SCCCMH Policies Index

This document lists approved abbreviations and acronyms that may be used in the case record. Included lists are general terms, Evidence Base Practices, medical terms, psychological assessments and measurement tools, groups and organizations.

04-001-0005

This document describes the process to ensure the safe and accurate administration of medication to the individuals we serve.

07-001-0006

This document provides additional the procedures that relate to the Standard in Board Policy 07-001-0005 Board Fiscal Responsibility.

05-001-0030

This Board policy provides direction to employees regarding a recipient?s right to receive information about and assistance with completing an advance directive (written document recognized under state law granting decision-making authority to an authorized individual if a person becomes incapacitated or identification of procedures a person does not want performed in the event they become incapacitated/suffer cessation of both respiration and circulation) as established by state law.

04-001-0020

This document describes management of adverse reactions to medication.

01-001-0045

This Board policy enforces our accountability to community stakeholders and to the individuals we serve, by providing them with the opportunity and responsibility to be a partakers in how services are implemented. This includes review of policies that direct services.

03-003-0010

This document outlines the process to ensure a full continuum of services by providing the people we serve with alternate services during non-regular business hours and the opportunity to attain assistance and supports in using their problem solving and coping skills.

01-002-0045

This document is to ensure comprehensive staff coverage when open and to that consistent and safe standards are followed for closing programs and/or the agency in the advent of adverse weather conditions or building problems.

02-001-0045

This document provides information and steps an individual has a right to take if unsatisfied with services and supports. The policy defines various legitimate reasons or grounds to appeal and processes to request an appeal and/or second opinion, along with timeframes for the complaints and timeframes for a resolution. Information regarding Adverse Benefits, State Fair Hearing, Dispute Resolution and expedited appeals are addressed.

05-001-0050

This Board policy provides an overview of the recipient rights appeals process available to appellants (complainants, recipients, and guardians) as established by the MDHHS-CMHSP contract and technical requirement, Recipient Rights Appeals Process.

03-001-0095

St. Clair County Community Mental Health Authority (SCCCMHA) shall provide and manage services of the Autism Benefit, including Applied Behavior Analysis, through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Benefit, according to all applicable Michigan Department of Health and Human Services (MDHHS) and federal standards and requirements.

02-003-0025

This document provides the rules/guidelines for implementing aversive and intrusive techniques to protect individuals who present aggressive behaviors that are harmful to themselves and/or others. Terms in this document include Sentinel Event, Special Consent, Restraint, Seclusion, Positive Behavior Supports, Physical Management, unexpected death, etc.

03-001-0060

This policy identifies the specified Committee structure and its oversight responsibilities, various types of restrictions, protective techniques, Recipient Rights involvement, the documents used to ensure Treatment Plan and diagnosis appropriateness as well as, BTPRC reporting. Terms in this document include Critical Incident, Intrusive Techniques, Risk Events, Sentinel Event, Lethality Reviews, etc.

07-001-0005

This Board policy is to ensure SCCCMHA operates in a manner that is fiscally responsible and ensures accountability for the use of the public funds; and proper internal controls are in place to manage risk and monitor performance. Included are numerous defined accounting terms.

01-001-0020

This Board policy requests Board Members to attend all SCCCMHA Board meetings, activity calendar; Special Committee/Advisory Council meetings that they have been appointed to by the SCCCMHA Board Chairman and be reimbursed for attendance and travel expenses.

09-001-0005

This document includes processes to ensure all St. Clair CMH locations maintain a safe atmosphere inside and outside, via periodic building inspections.

07-002-0085

This document provides a description of how the building reserve fund is established, managed, accessed and replenished to pay for ongoing expenses such as repairs.

03-001-0015

This document defines Casemanagment, Supports Coordination and Person Centered Planning Facilitator. It ensures quality services with options of whom may provided those services.

03-002-0005

This document gives a description of the EHR (Electronic Health Record), the location of documents within the EHR. Responsibilities and process for Records Staff, scanning/uploading etc.

03-002-0010

This document identifies the timeframes for case record documentation.

02-001-0025

This document defines various assessment tools, medical necessity, hours, days and locations of operation for CIU. Provides processes for new recipients of services, court appointed recipients, outreach and referrals.

03-001-0030

This document explains the funding source of the CW program, the services it offers and who qualifies for CW services.

05-001-0085

This Board policy provides direction to employees regarding the procedures for processing a recipient?s request to choose/change their mental health professional as established by the Mental Health Code.

