated until clearance to the infected area(s) is granted by the exterminator.

PURPOSE

The purpose of this policy is to establish procedures for proper waste removal.

POLICY

It is company policy that all waste be removed in a manner that promotes clean and safe facilities for all clients, employees, and visitors.

PROCEDURES

Non-Hazardous Waste Materials

The organization will collect, store, and dispose of all solid or liquid waste (which is not regulated medical waste), garbage, and trash in accordance with all applicable state and local laws. In addition, the facility will comply with the following:

• Store solid waste in insect-proof, rodent-proof, fire-proof, nonabsorbent and watertight containers with tight fitting covers.
• Collect solid waste from storage areas regularly to prevent nuisances, such as odors.
• Provide for regular, scheduled cleaning of storage areas and containers for all waste.
• If garbage compactors are used, staff will utilize them in compliance with all state and local laws.

Hazardous Waste Materials

• Hazardous waste materials include, but are not limited to:

• Needles
• Scalpels
• Dental wires
• Lancets
• Syringes
• IV catheters
• Suture needles
• Broken glass with blood
• Items what would release blood or other hazardous liquids
• Items that are caked with dried blood or other hazardous liquids that are capable of releasing these materials during handling
• Body fluids such as semen, vaginal secretions, saliva, vomit/feces that is visually contaminated with blood

• Employees involved in handling body fluids or other hazardous waste must practice Standard Precautions. Employees are to assume that all body fluids and waste are potentially infectious, and they must protect themselves from contact with the materials by wearing PPE (personal protective equipment - gloves, splashguards, or protective garments).
• All hazardous waste must be always locked up while in a facility to ensure that clients and any unauthorized individuals do not have access to the waste.

Sharps

• Sharps are any device having acute rigid corners, edges, or protuberances capable of cutting or piercing. including, but not limited to
• All contaminated, unused, or potential sharps must be discarded immediately. Containers for sharps disposal must be puncture resistant, leak proof, and red in color to ensure that everyone knows that they are for hazardous materials. Containers must have a lid and be kept upright to keep liquids and sharps inside.

Red Bags

• Red bags must be used only for the disposal of hazardous waste. Each facility that maintains hazardous waste must contract with a regulated waste hauler for the removal of hazardous waste. Waste must be removed from a facility according to federal, state, and local regulations. Medical personnel with maintain documentation of all hazardous waste.

PURPOSE

The purpose of this policy is to outline the appropriate use of tobacco products.

POLICY

It is company policy that no one will use of any tobacco products inside any facility. Clients, employees, and visitors may only use tobacco products in designated outdoor areas.

PROCEDURES

Definitions

Tobacco products shall include, but is not limited to, cigarettes, cigars, pipes, lighters, matches, rolling papers, cigarette filters, loose tobacco, chewing tobacco, plug tobacco, snuff, pipe filters, electronic cigarettes, and other tobacco related paraphernalia.

Prohibited Acts

• Clients, employees, and v1s1tors are prohibited from using any tobacco products within the facility.
• Adolescents are prohibited from using portable vaporizers while at the facility.

Permitted Acts

• Clients, employees, and visitors are permitted to use tobacco products in designated areas only. Designated areas will be identified by the agency.
• Adults are permitted to use vaporizers.
• Adolescents who smoke or who use vaporizers will be provided with a psychoeducational group about the health hazards of smoking and/or vaping.

Notification

Notification of the prohibited acts shall be conspicuously posted throughout the facility, easily visible to all clients, employees, and visitors.

Nicotine Replacement Therapy (NRT)

• Every client will be assessed for nicotine addiction upon admission and if deemed necessary, will be addressed in his/her treatment plan and continuing care plan.
• Nicotine addiction related didactic sessions and support groups will be made readily available to all clients during treatment.
• Nicotine replacement therapy (NRT) will be offered to all clients.

PURPOSE

The purpose of this policy is to outline the appropriate use of aromatherapy at the facility.

POLICY

It is company policy that all facilities use essential oils and aromatherapy in a safe and appropriate manner to enhance client treatment.

PROCEDURES

Diffuser Use and Maintenance

• Diffusers are to be kept in a common area where they are unobstructed, conspicuously displayed, and out of reach of children.
• All essential oils are to be kept in a locked, secure area only accessible to employees.
• Diffusers are to be refilled on a daily basis with room-temperature water to the recommended fill line. Water is not to exceed the fill line.
• While in use, the following safety procedures shall be observed:
• The diffuser's adapter is to never be wrapped with cloth or paper. The diffuser is to never be handled with wet hands.
• The diffuser is to never be immersed in water.
• Nothing is to be placed or removed from the diffuser's water reservoir during operation.
• No one is to place their fingers in the water during operation.
• The diffuser is never to be shaken.
• On a weekly basis, the diffuser's ultrasonic plate must be cleaned to remove any oil build up with a cleaning sponge or a cotton swap and the lid must be cleaned with mild soap and water. The diffuser is to be unplugged before cleaning.
• Aerosol sprays, solvents, and abrasives are not to be used while cleaning the diffuser.
• Any diffuser is to be immediately unplugged and its use discontinued in the event of smoke or a burning smell.
• At the discretion of the Program Director, the use of diffusers may be discontinued if there is a health or safety risk to clients or employees.

Client Allergies

• If a client has a known allergy to an essential oil, it must be documented in the client's medical record. Once a client's allergy to an essential oil is identified, staff will accommodate to a client's medical needs to ensure that he/she does not experience an allergic reaction (i.e.. removing that oil from the diffuser, removing a diffuser, etc.).
• If a client believes that he/she is having an allergic reaction to an essential oil, he/she must be immediately examined by medical personnel.

