Reports, Policies & Procedures Outlilne 2009

O Write ethical code of conduct for (1.A. 4.a.) Business Marketing Service delivery Professional responsibilities Human resources oWrite procedure to deal with (1.A.4.b.) Allegations of violations of ethical codes oWrite policy and procedure for (1.A.4.d.) Waste, fraud, abuse, and other wrongdoing that includes (1) no-reprisal approach for personnel reporting (2) time frame to initiate an investigation oWrite policy on contractual relationships (1.A.4.f.) oWrite a policy on corporate compliance (1.A.5.) Adopted by leadership Formal resolution that authorizes establishment of the compliance program Written designation of a staff member to serve as primary point of conduct Monitoring compliance Reporting compliance oWrite strategic plan that includes (1.C.1.) Reflects current and projected financial position Sets Goals Priorities Is implemented Is shared Is reviewed and updated Expectations of persons served Expectations of other stakeholders The competitive environment Financial opportunities Financial threats Organization’s capabilities Service area needs Demographics of the service area Relationships with external stakeholders Regulatory environment Legislative environment oWrite conclusions for analysis from input from (1.D.2.) Program planning Performance improvement Strategic planning Organizational advocacy Financial planning Resource planning oWrite process complying with legal and regulatory requirements including (1.E.1) Rights of persons served Confidentiality requirements Reporting requirements Contractual agreements Licensing requirements Corporate status Employment practices mandatory employee testing Privacy of persons served Debt covenants All others, as applicable oWrite procedure to guide personnel in responding to (1.E.2.) Subpoenas Search warrants Investigations Other legal actions oWrite established outcomes for persons served (1.F.1.a) oWrite organizational performance objectives (1.F.1.b.) oWrite budget comparison to historical performance (1.F.2.a.3) oWrite quarterly review of actual financial results (1.F.3.c.) oWrite review of (1.F.4.) Revenues and expenses Internal and external Financial trends Financial challenges Financial opportunities Business trends Management information Financial solvency with development of remediation plans if appropriate oWrite fiscal policies and procedures (1.F.6.) Include internal control practices Provides initial and ongoing training (on billing and coding procedures) oWrite organizational fee structure (1.F.8.) For review of fee schedules Comparison of fee schedules Modification of fee schedules when necessary Disclosure to persons served of all fees they will be responsible for oWrite procedure for being responsible for funds of persons served including (1.F.11.) – Is there something in place for holding Gaspar’s money or any others? How persons served give informed consent for expenditure of funds How persons served will access records for funds How funds are segregated for accounting purposes Safeguards for ensuring funds go to designated and appropriate purposes How interest will be credited oWrite a risk management plan that (1.G.1.) Identify loss exposures (changes in funding, growth, facilities, security or procedures) Analyses and evaluates loss exposures Identifies how to rectify identified exposures List monitoring actions to reduce risk Result report of actions taken to reduce risk Inclusion of risk reduction in performance improvement activities oWrite written procedures to promote safety of (1 H.2.) Persons served Personnel oWrite competency-based training in (1.H.4.) Health and safety practices Identification of unsafe environmental factors Emergency procedures Evacuation procedures Identification of critical incidents Reporting of critical incidents Reducing physical risks oWrite emergency procedures (1.H.5.) Satisfy applicable authorities Local practices Fires Bomb threats Natural disasters Utility failures Medical emergencies Safety during violent or other threatening situations Evacuation process When appropriate To completely evacuate physical facility Provide safety of evacuees Account for all persons involved Provide shelter when applicable Identifies essential services Continues essential services Contains emergency phone numbers Notifies appropriate emergency authorities oWrite procedures regarding critical incidents that include (1.H.7.) Prevention Reporting Remedial action for Medication errors Use of seclusion or restraint Incidents involving injury Communicable disease Infection control Violence or aggression Use or possession of weapons Elopement and/or wandering Bio-hazardous accidents Unauthorized use or possession of licit or illicit substances Abuse and neglect Suicide or attempted suicide Other sentinel events oWrite annual analysis of all critical incidents addressing (1.H.8.) Causes Trends Actions for improvement Results of performance improvement plans Necessary education and training of personnel Prevention of recurrence Internal and external reporting requirements oWrite review of driving records of all drivers on an ongoing basis (1.H.10.c.) oWrite a report that identifies (1.H.11.) Areas inspected Recommendations for areas needing improvement Actions taken to respond to recommendations For an annual comprehensive health and safety inspection by a qualified external authority oWrite a report that identifies (1.H.12.) Areas inspected Recommendations for areas needing improvement Actions taken to respond to recommendations For a semi-annual comprehensive health and safety inspection by a qualified internal authority oWrite an annual report that tests all emergency procedures that (1.H.13.) Include actual or simulate dphysical evacuations, when included in the procedures Analyzed for performance improvement Result in improvement or affirm satisfactory current practice oWrite a procedure to verify prior to delivery of services, throughout employment and in response to information received (1.I.2.) Required credentials of personnel Background of personnel for Criminal checks Immunizations Fingerprinting Drug testing oWrite performance improvement report updated annually that include (1.I.5.) Annually updated job descriptions Promotional guidelines Job posting guidelines Performance evaluations based on Identified job functions and competencies Evidenced in personnel file Conducted by supervisor with evidence of personnel input oUsed to assess performance improvements since the last evaluation period oEstablish measurable performance objectives for the next year Annual review of all contract personnel that oAssesses performance of contracts oShows following of all applicable policies and procedures oEnsures they conform to CARF standards oWrite a signed agreement for students or volunteers identifying their (1.I.6.) Duties Scope of responsibility Supervision Orientation and training Assessment of their performance Background checks when required Policy and procedure for volunteer dismissal Policy for confidentiality oWrite a policy and procedure for volunteer dismissal (1.I.6.e.) oWrite a policy for confidentiality (1.I.6.f.) oWrite an established and maintained accessible personnel policy that is reviewed annually and updated as needed and includes (1.I.7.) Grievance and appeal procedures for all personnel Identify hiring practices Include nondiscrimination in areas of Employment Compensation Assignment of work Promotion ,[object Object]

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Supports information management and performance improvement activities

Reports, Policies & Procedures Outlilne 2009

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