07-002-0025

This document explains the claims payment/repayment grievance and appeal process and the standards followed.

02-003-0020

This document defines various types of claims and provides the guidelines for claims management as defined by federal and state regulations and MDHHS.

01-002-0015

This document identifies types of eligibility status, Evidence Based Practices and other clinically approved practices and disseminates that information to the SCCCMHA provider network to guide and determine appropriate behavioral healthcare and substance use services.

04-001-0085

This document provides a process to safely provide Clozaril to appropriate individuals and to maintain compliance with associated regulatory (REMS) guidelines.

07-002-0105

This document ensures its providers of behavioral health services have the working capital necessary to cover operating expenditures, such as payroll and vendor payments, in a timely manner.

05-003-0030

This administrative procedure provides direction to employees regarding a resident’s right to communicate with persons of their choosing at any time via in-person visits, mail, and telephone communications as established by the Mental Health Code and MDHHS Administrative Rules, and the Licensing and Regulatory Affairs rules for group homes.

08-003-0025

This document provides a description of CEHR (Community Electronic Health Record), a secure, confidential and easy to use website, allowing 24-hour access to elements of an individual?s health record.

07-002-0080

This document describes the funds that are set aside to pay for earned leave time and related fringe benefit costs and restrictions of fund use and how maintained.

05-001-0035

This administrative procedure provides a general overview of the recipient rights complaint investigation system as established by the Mental Health Code.

03-001-0055

This document outlines CIU?s procedures to follow when completing an intake on an individual to determine service eligibility, the documentation that needs to be completed and the tasks of staff.

08-001-0010

This document ensures proper use and integrity of agency?s computer resources and information systems.

01-001-0030

This Board policy provides the guidelines by which all employees are obligated to conduct business that prohibit actual or potential conflicts of interest.

03-002-0025

This document identifies and lists all clinical and some financial consent forms used by St. Clair CMHA. Consent forms list include, state required, program and activity specific as well as, St. Clair County Court consent forms.

07-002-0035

This document describes the process in which SCCMHA reviews the audited financial statements for contract agencies, the expectations of the audit and the process is to resolve any findings or disagreements found as a result.

01-003-0021

This Board policy to ensure maintenance of system of contract management in accordance with applicable federal, state and local laws as well as, the MDHHS and PIHP contracts.

03-003-0070

This document applies to Peoples Clinic and provides prescribing safety and consistency for controlled substances. It also provides a means of follow up and coordination with SCCCMHA should concern arise that abuse or misuse of controlled substances may be occurring.

03-001-0020

This document provides the guidelines to ensure care coordination between the individuals served and their primary care and/or other health providers, to ensure a more inclusive, holistic and communicative service experience.

08-003-0035

This document provides a description of how CMH and its providers need to fully support US and international copyright law to fulfill moral and legal obligations with respect to use of the copyright protected materials of others.

01-002-0020

This Board Policy is to have a corporate compliance program that includes a compliance plan; education and training; a process for receiving and investigating complaints; and reporting.

07-001-0011

This document describes the standards and procedures followed for determining rates used in SCCCMHA contracts and the guidelines followed.

01-003-0040

This document identifies which county is financially responsible for Specialty service(s) provided outside the county in which the individual resides.

03-001-0045

This document defines the process for ensuring court ordered treatment while protecting the rights of the recipient.

06-001-0125

This document highlights the external Trauma Response Team and their tasks to assist the community with Critical Incidents, such as suicide of a high school student, line of duty death, homicide, events involving multiple children or injuries.

06-002-0010

This Board policy ensures MDHHS cultural competency guideline adherence by providing staff with cultural competency training or sensitivity training to promote mutual respect and awareness of differing cultures, people, nationalities, religious beliefs, sexual orientation social class, etc.

02-002-0005

This document provides the guidelines for initial and on-going access into the CMH system, as well as Customer Service Department outreach. This policy enforces the reality that all departments, whether front line direct services or secondary administrative services, provide some form of service to ensure customer satisfaction, which may include assistance with a grievance compliant and/or an appeal.

05-001-0010

This Board policy provides direction to employees regarding the reporting requirements for recipient deaths as established by the MDHHS-PIHP contract.

08-002-0015

This document provides a description of the demographic and clinical data contained in OASIS on each individual prior to submitting any service provision data.

06-001-0120

This document mandates notification (Duty to Warn) be made to applicable parties when a recipient of services makes threat against third parties.