PURPOSE

The purpose of this policy is to detail security protocols used at the facility to keep clients, employees, and visitors safe.

POLICY

It is company policy that all staff maintain security protocols in order to provide a safe and secure environment.

PROCEDURES

Employee ID Badges

Every employee will be issued a photo ID badge upon hire. Employees are required to conspicuously wear their ID badges daily while within the facility. If an employee loses his/her ID badge, a new ID card is to be issued to that employee.

In addition, employees will be issued supplemental cards to accompany their photo ID badge. Information includes emergency phone numbers for his/her primary facility, R.A.C.E. and P.A.S.S. fire prevention procedures, and a legend detailing the emergency color code system. If an employee loses these supplemental cards, he/she is to notify the Director of Corporate Compliance immediately for new cards.

Emergency Color Code System

The facility is to utilize the following emergency color code system for whenever certain emergencies are occurring:

• Code Red Fire
• Code White Medical Emergency
• Code Black Bomb Threat
• Code Orange Gas Odor/Leak
• Code Silver Person with a Weapon
• Code Yellow Tornado
• Code Green Industrial/Radiological Accident

Code 99 Missing/Eloping Client

Employees should be prepared to spontaneously state what a particular color code means and what procedures are to be followed if questioned. Refer to "Safety" section of the policy and procedure manual.

• Code 99
• In the event that a client is missing or is eloping from a facility, a "Code 99" must be issued. When a Code 99 is issued, the following must occur:
• Through word of mouth, or if there is an intercom, employees are to relay/announce to each other that a Code 99 is taking place.
• The name of the client and, if applicable, the physical description of the individual is passed out amongst employees.
• Employees are to stop what they are doing, look for the client in all rooms of the facility, and monitor entrances to see if the client is attempting to leave the facility.
• If after 15 minutes the client is not found or it has been determined that the client has officially eloped from the facility, the Program Director and/or designee is to notify the client's emergency contact, police (if necessary), and any other external entities that need to be notified (i.e. probation officer, referral source) pending a valid consent form.

Emergency Egress Maps

In the event that a facility needs to be evacuated, emergency egress maps are displayed throughout all facilities depicting primary and secondary evacuation routes.

Visitors

All visitors (including vendors) will be required to report to the receptionist upon entry and sign in. Visitors will be required to sign a client confidentiality agreement as well as the visitor log book.

Visitors will then be given a visitor ID badge and will wait in the waiting area until they can be escorted to the appropriate location. All visitors must be escorted though the facility by an employee.

Loitering/Trespassing

If there is, or there is a suspicion of, individual(s) loitering or trespassing on agency property, employees must dial 9-1-1.

Offices

Employees will be issued a set of keys that will allow them access to certain rooms/offices, depending on their position. Employees are expected to lock any rooms/offices that are not in use and/or may

contain any confidential information. Employees are required to always keep their keys on them, and not to lend their keys out to anyone else. If an employee loses his/her keys, their immediate supervisor is to be notified immediately. It will be up to the discretion of the Program Director to determine if a door's lock needs to be changed as to ensure no unauthorized access takes place.

Infection Control

PURPOSE

The purpose of this policy is to outline protocols on how the organization will control and prevent the spread of infections.

POLICY

It is company policy to establish infection control guidelines to assist in the surveillance, prevention, and control of diseases. In addition, the organization will incorporate infection control procedures into its overall performance improvement processes.

PROCEDURES

Infection Prevention and Control Plan

The organization shall maintain a written Infection Prevention and Control Plan, which will detail how facilities are to respond to specific healthcare-associated infections (HAis), as well as general practices that are to be always followed. The Infection Prevention and Control Plan is to be reviewed annually for continued compliance and updated as needed.

The Infection Prevention and Control Plan will address a minimum for each HAI identified:

• Responsibilities of the Infection Control Officer
• Ways to promote vaccines (as applicable)
• How to minimize potential outbreaks
• How to monitor employees for infections
• How to adhere to standard precautions
• Ways to control the environment of care
• Providing in-service education to employees

General Practices

The following are universal practices that Summit Behavioral Health recognizes as best practices to prevent and/or control the spread of infections.

• Having the Program Director designated as the Infection Control Officer to monitor, report, and maintain records of any outbreaks.
• Enforcing the general rule that to have sick clients stay home until symptoms are gone. Promotion of the use personal protective equipment (PPE - face mask, gloves).
• Having all restrooms consistently stocked with hand soap and paper towels.
• Having the facility will be adequately stocked with Kleenex tissues, as well as hand sanitizer.
• Having all public restrooms will have postings with the Center for Disease Control and Prevention (CDC) guidelines for proper hand washing.
• Encouraging employees stay home when they are sick so to prevent the spread of infection.
• Disinfecting and sanitizing any materials that came in contact with an infected individual.
• Training and monitoring employees to ensure that standard precautions are followed at all times.

Data Collection/Performance Improvement

The Director of Corporate Compliance will be responsible for collecting the following data for the performance improvement measures:

• Randomly testing employees demonstrating conformance to CDC hand washing guidelines

• Tracking the percentage of employees who have been vaccinated to seasonal influenza

Data will be discussed during the Performance Improvement Committee meetings with reports disseminated to the agency's governance.

Infection Control Officer

Any potential or identified infection will be reported immediately to the facility's Infection Control Officer. Each facility's Infection Control Officer is responsible to perform any follow-up, maintaining records of reported infections, trend data, and for reporting infectious processes to local authorities as required by federal and state law.

The Infection Control Officer will report all pertinent infection control and/or the need for educational in-services to the Director of Corporate Compliance.

PURPOSE

The purpose of this policy is to establish guidelines to utilize Universal Precautions to prevent and/or minimize the transmission of infections.

POLICY

It is company policy to require and enforce Universal Precautions to prevent infection among clients, employees, and visitors. It shall require practices and procedures that minimize the risk of the development and/or spread of communicable illness.

PROCEDURES

Universal Precautions

• All employees shall follow the Universal Precautions in which there is potential exposure to blood, body fluids, or any potentially infectious tissues.
• All employees shall handle all potentially infectious substances as if they were infectious regardless of the substances or any prior information about their source of relative seriousness of the potential infection.
• Infection control techniques associated with Universal Precautions shall be routinely and continuously implemented without exception by all employees.
• Employees shall be prepared to spontaneously state why and how Universal Precautions are utilized if questioned by a client, family member, supervisor, or others.
• Gloves should be worn when in contact with all potentially infectious substances and/ or contaminated surfaces, including venipuncture, intravenous therapy, obtaining culture specimens, and handling urine specimens. Gloves can be obtained at the Nursing Office.
• All mucosal splashes or contamination of open wounds with blood or other body fluids should be immediately reported to the facility's executive director.
• Blood spills should be cleaned with a solution of sodium hypochlorite (household bleach) diluted 1: 10 with water.
• Broken glass is to not be picked up with someone's hands and only be cleaned up with a brush and dustpan.
• All table surfaces are wiped down with antiseptic cleaner before and after all meals.
• Articles contaminated with potentially infectious substances should be discarded or double bagged and sent for cleaning and decontamination.
• Unless an airborne disease is suspected and/or diagnosed, Universal Precautions eliminate the need for isolation procedures. However, if an airborne disease is suspected and/or diagnosed ( e.g. tuberculosis, chicken pox), the affected individual will be segregated to the facility's executive director and will remain in his/her office under observation until he/she is sent home or to another health care agency for indicated treatment.
• An Incident Report should be completed by the executive director at the time of the incident and submitted to the Chief Operating Officer within 24 hours of the occurrence.
• Failure to follow the infection control procedures will result in counseling and a memo will be placed in the staff member's personnel file.

Hand Washing

• Hands should always be washed before and after contact with clients, even when gloves have been used. When hands come in contact with potentially infectious substances, they must be immediately washed.
• The following procedures shall be adhered to by all employees:
• All restrooms will have running water, dispensable soap, and disposable towels.
• All employees will wash their hands with soap and water (1-2 minutes) before and after eating, each use of the restroom, each physical contact and/or as needed.
• All employees must also wash any skin area with soap and water that has come in contact with a patient's body fluid. All employees will wash his/her hands in the following manner:
• Turn on the water and adjust to a comfortable temperature, standing away from the sink to avoid splashing.
• Moisten the hands, apply enough soap to lather, cover the hands with soap going beyond the possible area of contamination.
• Use friction, one hand upon the other with fingers interlaced, for at least 10 seconds.
• Rinse hands thoroughly under running water, holding elbows higher than hands, allowing water to run through fingertips.
• Repeat the previous 3 steps as needed.
• Dry hands and arms with a paper towel and tum off the faucet with the same towel before discarding.

Employee Education

• All new employees shall receive detailed instructions regarding Universal Precautions as part of their orientation prior to being assigned to a workstation by the Infection Control Officer or designee of his/her worksite. Continuing education regarding infection control practices, including universal precautions, shall be conducted no less than annually for all employees. Topics addressed in the orientation include:
• Infection Control Program
• Bloodborne Pathogens/Exposure Control Plan
• Hand Washing
• Tuberculosis Exposure Control Plan
• Universal Precautions
• Hepatitis B
• Employee Health
• HIV/AIDS
• Documentation of the completion of the continuing education shall be maintained in each employee's personnel

PURPOSE

The purpose of this policy is to describe the protocols of minimizing the risk of Tuberculosis within the facility.

POLICY

It is company policy to have a defined Exposure Control Plan for Tuberculosis to ensure that potential transmission of Tuberculosis minimized.

PROCEDURES

Employees

• No applicant with active Tuberculosis may be hired at the facility until certified by the County Health Unit as non-contagious or cured. An employee with active Pulmonary Tuberculosis may not continue to work at the facility unless under treatment and no longer contagious.
• An employee with inactive Pulmonary Tuberculosis may continue to work at the facility if he/she has been correctly treated or is on chemoprophylaxis, and the latest chest x-ray shows no changes.
• Compliance with this procedure is a condition of employment at the facility.

Annual

A symptomology screening is required by all employees on an annual basis. If any results or symptoms are reported, the employee must undergo a Tuberculosis screening.

Repeat Screening of Personnel with Significant Reactions

Individuals with known significant reactions to Tuberculosis have no need for additional Tuberculin tests. Radiographs shall be indicated for first time reactions and employees reporting one or more symptoms as specified on the Tuberculosis Screening Form. The x-ray will be taken and sent to the County Health Contract.

Management Of Personnel And/or Clients After Exposure

If employees or clients are exposed to an infected person with active pulmonary Tuberculosis and proper precautions were not used, skin testing of these persons will be done as soon as possible to obtain a baseline and then 10 weeks after exposure. The same procedure as outlined previous for interpretation of skin rest will be followed for clients and employees.

SYMPTOM ASSESSMENT FOR PULMONARY TUBURCULOSIS (TB)

PURPOSE

The purpose of this policy is to outline procedures if boil water advisory is issued for the facility.