08-003-0005

This document provides a description of the Electronic Health Record including but not limited to Integrity of data, the request to amend the record, correction, deletion and disclaimers.

09-003-0050

This document defines critical and emergency events, identifies required safety drills and the describes processes for responding to those events.

05-001-0025

This document provides direction to employees regarding the federal requirement that providers notify Medicaid beneficiaries/enrollees of their rights as established by the United States Code of Federal Regulations and the Medicaid Provider Manual.

05-001-0020

This administrative procedure provides a general overview of the rights of Medicaid beneficiaries/enrollees as established by the United States Code of Federal Regulations and Medicaid Provider Manual.

07-002-0045

This document provides the recording and disposing of inventory in accordance with HIPAA guidelines.

03-003-0040

This document instructs staff on how to determine whether or not services for an intoxicated or impaired person should be postponed and rescheduled due to the individual inability to benefit from services.

05-003-0020

This administrative procedure provides direction to employees regarding a recipient?s right to receive notice of the availability of family planning and health information services as established by the Mental Health Code.

05-003-0010

This administrative procedure provides direction to employees regarding the requirements for capturing fingerprints, photographs, or audio-recordings of recipients, and the requirements for the use of one-way glass for observation of a recipient as established by the Mental Health Code.

09-003-0035

This document ensures the CARF requirement of the availability of adequately stocked First Aid kits at all of our locations and agency vehicles.

01-002-0025

This document provides the processes to obtain information. It includes who can release information and associated costs.

05-003-0040

This document provides direction to employees regarding a resident?s right to not have their freedom of movement limited unless the resident demonstrates an imminent risk of physical harm to themselves or others. The document includes treatment team involvement approval of Behavior Treatment Plan Review Committee, used of the special consent and training regarding the parameters of the resident?s limitation.

01-002-0060

This document provides a system of structure for its general management and transmission of documents (non-case record). Procedures for electronic/file path name, facsimile and mail.

02-001-0030

This administrative procedure provides a description of specific guidelines establishing Community Mental Health Services Program (CMHSP) General Fund (GF) Waiting List (WL) operations consistent with MDHHS technical guidelines.

03-002-0040

This document provides the guidelines for writing goals, objectives and interventions in the IPOS/Treatment /Support Plans.

02-001-0040

This document permits recipients of services the opportunity to voice their dis-satisfaction with services and provides the steps to ensure their complaint is heard by someone in authority and to receive some form of disposition or resolution.

03-003-0020

This policy provides definitions of the different types of guardianships and the process of obtaining guardianship for CMH recipients.

03-001-0025

This document provides a description of HSW program, discusses requirements of PIHP, MDHHS and Medicare/Medicaid.

05-001-0055

This Board policy provides direction to employees regarding their right to not be discriminated against due to their involvement in a recipient rights complaint as established by the Mental Health Code.

04-002-0010

This document describes a document used in residential settings to log/record all medical health activity including medication reviews, prescription, medication administrating (including PRN), lab tests, immunizations, eye, dental hearing exams etc. All entries are dated and signed by recording staff.

05-001-0065

This Board policy provides direction to employees regarding the requirements of a Do-Not-Resuscitate Order and the responsibilities of employees in carrying out such an order as established by the Michigan Do-Not-Resuscitate Procedure Act.

08-002-0006

This document reaffirms to personnel that they must preserve the integrity and the confidentiality of client information.

04-002-0090

This document describes the provisional approval that allows the Pre‐Paid Inpatient Health Plan (PIHP)/Community Mental Health Service Provider (CMHSP) to contract with new providers who do not have a current HCBS participant receiving Medicaid services in their setting, ensuring that providers are not institutional or isolating in nature.

07-003-0010

This document defines what housing costs will be used and eligibility guidelines followed in the case of an emergency situation. This is to prevent an episode of homelessness or to provide limited term financial assistance.

04-002-0030

This document provides a process to maintain a safe and healthy environment for individuals and staff who attend community based programs. It includes disease-specific information, St. Clair County Health Department (SCCHD) reporting requirements, and exclusion guidelines as per SCCHD.

05-001-0040

This document provides direction to employees regarding the reporting requirements for unusual incidents discovered about or exhibited by recipients as established by the Mental Health Code and CARF manual.

01-001-0035

This Board policy is to ensure the individuals we serve are included in creating, evaluating and operating of mental health and substance use disorder services, via LEP and Person First language documents, board participation, community education, surveys, Person Centered Planning, etc.