POLICY

It is company policy to provide safe water for its clients, employees, and visitors during a boil water advisory.

PROCEDURES

The organization will adhere to the following precautions if a boil water advisory is issued:

• All water for oral intake is to be boiled for a minimum of 10 minutes before use or bottled water will be provided.
• Any water fountains and ice machines are to be labeled: "Do Not Use." Client room sinks are to be labeled: "Do Not Drink - For Hand Washing or Bathing only."
• Bottled water will be provided to clients.
• Employees' hands may be washed with tap water and followed by use of alcohol based waterless hand cleanser.

PURPOSE

The purpose of this policy is to outline the proper procedures for how personnel respond to when they sustain an accidental needle puncture or exposure to mucous membrane.

POLICY

It is company policy that any employee who sustains an accidental needle puncture or mucous membrane exposure is treated as a work-related injury and receives immediate medical attention as to prevent the spread of bloodborne pathogens.

PROCEDURES

Whenever an employee is accidentally punctures him/ herself or is exposed to mucous membranes (blood, semen, vaginal secretions), the following procedures are to take place:

• If an employee is accidently punctured with a needle, he/she must immediately wash the area with soap and water. If an employee is accidently exposed to mucus membranes, he/she must wash the area exposed with soap and water. Exposure areas include eyes, mouth, ears, nose, skin breaks not completely healed, and wounds from biting. Any exposure to an employee's eye(s) must be thoroughly rinsed with water.
• Any accidental exposures with any potentially infectious body fluids must be recorded by completing an Incident Report detailing the incident. The name of the client related to the incident, the client's room number (if residential facility), client diagnosis, the location of the client, and detailed description of how the incident occurred must all be documented.
• Any exposure to blood/body fluids must report to the nearest Emergency Room within 2 hours of exposure. Employees are to immediately report any injuries/exposures to their supervisor and the Director of Human Resources so that the appropriate worker's compensation carrier may be contacted.

Medical

PURPOSE

The purpose of this policy is to establish proper guidelines for which all new clients to receive physical examinations upon admission. Additionally, all new outpatient clients are to submit documentation of his/her medical history and a current physical examination upon admission.

POLICY

It is company policy that clients being admitted are asked if they have had a physical examination and bloodwork within the last year. If they have not, the client is asked to see their primary care physician within 4 weeks of starting in program. This request would be included as part of the client's treatment plan.

PROCEDURES

Therapists shall obtain applicable health related information from a new client and place this documentation into his/her file. Information includes, but is not limited to:

• Significant medical history
• Hospitalizations
• Treatments
• History of communicable diseases
• Most recent Mantoux test and results
• Risk of Hepatitis B and HIV exposure
• Pregnancies and sexually transmitted diseases
• Any current symptomatology

If the organization determines that there is an indication for additional medical treatment or screening, the agency will coordinate referral(s) for the client to appropriate medical services. The resolution of any health-related problems will be included in the client's treatment plan and all referrals will be documented in the client's file.

PURPOSE

The purpose of this policy is to outline procedures to ensure that all clients are properly screened for tuberculosis.

POLICY

It is company policy that all clients are screened for tuberculosis to prevent the risk of infection.

PROCEDURES

• The clinician screens the client for symptoms of or exposure to tuberculosis.
• If screening is positive then the client is referred to primary care physician for further evaluation.
• The client must be seen by physician within 72 hours and provide a note of medical clearance.

PURPOSE

The purpose of this policy is to establish procedures for when clients are assessed for the risk of suicide.

POLICY

It is company policy that all clients are properly assessed for suicide risk and, if he/ she is at risk they are immediately redirected and/or provided with the resources to assist them with their emergency.

PROCEDURES

• If during the admission process, or during treatment, an individual expresses suicidal ideation he or she would be evaluated immediately (suicide risk assessment). If needed, either a mobile crisis team will be called to the location or client will be sent to the nearest crisis center for further evaluation. Client and clinician are to follow the recommendations made by the mobile crisis team (i.e. client being transferred to a program with a higher level of care). The client is to be placed on one-to-one (1:1) visual supervision by staff until the mobile crisis unit arrives.

PURPOSE

The purpose of this policy is to address the safe use of look-alike/ sound-alike medications used or could possibly be used at the facility.

POLICY

It is company policy that all reasonable measures are to be followed while managing medications that are on the "Confused Drug Names" list.

PROCEDURES

The organization shall maintain a "Confused Drug Names" list, consisting of the names of medications that look-alike and/or sound-alike. This list shall be revised as needed and shall be reviewed on an annual basis for continued compliance.

The "Confused Drug Names" list shall be conspicuously posted in the facility and be readily available to all employees.

Refer to: ISMP's List of Confused Drug Name (https://www.ismp.org/tools/confuseddrugnames.pdf)

PURPOSE

The purpose of this policy is to address the safe use of its high-alert medications that are used or could possibly be used at the facility.

POLICY

It is company policy that all reasonable measures are to be followed while managing medications that are on the "High-Alert Medications" list.

PROCEDURES

The organization shall maintain a "High-Alert Medications" list. This list shall be revised as needed and shall be reviewed on an annual basis for continued compliance.

The "High-Alert Medications" list shall be conspicuously posted in the facility and be readily available to all employees.

While handling any of the high-alert medications, nursing staff are to manually double check all orders and doses prepared to ensure that there are no errors.

PURPOSE

The purpose of this policy is to describe how Vivitrol is administered, stored, handled, and disposed of at the facility.

POLICY

It is company policy to only administer, store, and safely handle Vivitrol.

PROCEDURES

Vivitrol is permitted to be dispensed. Each dose must be documented detailing the medication's lot number(s), expiration dates, when the medications were received from the pharmacy, and the name of each client that received the medication. Vivitrol is the only medication administered in outpatient settings.

No other medications are to be administered, stored, safe handled, or disposed of at the facility.

PURPOSE

The purpose of this policy is to list the prohibited abbreviations, acronyms, symbols, and dose designations.

POLICY

It is company policy to maintain and update a list of abbreviations, acronyms, symbols, and dose designations that are prohibited from being entered in any medical and clinical documentation.

PROCEDURES

The organization’s "Official Do Not Use" list can be found below. This list shall be revised as needed and shall be reviewed on an annual basis for continued compliance.

The "Official Do Not Use" list shall be conspicuously posted in the facility and be readily available to all employees. The prohibited list applies to all orders and medication documentation.

Official "Do Not Use" List

PURPOSE

The purpose of this policy is to establish an approved list of abbreviations that are universally accepted and recognized.

POLICY

It is company policy that it shall establish and maintain an approved list of abbreviations for all documentation. Any abbreviations that do not appear on the list shall be considered not approved for use.

PROCEDURES

The organization shall maintain a list of approved abbreviations. This list shall be revised as needed and shall be reviewed on an annual basis for continued compliance.

The approved list shall be conspicuously posted in the facility and be readily available to all employees.

See also: Prohibited Abbreviations.

PURPOSE

The purpose of this policy is to outline the proper procedures for how critical lab and tests values are identified and reported in an appropriate and timely manner.

POLICY

It is company policy that all laboratory and test results are documented in the client's record.

PROCEDURES

• If a client needs to be referred to an external laboratory, clinic, or testing facility, the therapist may assist the client with the referral.
• The therapist is to have the client bring all documentation regarding the referral back to the facility, make a copy of the results, and placed in the client's record.

PURPOSE

The purpose of this policy is to outline the proper procedures for urinalysis protocol.

POLICY

It is company policy that all urine drug screening (UDS) will be based on medical necessity determined by observation and documented symptoms and behaviors including but not limited to:

• History of use
• Current presenting symptoms
• Relapse risk factors
• Protective factors
• Compliance and engagement with treatment

For PHP/ IOP/ OP facilities, providers are to document any relevant test results in the client's EMR. This information is shared with the Clinical Director and discussed in the weekly staff meeting. This information may be considered in the treatment plan.

PROCEDURES

The following procedures will be followed in the identified timeframe: 

Phase 1 : Initiation into Treatment

Length of Time: 2-4 weeks

Frequency: 2-3 x's/week based upon observation of presenting symptoms and behaviors indicating medical necessity

At admission, 1st UA Panel will be collected on site, sent for screening and confirmation to establish baseline(panel will include Psychotropic Medications). Testing in this phase will include screening and confirmation to monitor abstinence and decreasing of levels. Once client has demonstrated continued abstinence, compliance with treatment plan goals, client will step down to Phase 2

Phase 2: Stabilization Length of Time: 2-4 months

Frequency of Testing: 1-2 x's/week based upon observation of presenting symptoms and behaviors indicating medical necessity

During Phase 2, clients will be tested routinely and randomly to monitoring continued abstinence with a customized panel based upon client's use history, presenting substance of use and as indicated by medical and clinical recommendations. Testing will include screening and only sent for confirmation when indicated positive (+) at POC unless otherwise necessary. Once client has demonstrated 8 negative (-) UAs, client will be tested with less frequency based upon presenting symptoms and behaviors observed by medical and clinical teams.

Phase 3: Maintenance Length of Time: 3-6 months

Frequency: 2-4 x's/ month based upon observation of presenting of symptoms and behaviors indicating medical necessity

During Phase 3, clients will be tested routinely and randomly to monitoring continued abstinence with a customized panel based upon client's use history, presenting substance of use and as indicated by medical and clinical recommendations. Initial UA in this phase will include screening and confirmation to ensure continued abstinence.

Special Considerations: The client's individualized needs are considered in the context of the timeframe. POC testing is exclusive of alcohol. In addition, POC results often present false negative for specific Benzodiazepines. These limitations should be considered when making determination for confirmation of specimen.

Evaluation of Proposed UA Protocol: The UA protocol will be reassessed for medical and clinical efficacy at minimum once per quarter to ensure adherence to medical necessity and maintenance of the highest standard of care. All authorizing providers will provide regular and ongoing feedback and recommendations to the Medical and Clinical teams focusing on upholding a best practice approach to the delivery of individualized services.

PURPOSE

The purpose of this policy is to ensure that all waived testing meet minimum requirements for quality control, identifying responsibility for testing, and reporting results according to all requirements for performing waived tests including Clinical Laboratory Improvement Amendments of 1998 (CLIA 88), state licensure, and the Joint Commission.

POLICY

It is company policy that all laboratory testing is high quality and cost-effective in order to contribute to optimal client care.

PROCEDURES

Definitions

Waived testing includes a variety of specimen testing including urinalysis. Waived tests are those that:

• Meet the Clinical Laboratory Improvement Amendments of 1998 (CUA 88) requirements to be classified as waived tests.
• Are cleared by the Food and Drug Administration (FDA) for home use.
• Use methodologies that are simple and accurate as to make the likelihood of erroneous results negligible.
• Pose no risk of harm to the client if the test is performed incorrectly.