05-002-0006

This administrative procedure provides direction to employees regarding the right of recipients/recipients? guardians to give informed consent for services, medications, and the release of confidentiality, meaning a recipient/guardian has the legal capacity to give consent; has knowledge about their services/confidentiality; is able to comprehend the services they agree to receive/information they agree to release/exchange; and gives their consent voluntarily as outlined by the Mental Health Code and MDHHS Administrative Rules.

03-003-0005

This document ensures the involvement of the people we serve and stakeholders in the planning, decision making, implementation and evaluation of the services they received.

07-003-0080

This document describes how all persons seeking to receive services from SCCMHA are required to apply for any insurance coverage to which they are entitled. It outlines the process followed to obtain insurance and notify responsible party. Also it outlines the procedures for obtaining the appropriate insurance information and data entry.

02-002-0021

This document ensures all Deaf/Hearing Impaired persons be given the opportunity to participate in and benefit from SCCCMHA programs or services in a manner that is equal to and as effective as the opportunities provided to hearing individuals.

08-001-0005

This document ascertains guidelines for technical assistance and related equipment provided by the Information Technology department.

03-001-0085

This Board policy outlines in detail the standards and requirements of the Jail Diversion Program and the process of linking individuals to the Jail Diversion Program.

09-001-0020

This document provides the details the process for Facilities? to maintain agency keys, building access via electronic badges, activation, deactivation and permissions on electronic badges.

01-003-0050

This Board policy is the processes used to have reasonable, fair and adequate lease agreements. This document in includes terms: appraisal, fair market value, option to extend and rent.

06-002-0015

This Board policy ensures alignment with MDHHS standards to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits.

08-001-0015

This document ensures that all data gathered and stored digitally shall be backed up in a secure manner and reside on server platforms controlled by SCCCMHA.

01-003-0045

This documents includes the process to assist in maintaining the Michigan Department of Health and Human Services (MDHHS) Provider Registry and Program Approval process in compliance with the Medicaid Provider Manual and MDHHS/ Prepaid Inpatient Health Plan (PIHP) Medicaid Contract.

04-002-0015

This document describes a document used in residential setting to ensure proper and accurate communication occurs regarding medical conditions between the individual, care provider and physician.

09-003-0010

This document is to ensure that individuals who experience a medical emergency while attending SCCCMHA/Contract Programs will receive appropriate first aid and medical treatment.

04-003-0035

This document provides procedures that align with Adult Foster Care Licensing Rules which requires maintaining a separate Medication Record for each individual. The Medication Administration Record (MAR) is the form used for this process.

04-001-0045

This document outlines the processes to be followed when a medication error occurs.

04-002-0035

This document provides a process to maintain a record of any medical, dental, surgical, significant injury, specialist care, or hospitalization history.

04-001-0050

This document describes processes to be followed to ensure safe, accurate and effective use of all medications, which are prescribed, monitored, and/or handled by SCCCMHA staff, providers, and contracted direct service providers. It also provides for coordination between SCCCMHA and Peoples Clinic.

04-003-0090

This document outlines expectations regarding: information provided by group homes, AFC?s, and (contracted) Supported Living Arrangement homes during medication reviews or psychiatric evaluation appointments. It also gives direction re: expectations for completing SCCCMHA prescriber-ordered diagnostic testing in order to ensure availability of this data at subsequent medication review appointments.

06-002-0045

The purpose of the Mentoring Program is to provide support and guidance to employees in achieving their professional, career, and personal goals, enabling them to reach their full potential.

03-003-0060

This document highlights a vocational vendor that assist the people we serve with obtaining job placement. The process includes a referral system.

08-001-0020

This document explains the procedure and utilization of mobile devices.

07-003-0070

This documents describes Model Payment System and how it is utilized and implemented at SCCCHMA.

09-003-0040

This document provides a standard of practice for MMRM insurances purposes. It requires the completion of the Non ?Employee Accident form with his/her signature to track issues of near misses and/or injury of individuals who are not receiving services (visitors).

07-003-0025

This document ensures that a non-residential fee determination process will be followed in accordance with the procedures herein and according to Chapter 8 of the Mental Health Code and the Michigan Department of Health and Human Services Part 8, Subpart 1 and 2. No person will be denied services for their inability to pay. Persons in non-emergent care may be denied services for refusal to pay their assessed fee.

08-003-0030

This document provides a description of the responsibility, standards and procedures in place to grant authority to prescribers, to issue electronic prescriptions as well as ensure prescribers meet and follow appropriate governmental guidelines etc. *St. Clair, Sanilac and Lapeer CMHs

03-003-0050

This document explains the purpose for outreach and how it is on-going until the person is discharged from services.

05-001-0060

This Board policy provides an overview of the Parent/Guardian Monitoring Program, which provides the parents and guardians of individuals residing in licensed facilities with the opportunity to evaluate the services provided to their family members/wards.

03-001-0005

This Board policy explains the Person Center Planning Process and how it is tailored to the individual based upon the person served unique needs, strengths, abilities, and preferences as well as, identified challenges regardless to age, disability or residential setting. The document explains the initial steps to access services through completion of the IPOS/PCP including authorizations, goals objectives, interventions, Periodic Review, Amendments as well as, applicable documentation timeframes.

07-003-0055

This document describes how SCCCMHA ensures that services provided are in compliance with Michigan Department of Health and Human Services (MDHHS) Administrative Rules.

03-003-0045

This document identifies how all Medicaid eligible individuals served in a licensed residential facility (specialized and non-specialized) will be assessed for person care services and what documentation needs to be completed by applicable staff.

05-003-0050

This administrative procedure provides direction to employees regarding a resident?s right to access and use their personal funds as they see fit as established by the Mental Health Code and MDHHS Administrative Rules, and Licensing and Regulatory Affairs rules for group homes, and the Licensing and Regulatory Affairs rules for group homes.

06-001-0005

This document explains that personal involvement with a recipient of services beyond the scope of therapeutic involvement, unless documented in the record and approved by the employee?s/volunteer?s supervisor and the guardian, is considered unprofessional, misuse of the clinical relationship, against agency policy / administrative procedures, and will be grounds for disciplinary action up to and including dismissal.

05-003-0025

This administrative procedure provides direction to employees regarding a resident?s right to have access to and use of their personal possessions, entertainment materials, and news as established by the Mental Health Code and MDHHS Administrative Rules, and the Licensing and Regulatory Affairs rules for group homes.

09-003-0005

This document ensures the availability and use of Personal Protective Equipment for staff, guest and persons served when applicable, and when there is a potential for injury or occupational hazards that may occur from exposure to bloodborne pathogens.

06-001-0135

This documents provides the process/eligibility to seek Employee Assistance Program and provides the approved sites for this service.

06-001-0010

This document provides the who, how, when, where, and why we test; adherence to DOT regulations.

06-001-0015

This document provides background check requirements & process.

06-001-0050

This document explains the of how to report changes in personal information and the process for updating personnel system(s).

06-001-0070

This document explains the requirements and reprocess for pre-employment reference checks.

06-002-0035

This document provides the processes to attend conference/training/workshop.

06-001-0055

This document provides the process for investigating, documenting and administering discipline. Listed are levels of disciplinary events/actions and results.

06-001-0045

This documents explains what constitutes short and long term disability, as well as the process for requesting these benefits.

06-001-0150

This document provides a description of appropriate vs. inappropriate attire.

09-003-0030

This document explains the process to Record accidents and receive medical treatment.

06-001-0030

This document explains the performance review process to evaluate employees work ethic, ability and or skills. Probation periods, job transfers and job development are included in this document.

06-001-0025

This document explains who is required or recommended to receive screening.

06-002-0006

This document provides the steps to ensure new and transferred employees, students, and volunteers have thorough and comprehensive orientation to agency/program/policies.

06-001-0105

This document defines harassment and explains what to do in the event of report of/suspected harassment.

06-001-0140

This document identifies who is eligible and process to obtain vaccination.

06-001-0080

This document explains the development and maintenance of job descriptions and functional job task lists.

06-001-0170

The purpose of this Administrative Directive is to publish standards and procedures for Lactation Accommodations immediately pending a new Administrative Procedure on the subject. St. Clair County
Community Mental Health Authority (SCCCMHA) shall follow the federal requirements set forth by the Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act, which amended the Fair Labor Standards Act in order to provide reasonable accommodations, in a safe environment, to help nursing employees meet their infant feeding goals while at work.

06-001-0040

This document provides the guidelines for requesting leave under the Family Medical Leave Act (FMLA).

06-001-0035

This documents explains the process to request a leave of absence that is not covered by Family Medical Leave Act (FMLA).