Urine Drug Screening Devices Used

• CLIA WAIVED Urine Drug Test Cup

Testing Milestones

• All clients receive an instant urine drug screen upon admission and throughout the course of treatment as deemed necessary by the treatment team.
• Clients must submit to individualized urine drug screens. Refusal to do so may result in discharge from treatment.
• All clients are subject to testing if there is suspicion of substance abuse within a facility.
• Urine specimens should be collected in a manner that communicates trust and respect, while taking reasonable steps to prevent falsification of specimens.
• All test results, and refusals, will be documented in the client's record.

Procedures to Collect Specimens

• Only qualified personnel who completed all required training and can demonstrate compliance with these procedures are permitted to collect urine drug specimens.
• Personnel shall adhere to the following procedures for collecting urine from a client:
• Urine drug screening may be conducted randomly OR if there is suspicion of a client is under the influence of a substance. At the discretion and approval of the program director, a client may be asked to produce a specimen for testing. Documentation must be present in the client's electronic medical record.
• Personnel of the client's sex are only permitted to collect and/or observe urine specimens.
• Personnel are to wash their hands and put on gloves. Clients are to wash their hands.
• Clients will not be permitted to use the sink again until the collection is complete. 
• The client's full name and date of birth are to be verified.
• Remove the test device from the sealed pouch.
• All urine specimens are to be collected in a bathroom and may be monitored by personnel. If personnel is to monitor the collection of urine, they are to "passively observe" the client by remaining outside the bathroom, with the bathroom door opened slightly to hear the collection. Personnel are not to observe body orifice-to cup collection or remain in the bathroom with the client during urination unless it is approved by the Program Director. Additionally, personnel are not to ask the client to remove any clothing or stay in the room during the entire time the client is producing the specimen.
• Specimens should be filled to the minimum fill line.
• Once the specimen is collected, personnel are to secure the test lid.
• The test cup is to be tilted on its side to activate test.
• All test results should be interpreted and validated within five minutes.
• Urine specimens should be placed in a secure area for pickup.

Quality Control

• Test cups have built-in internal procedural controls. The appearance of the control band is considered an internal procedural control. This band should always appear if adequate sample volume is used and all testing procedures are followed. Additionally, the background color should become clear and provide distinct test results. If the control band does not appear, then the test is invalid, and testing should be repeated.
• If there is suspicion that a specimen may have been tampered with, the test should be repeated, and a new specimen should be collected and the Director of Nursing and/or Program Director shall be informed who will take necessary measures to remedy the problem.

PURPOSE

The purpose of this policy is to outline the procedures if a client has a seizure.

POLICY

It is company policy that all employees are properly trained on the procedures if a client has a seizure that is considered best practice.

PROCEDURES

If a client suffers a seizure, the following procedures are to be adhered to:

• Employees are to immediately dial 911.
• During a seizure, the main goal is to prevent injury, so the client is to not have their movement physically restricted. Gradually lower the client to a lying position and tum the client on the side to allow fluids in the mouth to drain out. This will prevent aspiration. Always support the head.
• Clear the area of hard objects.
• Only medical personnel should remain in the area. The Charge Nurse shall contact the on-call physician immediately.
• Do not force or put anything, including fingers, into the client's mouth.
• A nurse shall remain with the client until emergency medical technicians arrive and monitor vital signs and neuro-checks every five minutes. The vital signs and neuro checks shall be document in the client's chart.
• After the seizure, infom1 the client that they have just had a seizure and that they are all right. If it is a detoxification client and he/she are in bed, keep the bed rails up.
• An Incident Report shall be completed at the time of transport.
• For the detoxification facility, when the client returns from the hospital a nurse is to continue monitoring the client in an observation area.

PURPOSE

The purpose of this policy is to outline procedures in which client allergies are properly identified, documented, and reported.

POLICY

It is company policy that all client allergies are properly documented in their records to ensure that compliance with federal and state regulations.

PROCEDURES

The client's therapist shall document any history of allergies and/or sensitivities, or any denial of allergies, on the outside of the client's record, or in the client's electronic record.

PURPOSE

The purpose of this policy is to provide instructions for clients, employees, and visitors to follow in the event a facility is to be evacuated.

POLICY

It is company policy to maintain strict standards and policies regarding the safety of clients, employees, and visitors.

PROCEDURES

Facility Evacuation

• In the event that any facility is to be evacuated, the following protocols are to be followed:
• If there is a fire, the fire alarm is to be pulled.
• Everyone is to evacuate the facility. If applicable, no one is to use the elevator while evacuating.
• Employees are to dial 911.
• If it is safe, employees are to use fire extinguishers.
• Employees are to check every room to ensure that everyone is evacuating the facility. If any part of the facility is too dangerous to check, employees are to inform emergency personnel upon their arrival.
• If possible, employees are to take the facility's attendance log and first aid kit.
• Everyone is to gather in the facility's designated emergency assembly area. The following are the designed emergency assembly area:
• Once everyone is at the facility's designated emergency assembly area, employees are to conduct a headcount to ensure that everyone is out of the building. Everyone is to keep passageways clear for emergency personnel.
• If the Program Director is not present, he/she is to be notified of the evacuation.
• Under no circumstances is anyone allowed to re-enter the evacuated facility until permitted to do so by emergency personnel.
• Clients may be asked to go home if the facility is unsafe to re-enter. Clients will be called when the facility is safe to re-enter.
  

Individuals with Functional Needs; Visually Impaired Individuals

• Inform the individual the nature of the emergency. Offer to guide him/her by offering your left/right elbow. Do not grab the individual's arm.
• Be sure the individual brings with them all mobility aides such as white canes. The individual may have a guide dog that may be disoriented. Ask the advice of the individual who is blind regarding the needed level of assistance.
• Give verbal directions to advise about the safest routes. Use compass directions, estimated distances and directional terms to orientate the individual. As you guide the individual, describe where you are and advise them of any obstacles.
• When you have reached the designated evacuation assembly area, orient the individual to where he/she is and ask if any further assistance is needed.
  