06-001-0085

This document explains the procedures for hiring new employees.

06-001-0160

This document explains restriction of cell phone use during paid working hours.

06-001-0090

This document outlines the format and maintenance process of personnel records.

06-001-0095

This document provides the process for hiring in compliance with federal and state laws.

06-001-0130

This document explains the process to evaluate a specific job when it is believed responsibilities are at a higher level than appropriate for its current grade level.

06-001-0115

This document identifies who does what when someone leaves employment.

06-001-0065

This Board policy explains the restrictions of solicitations in order to minimize interference with agency operations.

06-002-0030

This document provides the guidelines for staff who do an (unpaid) internship at CMH while also employed by CMH.

06-001-0110

This documents explains the process for onboarding students and volunteers.

06-001-0020

This document provides requirements that supervision must be provided to all staff.

06-001-0145

This document explains the rules and parameters for temp assignments and employment.

06-001-0100

This document provides the guidelines for processing transfer requests, transfers and reassignments in accordance with Union contracts.

06-002-0025

This document defines the eligibility criteria and process to request reimbursement

06-001-0075

This document identifies work time options, benefits and how to request time off and how to record time worked.

07-002-0070

This document describes the use and amounts of petty cash funds and how they are handled.

04-002-0040

It shall be the policy of the St. Clair County Community Mental Health Authority (SCCCMHA) to perform blood draws optimally and appropriately completed by national- or state-certified phlebotomy technicians (CPT). If only state-certified, it must be obtained in the State of Michigan.

Review

List of current policies under review.

01-002-0040

This document provides the opportunity for a legitimate exception. Users of can be internal (employees) or external (contract providers: individuals and/or agencies). Application of this policy allows St. Clair CMHA to keep track of exception(s) via form #232 Policy/Administrative Procedures Exception.

01-001-0040

This Board policy provides a standardized structure for SCCCMHA policies/administrative procedures and ensures representation from most SCCCMHA departments to ensure procedures are congruent with application and that all policies and, applicable forms, receive an annual review. Forms development are part of this document.

08-002-0010

This document provides descriptions of standard procedure codes to be used throughout the entire region. These codes will be compliant with state and federal regulations.

01-003-0016

This Board policy provides the processes to select a qualified provider through various methods, including sole sourcing, use of a Request for Information (RFI) any willing and qualified provider or competitive procurement process for certain designated services as required by federal and state rules on provider selection and procurement. Process includes Request for Proposal as well.

08-002-0005

This document ensures written procedures are in place to meet Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) privacy standards.

01-003-0011

This documents explains the requirements and process to ensure only qualified employees and contract providers (organizations and practitioners) provide services to the people we serve. Professional classifications are defined, populations are identified and terms/timeframes are enforced.

01-003-0005

This documents provides a description of provider enrollment process whereby employee information is submitted and entered into the OASIS Software system. This process will facilitate data entry for First and/or Third Party billing.

07-003-0050

This document describes the process for calculating the rates for fee-for-service and shadow fee for service payments and the official guidelines followed.

01-003-0006

This document explains the process to attain, maintain and review applications from current and potential contract agency and independent contractor providers.

03-003-0025

This document describes the processes for obtaining, scheduling, providing, and documenting psychiatric services. It includes the process for managing appointments in which the recipient neither attends nor cancels.

03-001-0040

This document describes the process of determining and obtaining a psychological evaluation for an individual when clinical need mandates.

05-002-0010

This administrative procedure provides direction to employees regarding the procedures for obtaining informed consent for psychotropic medication as established by the Mental Health Code.

01-002-0035

This Board policy ensures all communications with the general public including media are presented in a clear & consistent format, along with a logo design & required reading proficiency levels.

01-002-0011

This Board policy provides a description of the Quality Improvement Council membership and responsibilities.

05-001-0005

This Board policy provides a general overview of the recipient rights protection system as established by the Mental Health Code.

05-001-0080

This Board policy provides an overview of the composition and functions of the Recipient Rights Advisory Committee as established by the Mental Health Code.

05-003-0060

This document provides a general overview of the recipient rights complaint investigation system for recipients receiving substance use disorder services as established by the Licensing and Regulatory Affairs, Bureau of Community and Health Systems, Substance Use Disorder Services Programs, and the Mental Health Code.

05-003-0055

This Board policy provides a general overview of the recipient rights protection system for recipients receiving substance use disorder services as established by the United States Code of Federal Regulations, Licensing and Regulatory Affairs, Bureau of Community and Health Systems, Substance Use Disorder Services Programs, and the Mental Health Code.

03-002-0060

This document identifies various types of documentation, regulations for how long it must be stored and when it can be discarded.

03-002-0075

This document is to ensure a collaborative approach to care through the coordination of care, treatment and community based services. The document applies to internal and external referrals including: dental, self- management support, health education and health promotion.

04-003-0060

This document provides a process for when medications are omitted or an individual refuses their medication.

03-002-0030

This document provides the process of releasing information related to an individual?s record.

03-003-0035

This documents identifies the circumstances for which an individual can be removed from site-based services to an alternative treatment service and the steps to do so.

05-001-0045

This policy provides direction to employees regarding the reporting requirements for known or suspected abuse or neglect of a recipient as established by the Mental Health Code and MDHHS Administrative Rules, Child Protection Law, and the Social Welfare Act.

05-003-0035

This administrative procedure provides direction to employees regarding a resident?s right to not be required to perform labor as a condition of their residential placement, but rather as agreed upon by the resident and with payment to the resident in accordance with federal and state labor laws and as established by the Mental Health Code and MDHHS Administrative Rules, and the Licensing and Regulatory Affairs rules for group homes.

05-003-0045

This document provides direction to employees regarding a resident?s right to use tobacco on the property of a licensed facility unless the facility has a policy that restricts tobacco use and provides the policy to the resident prior to the resident?s admission to the licensed facility. This policy pertains to residents who are 21 years of age and older.

09-003-0015

This document explains the process to ensure fire safety awareness in residential facilities and the logging of fire evacuation drills as required by the Fire Safety Code and Michigan Licensing.

03-001-0050

This document identifies who is eligible for Respite Services, explains what is and is not included with Respite Services, and outlines the procedures for requesting Respite.

05-001-0070

This Board policy provides direction to employees regarding their inability to use restraint (physical device used to restrict the movement of a recipient) or seclusion (temporary placement of a recipient in a room where egress is prevented by any means) on a recipient while providing services to a recipient in any service location outside of a licensed psychiatric hospital or child-caring institution as established by the Mental Health Code.

Review for policy 02-001-0030

09-003-0045

This document promotes safety for employees and persons served when providing services in the office (individual session, group session and program).

09-003-0020

This document provides Safety guidelines to frontline St. Clair CMHA employees when they provide services in the community.

03-003-0065

This Board policy provides a description of the Satisfaction Survey process.

09-002-0015

This documents sets forth expectations for staff and passengers in CMH owned vehicles, as well as personal vehicles used for official agency business based on state law.

04-002-0025

This document describes management of seizures, as well as post-seizure management. Includes documentation expectations.

03-001-0010

This Board policy assures that Self Determination/Directed (SD)arrangements are available to all adult individuals with a mental illness and /or developmental disability who are eligible for public mental health services. Choice Voucher is what Self Determination/Direction is called for children. SD involves a Fiscal Intermediary or Financial Management Service to assure fiduciary accountability of the individuals served budget and support as defined in contract. Roles and activities are explained.

05-001-0016

This Board policy provides direction to employees regarding the reporting requirements for reportable events (sentinel events, critical incidents, and risk events) as established by the MDHHS, Mental Health and Substance Use Services, Guidance on Sentinel Events Reporting and CARF manual.

03-003-0075

This policy provides a definition for Service Animal and Support Animals and provides the two questions that businesses can ask owners to verify the Service Animal qualification.

09-001-0025

This document promotes and enforces a smoke-free CMH campus.

06-001-0155

This document establishes guidelines to ensure confidentiality of social security numbers.

07-003-0035

This document describes assessment process to determine a proposed level of care rate for Specialized Foster Care reimbursement.

07-003-0030

This document describes the procedures followed in the Specialized Residential Fee Determination Process, and state guidelines used.

07-003-0065

This document provides a description of how individuals who are not covered by any other funding sources, may submit a request for funds for these items. The purpose is to enable their greater independence.

04-001-0090

This document ensures a coordinated management system regarding the prescribing and monitoring of the medication Spravato. The document instructs the Prescriber to follow the requirements and guidelines set forth in Spravato REMS Program.

01-002-0055

This document is to ensure staff meetings occur in each program to promote the collection, dissemination and utilization of relevant information between line staff, supervisors and management staff.

04-001-0070

This document defines the process for providing minor symptom relief using over the counter medications in compliance with doctor or mid-level practitioner orders/prescriptions.

04-003-0075

This document provides for a physician ordered procedure if medication is missed or refused. This can include permitting medication to be administered later than the regularly scheduled dose in order to promote medication adherence.

03-002-0035

This document provides information about response to subpoenas and fees.

FTOC

Forms Table or Contents

TOC

Policy Table of Contents

03-001-0105

This document describes the requirements and process for providing psychiatric services via video-conferencing while remaining in compliance with regulatory guidelines.

06-002-0040

This document explains the process for planning, requesting, approving, organizing, managing and tracking training.

03-002-0065

This document provides the guidelines to securely transfer case records between programs and or agency within the mental health system in a coordinated and consistent manner that promotes continuity of care.

09-002-0010

This document establishes procedures and protocols for CMH staff transportation staff (primarily CMH van drivers), including alternate drop off plans, required training for staff, safe and secure transport of individuals.

04-001-0065

This document describes the process for ensuring a medication supply for recipients requiring medication be given while at program. It also describes the process for ensuring the safe and proper transfer of home medications for individuals requiring their medication be home-delivered.

09-002-0005

This document provides the procedures and protocols established for CMH staff who are not able to reserve a CMH owned vehicle, but are required to transport an individual receiving services in their personal vehicle.

07-003-0020

This document describes how employees will be reimbursed for expenses incurred during the performance of their job responsibilities, or for expenses incurred at approved activities.

02-001-0015

This document explains that all services must be authorized by the appropriately credentialed staff prior to services implementation, except urgent hospitalization, for which authorization is may be obtained after treatment. Also, authorization must meet a medically necessary threshold initially and periodically. The document provides timeframes for authorizations and references grievance and appeal processes as well as, the UM review processes.

05-003-0015

This administrative procedure provides direction to employees regarding a recipient?s right to obtain treatment by spiritual means, which is a spiritual discipline or school of thought that a recipient wishes to rely on to aid in their physical or mental recovery, as established by the Mental Health Code.

05-003-0005

This administrative procedure provides direction to employees regarding the reporting requirements for incidents where a resident (recipient residing in a licensed facility) is unaccounted for/leaves the facility without prior authorization as established by the Licensing and Regulatory Affairs rules for group homes.

03-003-0030

This document defines unauthorized Leave of absence and identifies the step to take to ensure the safety of the individual.

07-002-0100

This document identifies the regulatory guidelines and documents the procedures for the administration of federal awards (grants) and internal controls in place as required.

09-002-0030

This documents gives the rules, procedures, guidance for CMH staff to reserve and drive agency owned vehicles.

09-001-0010

This document ensures there are write procedures and processes to be followed when using SCCCMHA facilities and equipment.

01-002-0075

This document implements best practices regarding use of social media, texting, and email relative to current laws and agency guidelines.

02-003-0011

This document provides the guidelines for clinical and fiscal service accountability via case record and claims reviews. Areas of focus include, diagnosis (medical necessity), funding sources, claims integrity, quality, credentialing requirements and documentation timeframes. It also identifies the UM team composition and tools (documents) used to measure and report UM results.

09-002-0025

This document provides guidance for Facilities? to provide regular maintenance on CMH owned vehicles, documenting performed maintenance, process for staff to notify Facilities? of any CMH vehicle related issues.

09-002-0020

This document provides the procedures and protocols to be followed in the event of an accident involving a CMH owned vehicle, also establishes the standard to follow if law enforcement requests the names of individuals receiving services as part of their investigation.

03-001-0100

This document outlines the process of providing and coordinating services and supports to Military Staff and veterans residing in St. Clair County that promote Recovery in accordance the Veterans Health Administration.

09-003-0025

This Board policy defines weapons and drugs as well as, the procedures to take when confronted by a person with a weapon or when drugs (legal and illegal are suspected or found. Note the perpetrators may include employees.

06-001-0165

This document provides the standards, procedures, criteria, and guidelines for determining appropriateness of remote work.

03-003-0080

This document sets forth the Standards of Care implemented with individuals receiving SCCCMHA services to ensure a commitment to individual safety and active engagement while striving for zero suicides per the ZERO SUICIDE evidence-based model of care. The Columbia Suicide Severity Rating Scale (C-SSRS), Life Events Checklist, Lethality assessment, etc. are referenced.