Hearing Impaired Individuals

• Write a note stating the emergency and the evacuation route.
• Turn the room lights on and off (if safe to do so) to gain attention. Indicate through hand gestures what is happening and what to do.
  

Individuals with Limited Mobility and Non-Ambulatory Individuals 

• Employees should be ready to physically assist in the evacuation of disabled individuals who may be present on a floor higher than the ground floor.
• If the emergency is not imminent, a designated employee(s) are to place the individual next to or in a stairwell, and stay with the stranded individual. Elevators may be used to evacuate disabled ONLY after it has been declared safe to use.
• If the emergency is imminent, the following procedures must be followed to ensure safety for all individuals involving in evacuation:
• Determine if the individual is at risk when transferred or carried. Individuals may have a physical condition that contraindicates lifting such as heart conditions, back problems, or other severe physical conditions.
• Semi-ambulatory individuals may lean against an employee's back while holding both of the individual's arms over their shoulders. The employee should lean forward slightly to take most of the individual's weight.
• Employees may form a two-handed seat (two employees link arms to form a backrest and grip wrists to form a seat) or utilize a two-person carry (one employee wraps his/her arms around the individual's chest, under the arms, while the second employee stands facing away from the individual between their legs and lifts the individual's legs under their knees with each of their arms).
• If the individual cannot be transferred from a wheelchair: o Secure the wheelchair.
• If necessary, remove the wheelchair battery.
• If possible, roll the wheelchair down the stairs, keeping it tilted back to keep the individual secure.
• If it is not possible to roll the wheelchair down the stairs, a minimum of 3 employees must carry the individual in their wheelchair down the stairs. The strongest employee must grip the wheelchair's handles at the back with other employees assisting while gripping the front seat frame or non-removable leg rests.
• Always keeps the wheelchair facing away from the stairs.

PURPOSE

The purpose of this policy is to provide guidelines for fire prevention and intervention.

POLICY

It is company policy to maintain strict standards and policies regarding the safety of clients, employees, and visitors.

PROCEDURES

Reporting Procedures

Alarms

If the fire alarm sounds, the facility must be evacuated in a timely and orderly fashion by everyone. The fire alarm will trigger a "CODE RED" for all employees. While evacuating, employees are to do the following:

• Immediately call 911.
• Make sure that all lights are left on.
• Leave all doors and windows unlocked.
• Attend to any ill or disabled individuals wherever possible without putting themselves in any danger.
• Ensure that everyone is out of the facility and conduct a headcount of all clients.
• Instruct everyone to gather in the facility's designated evacuation assembly location.
• The Program Director or his/her designee is to complete an emergency drill evaluation form.
• Notify the Executive Director.

Actual Fire

In the event of a fire being discovered, the R.A.C.E. procedure shall be followed: 

Rescue those in immediate danger by removing them to a safer area. 

Activate the alarm system by pulling the alarm box. 

Confine the fire by closing all doors and windows. 

Evacuate the building.

Each floor will display the emergency exit plan for that floor near the fire alarm. All persons are to evacuate the area in an orderly manner according to the evacuation diagram.

Fire Suppression

Fire extinguishers are located on each floor. To operate fire extinguishers, P.A.S.S. should be used:

Pull the pin.

Aim the nozzle at the base of the fire.

Squeeze the handle.

Sweep the fire extinguisher from side to side, keeping a distance of 4 to 6 feet from it.

Evacuation Plans

Evacuation plans for all facilities are to include a primary and a secondary evacuation route. All clients and employees are to become familiar with the routes of each building when in them.

PURPOSE

The purpose of this policy is to provide guidelines to be undertaken by clients and employees in the event of a heat emergency.

POLICY

It is company policy to maintain strict standards and policies regarding the safety of its employees and clients.

PROCEDURES

Staff shall follow the outlined protocol in the event when a facility's indoor temperature is 82 degrees

Fahrenheit or higher for 4 consecutive hours.

Services may be suspended until the facility's indoor temperature drops below 82 degrees. The Executive Management team will determine if the facility is to suspend services.

PURPOSE

The purpose of this policy is to ensure immediate treatment of anyone within the facility in the event of a medical emergency.

POLICY

It is company policy to establish the physical stability of the individual in need of medical attention until he/she receives emergency medical treatment.

PROCEDURES

Medical Emergency Description

A medical emergency is an incident occurring in which people are injured, infected, or otherwise harmed that requires professional medical attention. This includes, but is not limited to, the following:

• Individual's physical status is questionable and may require intensive medical monitoring.
• Individual's immediate physical needs outweigh any needs related to addictions treatment as identified in the treatment model.
• Individual has developed a physical illness which cannot be appropriately treated on-site.
• Individual injured themselves and the condition requires additional medical evaluation and/or treatment.
• Individual demonstrates violent and/or aggressive behavior which may put the individual or others in physical and/or emotionally jeopardy.

Employee Responsibilities

• Employees are to be notified by announcing "CODE WHITE" over the intercom or by word of mouth that there is a medical emergency occurring.
• The responding employee must immediately call 911. Employees must disclose to the operator where the medical emergency is taking place. All directives from the operator are to be followed.
• If a head injury occurred, the individual is not to be moved.
• After all appropriate emergency procedures have been completed, the Program Director is to be immediately notified.
• If the individual is a client, the client's emergency contact person is to be immediately notified. If possible, an employee is to accompany the client to the hospital and report back exactly where the client was transported to.
• If the individual is an employee, the Human Resources Department is to be immediately notified. The Human Resources Department will notify the applicable worker compensation, medical, and insurance agencies.
• Following the incident, an Incident Report is to be completed with ongoing documentation completed by staff. If possible, employees are to document the following documentation:
• All notifications, including physicians
• Assessment data
• Emergency treatment/ first aid provided
• Who, if anyone, accompanied the individual
• Mode of transportation
• Physicians' orders
• Medications taken
• Times of all events
• Pertinent changes with individual's condition
• If any, consents obtained
• If the individual is a client, only the information that is relevant to the illness or injury will be released. In life-threatening situations, or when the client's condition precludes the possibility of obtaining written consent, information may be released as to ensure the health and safety of the client. When this is done, the responsible employee will enter the following data into the client's record:
• Date of emergency
• Person(s) spoken to
• Reason for release of information
• Reason why no consent was obtained
• Details of specific information released

Employee injuries/Medical Emergencies

Any employee who sustains an injury or is suffering from a medical emergency, and is in need of immediate medical attention, will be instructed to go to the nearest emergency room and/or have another employee dial 911 on their behalf.

PURPOSE

The purpose of this policy is to outline procedures for when an individual is confirmed dead on premises.

POLICY

It is company policy that when an individual is confirmed dead on the premises that the state and local authorities and the individual's family are notified in a timely and appropriate manner.

PROCEDURES

Upon confirmation of a death on the premises of the facility, the following is to occur:

• Dial 911 and request immediate assistance.
• The Program Director and Program Director are to be immediately notified.
• Employees are to ensure that all of the individual's possessions are secured and are turned over to the police.
• If the individual is a client or employee, the Program Director is to notify the family of the deceased. If the family cannot be immediately reached, the local police department of where the family resides may be requested to assist in the making of the notification.
• An Incident Report is to be completed.

PURPOSE

The purpose of this policy is to provide guidelines when controlled substances or related paraphernalia are brought into treatment.

POLICY

It is company policy to maintain strict standards and policies regarding the safety of clients and employees. In addition, it is policy to address the delivery, possession, or distribution of controlled substances and/or related paraphernalia in a timely and appropriate manner in accordance with federal and state laws.

PROCEDURES

If any controlled substances or related paraphernalia are brought into the facility, the following is to occur:

• If a client or employees comes to know that another client, employee, visitor, or any other person is in possession of a controlled substance or related paraphernalia on property, that client or employee must immediately inform the Program Director. If the Program Director is not available, the employee in charge must be notified.
• The Program Director, or employee in charge, must gather all relevant information. This information includes, but is not limited to, information concerning where the substance or item was found and the identity of all persons believed to have been in actual, joint, or constructive possession of the substance or item.
• If the reporting party is a client, confidentiality of the client cannot be compromised. Therefore, in all documentation, the client shall be documented as a "client" who reported the information to the Program Director. The identity of the client, including but not limited to name, age, or staff position, cannot be recorded in any sense or transcribed in any official documentation.
• After gathering all information, the controlled substance is to be disposed of in the facility's Rx Destroyer. Any related paraphernalia is to be discarded in a sharp’s container.
• Employees must file an incident report on the situation and collect and file any other documentation that relates to the incident.
• The Program Director is responsible for reviewing any incidents and follow up.

PURPOSE

The purpose of this policy is to provide guidelines when licit drugs are brought into the facility both lawfully and unlawfully.

POLICY

It is company policy to maintain strict standards and policies regarding the safety of clients and employees. In addition, it is policy to address any unlawful delivery, possession, or distribution of any drugs or-related paraphernalia in a timely and appropriate manner in accordance with federal and state laws.

PROCEDURES

Lawful Delivery by a Client, Visitor, or Employee

If any licit drugs are brought into the facility lawfully, the following is to occur:

• Employees and visitors are not permitted to have any medication prescribed to themselves on their person while inside any facility. Medications must be either kept inside their cars or secured in a lock cabinet/drawer.
• In the event employees or visitors are delivering a licit drug for a client, the following procedures are to occur:
• All deliveries are to be screened by employees then placed stored appropriately per company policy. Facilities reserve the right to hold onto a client's medication until he/she is completed with residential treatment or until the end of an outpatient session.
• If the licit drug is no longer needed, the drug will be disposed of it in an appropriate manner, per company policy.

Unlawful Delivery and Possession

If any licit drugs are brought into any facility unlawfully, the following is to occur:

• The item is to be confiscated by employees and the Program Director is to be contacted immediately.
• If there was intent to distribute, the procedures in the "Possession of a Controlled Substance or Related Paraphernalia" policy are to be followed.
• If there was no intent to distribute, the licit drug should be immediately disposed of by the Program Director or the employee in charge in an appropriate manner.
• If there was no intent to distribute and the offending party was a visitor, they are to be immediately removed from the facility. If the offending party was an employee, they are to be referred to Human Resources by their supervisor for appropriate action.

PURPOSE

The purpose of this policy is to provide guidelines to be undertaken by clients, employees, and visitors in the event of an emergency and/or natural disaster.

POLICY

It is company policy to maintain strict standards and policies regarding the safety of its clients, employees, and visitors.

PROCEDURES

The Executive Director or designee will immediately notify the appropriate licensing authority in the event of:

• Death of clients or employees; or
• Evacuation/closure of the facility resulting in a significant disruption of services.

A written report is to also be sent to the appropriate state entity within 48 hours of the event.

The following courses of action are to be undertaken for the following emergencies: