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PREGNANT AND POST-PARTUM INTERVENTION (PPI) PROGRAM

(WEBB, ZAPATA, & STARR COUNTIES)

POLICIES AND PROCEDURES MANUAL FY17-18

TABLE OF CONTENTS Policy Policy Page Number Name Number 001……….. General Requirements…………………………………… 3 002……….. Management and Organization………………………….. 4 003……….. Operational Plan & Policies and Procedures……………. 6 004………..Organizational and Personnel Changes ………………….. 9 005………..Personnel Requirements and Documentation……………. 10 006………..Commission/DSHS Logo………………………………… 12 007……….. General Standards of Care……………………………….. 13 008……….. Standards for Evidence-Based Programs………………... 18 009……….. Limiting Barriers………………………………………… 20 010……….. Specific Acts Prohibited………………………………… 22 011……….. Quality Management…………………………………….. 24 012……….. General Environment……………………………………. 25 013……….. General Documentation Requirements………………….. 26 014……….. Client Records…………………………………………… 27 015……….. Hiring Practices…………………………………………. 29 016……….. Students and Other Volunteers………………………….. 31 017……….. Staff Training……………………………………………. 32 018……….. Client Rights…………………………………………...… 35 019……….. Complaints and Procedures……………………………… 37 020……….. Staffing…………………………………………………... 39 021……….. Standards of Conduct……………………………………. 41 022………..Client Eligibility Criteria………………………………… 42 023………..Non-Discrimination of Clients…………………………… 43

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024………..Fee Policy………………………………………………… 44 025………..Client Rights and Safety…………………………………. 45 026………..Orientation for Clients…………………………………… 46 027………..Client Grievances………………………………………… 47 028………..Resolution of Client Grievances…………………………. 51 029………..Client Record Security…………………………………… 53 030………..Release of Confidential Information…………………….. 60 031………..Retention of Records…………………………………….. 62 032………..Staff Member Orientation and Training…………………. 63 033………..Cultural Competency and Awareness…………………… 65 034………..Drug-Free Workplace……………………………………. 66 035……….. Program Design and Implementation…………………… 68 036………..Documentation…………………………………………… 70 037………..Procedures for Prospective Clients.................................... 75 038………..Procedures for Engaging Clients………........................... 76 039………..Client Records (Admission & Consent)………………… 77 040………..Client Records (Screening & Assessment)……………… 79 041………..Client Records (Service Plans)………………………….. 80 042………..Client Records (Progress Notes)………………………… 81 043………..Performance and Activity Measures…………………….. 82 044………..Information Dissemination………………………………. 83 045………..Problem Identification and Referral……………………… 84 046………..Prevention Education/Skills Training……………………. 86 047………..Alternative Activities…………………………………….. 87 048………..Crisis Intervention……………………………………….. 88 049………..Service Completion……………………………………… 89 050………..Client Follow-Up………………………………………… 90 051………..Community-Based Process……………………………… 91 052………..HIV/AIDS Workplace Guidelines………………………. 93 053………..Child Abuse Reporting Procedures……………………… 94 054………..Tobacco Products………………………………………… 95 055………..Transportation……………………………………………. 96 056………..Employee Performance Evaluations……………………... 97 057………..Staff Competencies………………………………………. 98 058………..CMBHS………………………….………………………. 99 059………..Quality Improvement…………..…………………………104

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001 GENERAL REQUIREMENTS POLICY: SCAN will establish and maintain effective internal programmatic and financial controls. Task 1: Programmatic and Financial Controls

Responsibility: Chief Executive Officer

PROCEDURES: Effective internal programmatic and financial controls will be established and maintained to ensure:

1) That the Pregnant and Post-Partum Intervention Program is operated efficiently and effectively;

2) To maintain compliance with other funding and regulatory agencies; 3) Appropriate controls are in place to safeguard assets; 4) Commission/DSHS funds are properly spent; 5) Commission/DSHS funds are properly accounted for; 6) Clients receive appropriate services; and 7) Client services are adequately documented.

FORMS: SCAN Financial Forms REFERENCE: N/A

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002 MANAGEMENT AND ORGANIZATION POLICY: The Board of Directors of SCAN is the governing body that is legally responsible for the integrity of the fiscal and programmatic management of the Pregnant and Post-Partum Intervention Program. It is a distinct business entity with legal authority to operate in the State of Texas. The program’s staff members, including the Chief Executive Officer do not serve on the Board of Directors. Task 1: Facility Operation

Responsibility: Chairperson of the Board of Directors

PROCEDURES: The Board of Directors will:

1) appoint a chief executive officer to manage the day-to-day operations of the organization and to ensure that the organization has the programmatic, managerial, and financial capability to ensure proper planning, management, and delivery of funded services;

2) provide all members with information about the responsibilities and liabilities of the governing body and its individual members; and

3) ensure that all of its members are familiar with the provider’s target population(s) and sensitive to the needs of the different cultures represented.

Task 2: Meetings

Responsibility: Chairperson of the board of Directors

PROCEDURES: The Board of Directors will meet at least quarterly and maintain minutes that include:

1) date, time, and place of the meeting; 2) names of members present and absent; and 3) summary of discussion and action taken.

Task 3: Responsibilities of the Chief Executive Officer

Responsibility: Board of Directors

PROCEDURES: The Chief Executive Officer will:

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1) have documented education and/or experience in financial, administrative, and personnel management, and other areas needed to manage the organization effectively;

2) ensure compliance with applicable laws and rules; 3) ensure that all staff are competent and trained; 4) establish mechanisms to ensure quality of services; and 5) maintain adequate financial records according to generally accepted accounting

principles.

Task 4: Organization Structure

Responsibility: Chief Executive Officer

PROCEDURES: The Chief Executive Officer will:

1) maintain a chart of the organization’s structure and 2) document its staffing pattern to identify all staff positions, the individuals filling those

positions, and current vacancies. 3) review and update the information (if necessary) at least annually.

FORMS: Board Minutes, Chief Executive Officer’s and Program Director/Supervisor’s Job Descriptions, Organizational Chart

REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.501

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003 OPERATIONAL PLAN & POLICIES AND PROCEDURES Policy: In accordance with TCADA/TDSHS standards of care and to guide the performance of

the programs, SCAN will function in accordance with the operational plan, as well as, maintain and implement a current manual that includes all policies and procedures required by TCADA/TDSHS. These Policies shall be approved by the SCAN Board of Directors, reviewed periodically, and revised as needed. Procedures shall be approved by the Chief Executive Officer, reviewed periodically, and revised as needed. SCAN will require that each employee reads the policies and procedures applicable to the position and maintain documentation signed by the employee that the policies and procedures have been read and understood.

Task 1: Operational Plan

Responsibility: CEO Procedures: SCAN’s TCADA/TDSHS funded programs will operate according to an operational plan. The operational plan shall reflect:

1. The program’s purpose or mission statement; 2. the program’s services and how they are provided; 3. the program’s description of the population to be served; and 4. the goals and objectives of the program.

Task 2: Policies and Procedures

Responsibility: CEO Procedure: SCAN will adopt and implement general written policies and procedures as well as program specific policies and procedures applicable to all TCADA/TDSHS funded programs as deemed necessary by the facility and as required herein. The policies and procedures shall contain sufficient detail to ensure compliance with all applicable Commission/DSHS rules.

1. The SCAN Board of Directors will approve all policies and procedures prior to implementation, review agency policies on a periodic basis, and revise them as needed.

2. The Chief Executive Officer will approve all policies and procedures, review them periodically, revise them as needed, and present them to the Board at regular Board meetings.

3. Minutes of the meeting will reflect that new policies and procedures and changes and revisions to existing ones were approved by the Board

4. The Program Directors will ensure that all program specific policies and procedures are current, consistent with program practices, individualized to the program, and easily accessible to staff.

5. The Program Directors will submit all program related policies and procedures to the Chief Executive Officer for review and approval.

6. Once approved, the program specific policies and procedures will be incorporated into the SOP Manual, bearing the signature of the Chief Executive Officer, the Board

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Chairperson, and the date the procedures were implemented or revised. 7. Within 10 days of a general or program specific policy or procedure change, the Program

Director will inform staff about any changes to the policy and procedure manual that are relevant to their job duties and document the notification. If training is needed, it will be provided and documented within 60 days.

8. The agency will ensure that each employee be required to acknowledge in writing that he/she has read and understood the agency’s general policies and procedures as well as the applicable program specific policies and procedures and maintain this documentation in the employee’s personnel file.

9. As applicable, the agency’s policy and procedure manual will include policies and procedures for the following items-

a. Fiscal Policies to cover i. Revenue/Accounts Receivable

ii. Billing/Payment Requests iii. Cost Allocation iv. Payroll v. Expenditures/Accounts Payable

vi. Procurement of Goods and Services vii. Match and Program Income and Expenditures

viii. Fixed Assets Inventory and Records ix. Petty Cash x. Cellular Phone Use

xi. Travel xii. Subcontractor Fiscal Compliance Monitoring

xiii. Financial Reporting b. TCADA/TDSHS Workplace and Education Guidelines for HIV and Other

Communicable Diseases in order to meet requirements as specified in the ADA Act.

c. Protections to safeguard client records and client-identifying information in accordance with 42 CFR Part 2 and the HIPAA Act of 1996.

d. Prohibition of Discrimination e. Handling Complaints f. Employee Background Checks g. Standards of Conduct h. Tobacco Use i. Facility Access for People with Disabilities

Task 3: Status of Policy and Procedure manuals

Responsibility: CEO and Program Directors Policy: SCAN’s general and program specific policy and procedure manuals will be current, consistent with TCADA/TDSHS rules, and easily accessible to staff members at all times. Procedure: Upon being employed with the agency, each employee will be issued a copy of the agency’s policies and procedures. Additionally, during program specific orientation, employees

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will review their program’s policy and procedure manual, and be shown where the manual is kept for future reference.

FORMS: Policy and Procedure Manuals REFERENCE: DSHS Substance Abuse Services 448 Standard of Care §448.502

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004 ORGANIZATIONAL AND PERSONNEL CHANGES POLICY: SCAN will keep the Commission/DSHS informed on a timely basis concerning all significant organizational and personnel changes. PROCEDURES: The agency will notify the Commission/DSHS in writing within ten business days of - 1) Any changes to the agency’s legal name, address, telephone number, official e-mail address, or legal status, and 2) Any changes in the following personnel: Certifying representative, board chair, chief executive officer, chief financial officer, security administrator and backup for the Behavioral Health Integrated Provider System, and project director/program director. FORMS: none REFERENCE: N/A

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005 PERSONNEL REQUIREMENTS AND DOCUMENTATION POLICY: SCAN will maintain complete, accurate, and current documentation including documentation related to agency personnel. PROCEDURES: A) The agency will keep complete, current documentation.

1) All required documents shall be factual and accurate. 2) Authentication of documents shall include signature, credentials when applicable, and date. If the document relates to past activity, the date of the activity shall be recorded. 3) Documentation shall be permanent and legible. 4) When it is necessary to correct a required document, the error shall be marked through with a single line, dated, and initialed by the writer.

B) The agency shall maintain current personnel documentation on each employee. Health related information shall be stored separately with restricted access as appropriate under Tex. Govt. Code Ann. Sec. 552.102 (Vernon 2000). Training records may be stored separately from the main personnel file, but shall be easily accessible upon request. Required documentation includes, as applicable: 1) A copy of the current job description signed by the employee.

2) Application or resume with documentation of required qualifications and verification of required credentials.

3) Verification of work experience. 4) Annual performance evaluations.

5) Personnel data that includes date hired, rate of pay, and documentation of all pay increases and bonuses. 6) Documentation of appropriate screening and/or background checks. 7) Signed documentation of initial and other required training, and 8) Records of any disciplinary actions.

C) The agency will have an adequate number of qualified staff to comply with Commission/DSHS rules, provide the services described in the program description, and protect the health, safety, and welfare of clients/clients. D) Every program shall have an employee designated to serve as director. The individual must have appropriate education and training and at least two years of experience providing related services.

1) The director of a prevention program must have at least 2 years of experience in substance abuse prevention. 2) The director of an intervention program must have at least 2 years experience in substance abuse intervention. 3) Prevention programs shall employ program directors designated as Certified Prevention Specialists or program directors who have completed 40 hours of prevention specialist training which must include-

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history of prevention as a discipline, facts about drugs and drug terminology, prevention theory including risk/protective factors and resiliency, currently recognized prevention strategies and principles, role of media and environmental prevention approaches, promising, effective and/or model programs as designated by CSAP, cultural content and ethics of prevention, and assessment and evaluation as prevention tools. 4) Intervention programs shall employ program directors that are Qualified Credentialed Counselors (QCC).

E) The program shall hire applicants who meet the minimum qualifications listed in the job description. FORMS: Employee Personnel File Checklist REFERENCE: N/A

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006 COMMISSION/DSHS LOGO AND SLOGAN POLICY: SCAN will not use the Commission/DSHS’s logo and slogan in publications, electronic media, or video material unless the Commission/DSHS has given written permission. PROCEDURE: Prior to the use of TCADA/TDSHS’s logo or slogan, the Pregnant and Post-Partum Intervention Program Supervisor or designee will contact the Commission/DSHS via telephone, letter, or e-mail to request the use of the logo and/or slogan. FORMS: none REFERENCE: N/A

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007 GENERAL STANDARDS OF CARE Policy: As a TCADA/TDSHS funded provider, SCAN adheres to all general standards of care as detailed in Chapter 448, Subchapter B. Responsibility: All Staff Standard 1: General Standard Procedure: SCAN will actively work to ensure that all program services provided to clients/clients are done so with integrity, and are adequate, appropriate, and consistent with best practices and industry standards. SCAN will strive to maintain objectivity in all matters concerning clients/clients, will respect every individual’s dignity, and will not engage in any intentional actions that might cause injury or harm. Standard 2: Scope of Practice Procedure: SCAN’s treatment programs will never provide services to clients/clients outside of their scope of practice nor allow staff members to use techniques that exceed their professional level of competence. Moreover, the agency will not make any claims that it possesses professional qualifications or affiliations to which it is not entitled. Standard 3: Competence and Due Care Procedure: SCAN will plan, adequately supervise, and evaluate all program related activities. All services will be rendered in a careful and prompt manner. SCAN will follow the technical and ethical standards related to service provision, strive to continually improve personal competence and quality of service delivery, and discharge its professional responsibility to the best of its ability. SCAN will always act in the best interest of its clients/clients and will ensure that services are designed and administered in such a way as to do no harm to them. Finally, SCAN will ensure that program services which are not beneficial, or are in any way detrimental, to clients/clients will be terminated in a timely manner. Standard 4: Appropriate Services Procedure: All SCAN treatment program services will be developmentally and age appropriate, culturally sensitive, non-exploitative, individualized to meet the specific needs and circumstances of clients/clients, and provided in a respectful manner. Standard 5: Accuracy Procedure: SCAN will report all information fairly, professionally, and accurately when providing services and when communicating with other professionals, the Commission/DSHS, and the general public. In published materials or public statements, SCAN will document and

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assign credit to all contributing sources. SCAN will not misrepresent directly or by implication any professional qualifications or affiliations to which it is not properly entitled. Standard 6: Documentation Procedure: SCAN will ensure that all treatment programs maintain required documentation of services provided and related transactions including financial records. Standard 7: Discrimination Procedure: SCAN will not discriminate against any individual on the basis of gender, race, religion, age, national origin, disability (physical or mental), sexual orientation, medical condition, including HIV diagnosis or because an individual is perceived as being HIV infected. Per Commission/DSHS rules, SCAN may consider economic condition and financial resources in admission criteria; however, once an individual is admitted, economic condition shall not affect services provided. Standard 8: Access to Services Procedure: SCAN will provide equal access to services, including providing information about other services and alternative providers, appropriately taking into account an individual’s financial constraints and special needs. Standard 9: Location Procedure: SCAN will not offer or provide services in settings or locations that are inappropriate or harmful to individuals served, family members, or other persons. Standard 10: Confidentiality Procedure: SCAN’s treatment programs will diligently work to protect the privacy of all individuals served and will not disclose confidential information without express written consent except as permitted by law. SCAN will work to ensure that its treatment program staff members remain knowledgeable of and obey all State and Federal laws and regulations relating to confidentiality of records relating to the provision of services. SCAN treatment programs will not discuss or divulge any information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes directly related to the case. Standard 11: Environment Procedure: SCAN will ensure that all of its treatment programs provide an appropriate, safe, clean, and well maintained environment.

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Standard 12: Communications Procedure: SCAN personnel will inform all individuals receiving services about all relevant and important aspects of the service relationship. A handbook of services will be provided to all clients of treatment services. Standard 13: Exploitations Procedure: SCAN will ensure that its treatment programs do not exploit relationships with individuals receiving services for personal or financial gain of the programs or its staff members. Should its treatment programs charge for services, these charges/fees will not be exorbitant or unreasonable. SCAN treatment programs will not pay or receive any Commission/DSHS, consideration, or benefit of any kind related to the referral of individuals for services. Standard 14: Duty to Report Procedure: SCAN and its staff members have a responsibility to report any unethical conduct or practice on the part of any person or provider to appropriate funding or regulatory bodies or to the public. If SCAN or its staff members receive an allegation or have reason to suspect that an individual has been, is, or will be subject to abuse, neglect or exploitation by any provider shall immediately inform TCADA/TDSHS’s investigations division. SCAN will take immediate action to prevent or stop the abuse, neglect, or exploitation and provide appropriate care and treatment. SCAN will report all allegations of child abuse or neglect to the Texas Department of Protective and Regulatory Services. SCAN will report all allegations of abuse, neglect or exploitation of elderly or disabled individuals to the Texas Department of Protective and Regulatory Services as well. If an allegation involves sexual exploitation, SCAN will comply with reporting requirements listed in the TEX. CIV. PRAC. & REM. CODE ANN. §81.006. Standard 15: Impaired Providers Procedure: When evidence of impairment in a staff member exists, SCAN will be supportive in providing assistance and access to information about treatment services. Standard 16: Ethics Procedure: SCAN and its employees will adhere to established professional codes of ethics. SCAN and all agency personnel will protect each client and will act in an ethical manner at all times. Standard 17: Specific Acts Prohibited Procedure: SCAN and its employees understand that in addition to the provider's general duty to provide services in a professional manner, the following acts are specifically prohibited and shall constitute a violation of these rules:

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(a) SCAN personnel shall not provide services, interact with individuals receiving services, or perform any job duties while under the influence or impaired by the use of alcohol, or mood altering substances, including prescription medications not used in accordance with a physician's order. (b) SCAN personnel shall not commit an illegal, unprofessional or unethical act (including acts constituting abuse, neglect, or exploitation). (c) SCAN personnel shall not assist or knowingly allow another person to commit an illegal, unprofessional, or unethical act. (d) SCAN personnel shall not falsify, alter, destroy or omit significant information from required reports and records or interfere with their preservation. (e) SCAN personnel shall not retaliate against anyone who reports a violation of these rules or cooperates during a review, inspection, investigation, hearing, or other related activity. (f) SCAN personnel shall not interfere with Commission/DSHS reviews, inspections, investigations, hearings, or related activities. This includes taking action to discourage or prevent someone else from cooperating with the activity. (g) SCAN personnel shall not enter into a personal or business relationship of any type with an individual receiving services until at least two years after the last date an individual receives services from the provider. (h) SCAN personnel shall not discourage, intimidate, harass, or retaliate against individuals who try to exercise their rights or file a grievance. (i) SCAN personnel shall not restrict, discourage, or interfere with any communication with law enforcement, an attorney, or with the Commission/DSHS for the purposes of filing a grievance. (j) SCAN personnel shall not allow unqualified persons or entities to provide services. (k) SCAN personnel shall not hire or utilize known sex offenders in adolescent programs or programs that house children. (l) SCAN personnel shall prohibit adolescent clients and clients from using tobacco products on the program site. Staff and other adults (volunteers, clients, clients and visitors) shall not use tobacco products in the presence of adolescent clients or clients. Standards 18: Standards of Conduct Procedure: SCAN and all of its personnel shall protect clients' and clients’ rights and provide competent services. (a) Any person associated with the facility that receives an allegation or has reason to suspect that a person associated with the facility has been, is, or will be engaged in illegal, unethical or unprofessional conduct shall immediately inform the Commission/DSHS's investigations division and the facility's chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported to the Commission/DSHS and the facility's governing body. (b) The facility and its personnel shall comply with TEX. HEALTH & SAFETY CODE ANN. ch. 164 (Vernon 2001 & Supp. 2003)(relating to Treatment Facilities Marketing and Admission Practices). (c) The facility shall have written policies on staff conduct that complies with this section. FORMS: SCAN policies and procedures

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REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.201- §448.218

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008 STANDARDS FOR EVIDENCE-BASED PROGRAMS Policy: SCAN will design and implement evidence-based programs. Procedure: The evidence-based programs will meet the following criteria: 1) Programs are designed to enhance protective factors and move toward reversing or reducing

known risk factors.

2) Program staff will be trained in risk factor and protective factor theory and research. 3) Programs are designed in a way that preserves the protective factors inherent in each culture

and individual. 4) Prevention programs will be age, developmentally and culturally appropriate. 5) Programs that are able to determine the level of risk of the target population. More intense

prevention programs are required for target populations with a recognized higher level of risk.

6) Programs that are appropriate for the target population(s) using universal, selective and indicated criteria. Programs have proven outcomes for the target population and are implemented with integrity and fidelity.

7) That when an evidence-based program is adapted to address the specific nature of the drug use or abuse problem in the local community, care is taken to adapt the program appropriately. The adaptation does not affect the integrity and fidelity of the program as it was designed.

8) Programs that teach skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency. Social competency skills, as they relate to reinforcement of attitudes against drug use, include skills related to communications, peer relationships, self-efficacy, and assertiveness.

9) Programs for adolescents include interactive methods, such as peer discussion groups, in addition to lecture-style teaching techniques.

10) Programs include a component which targets parents or caregivers. The parent/caregiver component reinforces what the youth clients are learning, such as facts about drugs and their harmful effects. This component opens opportunities for family discussions about use of legal and illegal substances and family policies related to their use.

11) That programs that are long-term, over the school career, including the repetition necessary to reinforce the original prevention goals. School-based efforts directed at elementary and middle school students, for example, include booster sessions to help with critical transitions from middle to high school.

12) That community programs that include media campaigns and policy changes, such as new regulations that restrict access to alcohol, tobacco, or other drugs, are accompanied by school and family interventions.

13) That community programs strengthen norms against drug use in all drug abuse prevention settings, including the family, the school, and the community.

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14) That schools offer opportunities to reach all populations and serve as important settings for specific sub-populations at risk for drug abuse, such as children with behavior problems or learning disabilities and those who are at risk of leaving school before graduation.

15) Programs will use formal and informal structures to receive and incorporate input from service recipients in the development, implementation and evaluation of prevention services.

16) Programs will be evaluated to determine outcomes and impact on the clients. Responsibility: board of Directors, CEO, Executive Vice President, Vice President, and Program Director(s). REFERENCE: DSHS Chapter 448.301

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009 LIMITING BARRIERS & GENERAL ENVIRONMENT Policy: SCAN does not discriminate in any of its practices. Task 1: Prohibition of Discrimination and Identification of Deficiencies

Responsibility: All Staff Procedures: SCAN will: 1) implement and enforce a written policy prohibiting discrimination against any individual

on the basis of gender, race, religion, age, national origin, disability (physical or mental), sexual orientation, medical condition, including HIV diagnosis or because an individual is perceived as being HIV infected. SCAN may consider economic condition and financial resources in admission criteria, but economic condition shall not affect the services once an individual is admitted;

2) ensure that no person or group of persons is restricted from receiving the same services or the same quality of services available to others;

3) make all facilities and programs accessible to persons with disabilities as required by the Americans with Disabilities Act;

4) ensure that the facility maintains documentation that it has conducted a self-inspection to evaluate compliance and implemented a corrective action plan, as necessary, with reasonable time frames to address identified deficiencies; 5) ensure that the facility has a certificate of occupancy from the local authority that reflects the current use by the occupant or documentation that the locality does not issue occupancy certificates; 6) ensure the site, including grounds, buildings, electrical and mechanical systems, appliances, equipment, and furniture shall be structurally sound, in good repair, clean, and free from health and safety hazards; 7) ensure that the facility provides a safe, clean, well-lighted and well-maintained environment; 8) ensure that the facility has adequate space, furniture, and supplies; 9) ensure that the facility has private space for confidential interactions, including all group counseling sessions; 10) ensure that the facility prohibits smoking inside facility buildings and vehicles and during structured program activities. If smoking areas are permitted, they shall be clearly marked as designated smoking areas and shall not be less than 15 feet from any entrance to any building(s) and comply with local codes and ordinances. Staff shall not provide or facilitate client access to tobacco products; 11) ensure that the facility prohibits firearms and other weapons, alcohol, illegal drugs, illegal activities, and violence on the program site; 12) Animals shall be properly vaccinated and supervised; 13) maintain documentation that it has conducted a self-inspection to evaluate compliance

and implemented a corrective action plan to address identified deficiencies; and 14) maintain documentation of formal agreements and contracts to address identified

deficiencies in access to program services for people with disabilities.

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FORMS: none REFERENCE: DSHS Chapter 448 Standard of Care §448.207, §448.505

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010 SPECIFIC ACTS PROHIBITED Policy: SCAN and all its agents will protect the health, safety, rights, and welfare of clients/clients. It will provide adequate and appropriate treatment as described in the program description and will comply with all applicable laws, regulations, policies, and procedures. It will also maintain required licenses, permits, and credentials, and will comply with professional and ethical codes of conduct. Additionally, the facility and its personnel shall comply with Chapter 164 of the Texas Health and Safety Code (relating to Treatment Facilities Marketing and Admission Practices). Task 1: Specific Acts Prohibited

Responsibility: All Staff, Volunteers, and Board Members

Procedures: Neither SCAN or any of its personnel will: 1) provide services, interact with individuals receiving services, or perform any job duties

while under the influence or impaired by the use of alcohol, or mood altering substances, including prescription medications not used in accordance with a physician’s order;

2) commit an illegal, unprofessional or unethical act (including client abuse, neglect, or exploitation);

3) assist or knowingly allow another person to commit an illegal, unprofessional, or unethical act;

4) knowingly provide false or misleading information; 5) falsify, alter, destroy or omit significant information from required reports and records or

interfere with their preservation; 6) retaliate against anyone who reports a violation or cooperates during a review, audit,

inspection, investigation, hearing, or other related activity; or 7) interfere with Commission/DSHS reviews, inspections, investigations, hearings, or

related activities. This includes taking action to discourage or prevent someone else from cooperating with the activity;

8) enter into a personal or business relationship of any type with an individual receiving services until at least two years after the last date an individual receives services;

9) discourage, intimidate, harass, or retaliate against individuals who try to exercise their rights or file a grievance;

10) not restrict, discourage, or interfere with any communication with law enforcement, an attorney, or with the Commission/DSHS for the purposes of filing a grievance;

11) not allow unqualified persons or entities to provide services; 12) not hire or utilize known sex offenders in adolescent programs or programs that house

children; 13) prohibit adolescent clients and clients from using tobacco products on site at the

treatment programs and staff members and other adults (volunteers, clients, clients, and visitors) from using tobacco products in the presence of adolescent clients or clients.

14) display favoritism or preferential treatment of one client, or group of clients/clients, over another. 15) deal with any client except in a professional relationship that will support the approved

goals of the program; specifically, employees, volunteers or board members must never accept for themselves or any member of their family, any personal gift, favor or service

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from a client or from any client’s family or close associate, no matter how trivial the gift or service may seem. In addition, no employee, volunteer or board member shall give gifts, favors or services to clients/clients, their families or close associates.

16) have any contact with a client or ex-client except for those activities which are an approved, integral part of the program and a part of the employee’s job description. Employees, volunteers and board members are expected to maintain this role-appropriate relationship with former clients/clients until at least two years after the service recipient’s discharge from services.

Task 3: Orientation of Staff and Volunteers to Standards of Conduct Responsibility: Program Director Procedure: The Program Director will ensure that: 1) all staff and volunteers are provided with a thorough explanation of standards of conduct during orientation; 2) all staff and volunteers will sign the Standards of Personal Conduct; and 3) the signed Standards of Personal Conduct are placed in the personnel file. Task 4: Reports of Violations Responsibility: Program Director Procedure: SCAN and all of its employees shall protect client rights and provide competent services. Any person associated with the facility that receives an allegation or has reason to suspect that a person associated with the facility has been, is, or will be engaged in illegal, unethical or unprofessional conduct shall immediately inform the Commission/DSHS’s investigations division and the facility’s chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported to the Commission/DSHS and the facility’s governing body. FORMS: Credential Verification Form, Standards of Personal Conduct Form REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.217 & 448.218

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011 QUALITY MANAGEMENT Policy: SCAN utilizes a formal, comprehensive, and ongoing quality management process to monitor the effectiveness of all DSHS Substance Abuse Services funded programs (prevention, intervention, and treatment). The agency will develop, update, implement, and submit a Quality Management Plan (QMP) to the TDSHS annually. The agency’s Quality Assurance Program members meet on a regular basis throughout the year to review the performance of all DSHS Substance Abuse Services funded programs and conducts regularly scheduled Client chart audits and performance measure binder audits. All agency program directors meet as a group at least 4 times a year to review the progress of each program in meeting contractual goals and obligations. The agency’s prevention, intervention, recovery, and other non-substance abuse treatment program directors meet separately throughout the year for the purpose of monitoring contractual goals and obligations and to conduct and review random Client chart audits and performance measure binder audits. The agency’s substance abuse treatment program directors meet on a monthly basis to monitor the completion of contractual goals and objectives as well as to ensure that therapeutic services are being provided in accordance with DSHS rules and standards of care. Responsibility: CEO, Executive Vice President, Vice President, and Program Directors Procedures: SCAN’s Quality Management Plan will describe methods to measure, assess, and improve the implementation of evidence-based practices and research-based approaches, client satisfaction with services, service capacity, and access to services, client continuum of care, and accuracy of data reported to the state. Additionally, SCAN’s Quality Assurance Program will establish and maintain: 1) goals and objectives that relate to the programs purpose or mission; 2) methods to review the progress toward the goals and a documented process to implement

corrections of changes; 3) a mechanism to review and analyze incident reports, monitor compliance with rules and

other requirements, identify areas where quality is not optimal and procedures to analyze identified issues, implement corrections, and evaluate and monitor their ongoing effectiveness;

4) methods of utilization review to ensure appropriate client placement, adequacy of services provided and length of stay; and

5) documentation of the activities of the quality management process. FORMS: Chart Audit Forms REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.504 DSHS FY 2017-18 Performance Contract – Service Requirements

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012 GENERAL ENVIRONMENT Policy: SCAN will provide a safe, secure, and well-maintained environment. It makes every concession and takes all measures to protect the public health, safety, and welfare of clients/clients and their families, and to ensure that chemically dependent individuals receive adequate treatment. Included in this policy is the regulation of tobacco products. Task 1: Facility License Requirements Responsibility: Program Director Procedure: SCAN will:

1. comply with the Americans with Disabilities Act. It will maintain documentation that it has conducted a self-inspection to evaluate compliance and implemented a corrective action plan within reasonable time frames to address identified deficiencies.

2. have a certificate of occupancy from the local authority that reflects the current use by the occupant or documentation that the locality does not issue occupancy certificates.

3. SCAN, including grounds, buildings, electrical and mechanical systems, appliances, equipment, and furniture shall be structurally sound, in good repair, clean, and free from health and safety hazards.

4. provide a safe, clean, well-lighted and well-maintained environment. 5. have adequate space, furniture, and supplies. 6. have private space for confidential interactions, including all group counseling sessions. 7. prohibit smoking inside facility buildings and vehicles and during structured program

activities. If smoking areas are permitted, they shall be clearly marked as designated smoking areas and shall not be less than 15 feet from any entrance to any building(s) and comply with local codes and ordinances. Staff shall not provide or facilitate client access to tobacco products.

8. Staff and other adults (volunteers, clients, clients, and visitors) will not use tobacco products in the presence of children or adolescent participating on the program site.

9. prohibit firearms and other weapons, alcohol, illegal drugs, illegal activities, and violence on the program site.

10. Animals shall be properly vaccinated and supervised. FORMS: Facility Incident Report Form REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.505

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013 GENERAL DOCUMENTATION REQUIREMENTS

Policy: SCAN shall keep complete and current documentation. Task 1: Factual and Accurate Information Responsibility: Program Director, all Employees, and Volunteers Procedure: All required documents will be factual and accurate. Task 2: Signing and Dating of Documents Responsibility: Program Director, all Employees, and Volunteers Procedure: All documents and entries will be dated and authenticated by the person responsible for the content.

1) Authentication of paper records shall be an original signature that includes at least the first initial, last name and required credentials.

2) Initials may be used if the client record includes a document that identifies all individuals initialing entries, including the full printed name, signature, credentials, and initials.

3) Authentication of electronic records shall be by a digital authentication key. Task 3: Legibility Responsibility: Program Director, all Employees, and Volunteers Procedure: Documentation will be permanent and legible. Task 4: Corrections Responsibility: Program Director, all Employees, and Volunteers Procedure: When it is necessary to correct a client record, incident report, or other legal document, the error shall be marked through with a single line, dated, and initialed by the writer. Task 5: Abbreviations Responsibility: Program Director, all Employees, and Volunteers Procedure: The records shall contain only those abbreviations included on the facility’s list of approved abbreviations. FORMS: none REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.507

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014 CLIENT RECORDS Policy: SCAN will protect client records and other client-identifying information from loss, tampering and unauthorized access or disclosure. All active client records will be stored at the different program sites. Task 1: Client Records – Treatment, Intervention, and Prevention Programs Responsibility: Program Director, all Employees, and Volunteers Procedure: The facility will establish and maintain a single record for every client at the time of admission. The content of client records shall be complete, current, and well organized. Task 2: Security of Client Records Responsibility: Program Director, all Employees, and Volunteers Procedure: SCAN will protect all client records and other client-identifying information from destruction, loss, tampering, and unauthorized access, use or disclosure. It will comply with the following: 1) All active client records shall be stored at the facility and inactive records in off-site

storage shall be fully protected. All original client records shall be maintained in the State of Texas.

2) Information that identifies applicants shall be protected to the same degree as information that identifies clients/clients.

3) Electronic client information shall be protected to the same degree as paper records and shall have a reliable backup system.

4) Access to records is restricted to staff whose job duties require use of the records 5) Client records are kept in a secure room, a locked file cabinet or other similar container

when not in use. Records are locked at all times unless an authorized person is continuously present in the immediate area.

6) SCAN will ensure that all client records can be located and retrieved promptly at all times.

7) SCAN will comply with Federal and State confidentiality laws and regulations, including 42 C.F.R pt. 2 (Federal regulations on the Confidentiality of Alcohol and Drug Abuse Patient Records), TEX. HEALTH & SAFETY CODE ANN. ch. 611 (Vernon Supp. 2004)(relating to Mental Health Records) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The facility shall also protect the confidentiality of HIV information as required in TEX. HEALTH & SAFETY CODE ANN. § 81.103 (Vernon 2001)(relating to Confidentiality; Criminal Penalty).

8) SCAN will not deny clients/clients access to the content of their records except as provided by TEX. HEALTH & SAFETY CODE ANN. § 611.0045 (Vernon Supp. 2004) and

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HIPAA. Clients requesting copies of their records must first complete a “Consent for Disclosure Form” prior to staff making copies and providing them to clients.

9) Treatment Program Client records shall be kept for at least six years. Records of adolescent clients shall be kept for at least five years after the client turns 18.

10) If client records are microfilmed, scanned, or destroyed, SCAN will take steps to protect confidentiality. SCAN will maintain a record of all client records destroyed on or after September 1, 1999, including the client’s name, record number, birth date, and dates of admission and discharge.

FORMS: none REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.508

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015 HIRING PRACTICES Policy: SCAN complies with all applicable laws and DSHS requirements regarding background checks and drug tests for employees and volunteers and the disclosure of employee and volunteer information. The agency’s employment and volunteer applications require that applicants inform the agency of any legal involvement including misdemeanors. All positions are filled by individuals who meet minimum qualifications specified in the job description as evidenced by an application or resume and documentation of current status for credentials required by the job description. The agency’s drug prevention programs require that background checks and pre-employment drug testing be conducted with all potential paid and volunteer staff prior to their delivering services and/or having direct contact with youth and/or their family clients. Task 1: Guidelines for Personnel Hiring Responsibility: Chairperson of Board of Directors, Chief Executive Officer, Executive Vice President, and Program Directors Procedure: SCAN will comply with the following requirements: 1) The facility employs counselor interns; therefore, it is registered with the

Commission/DSHS as a clinical training institution and complies with all applicable requirements.

2) The facility verifies the current status of all required credentials with the credentialing authority by Internet, phone, or letter.

3) The facility complies with all applicable laws, including the Texas Civil Practice and Remedies Code §81.003, which relates to employment reference checks.

4) The facility obtains and assesses the results of a statewide criminal background check from the Department of Public Safety on all staff within four weeks of the date of hire. It uses the criteria listed in the Texas Occupations Code §53.022 and §53.023, to evaluate criminal history reports and make related employment decisions. Additionally, employees pending the results of a background check will be prevented from having any client contact.

5) The facility will not hire an individual who has not passed a pre-employment drug test that meets criteria established by the Commission/DSHS. SCAN may conduct random checks on its employees as permitted by law.

6) The facility shall develop a job description which outlines job duties and minimum qualifications for all personnel.

7) The facility maintains a personnel file for each staff member with documentation

demonstrating compliance with this section.

FORMS: Application for Employment, Volunteer Application, Verification of Credentials Form, Criminal Background Check

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REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.601 DSHS Contract, Statement of Work 2017-18

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016 STUDENTS AND OTHER VOLUNTEERS Policy: SCAN will use students and other volunteers to augment treatment services and will ensure that all students and other volunteers comply with standards of performance and conduct. Task 1: Selection of Volunteers Responsibility: Program Director Procedure: SCAN will ensure that volunteers are appropriate and qualified to perform assigned duties. It will: 1) require an application from prospective volunteers; 2) students and volunteers will be qualified to perform assigned duties; 3) screen volunteers through an interview process; 4) complete a reference check on all volunteers; 5) complete a background check and drug test for those working with drug prevention, intervention, and treatment programs; 6) provide a job description or written agreement for each volunteer position; and 7) maintain documentation in the volunteer’s file. Task 2: Training and Use of Volunteers Responsibility: Program Director Procedure: SCAN will: 1) ensure that volunteers receive orientation and training appropriate to their qualifications

and job responsibilities; 2) monitor and evaluate volunteers’ work performance; 3) ensure that volunteers follow all required policies and procedures; 4) ensure that volunteers are appropriately supervised by staff; and 5) ensure that direct care volunteers in residential programs without CPR certification will

have immediate supervision from certified staff. FORMS: Job Description, Training Table or Roster, Verification of Credentials Form, Counselor Competence Form, Direct Clinical Supervision Documentation Form REFERENCE: DSHS Standard of Care Chapter 448 Standard of Care §448.602

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017 STAFF TRAINING - ALL PROGRAMS Policy: All staff will receive all required training within the time frames required by the Texas Commission/DSHS on Alcohol and Drug Abuse and other funding or regulatory agencies. The length and type of training for contract personnel shall be based on the amount of time spent at the facility, degree of client contact, and individual qualifications and responsibilities. Unless otherwise specified, video, manual, or computer-based training is acceptable if the supervisor discusses the material with the staff person in a face-to-face session to highlight key issues and answer questions. SCAN may accept documented training from another organization completed during the year prior to employment if it meets Commission/DSHS requirements. SCAN maintains documentation of all required training for each staff person. All staff members working in adolescent treatment programs will receive appropriate training according to TCADA/TDSHS’s rules and contract requirements. The program shall ensure also that there are procedures for quality assurance for staff training. Task 1: Modality of Trainings. Persons Responsible: Training Coordinator and Program Directors Procedure: Unless otherwise specified, video, manual, or computer-based training is acceptable if the supervisor discusses and documents the material with the staff person in a face-to-face session to highlight key issues and answer questions. Task 2: Documentation of required training. Persons Responsible: Training Coordinator and Program Directors Procedure: SCAN will:

(1) Keep documentation of external training shall include: (A) date; (B) number of hours; (C) topic; (D) instructor's name; and (E) signature of the instructor (or equivalent verification).

(2) Maintain documentation of all internal training. For each topic, the file shall include: (A) an outline of the contents; (B) the name, credentials, relevant qualifications of the person providing the training, and (C) the method of delivery.

(3) For each group training session, SCAN will maintain on file a dated attendee sign-in sheet.

Task 3: Orientation Training Responsibility: Program Director, and Training Coordinator Procedure: Prior to performing their duties and responsibilities, SCAN will provide orientation to staff, volunteers, and students. This orientation shall include information addressing:

(1) TCADA/TDSHS rules; (2) SCAN’s policies and procedures;

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(3) client rights; (4) client grievance procedures; (5) confidentiality of client-identifying information (42 C.F.R. pt. 2; HIPAA); (6) standards of conduct; and (7) emergency and evacuation procedures.

Task 4: Initial Trainings Responsibility: Program Director Procedure: The following initial trainings must be received within the first 90 days of employment and must be completed before the employee can perform a function to which the specific training is applicable. Subsequent training must be completed as specified.

(1) Abuse, Neglect, and Exploitation. All residential program personnel with any direct client contact shall receive eight hours of face-to-face training as described in Figure: 40 TAC §148.603(d)(1) which is attached hereto and incorporated herein as if set forth at length. All outpatient program personnel with any direct client contact shall receive two hours of abuse, neglect and exploitation training. (2) HIV, Hepatitis B and C, Tuberculosis and Sexually Transmitted Diseases. All personnel with any direct client contact shall receive this training. The training shall be based on the Texas Commission/DSHS on Alcohol and Drug Abuse Workplace and Education Guidelines for HIV and Other Communicable Diseases.

(A) The initial training shall be three hours in length. (B) Staff shall receive annual updated information about these diseases.

(3) Cardio Pulmonary Resuscitation (CPR). (A) All direct care staff in a residential program shall maintain current CPR and First Aid certification. (B) Licensed health professionals and personnel in licensed medical facilities are exempt if emergency resuscitation equipment and trained response teams are available 24 hours a day.

(4) Nonviolent Crisis Intervention. All direct care staff in residential programs and outpatient programs shall receive this training. The face-to-face training shall teach staff how to use verbal and other non-physical methods for prevention, early intervention, and crisis management. The instructor shall have documented successful completion of a course for crisis intervention instructors or have equivalent documented training and experience.

(A) The initial training shall be four hours in length. (B) Staff shall complete two hours of annual training thereafter.

(5) Restraint and/or Seclusion. All direct care staff in residential programs that use restraint or seclusion shall have face-to-face training and demonstrate competency in the safe methods of the specific procedures. This includes programs that accept adolescent residential and emergency detentions.

(A) The initial training must be four hours in length. (B) Staff shall complete four hours of annual training thereafter. (C) The training shall include hands-on practice under the supervision of a qualified instructor.

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(6) Intake, Screening and Admission Authorization. All staff who conduct intake, screening and authorize admission for applicants to receive program services shall complete training in the program's screening and admission procedures. The training shall include two hours of DSM diagnostic criteria for substance-related disorders, and other mental health diagnoses.

(A) The initial training shall be eight hours in length. (B) Staff shall complete eight hours of annual training thereafter. (C) The training shall be completed before staff screen or authorize applicants for admission.

(7) Self-administration of Medication. All personnel responsible for supervising clients in self-administration of medication, who are not credentialed to administer medication, shall complete this training before performing this task.

(A) Staff shall complete two hours initial one time training. (B) The training shall be provided by a physician, pharmacist, physician assistant, or registered nurse before administering medication and shall include:

(i) prescription labels; (ii) medical abbreviations; (iii) routes of administration; (iv) use of drug reference materials; (v) storage, maintenance, handling, and destruction of medication; (vi) documentation requirements; and (vii) procedures for medication errors, adverse reactions, and side effects.

FORMS: Training Table or Roster REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.603

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018 CLIENT RIGHTS Policy: SCAN respects and protects client rights and complies with all state and local regulations for client rights and the documentation/reporting of such rights. Task 1: Client Rights Responsibility: All Employees and Volunteers Procedure: Clients/Clients have the following rights:

1) You have the right to a humane environment that provides reasonable protection from

harm and appropriate privacy for your personal needs. 2) You have the right to be free from abuse, neglect, and exploitation. 3) You have the right to be treated with dignity and respect. 4) You have the right to appropriate treatment in the least restrictive setting available that

meets your needs. 5) You have the right to be told about the program’s rules and regulations before you are

admitted. 6) You have the right to be told before admission:

a) the condition to be treated; b) the proposed treatment; c) the risks, benefits, and side effects of all proposed treatment and medication; d) the probable health and mental health consequences of refusing treatment; and e) other treatments that are available and which ones, if any might be appropriate for you.

7) You have the right to accept or refuse treatment after receiving this explanation. 8) If you agree to treatment or medication, you have the right to change your mind at any

time (unless specifically restricted by law). 9) You have the right to a treatment plan designed to meet your needs, and you have the

right to take part in developing that plan. 10) You have the right to meet with staff to review and update the plan on a regular basis. 11) You have the right to refuse to take part in research without affecting your regular care. 12) You have the right not to receive unnecessary or excessive medication. 13) You have the right not to be restrained or placed in a locked room by yourself unless you

are a danger to yourself or others. 14) You have the right to have information about you kept private and to be told about the

times when the information can be released without your permission. 15) You have the right to communicate with people outside the facility. This includes the

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right to have visitors, to make telephone calls, and to send and receive sealed mail. This right may be restricted on an individual basis by your doctor or the person in charge of the program if it is necessary for your treatment or for security, but even then you may contact an attorney or the Commission/DSHS at any reasonable time.

16) You have the right to be told in advance of all estimated charges and any limitations on the length of services that the facility is aware of.

17) You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment.

18) If you consented to treatment, you have the right to leave the facility within four hours of requesting release unless a physician determines that you pose a threat of harm to yourself and others.

19) You have the right to make a complaint and receive a fair response from the facility within a reasonable amount of time.

20) You have the right to complain directly to the Texas Commission/DSHS on Alcohol and Drug Abuse at any reasonable time.

21) You have a right to get a copy of these rights before you are admitted, including the address and phone number of the Texas Commission/DSHS on Alcohol and Drug Abuse..

22) You have the right to have your rights explained to you in simple terms, in a way you can understand, within 24 hours of being admitted.

Task 2: Restriction of Free Communication Responsibility: All Employees and Volunteers Procedure: If a client’s right to free communication is restricted under the provisions of paragraph (15) of this section, the physician or program director shall document the clinical reasons for the restriction and the duration of the restriction in the client record. The physician or program director shall also inform the client, and, if appropriate, the client’s consenter of the clinical reasons for the restriction and the duration of the restriction. FORMS: Client Bill of Rights; Client Handbooks REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care §448.701

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019 COMPLAINTS AND PROCEDURES POLICY: SCAN has a policy that addresses the procedures for handling complaints from clients and their families. Task 1: Complaint Procedure

Responsibility: All Staff

PROCEDURES: Clients and their families may seek remedy for any complaint about any violation of their rights or Commission/DSHS rules by:

1) complaining directly to any staff member; 2) submitting a compliant in writing and receiving assistance to write their complaint if they

are unable to read or write; 3) verbally complaining to any staff member, in which case the staff member receiving the

complaint must reduce the verbal complaint into writing immediately and seek the Client’s signature to ensure that the complaint was recorded accurately;

4) complaining directly to DSHS Substance Abuse Services (formerly the Texas Commission/DSHS on Alcohol and Drug Abuse) at any time. The address and telephone number of the Commission/DSHS are: 1100 W. 49th St. (physical address) Austin, Texas 78756 (512) 776-7111 (888) 963-7111

5) asking for pens and paper, envelopes, postage, and access to a telephone upon request in order to file a complaint.

Task 2: Informing the Public Responsibility: All Staff

PROCEDURES: SCAN will: 1) display a sign informing the public of the policy and procedures on complaints. The sign shall

be prominently displayed at all times and shall provide notice of the Commission/DSHS’s investigations division and its current mailing address and toll-free phone number.

2) verbally report all allegations of Client or Client abuse, neglect, and exploitation to the Commission/DSHS’s investigations division at (800) 832-9623 within 24 hours, and submit documentation within two working days.

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3) investigate the allegation, take appropriate action, and maintain documentation of the investigation and resulting actions.

Task 3: Reports to the Commission/DSHS Responsibility: Chief Executive Officer, Associate Administrator, and Program Director/Supervisor

PROCEDURES: The Executive Director or designee shall report the following incidents to the Commission/DSHS’s investigations division at (800) 832-9623 within 72 hours of discovery. Any incident within these categories that meets the definition of abuse, neglect, or exploitation must be reported within 24 hours as described in subsection (c). 1) all fires; 2) substantial disruption of program operation; 3) death of an active Client (on or off the program site); 4) suicide attempt by an active Client (on or off the program site); 5) medical and psychiatric emergencies that result in admission to the inpatient unit of a medical

or psychiatric facility; 6) violent behavior on the program site that results in injury or a police report; 7) illegal, unethical, or unprofessional conduct; and 8) legal, regulatory, or contractual action taken against the program.

Task 4: No Retaliation Responsibility: Chief Executive Officer, Associate Administrator, and Program Director/Supervisor

PROCEDURES: SCAN will not retaliate against anyone who reports a violation or cooperates during an investigation or related activity. FORMS: none REFERENCE: DSHS Chapter 448; Standard of Care

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020 STAFFING POLICY: SCAN will have an adequate number of qualified staff to comply with Commission/DSHS rules, provide the services described in the program description, and protect the health, safety, and welfare of clients/clients. Task 1: Program Director/Supervisor

Responsibility: Vice President

PROCEDURES:

The program will have an employee designated to serve as director. The individual must have appropriate education and training and at least two years of experience providing related services. The Program Director/Supervisor will spend and document sufficient time at the program site to provide appropriate oversight and supervision.

Task 2: Hiring of Applicants

Responsibility: Program Director/Supervisor

PROCEDURES: SCAN will hire applicants who meet the minimum qualifications listed in the job description. The application or resume shall document required education, training, and related work experience. Task 3: Suitability of an Employee

Responsibility: Program Director/Supervisor

PROCEDURES:

Prior to hiring an applicant, SCAN will check at least three (3) references of which at least one (1) will be a former employer in order to review the background and suitability of any employee with access to the program’s clients/clients or funds. The review shall be appropriate for each person's level of access and shall adequately protect the program’s clients/clients and financial resources.

Task 4: Statewide Criminal Background Check

Responsibility: Program Director/Supervisor and Human Resource Officer

PROCEDURES:

Prior to hiring an applicant, SCAN will obtain the results of a statewide criminal background check from the Department of Public Safety on all staff. The program shall use the criteria listed in the Texas Occupations Code, §§53.022 and 53.023 to evaluate criminal history reports and make related employment decisions.

Task 5: Pre-employment Drug Test

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Responsibility: Program Director/Supervisor and Human Resource Officer

PROCEDURES:

SCAN will require all prospective staff to pass a five (5) panel pre-employment drug test that meets criteria established by the Commission/DSHS. Specifically this drug test will screen for amphetamines, cocaine metabolite, marijuana metabolite, opiates, and phencyclidine.

Task 6: Staff Training

Responsibility: Program Director/Supervisor

PROCEDURES:

SCAN will ensure that staff is adequately trained and competent to perform job duties. All staff shall complete initial training during the first 30 calendar days of employment. The initial training shall be documented and shall include, as applicable: 1) Client rights; 2) Client complaint procedures; 3) confidentiality of Client-identifying information; 4) Client abuse, neglect, and exploitation; 5) requirements for reporting abuse, neglect, and exploitation; and 6) standards of conduct. Task 7: Annual Staff Training Plan

Responsibility: Program Director/Supervisor

PROCEDURES: SCAN will establish an annual staff training plan for employees based on the program design and identified staff needs. The plan must include annual training for all employees on: 1) cultural competency; and 2) standards of conduct. FORMS: Clinical Supervision Documentation Form, Job Description, Reference Check, Statewide Criminal Background Check, Pre-employment Drug Test, Training Record, Annual Staff Training Plan REFERENCE: DSHS Chapter 448; Standard of Care

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021 STANDARDS OF CONDUCT POLICY: SCAN and all its agents will protect the health, safety, rights, and welfare of clients, will provide competent services, and will uphold and demonstrate the highest standards of ethical and professional conduct. Responsibility: All employees, volunteers, and board members

PROCEDURES: a) Any person associated with the facility that receives an allegation or has reason to suspect that a person associated with the facility has been, is, or will be engaged in illegal, unethical or unprofessional conduct shall immediately inform the Commission/DSHS's investigations division and the facility's chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported to the Commission/DSHS and the facility's governing body. (b) The facility and its personnel shall comply with TEX. HEALTH & SAFETY CODE ANN. ch. 164 (Vernon 2001 & Supp. 2003)(relating to Treatment Facilities Marketing and Admission Practices). (c) The facility shall have written policies on staff conduct that complies with this section.

All employees, volunteers, and board members of SCAN will: 1) protect the health, safety, rights, and welfare of clients/clients; 2) provide adequate services as described in the program description; 3) comply with all applicable laws, regulations, policies, and procedures; 4) maintain required licenses, permits, and credentials; and 5) comply with professional and ethical codes of conduct. No employees, volunteers, or board members of SCAN will: 1) abuse, neglect, or exploit clients/clients; 2) commit an illegal, unprofessional or unethical act; 3) assist or knowingly allow another person to commit an illegal, unprofessional, or unethical

act; 4) knowingly provide false or misleading information; 5) omit significant information from required reports and records or interfere with their

preservation; 6) retaliate against anyone who reports a violation or cooperates during a review, audit,

inspection, investigation, hearing, or other related activity; or 7) interfere with Commission/DSHS reviews, inspections, investigations, hearings, or related

activities. This includes taking action to discourage or prevent someone else from cooperating with the activity.

FORMS: Credential Verification Form, Standards of Personal Conduct Form REFERENCE: DSHS Rule §448.218

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022 CLIENT ELIGIBILITY CRITERIA

POLICY: In order for clients to obtain the most appropriate services, the Pregnant & Post-Partum Intervention Program has in place specific eligibility criteria which are utilized to screen clients and make placement decisions accordingly. PROCEDURES: Individuals referred to the Pregnant & Post-Partum Intervention Program must be adolescent or adult pregnant or postpartum females who are Texas residents and who are identified as being at risk of having, or who have, a substance use disorder. Post-partum includes the period from birth through 18 months of age of the female’s infant. Females referred by the Department of Family and Protective Services (DFPS) who are identified as being at risk of having, or who have, a substance abuse use disorder and who have children under the age of six. Risk factors include the following: Teen pregnancy (including females through age 19) Current or past involvement with DFPS or other children protective services agency Current or past use/abuse of, or dependence on, alcohol and/or drugs Current or past domestic violence Current or past mental health problems, especially perinatal mood disorders Living in a household with a person who abuse alcohol or drugs Current or past history of sexual, emotional, or physical abuse Insufficient, late (third trimester) or no prenatal care, Financial distress FORMS: Referral Forms

Comprehensive Screening and Assessment Form REFERENCE: DSHS Chapter 447; Contract Program Requirements DSHS Chapter 448; Standard of Care DSHS Contract, Statement of Work 2017-18

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023 NON-DISCRIMINATION OF CLIENTS

POLICY: The Pregnant & Post-Partum Intervention Program provides comprehensive intervention services to adolescent and adult females who are pregnant or post-partum and who are using or experiencing problems related to alcohol, tobacco, and other drugs regardless of race, religion, ethnicity, country of origin, disability (including mental illness), sexual orientation, or gender. PROCEDURE: The Chief Executive Officer of SCAN, Inc. as well as the Program Director/Supervisor for the Pregnant & Post-Partum Intervention Program will be responsible for ensuring that the agency and program adhere to the policy of non-discrimination for clients. FORMS: N/A REFERENCE: DSHS Chapter 448; Standards of Care; §448.207

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024 FEE POLICY

POLICY: All services provided to clients meeting DSHS eligibility requirements will receive services rendered by the Pregnant and Post-Partum Intervention Program free-of-charge. Individuals that do not meet DSHS eligibility requires, but that want to participate in parenting education services can do so by paying a $40 fee. PROCEDURE: Individuals not meeting DSHS eligibility requirements can pay the required $40 fee through cash or check. FORMS: None. REFERENCE: DSHS Chapter 448; Standard of Care; §448.213 SCAN PPI Program Policies and Procedures 2017-18

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025 CLIENT RIGHTS & SAFETY POLICY: The PPI Program treats all clients with the utmost respect and dignity. All services provided by the program through paid staff members or volunteers will be conducted in a respectful, non-threatening, non-judgmental, and confidential manner. Therefore, the PPI Program shall ensure that all clients receive individualized and age-appropriate services and will have the rights described below and that they will be informed of them in simple, non-technical terms when they enter services.

PROCEDURES: 1. Staff will treat all clients with the utmost respect regardless of the individual’s age, presenting

problems, background, education level, religion, ethnicity, sexual preference, gender, etc. 2. When interacting with clients, staff are to be courteous at all times regarding language spoken, body

language, and facial expressions. 3. All services provided by staff to clients are to be done in a professional and non-threatening manner.

For example, when addressing late arrivals to appointments, missed counseling sessions, addressing problematic behaviors, etc. to clients, staff can address these matters in a firm and directive manner, but are to remain calm and respectful in doing so.

4. At all times, staff are expected to remain nonjudgmental towards clients. These individuals need to feel comfortable and safe when discussing actions, attitudes, and feelings to staff without the fear of being criticized or judged – especially when they conflict with those attitudes and feelings held by staff.

5. At the outset of program services and continuing throughout participation in the program, clients need to be made aware of the rules regarding confidentiality. At all times, staff are expected to make a concerted effort to provide services in confidential settings and to actively work to prevent any confidential information relating to clients from being accidentally released.

6. Upon admission to the PPI Program, all clients shall be provided with a copy of the Client Handbook which contains the following rights: A. Be free from abuse, not be ignored, and not be taken advantage of; B. Be treated with honor and respect; C. Make a complaint to the program or DSHS at any time; D. Be told about the program rules before participation; E. Accept or refuse services after being told about the services or their responsibilities; F. Be informed about the program goals, program rules, and client rights.

7. Upon request, clients can receive an explanation of their rights at any time throughout the span of service.

8. Client rights are written in both English and Spanish in clear, simple language that is appropriate to the target population.

9. During intake, the client will be informed of her rights and will be asked to sign a Receipt of Information and Voluntary Participation Form acknowledging that she has received a copy of the handbook, has been given a clear explanation of her rights, and agrees to voluntarily participate in the program.

10. Copies of the PPI Program Handbook are available for distribution to clients or other interested parties at the SCAN main office.

FORMS: Receipt of Information & Voluntary Participation Form Client Handbook REFERENCE: DSHS Chapter 448; Standards of Care SCAN PPI Program Policies and Procedures 2017-18

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026 ORIENTATION FOR CLIENTS AND LEGAL CONSENTERS

POLICY: The Pregnant and Post-Partum Intervention Program provides an orientation to all clients and their parents, legal guardians, or significant other adults identified by the clients. Whenever possible, orientation information is presented in person. However, the information can be provided over the phone or by mail upon request. PROCEDURES: The orientation and intake, which is provided upon admission by Intervention Specialists in the Pregnant and Post-Partum Intervention Program, includes the following information: Philosophy and objectives of the Program; Services available; How services can be provided; Complaint process; General Rules of the Program; and Client Rights and Responsibilities. FORMS: Client Rights Handbook Participation Consent Form REFERENCE: DSHS Chapter 448; Standards of Care SCAN PPI Program Policies and Procedures 2017-18

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027 CLIENT GRIEVANCES

General Policy: SCAN has a written grievance procedure that addresses all client grievances. Every staff member and volunteer must know the procedure and be able to assist clients/clients with the process. SCAN will not discourage, intimidate, harass, or seek retribution against clients or family members who try to exercise their rights or file a grievance; or restrict, discourage, or interfere with client communication with an attorney or with the `Commission/DSHS for the purposes of filing a grievance. It is a policy of Serving Children and Adults in Need, Inc. that there are systems in place to ascertain that the program provides current and updated information to clients, visitors and families in regards clients rights and client grievance procedure, especially information about accessing TCADA/TDSHS. Task 1: Informing Clients/Clients and their Families by Displaying Information in Prominent Places

1) SCAN, Inc. will display a sign informing the public of the policy and procedures on complaints. The sign will be prominently displayed at all times and will provide notice of the Commission/DSHS’s investigations division and its current mailing address and toll-free phone number.

a. Program Directors of Residential Programs will conduct reviews of the facility every week

b. Program Directors of Residential Programs will conduct reviews of the facility every month

c. During reviews of the facilities, Program Directors will also ensure that all appropriate postings are placed and that the information is accurately displayed.

2) SCAN, Inc. will verbally report all allegations of treatment program client abuse, neglect, and exploitation to the Commission/DSHS’s investigations division at (800) 832-9623 within 24 hours, and submit documentation within two working days. SCAN, Inc. will investigate the allegation, take appropriate action, and maintain documentation of the investigation and resulting actions.

Task 2: Informing Clients Through handing copies of the Client Grievance Procedure Responsibility: All Employees and Volunteers Procedure: In order to ensure that clients understand the grievance procedure, staff will give each client and his or her consenter, a copy of the grievance procedure within 24 hours of admission and explain it in clear, simple terms that the client understands. Task 3: Grievance Procedure Responsibility: All Employees and Volunteers Procedure: The grievance procedure tells clients that they can: 1) file a grievance about any violation of client rights or Commission/DSHS rules; 2) submit a grievance in writing and get help writing it if they are unable to read or write;

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3) request writing materials, postage, and access to a telephone for the purpose of filing a grievance.

Task 4: Retaliation

Responsibility: Facility

Procedure: Neither the agency nor any of its employees will:

1) retaliate against clients who try to exercise their rights or file a grievance, or

2) restrict, discourage, or interfere with client communication with an attorney or with the Commission/DSHS for the purposes of filing a grievance.

Task 5: Complaining Directly to TDSHS Substance Abuse Services Responsibility: All Employees and Volunteers Procedure: The grievance procedure informs clients that they may seek remedy for any grievance about any violation of client rights or Commission/DSHS rules by complaining directly to the TDSHS Substance Abuse Services at any time. The address and telephone number of the TDSHS Substance Abuse Services are:

1100 W. 49th St. Austin, Texas 78756

Telephone: (512) 776-7111 Toll Free: (888) 963-7111

Task 6: Resolution of Grievances Responsibility: All Staff Procedure: Staff members will adhere to the following procedures when responding to client grievances: 1) Staff will make every effort to resolve the grievance informally by discussing the situation or

circumstances with the client. 2) Staff members who are involved shall not be included in the acceptance, investigation or

decision-making concerning the grievance. 3) All staff members and volunteers must record formal grievances made by clients/clients in the

client’s chart within 24 hours and notify the Program Director or designee. 4) An incident report shall be completed within 24 hours. 5) The Program Director will evaluate the grievance thoroughly and objectively, obtaining

additional information as needed. 6) The Program Director will provide a written response to the client within seven calendar days

of receiving the grievance. 7) If the grievance is not resolved at the Program Director’s level, resolution will progress through the following channels:

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A) the Program Director will be responsible for forwarding that information within 24 hours of client’s request for grievance to be handled by the next level, or if the Program Director decides that the information should be resolved at a different level;

B) the Executive Vice President will follow the same procedure for informing the Chief Executive Officer if the grievance is not resolved within seven days, or to the client’s satisfaction, or the Executive Vice President’s satisfaction;

C) the Chief Executive Officer will follow the same procedure for informing the Board of Directors if the grievance is not resolved at that level; and clients will also have access to the Executive Vice President, Chief Executive Officer, and the Board of Directors.

8) Action will be taken to resolve all grievances promptly and fairly. 9) All grievances will be documented, including the final disposition, and the documentation will be kept in a central file. Program Specific Policy: SCAN shall provide guidance to all staff and volunteers of the Pregnant and Post-Partum Intervention Program to ensure compliance regarding Texas Commission/DSHS on Alcohol and Drug Abuse Standards regarding Client grievances. PROCEDURES: 1. During orientation, staff and volunteers will receive an in-depth explanation of the Client

grievance process and will be trained to handle grievances in an appropriate manner. 2. Staff and volunteers will be made aware of their responsibilities for handling complaints.

They will be informed of the right that clients have to grieve to them directly and of their responsibility to direct all complaints to their Supervisor, who will in turn report this complaint to the Chief Executive Officer.

3. All complaints must be acknowledged and documented within 24 hours (72 hours on

weekends). Complaints do not need to be resolved within 24 hours. A response to the person lodging a complaint will be made within seven calendar days.

4. The person lodging the complaint will be informed in writing of the findings and

recommendations regarding their complaint within seven calendar days. 5. Final disposition of all complaints will occur within 10 working days. Final disposition refers

to disposition within SCAN including appeal to the governing authority - not to include further investigation or action by outside agencies.

6. The Chief Executive Officer will take action to resolve all complaints. 7. SCAN will forward all complaints that cannot be resolved to the Texas Commission/DSHS on

Alcohol and Drug Abuse. 8. All complaints, including the final disposition, will be documented and maintained in a central

file.

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FORMS: SCAN's Training Roster REFERENCE: DSHS Rule §448.702 SCAN PPI Program Policies and Procedures 2017-18

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028 RESOLUTION OF CLIENT GRIEVANCES

POLICY: SCAN shall provide formal channels for receiving and responding to all complaints from clients, parents, legal guardians, close family members, and the public at large regarding matters related to the operation of the Pregnant and Post-Partum Intervention Program and/or its services. PROCEDURES: 1. Parties wishing to seek remedy for any complaints concerning policy, procedure, personnel, or

Client treatment should direct them to the Chief Executive Officer, the Chairperson of the Board of Directors, and/or the Texas Commission/DSHS on Alcohol and Drug Abuse (TCADA/TDSHS) as applicable.

2. Clients, parents, legal guardians, and close relatives of the clients shall be supplied with the

information needed to lodge a complaint and the appropriate person or agency to contact upon admission into the Pregnant and Post-Partum Intervention Program. This information shall be contained in the Pregnant and Post-Partum Intervention Program Client Handbook.

3. The complaint process will be detailed as follows:

• You may file a complaint using any typed or written material. Include a statement of the desired resolution.

• You may state your complaint directly to any staff member. They will direct it to the

appropriate administrative authority.

• You may have direct access to the Chief Executive Officer and the governing authority at

some point in the complaint process. • You may have assistance in writing your complaint. You may place it in a sealed

envelope to ensure confidentiality. You may also ask for a pen, paper, envelope, postage, and access to the telephone, if necessary.

• You may also make a complaint directly to the Texas Commission/DSHS on Alcohol and

Drug Abuse at any time by either calling or writing to:

DSHS Substance Abuse Services 1100 W. 49th St.

Austin, Texas 78756 Telephone: (512) 776-7111

Toll Free: (888) 963-7111

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4. Clients shall be provided with pen, paper, envelopes, postage, and access to a telephone upon request.

FORMS: N/A REFERENCE: DSHS Rule §448.702

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029 CLIENT RECORD SECURITY

POLICY: SCAN, Inc. shall abide by the Federal Regulations; (S2 12) 42 Code of Federal Regulations Part 2, et. seq. (1987) which are the Laws of Confidentiality for Drug and Alcohol Abuse. (Sections referred to throughout have been taken from the Federal Register unless otherwise indicated.) PROCEDURES: 1. All staff members and volunteers will follow the written procedures for responding to verbal and written requests for Client-identifying information. 2. Procedures for Release of Information: A. Steps for the Active Client:

(1) Whenever Client-identifying information is released, the Client record contains a signed consent form. SCAN will utilize a Consent for Disclosure of Information Form and ensure that it is properly completed and signed. The consent form should include the following information:

(a) Client's full name and date of birth; (b) Name of the person or organization to release the information; (c) Name of person or organization to which disclosure is to be made; (d) Purpose or need of requested information; (e) Extent or nature of information with inclusive dates of service; (f) Specific date, event, or condition upon which the will expire; (g) Statement that the consent is subject to revocation except to the extent that disclosure has already been made in reliance upon it; (h) Signature of legal consenter; (i) Date of signature and (j) Signature and address of witness (2) Information released is limited to that required to fulfill the purpose stated on the consent. Consents stating "any and all pertinent information..." or other such broadly inclusive statements ARE NOT HONORED. A release of information that is not essential to the stated purpose is specifically prohibited.

(3) The assigned Intervention Specialist will review the information to be disclosed according to the current Federal regulations regarding confidentiality.

(4) The signed consent is retained in the Client's records with the specific type of information released documented in the progress note. The date of release and the signature of the individual who released the information are included.

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B. Steps for the inactive Client: (1) Intervention Specialists will sign the Release of Information Form and prepare the information to be disclosed according to the current Federal Regulations regarding confidentiality.

(2) Final approval for disclosure is given in the same manner as with active clients. 3. General guidelines: A. Penalties for violation are not more than $500.00 for the first offense and not more than $5,000 for each subsequent offense. B. Any disclosure, with proper consent, shall be limited only to needed information. 4. Special Guidelines: A. Records of a person whose treatment application is not consummated or who is terminated from treatment are equally covered by these rules as the person who enters treatment. B. Implicit and negative disclosures about persons are prohibited as much as that of a positive disclosure. C. Crime or threatened crime that occurs at the facility and/or at the facility's premises during the course of treatment, may be reported to a law enforcement agency but the person cannot be identified as a Client. D. Since Texas allows minors age 16 or above as having legal capacity to receive treatment, consent required for disclosure may be given only by the Client. E. If the minor applicant age 16 or above refuses consent, it must be explained to the applicant that, without such consent, services cannot be provided (Sec. 2.15d of Regulations). F. Any information regarding a minor's application for alcohol services may be communicated to the parent, guardian, or other person authorized under Texas law to act on his behalf if in the judgment of the Clinical Director, the minor, because of a mental or physical condition, lacks the capacity to make a rational decision on whether to consent to the notification of his or her parent or guardian and the situation poses a substantial threat to the physical well-being of any person which may be reduced by communicating relevant facts to the minor's parent or guardian.

G. Records containing any information pertaining to clients shall be kept in locked file cabinets. One filing cabinet will be designated for all Intervention Specialists’ Client records. Each Intervention Specialist is responsible to account for his or her records at the end of the day. The program supervisor/director will perform random checks to ensure that this procedure is followed.

H. Access to records is prohibited to staff whose job responsibilities do not require use of the records.

I. Records are kept in a locked filing cabinet and/or room at all times unless an authorized person is continuously present in the immediate area.

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Continued 5. Written consent provisions: A. Copies from a record provided to authorized external users are accompanied by a statement (face letter) which prohibits the disclosure of information by recipient to a third party. All copies are marked confidential. B. With written consent, information evaluating the Client's current or past status in an intervention program may be furnished. C. Any information in the Client's record may be provided to an attorney of his choice with written permission of the Client and endorsement by the attorney. The attorney may not further disclose the information. D. Only necessary information for legal or contractual purposes may be disclosed to third party payees. They must follow this confidentiality rules also. E. With written permission, a program may make disclosures to public or private employment agencies, employment services, or employees. Ordinarily, disclosure should be limited to a treatment status, general evaluation or status verification.

F. For clients seeking treatment, while in a correctional status, they may consent to unrestricted communication between the treatment program and correctional authority. The consent expires in 60 days or with a major legal status change, whichever is later. Client may not revoke his consent to communication between program and correctional authority until release there from. Correctional authorities cannot further disclose except in connection with official duties regarding the Client.

G. Client's benefit criteria must be met for all other disclosures. (1) Consent must be freely given (2) No harm between Client and program in general must be created. (3) No harm to Client. 6. Disclosure Without Client Consent:

A. Staff and volunteers do not acknowledge the presence of a Client or disclose any Client identifying information unless:

(1) the Client gives full written consent; (2) the disclosure is authorized by an appropriate court order; (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or (4) the disclosure is otherwise permitted by law (5) Any oral disclosures must be documented by a written note in the record with Client's name and case number, date and time of disclosure, information disclosed, and names of disclosers and discloses. B. For government agency reviews, personnel lacking either the responsibility or the ability to conduct scientific research or evaluate treatment standards should be confined to examining administrative and financial records. Programs will organize their records with such separation of information possible.

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Continued C. No state agency, with the exception of licensing and funding agencies (e.g. TCADA/TDSHS) may request information that allows identity of any individual Client. Other restrictions also apply and verification by opinion of the attorney general is required before any patient ID data is to be submitted. D. Disclosures of information to auditors must wait until the examiner furnishes a written statement that no records will be made or retained unless the specific purposes is given, the location of storage is specified, and the name, official title, address, and telephone number of the responsible individual is provided. E. Authorized agents of a qualified state health agency shall have access to premises and records to ascertain compliance with treatment standards established under state law. No Client's ID and regulatory information may be removed by the agents. F. Information may be disclosed without consent to medical personnel to meet a medical emergency. 7. Court Orders: A. A subpoena will be honored. B. Court orders can only refer to primary treatment records and can only call for objective data (e.g., facts or dates of enrollment, discharge, attendance, and medication). When a Client offers testimony in litigation, an order may authorize submission of testimony or other evidence by the program. C. Any court order authorizing disclosure shall limit disclosure to essentials of the records; limit to whom disclosure is made, and limit disclosure to a minimum in order to preserve treatment efficiency. D. For court order applications for investigative purposes, any program whose records are sought shall be notified re: the application and have the opportunity to appear and be heard thereon. The court can issue such order but only several specific conditions. The application shall be denied unless the program has counsel independent of the applicant.

E. Programs may be investigated under court order that can be granted without notice. However, programs shall have the opportunity to seek revocation or amendment of such order. Use of Client's ID information and use of program information against Client are prohibited under this section.

F. Court orders without notice may be granted to have an undercover agent in a program without notice only if the Program Director/Supervisor is suspected to be directly or indirectly involved in criminal conduct. Otherwise, the Program Director/Supervisor must be afforded notice for a hearing. Other restrictions on the granting of such an order also are cited.

8. Utilization of Clinical Records for Research, Audits, and Reviews. A. Clinical records may be utilized only with the approval of SCAN's Chief Executive Officer for Scientific research, management audits, financial audits, program reviews, or evaluation studies. Such exceptionally authorized personnel must sign a statement that they will abide by the Federal Laws of Confidentiality for Alcohol and Drug Abuse Patient Records, and certify in writing;

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Continued (1) The Client's right to privacy and confidentiality will be protected. (2) All appropriate Federal Laws, program policies, and JCAHO standards will be followed. (3) Why there is a need to utilize the records. (4) The manner in which this information will be used. B. All personnel on the approved list must sign a statement that he/she knows the Federal Laws of Confidentiality for Alcohol and Drug Abuse Patient Records and will abide by these laws. This agency abides by these laws and any personnel who fail to do so are subject to dismissal and/or prosecution. 9. Authorization for Release of Information A. All release of information forms of program clients are reviewed by the Program

Director/Supervisor who reviews to determine if consent forms are in accord with Federal Laws of Confidentiality and program regulations. If appropriate, the secretary will complete the information and submit to Program supervisor, or his designee, for approval and mailing. The secretary will subsequently place the consent for release form in the record, log the date, agency information was sent to, and the material sent on the reverse side of the Consent Form.

B. The identity, diagnosis, and treatment of all applicants including active and inactive

clients shall be confidential and no information will be released without their written permission. Exceptions are where the Federal Laws of Confidentiality for Alcohol and Drug Abuse Patient Records has provisions.

C. Upon receiving a telephone inquiry as to whether or not an individual is an applicant or Client

of the program, the staff members should respond in a manner that does not imply the program knows of the individual and that such information cannot be released without the written consent of the individual who is the subject of the inquiry.

Example: "I am sorry, but Federal Regulations do not permit me to say if an individual is in our program or not without their specific written consent." D. Approval of the Client's consent to disclosure of information shall be considered valid when

the following conditions are met: (1) Full understanding by the Client of the specific type of information requested to be released.

(2) The Client is informed of the name of the person, agency, or organization requesting the information.

(3) The Client is informed of the purpose or need for such information. (4) Treatment services are not contingent upon the Client's decision concerning authorization for release of information. (5) Client must give his/her consent freely and voluntarily.

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Continued

E. All release of information forms from outside agencies must have the following items completed so as to be valid: (1) Date consent signed (2) Client's signature (3) Name of Program (4) Name of receiving program (5) Purpose of need for disclosure (6) Specific type of information to be disclosed (7) Subject to revocation at any time by the Client (8) Signature of witness and date of consent (9) Each release form is valid only for completion of one (1) transaction or date, event, or condition shown on form (10)All information released will be stamped "Confidential"-This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42-CRF Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose."

F. In life threatening situations or when an individual's condition precludes obtaining written consent, the Program Director/Supervisor, or his designee, after establishing the validity of the emergency will divulge pertinent medical information to the medical personnel responsible for the Client's medical care, if obtaining authorization would cause an excessive delay in delivering vital treatment for the Client. In such cases, the Program Director/Supervisor, or his designee, shall enter into the Client's clinical record all details pertaining to the transaction which will minimally include:

(1) Name of the Client and case number (2) Date the information was released (3) To whom the information was released (4) By whom the information was released (5) The reason and specific steps of verifying the emergency which precluded the obtaining of a signed release (6) Specific details of the information divulged. G. As soon as possible, the Client shall be informed that such information was released. This transaction, with an explanation, shall become a part of the Client's record. 10. Client information in computer-based data systems is protected from unauthorized access. 11. Client records are kept for at least five years after the Client turns 18.

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Continued 12. Client records are not microfilmed and they will be shredded when destroyed. 13. The facility does not in any way compromise Client confidentiality. FORMS: Consent for Disclosure of Information (MHRS 9-13) REFERENCE: Federal Regulations-Confidentiality of Alcohol and Drug Abuse Patient Records

DSHS Chapter 448; Standard of Care; §448.508

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030 RELEASE OF CONFIDENTIAL INFORMATION POLICY: Staff and volunteers follow written procedures for responding to verbal and written requests for Client-identifying information. SCAN, Inc, provides staff with written procedures as well as documented training for the protection and release of Client and applicant information. Procedures conform to federal and state confidentiality laws and regulations, including 42 CFR Part 2 (the Federal regulations on the Confidentiality of Alcohol and Drug Abuse Patient Records) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). SCAN does not compromise confidentiality in any way. Task 1: Client-Identifying Information

Responsibility: All Staff

PROCEDURES: Staff and volunteers do not disclose any Client-identifying information unless: 1) the Client gives full written consent; 2) the disclosure is authorized by an appropriate court order as defined in the federal regulations; 3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation; or 4) the disclosure is otherwise permitted by law. Task 2: Written Consent

Responsibility: All Staff

PROCEDURES: The Client’s written consent to release information will include: 1) the name of the person or program releasing the information; 2) the name of the individual or organization receiving the information; 3) the name of the Client; 4) the specific purpose of disclosure; 5) how much and what kind of information will be released; 6) the signature of the legal consenter; 7) the date of signature; 8) a statement that the consenter may revoke the consent at any time (unless otherwise restricted by law), but the revocation will not affect information already released under the consent; and 9) the date, event, or condition upon which the consent will expire.

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Task 3: Client Access to Content of Records

Responsibility: All Staff

PROCEDURES: SCAN does not deny clients/clients access to the content of their records except as provided by the Texas Health and Safety Code, §611.0045. If the release of any part of the Client’s record is determined would be harmful to the Client’s physical, mental, or emotional health by the Program Director/Supervisor, the Program Director/Supervisor will document clearly that evidence. Each attempted access must be clearly documented and treated individually.

FORMS: Consent for Disclosure of Information Form REFERENCE: Code of Federal Regulations, Title 42, Part 2 DSHS Chapter 448; Standard of Care HIPAA Act of 1996

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031 RETENTION OF RECORDS

POLICY: It is the policy of SCAN to retain all records for a period of four (4) years from the date the independent financial audit is accepted (when required) or would have been due (when not required). PROCEDURES: 1. All records relating to the Pregnant and Post-Partum Intervention contract will be retained for

at least four years from the end of each fiscal year. 2. If litigation or a claim has been initiated before the expiration of the four-year period, records must be retained until all litigation, claims, or other findings involving the records have been resolved. 3. SCAN, must make all records, books, papers, documents or recordings pertaining to the award and the general operation of the organization available for examination, copy or mechanical reproduction during normal business hours, on or off the premises, to the Commission/DSHS or any of their duly authorized representatives and to duly authorized federal, state or local authorities. 4. SCAN, must also make such documents available to be retrieved and taken from the provider's location upon request by the Commission/DSHS or other duly authorized authorities. 5. If SCAN closes business operations, it shall ensure that all records relating to the contract are

securely stored for a period of at least four years. FORMS: None REFERENCE: DSHS Chapter 448; Standard of Care: §448.508

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032 STAFF MEMBER ORIENTATION AND TRAINING

POLICY: All Pregnant and Post-Partum Intervention staff members at SCAN, including temporary, relief, and volunteers, will receive an orientation and proper training before independently assuming any job responsibilities.

PROCEDURES: 1. All staff members will receive an orientation and training to properly assume their job duties

within the first six months of being hired. This orientation and training will be appropriately documented in the employee’s personnel files.

2. All staff members will receive training in the following areas:

• Trauma-informed systems of care and approaches • Clinical aspects of pregnant/postpartum care, including communicable diseases associated

with substance use/abuse, and addressing health concerns and risks associated with substance abusing behaviors to the eligible population

• Motivational interviewing techniques • FASD through the FASD Center for Excellence Course – FASD: The Course and

Curriculum for Addiction Professionals (CAP): Level 1 3. Other training topics will include the following

• Specific training in the Evidence-Based Parenting Curriculum before facilitating the curriculum independently

• Explanation of job duties • Orientation to SCAN and to their specific program • Client confidentiality and security of Client identifying information • Client rights and grievance procedure • Requirements for reporting abuse, neglect, exploitation, and other serious incidents • Personal and ethical standards of conduct • Alcohol, Tobacco, and Other Drug Education • Philosophy of Pregnant and Post-Partum Intervention Program services • Client charts • Documentation • Program participation • Monthly reporting

3. All Intervention Specialists will receive a minimum of 15 hours of continuing education

related to the program design on an annual basis.

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4. All Intervention Specialists will receive at least one (1) hour of cultural sensitivity/awareness training and one (1) hour of training on personal and ethical standards of conduct on an annual basis.

5. Each training session will be documented and placed in the employees' personnel files. This

documentation will include the following:

A. Date; B. Topic; C. Instructor's name; D. Number of hours.

FORMS: Employee Orientation Form Training Roster REFERENCE: DSHS Rule §447.106 DSHS Contract, Statement of Work 2017-18

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033 CULTURAL COMPETENCY/AWARENESS

POLICY: All SCAN employees will show cultural sensitivity to the clients they serve and will continually attempt to increase their awareness and understanding of the cultures of these clients. PROCEDURES: 1. All Pregnant and Post-Partum Intervention (PPI) Program employees will attend/participate in at

least one training session per year on cultural sensitivity and awareness. 2. All PPI Program employees will make efforts to eliminate barriers to service. Employees will

ensure that Program materials are culturally appropriate and relevant for the target population. 3. All PPI Program employees will work to identify the positive values of different cultures that will

help to promote a drug-free and productive life. FORMS: Training Roster REFERENCE: DSHS Chapter 447; Contract Program Requirements; §447.113 DSHS Chapter 448: Standard of Care: §448.204 SCAN PPI Program Policies and Procedures 2017-18

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034 DRUG-FREE WORKPLACE

POLICY: In an effort to educate employees about the dangers of drugs and alcohol abuse in the workplace and to insure that employees with drugs or alcohol problems receive appropriate treatment, Serving Children and Adults In Need, Inc., has instituted a policy establishing an ongoing drug-free awareness program. Serving Children and Adults In Need, Inc., will also inform all employees about its philosophy about drug and alcohol use and its policies regarding maintaining a drug-free workplace. PROCEDURES: 1. Before they begin in their duties, all employees will be: A. Informed about SCAN's policy on maintaining a drug-free workplace. B. Given information about the dangers of drug abuse in the workplace. C. Given information about the available drug counseling, rehabilitation and employee assistance program. D. Informed about the penalties that may be imposed upon employees for drug abuse violations occurring in the workplace. E. Give a copy of this policy and SCAN's policy that prohibits controlled substances in the workplace and ,that, as a condition of employment they will: i. Abide by the statement of this policy and ii. Notify the employer in writing of any criminal statue conviction for a violation occurring in a workplace no later than five calendar days after such conviction. 2. The Chief Executive Officer will notify the appropriate funding agency(ies) in writing within ten calendar days after receiving notice under section (E) (ii) of this policy, with respect to any employee or otherwise receiving actual notice of such conviction. 3. SCAN, Inc., will take one of the following actions, within 30 calendar days of receiving notice under section (E) (ii) of this policy, with respect to any employee who is so convicted. i. Taking appropriate personnel action against such an employee, up to and including termination. ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency. FORMS: SCAN's policies on drug-free workplace and on prohibition of controlled substances.

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REFERENCE: Drug-Free Workplace Act (Public Law 100-690 Title V. Subtitle D, 41, U.S.C. 701 et seq) SCAN Policies and Procedures

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035 PROGRAM DESIGN AND IMPLEMENTATION

LOCATION AND TARGET POPULATION

The Pregnant & Post-Partum Intervention Program, with its main office located in Laredo, Texas, is a component of Serving Children and Adults in Need (SCAN). The program provides a variety of comprehensive, holistic, and culturally sensitive services to adolescent and adult females who are pregnant or post-partum and using or experiencing alcohol, tobacco, or other drug related problems. The Pregnant & Post-Partum Intervention Program is research-based and built upon best practice principles in the field of drug prevention and intervention. Program goals and outcomes are clearly defined and measurable. Services are provided in a three-county area (Webb, Zapata, and Starr) and in a variety of locations including on-site at various schools, community centers, at SCAN’s offices, and at the homes of clients. SCAN’s main office is located at 1605 Saldana Ave. in Laredo, Texas.

PROGRAM PHILOSOPHY Drug use and abuse is a staggering problem among the adolescent and adult population of the United States. This problem is particularly severe along the Texas-Mexico Border, where easy access to alcohol, tobacco, and illicit drugs contributes to many substance use related problems. The availability of inexpensive, high-grade drugs compounded with the social and economic factors of this region has continued to generate a fertile ground for drug experimentation, abuse, and dependence. The Pregnant & Post-Partum Intervention Program views intervention services as a primary means of deterring the misuse of alcohol, tobacco, and other drugs among pregnant and post-partum females. Through the provision of comprehensive and quality services such as screening and assessing for substance problems, parenting education sessions, alternative activities, and information dissemination, the Pregnant & Post-Partum Intervention Program believes that pregnant and post-partum females with substance-related problems can receive the skills necessary to avoid and overcome these problems. The Pregnant & Post-Partum Intervention Program emphasizes the reduction of risk factors and enhancement of protective factors in the lives of females participating in the program. The program is based on a logical framework that incorporates specific goals and objectives approved by the commission to address alcohol, tobacco, and other drug use among clients. The program utilizes the Systematic Training for Effective Parenting (STEP) Curriculum. All program materials are available in both English and Spanish, and services are provided using a holistic, individualized, and culturally sensitive approach.

PROGRAM’S MISSION SCAN believes that the use and abuse of alcohol, tobacco, and other drugs has a damaging effect on the mind, body, and spirit. The proliferation of crime, spread of infectious diseases, lack of productivity, physical and mental deterioration, and automobile accidents are just some of the problems caused by the misuse and abuse of alcohol and other drugs. These problems affect our community and every one of its members. By working in a collaborative manner, SCAN, Inc.'s Pregnant & Post-Partum Intervention Program will work in conjunction with schools, criminal justice agencies, social service agencies, parents, and other individuals to provide the services that will meet the ongoing needs of at-risk pregnant and post-partum females in the community.

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SCAN, Inc.'s mission, through the Pregnant & Post-Partum Intervention Program, is to provide comprehensive and quality intervention services to those pregnant and post-partum females with substance-related problems. By providing the education and community linkages necessary to avoid these drugs, SCAN will contribute to the fight against drug abuse in our society and will help individuals lead enjoyable, healthy and productive lives as integrated members of our community. CORE SERVICES The Pregnant & Post-Partum Intervention Program offers the following core services: Information Dissemination Parenting Education Sessions Screening and Assessment Motivational Counseling Problem Identification and Referrals Crisis Intervention Community-Based Collaboration FORMS: N/A REFERENCE: DSHS Rule §447.103 DSHS Contract, Statement of Work 2017-18

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036 DOCUMENTATION

POLICY: The Pregnant and Post-Partum Intervention Program believes in being accountable for each of the services that it provides. In order to ensure that all services are documented properly, the Pregnant and Post-Partum Intervention Program has in place several required forms and databases for documentation purposes. PROCEDURES: 1. Client Database

Each Intervention Specialist is responsible for maintaining a Client database each cohort (Fall, Spring, and Summer) that contains detailed demographic and service data for each Client served. The information entered in the database comes directly from information placed in Client charts. The database information is used to generate the monthly DSHS Performance and Activities Measures Report as well as to generate data to help evaluate the program’s performance.

2. Incoming Referral Log

All incoming referrals to the Pregnant and Post-Partum Intervention Program are entered in a referral log. The referral log contains copies of all referrals received by the Pregnant and Post-Partum Intervention Program. These referrals serve as back-up data for the referral database.

3. Outgoing Referrals

Anytime a Pregnant and Post-Partum Intervention Client is referred to an agency or program outside of the Pregnant and Post-Partum Intervention Program, this referral is to be documented in the Client’s chart. If an individual is referred to the Pregnant and Post-Partum Intervention Program, and, following the screening process, it is determined that the individual is not appropriate for the Program, the individual will be immediately referred to an appropriate SCAN Program or other social service agency in the community. A copy of this referral will be placed in an outgoing referral log. The information on the referral will also be entered into the Referral Database by the Program Coordinator or designee.

5. Screening

The Pregnant & Post-Partum Intervention Program utilizes a comprehensive PPI Risk Screening Instrument for Screening and Assessment purposes. This form is used for all potential program clients and gathers detailed demographic, medical, educational,

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employment, OB/GYN, birth control, family structure, legal, mental health, and drug use information. The Intake Application serves as the basis for Service Plan development and to ensure that comprehensive referrals are made to other agencies.

6. Action/Service Plan

A service plan is completed for each Client who agrees to participate in the Pregnant and Post-Partum Intervention Program. The service plan includes short-term goals, tasks, time frames, and persons responsible. The Intervention Specialists will work with the Client in developing the plan. Input from parents and guardians, for adolescent clients, is encouraged during service plan development. Short-term goals should, in most cases, relate directly to information uncovered in the screening process.

7. Progress Notes

Progress notes provide a record of all contacts with clients and their family members as well as all services provided on behalf of these individuals. Consequently, progress notes must be comprehensive and maintained on a regular basis. Entries are to be made each time that a Client or a Client’s family members are contacted or an attempt is made to contact them. Progress note entries will be in the DAP format and include the date the contact was made, what services were provided, and an assessment of the Client or family member at the time the service or services were provided. Progress notes will be signed by the person making the entries.

8. Consents and Receipt of Information

Signed Consent to Services forms demonstrate the willingness of adult clients and parents or legal guardians of adolescent clients to have their sons or daughters participate in the Pregnant and Post-Partum Intervention Program. Adult and adolescent clients are asked to sign a Receipt of Information & Voluntary Participation Form. Since many Pregnant and Post-Partum Intervention Program clients are between the ages of 11 to 17, parent or legal guardian consent must be obtained for these clients to participate in the Program. Whenever possible, the Intervention Specialists are to obtain these consents in person from the parent or legal guardian. In situations where the Intervention Specialist is having difficulties obtaining these consents in person, he/she is to attempt to contact the parents or legal guardians by telephone or mail to explain the program. If telephone contact is made and the parent or legal guardian gives verbal consent, this consent is to be documented in the clients’ progress notes. Similarly, if a consent is mailed to a parent or legal guardian, this too is to be documented in the clients’ progress notes. Under no circumstance is a Client to receive all Pregnant and Post-Partum Intervention Program services without having a signed consent form in their chart. The Consent for Disclosure form must be signed by the Client and his/her parent or legal guardian if any information pertaining to the Client will need to be disclosed outside of the agency. Exceptions to this rule exist under the following circumstances: A. A Client has indicated that he/she has been or is being abused (physically, verbally, or

sexually);

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B. A Client has indicated that he/she is a threat to cause harm to himself/herself; C. A Client has indicated that he/she is a threat to cause harm to another person; D. Disclosure is authorized by an appropriate court order; E. Disclosure is made to medical personnel in a medical emergency; F. Disclosure is made to qualified individuals for research, audit, or program evaluation; or G. Disclosure is otherwise permitted by law. H. Any oral disclosures must be documented in writing in the Client record. This

documentation will include the date and time of disclosure, the information disclosed, and the name of individual and agency/organization receiving this information.

In situations where a parent or legal guardian inquires as to the type or frequency of drug use by their son/daughter, Pregnant and Post-Partum Intervention staff members will not release this information without a signed Consent for Disclosure form by the Client (even though the parent or legal guardian has consented for their son/daughter to participate in the Pregnant and Post-Partum Intervention Program). A signed Receipt of Information form, which is obtained during intake with the Client, serves as evidence that the Client was given both a verbal and written explanation of their rights and the services to be provided. This form also indicates that the Client is willing to participate in the Program.

9. Service Completion

A Service Completion form will be completed for each Client that finishes program services or leaves the program prior to completion. This completion form includes information on whether or not the Client completed all or some services, needed alternative services, or was discharged for other reasons such as noncompliance.

10. Follow-up A Follow-up form will be completed for each Client that has successfully completed all Pregnant and Post-Partum Intervention Program services. Follow-up forms will be completed at 90 days after service completion.

11. Crisis Intervention The Intervention Specialists will record all crisis interventions conducted in-person or over the telephone on a Crisis Intervention form. The Crisis Intervention form includes the date the crisis took place, the name of the individual experiencing the crisis, and a short summary of the crisis.

12. Presentations and Information Disseminated All presentations made and information disseminated by Pregnant and Post-Partum Intervention staff members will be recorded on a Presentation Form. The Presentation Form includes information about where a presentation was made, when it was made, how many

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persons were in attendance, what types of information were disseminated, and provides the name of a contact person for verification. All presentations (AOD and Minor and Tobacco) must be at least 30 minutes in duration.

13. Community-Based Organizational Contacts Copies of signed cooperative working agreements or memorandums of understanding will be secured to document all community-based organizational contacts reported to TCADA/TDSHS.

14. Signature/Attendance Sheets

Youth and adults participating in counseling sessions, alternative activities, education sessions are asked to write their names on attendance sheets for each of these activities.

15. Documentation in CMBHS The PPI Program will use the following components in CMBHS for each eligible client

receiving DSHS funded intervention services- client profile; PPI screening; open case; close case; consent for release of information; service plan; referral and referral follow-up; psycho-educational notes; progress notes; and administrative notes.

FORMS: Referral Form Comprehensive Screening and Assessment Form Substance Abuse Screening Tool Program Participation Consent Form (Youth under 18 years of age) Receipt of Information & Voluntary Participation Form (Youth and Adults) Service Plan Progress Notes Consent for Disclosure Form Receipt of Information Form Discharge Form (program evaluation form) Follow-up Form Signature/Attendance Sheets CMBHS:

Client Profile PPI Screening Open Case Close Case Consent for Release of Information Service Plan Referral and Referral Follow-up Psycho-educational Note Progress Note Administrative Note

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REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention DSHS Contract, Statement of Work 2017-18

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037 PROCEDURES FOR PROSPECTIVE CLIENTS

POLICY: The Pregnant and Post-Partum Intervention Program will strive to ensure that each individual referred to the Program will be attended to properly. PROCEDURES:

1. The Pregnant and Post-Partum Intervention Program has an open referral policy which means that it accepts referrals from any source in counties served including, but not limited to, self-referrals, schools, parents, probation departments, and other social service agencies.

2. SCAN will strive to ensure that referring agencies are provided with appropriate referral

forms.

3. Every referral will be entered in the Pregnant and Post-Partum Intervention Referral Database (regardless of whether or not they meet the criteria for admission).

4. Once a referral is received, the Pregnant and Post-Partum Intervention Program Director or

designee will

A. Screen the referral; B. If the individual qualifies for program services, initiate intake procedures; C. If the individual does not qualify for program services, she will be referred to another

SCAN program or other agency in the community; D. Enter the referral into the referral database;

5. If a referral does not meet the criteria for the Pregnant and Post-Partum Intervention Program

or another SCAN Program, all efforts will be made to find an appropriate outside agency to meet the needs of the individual.

FORMS: Referral Form REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention SCAN PPI Program Policies and Procedures 2017-18

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038 PROCEDURES FOR ENGAGING CLIENTS

POLICY: The Pregnant and Post-Partum Intervention Program will strive to actively engage all individuals referred for program participation from first contact through the completion of services. PROCEDURES:

The Pregnant and Post-Partum Intervention Program has an open referral policy which means that it accepts referrals from any source in counties served including, but not limited to, self-referrals, schools, parents, probation departments, DFPS, and other social service agencies. The PPI Program staff members will make a concerted effort to engage clients to take part in the program and the services that it provides.

1. SCAN will attempt to contact all individuals referred for program services within 3 days of

receiving a referral to introduce themselves and arrange an appointment. 2. The initial appointment will determine if the individual is eligible for the program, and staff

members will explain the program, and provide a detailed overview of services that the individual would receive.

3. Prior to the initial appointment, staff will contact the individual to confirm the date and time and to remind her of any documents that she needs to bring to the appointment.

4. SCAN PPI staff will use a client-centered engagement process that relies on exhibiting unconditional positive regard and empathic understanding.

5. SCAN PPI staff will also use motivational interviewing techniques, which are non-judgmental, non-confrontational, and non-adversarial, to encourage individuals to actively take part in program services.

6. To help keep clients engaged in the program, staff members will provide ongoing feedback to clients regarding their process in achieving agreed upon goals and objectives as detailed in their individualized service plans.

FORMS: Referral Form REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention SCAN PPI Program Policies and Procedures 2017-18

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039 CLIENT RECORDS (ADMISSION AND CONSENT)

POLICY: The record system of the Pregnant and Post-Partum Intervention Program is designed to achieve a dynamic, evaluative process that is responsive to the changing needs of clients. The record system is designed to reflect individualized service. The information in Client records is collected in a uniform and consistent fashion that upholds the legal interests of the clients and SCAN PROCEDURES: ADMISSION DOCUMENTATION 1. There is a Client record for each individual admitted to the Pregnant and Post-Partum

Intervention Program. 2. All Client records conform to SCAN’s written procedures defining standard content and

organization. 3. All entries in Client records are made in black ink, signed, and dated. 3. The following information shall be documented at the time of admission:

A) Date of admission; B) Evidence that the Client meets admission criteria; C) Documentation that the Client has been informed of her rights;

1) The Client record contains a signed Receipt of Information form which documents that the Client:

2) Has received a written copy of the program’s Client Handbook; 3) Has received an explanation of the Client rights policy, the Client

grievance procedure, and the Program’s policies and procedures; and 4) Understands the explanations given.

4. The Client record contains documentation for consent to services by a parent or legal guardian

as evidenced by the following:

A) A signed Consent for Services form; and B) A progress note entry that the individual and/or parent or legal guardian has

received an explanation of the Pregnant and Post-Partum Intervention Program and the services to be provided.

FORMS: Client Handbook Client Profile (CMBHS) Outline of Sessions Form

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CMBHS Consent Form Consent to Participate in Services Form (youth only) Open Case (CMBHS) Progress Notes (CMBHS) REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention SCAN PPI Program Policies and Procedures 2017-18

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040 CLIENT RECORDS (SCREENING & ASSESSMENT)

POLICY: The Pregnant and Post-Partum Intervention Specialists will perform comprehensive screenings and assessments of potential clients. The information gathered during the screening process will form the basis for developing relevant and therapeutic service plans. Information for screenings will be gathered from potential clients and, when possible, from parents, legal consenters, relatives, or the referral agent. PROCEDURES: 1. All prospective clients will be given a comprehensive screening. The comprehensive

screening will be signed by Pregnant and Post-Partum Intervention Specialists. 2. The Comprehensive Screening form includes the following:

A. Client Information B. Referral Information C. Parental and DFPS Status D. Risk Factors E. Current Substance Use F. Outcome and Recommendations

3. The assessment shall address a) substance use issues; b) mental health problems; c) intimate partner violence risks and history of sexual, emotional or physical abuse and other interpersonal violence; d) medical care needs; e) financial resource needs; f) education and employment needs; and g) any needs of the client’s children. FORMS: Pregnant and Post-Partum Intervention Screening Form (SCAN and/or CMBHS) REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention SCAN PPI Program Policies and Procedures 2017-18

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041 CLIENT RECORDS (SERVICE PLAN)

POLICY: The Intervention Specialists will develop therapeutic and Client-directed service plans for all clients admitted to the Program. PROCEDURES: 1. The service plan is developed and implemented to meet the Client’s individual needs as

identified in the screening and assessment process. 2. Client participation must be solicited in the development of the service plan and this

participation must be documented in the client’s record. When possible, parent or legal consenter input will also be requested in developing service plans. Similarly, this participation will be documented in the youth Client’s record.

3. Goals will be stated clearly and in behavioral terms.

4. Each identified problem/issue will include a goal, objective and strategy as agreed upon by

staff and client. 5. All services to be provided to the Client will be specifically stated.

6. All service plans will be signed by both client and intervention specialist and will be placed in

the Client’s record. FORMS: Pregnant and Post-Partum Intervention Service Plan (SCAN and/or CMBHS) REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention SCAN PPI Program Policies and Procedures 2017-18

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042 CLIENT RECORDS (PROGRESS NOTES)

POLICY: In order to provide integrated, sequential documentation of all events effecting the care and service of clients, the Intervention Specialists will record progress note entries after each contact or attempted contact with the Client or the Client’s family members. All other significant events relevant to the Client’s participation in the Program will be documented accordingly. PROCEDURES: 1. Following each Client or family member contact or attempted contact, the Intervention

Specialist will make a progress note or administrative note entry in CMBHS and a copy of the progress note will be placed in the Client record.

2. These entries will be recorded electronically in CMBHS, printed and signed in black ink by

intervention specialist. Correction fluid should not be used. If an error is made while recording an entry, the individual making the entry will cross out the word(s) with a single line, write “error” and his/her initials above the crossed out word(s).

3. All entries will be dated and signed by the Intervention Specialists and progress notes will

indicate the type of service provided. 4. All entries will be in the DAP format and provide a description of the service provided, a brief

assessment of the Client’s attitude, and a description of the Client’s level of participation. FORMS: Progress Notes (CMBHS) Administrative Notes (CMBHS) REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention SCAN PPI Program Policies and Procedures 2017-18

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043 PERFORMANCE AND ACTIVITY MEASURES REPORTING PROCEDURES

POLICY: All Intervention Specialists will be responsible for documenting and submitting numerous reports to the Program Director/Supervisor. These activity reports will serve to summarize those services and activities rendered by each Intervention Specialist. PROCEDURES: 1. Monthly Activity Reports

• Intervention Specialists will turn in a Monthly Activity Report at the end of each month to the Program Director/Supervisor. These reports detail information about the number of Intervention Specialist contact hours as well as information about their caseloads.

2. TCADA/TDSHS Performance and Activity Measures

• Intervention Specialists will turn in a TCADA/TDSHS Performance and Activity Measures form at the end of each month to the Program Director/Supervisor. This form provides specific information about the number of services and activities performed by Intervention Specialists during the month.

• Intervention Specialists will provide supporting documentation to substantiate all numbers reported.

• Performance and activity measures will be submitted to TCADA/TDSHS on a monthly basis. These measures will be submitted on or before the 15th of the following month.

3. Client Database

• Intervention Specialists will provide a printout of their databases to the Program Director/Supervisor on a monthly basis.

4. Quarterly Reports

• The program director will submit a quarterly report by e-mail to the designated DSHS representative by the 15th of the month following the end of a quarter.

FORMS: Monthly Activity Reports TCADA/TDSHS Performance and Activity Measures Client Database

REFERENCE: DSHS Rule §447.104 DSHS Contract, Statement of Work 2017-18 SCAN PPI Program Policies and Procedures 2017-18

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044 INFORMATION DISSEMINATION

POLICY: The Pregnant and Post-Partum Intervention Program will disseminate information in the community to increase awareness and knowledge of ATOD use, abuse, and addictions and their harmful effects on individuals, families, and communities and provide awareness of available programs and services to youth and adults. PROCEDURES:

The Intervention Specialists will distribute printed materials to youth and adults in the community on a regular basis throughout the year.

Information shall be accurate and current.

The information will be accessible and understandable to the target population regarding content

and location of delivery.

The number or individuals receiving information/literature shall be appropriately documented and will include the following –

Date, time, and duration of activity; Location of activity; Staff/volunteers conducting the activity; Purpose and goal of activity; and Number of clients.

FORMS: Presentation/Information Dissemination Form REFERENCE: DSHS Rule §447.107

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045 PROBLEM IDENTIFICATION AND REFERRAL

POLICY: The Pregnant and Post-Partum Intervention Program will provide problem identification and referral services to ensure access to the appropriate level and type of services needed by clients and their family members. PROCEDURES:

1. The Intervention Specialists will screen all program clients to identify warning signs for ATOD use and abuse. The screening process shall also attempt to identify STD/HIV risk factors as appropriate.

2. The program shall identify needs that it cannot meet and will make referrals to other

community resources as appropriate.

3. Whenever possible, the Intervention Specialists will follow-up on referrals made.

4. All screenings will be documented and will include the following information -

a. Date of the screening; b. Method of screening; c. Interview setting; d. Referral Source; e. Referral made; and f. Any follow-up contacts.

5. All assessments will be documented and will include the following information:

a. Client ID number b. Medical Care needs, including contraceptive information c. Mental Health d. Interpersonal Violence and History of Sexual, Emotional, or Physical Abuse (Trauma) e. Substance Use Issues f. Needs of Children/CPS Involvement g. Education and Employment Needs h. Financial Resource Needs i. Support System j. Recommendations

6. All referrals will be documented and will include the following information:

a. Client name b. Name of Community Agency being referred to c. Contact information including address and phone number of location

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d. Reason/Purpose of Referral

FORMS: Screening Form (SCAN and/or CMBHS) PPI Assessment (SCAN) CMBHS Consent Form (to referring entities) CMBHS Referral Form Progress Note Form (CMBHS) REFERENCE: DSHS Rule §447.110

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046 PREVENTION EDUCATION/SKILLS TRAINING

POLICY: The Pregnant and Post-Partum Intervention Program will provide prevention education/skills training to each Client admitted to the Program. The education/skills training will focus on parenting, current infant and child safety guidelines, fetal and child development, HIV/STDs, family violence and safety, pregnancy planning and reproductive health, effects of alcohol, tobacco, and other drugs on the fetus, and alternative activities to promote healthy life styles and mother/child and family bonding. PROCEDURES: 1) After an individual has been admitted to the Program, she will participate in evidence-based

parenting education sessions, additional educational sessions and motivational counseling sessions.

2) Participation in these sessions will be documented in progress notes. 3) Documentation will include the following –

Date, time, and duration of activity; Location of activity; Staff conducting activity; Type and name of activity; Purpose and goal of activity; Number of clients; and Demographics of clients.

FORMS: PPI Attendance Sheet

Progress Notes (CMBHS) REFERENCE: DSHS Rule §447.108 DSHS Contract, Statement of Work 2017-18

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047 ALTERNATIVE ACTIVITIES

POLICY: The Pregnant and Post-Partum Intervention Program will offer clients the opportunity to participate in alternative activities designed to promote healthy lifestyles and mother/child bonding and family bonding. These activities will be designed to meet the emotional, social, and cultural needs of the clients and must be at least 30 minutes in duration. PROCEDURES: 1. Intervention Specialists will provide program clients with the opportunity to participate in

alternative activities. 2. These activities will be designed to help clients -

A. Master new skills; B. Develop/maintain relationships; C. Bond with peers, family, school, and community; D. Build cultural understanding, and honor diversity; and E. Identify activities that will encourage mother/child and family bonding in different

settings and in productive ways. 3. All program clients will be offered the opportunity to participate in at least one (1) alternative

activity while participating in the Program. 4. Participation in these activities will be documented in progress notes and through sign-in

sheets and will include the following - Date, time, and duration of activity; Location of activity; Staff conducting the activity; Purpose and goal of activity; and Number of clients.

FORMS: Pregnant and Post-Partum Intervention Alternative Activity Attendance Form Progress Notes (CMBHS) REFERENCE: DSHS Rule §447.109 PPI Program Policies and Procedures 2017 DSHS Contract, Statement of Work 2017-18

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048 CRISIS INTERVENTION SERVICES

POLICY: The Pregnant and Post-Partum Intervention Program will provide crisis intervention services to clients and their families to intervene in situations that may or may not involve ATOD use and that may escalate and result in crisis if immediate attention is not provided. Symptoms requiring immediate attention include, but are not limited to: A) Psychotic behavior; B) Acute or persistent confusion or hallucinations; C) Acute paranoia, agitation, or decreased attention span; D) Homicidal or suicidal behavior; E) Uncontrollable aggressive behavior; F) Other acutely abnormal or bizarre behavior. G) Medical problems PROCEDURES: 1. Crisis intervention may be offered through telephone contacts and/or face-to-face individual,

family, and group contacts. 2. In the event of a psychiatric emergency the Intervention Specialists will provide

crisis intervention and will notify the Border Region Behavioral Health Center and/or 911. 3. The Intervention Specialists will provide one-on-one monitoring until a Border Region employee,

law enforcement officer, or EMS technician arrives. 4. The Intervention Specialists will remain with Client until she is seen by the Border Region

employee, transported to a medical center, or the Client has become stable. 5. In the event of a medical emergency, staff will call emergency medical services (911). 6. The Intervention Specialists will contact the parents and/or legal guardians of youth as soon as

possible to inform them of the emergency. 7. Crisis intervention services must be documented in detail in the Client’s record. FORMS: SCAN, Inc., Referral/Consultation Form SCAN, Inc. Progress Notes Crisis Intervention Form

Consent for Disclosure of Information REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention PPI Program Policies and Procedures 2017

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049 SERVICE COMPLETION

POLICY: All clients completing Pregnant and Post-Partum Intervention Program services or who leave the program prior to service completion will have documentation in their charts detailing the reason for closing the case. PROCEDURES: 1. Pregnant and Post-Partum Intervention Program clients will have their cases closed if:

They have successfully completed the Program; An individual requests to leave the Program;

An individual requires services more specialized than those offered by the Program;

An individual’s behavior is detrimental to the Program or the clients that it serves;

The individual is non-compliant regarding Program participation (lack of participation/attendance must be clearly documented in the Client’s record).

2. The Intervention Specialists will complete a Closed Case/Exit Summary Form (CMBHS) for

each Client discharged from the Program. This form must be signed by the Intervention Specialist and placed in the Client’s record.

3. The Intervention Specialists will make a progress note entry for all closed cases.

4. All clients completing program services will be asked to complete an anonymous service

rating/program evaluation form. The form will be completed by clients, placed in a sealed envelope provided to clients, and forward to the program director.

5. The director will enter the information provided into an Excel spreadsheet and use the feedback from clients to help guide possible programmatic changes.

FORMS: Closed Case Form/Exit Summary (CMBHS) Program Evaluation Form Progress Notes (CMBHS) REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention PPI Policies and Procedures 2017-18 DSHS Contract – Statement of Work 2017-18

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050 CLIENT FOLLOW-UP

POLICY: The Intervention Specialists will conduct follow-up contacts with all clients who have successfully completed the Program and whose case has been closed. PROCEDURES: 6. After a Client who has successfully completed services leaves the Program, the Intervention

Specialist will be responsible for contacting the Client via telephone or in-person at 90 days from closure to obtain follow-up information. Due to the confidential nature of the follow-up information, follow-ups are to be done one-on-one (in person or via telephone) and not in a group setting.

7. Each contact will be documented on a CMBHS Follow-up form. 8. If it is not possible to establish a contact with the former Client, attempts at contacting the

Client are to be documented in the Client record with an administrative note. FORMS: Pregnant and Post-Partum Intervention Follow-up Form (CMBHS) Administrative Notes (CMBHS) REFERENCE: DSHS Chapter 447; Contract Program Requirements; Prevention & Intervention PPI Policies and Procedures 2017-18

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051 COMMUNITY-BASED PROCESS

POLICY: Inter-agency collaboration, coalition building and network linkages with key organizations in the community will play an important role for SCAN's Pregnant and Post-Partum Intervention Program. The Pregnant and Post-Partum Intervention Program will work with other service providers, organizations, individuals, and families to promote substance abuse services and improve the community’s ability to prevent substance abuse and related problems. This collaboration assists SCAN in obtaining additional resources for program youth, prevents duplication of services, enhances services and organizes support groups and volunteers to enhance the efficiency and effectiveness of our services to the target population served by this program. PROCEDURES: 1. The Pregnant and Post-Partum Intervention Program Director will regularly make contact

with other service providers, organizations, individuals, and families to promote substance abuse services and build a continuum of substance abuse services in the community.

2. Program personnel will document all community-based contacts as well as active participation

in collaborations to support community resource development. 3. Cooperative Working Agreements/Memorandums of Understanding (MOUs) will be obtained

from other service providers whenever the Pregnant and Post-Partum Intervention Program coordinates services with these providers. These MOUs will be renewed annually and address the non-duplication of services. These MOUs will contain the following information – Names of the providers entering into the agreement; Services or activities that each provider will provide; Signatures of authorized representatives; and Dates of action and expiration.

4. At a minimum, the PPI Program will have MOUs with the following- DSHS-funded OSAR DSHS-funded substance abuse treatment providers DSHS-funded LMHA DSHS-funded WIC programs DARS-funded ECI programs DFPS regional office Local and regional perinatal clinics Local and regional family planning providers Local and domestic violence shelters, and Local homeless shelters for females and females with children

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FORMS: Community-Based Contact Form Cooperative Working Agreements/MOUs REFERENCE: DSHS Rule §447.111 DSHS Contract, Statement of Work 2017-18

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052 HIV/AIDS WORKPLACE GUIDELINES POLICY: It is the policy of SCAN that employees with HIV/AIDS be treated no differently than the employees with other life-threatening illnesses. Additionally, SCAN follows TCADA/TDSHS workplace and education guidelines for HIV and other communicable diseases. PROCEDURES: 1. SCAN does not discriminate against people with disabilities including HIV and AIDS. 2. Employees with HIV/AIDS will be provided with reasonable accommodations as long as they are medically able to perform their assigned duties an do not pose a danger to their own health and safety or the health and safety of others. 3. Any medical documentation or information provided by an HIV/AIDS infected employee to medical or management personnel must be considered confidential and private information.

Employers are forbidden by law to disclose this information without the employee's knowledge and consent, except as provided by the HIV Services Act.

4. Policies regarding health care workers with HIV and their specific work assignments will be

specific with guidelines from the U.S. Centers for Disease Control and State Law. It is also the policy at S.C.A.N. Inc., that there be no discrimination in any employment practices, or other items, privileges and conditions of employment with this agency regarding employees with HIV, AIDS conditions. Any employee who believes he has been discriminated against because of AIDS or an AIDS related condition may contact 1-800-299-AIDS.

4. Any individual who breeches the HIV/AIDS infected employee's rights commits a serious offense. This breech may be cause for litigation resulting in both civil and criminal penalties. This criminal offense will be a Class A Misdemeanor. 5. S.C.A.N., Inc. will provide, through the City of Laredo Health Department AIDS Division,

additional information and/or training upon request to employees. 6. New employees will be required to read this policy as part of the facility orientation at

S.C.A.N., Inc. FORMS: None REFERENCE: DSHS Chapter 448, Standards of Care PPI Policies and Procedures 2017-18

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053 CHILD ABUSE REPORTING PROCEDURES

POLICY: All employees of the Pregnant and Post-Partum Intervention Prevention Program are required by law to report child abuse and neglect to Child Protective Services. PROCEDURES: 1. Chapter 34 of the Texas Family Code (TFC) requires every person who suspects that a child has been abused or neglected to report the suspected abuse or neglect to DHS or to another state agency authorized to receive the report. The law also specifically requires that "professionals" make a report to an appropriate local or state agency within 48 hours after first suspecting abuse or

neglect. 2. Staff who directly provide prevention/intervention services through the Pregnant and Post-Partum Intervention Prevention Program are considered "professionals" under the law. 3. Per TDSHS rules, staff shall report all allegations of child abuse or neglect to the Texas Department of Family and Protective services by phone or online. FORMS: None REFERENCE: DSHS Chapter 448, Standards of Care

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054 TOBACCO PRODUCTS POLICY:

Tobacco products at the program’s site are not allowed. SCAN does not permit any employees to use tobacco at any time during work hours. Violation of this policy will be cause for disciplinary action that may be grounds for termination.

Task 1: Distribution and Use of Tobacco Products

Responsibility: Program Director/Supervisor, All Employees, and Volunteers

PROCEDURES:

The Program Director/Supervisor will ensure that: 1) tobacco products are prohibited inside program buildings; 2) vending machines that dispense tobacco products on the site are not allowed;

3) staff shall not provide, distribute, or facilitate Client access to tobacco products;

4) staff and other adults (volunteers, clients, and visitors) shall not use tobacco products in the presence of children or adolescent clients on the program site; and

5) the program shall prohibit children and adolescents from using tobacco products on the program site or during structured program activities.

FORMS: none

REFERENCE: DSHS Chapter 448; Standards of Care SCAN Policies and Procedures

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055 TRANSPORTATION POLICY:

SCAN employees will comply with procedures on the use of facility vehicles and/or staff vehicles to transport clients/clients. All staff can use facility vehicles. However, only the Outreach Service Coordinator will be allowed to use his or her personal vehicle for transportation purposes during emergency situations.

Task 1: Transportation Procedures

Responsibility: Program Director/Supervisor and All Employees

PROCEDURES:

The following procedures will be followed: 1) Any vehicle used to transport a Client must have appropriate insurance coverage for business

use with a current safety inspection sticker and license. 2) All vehicles used to transport clients must be maintained in safe driving condition.

3) Drivers must have a valid driver’s license.

4) Drivers and passengers must wear seatbelts at all times the vehicle is in operation.

5) A vehicle shall not be used to transport more passengers than designated by the manufacturer.

6) Drivers shall not use cellular phones while driving.

7) Use of tobacco products shall not be allowed in the vehicle. 8) Every vehicle used for Client transportation shall have a fully stocked first aid kit and A:B:C

fire extinguisher that are easily accessible.

FORMS: Vehicle Safety Checklist REFERENCE: DSHS Rule §448.510

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056 EMPLOYEE PERFORMANCE EVALUATIONS POLICY: All employees of SCAN, Inc. shall be given a regular formal evaluation of their performance in relation to their position description. PROCEDURES: 1. Preparation of Evaluations At least five (5) days prior to the end of the orientation period, a written evaluation must be prepared, by the responsible supervisor, which will require the evaluator to assess the employee in relation to the job description and to comment on his or her ability, improvement and cooperativeness. Such written evaluation should also contain comments about the employee regarding any problems, need for improvement, overall performance etc. 2. Evaluator(s) Recommendations

At least five (5) work days prior to the end of the orientation period, the evaluator(s) must be submitted to the Chief Executive Officer with written recommendations to either (a) dismiss the employee, (b) place the employee on career status, or (c) extend the orientation for a period not to exceed one hundred twenty (120) days.

3. Annual Evaluations After the initial evaluation, evaluations will be conducted annually thereafter in the month of August. FORMS: SCAN job evaluation form. REFERENCE: SCAN Policies and Procedures

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057 STAFF COMPETENCIES POLICY: SCAN drug prevention and intervention programs shall ensure that the designated PPI Program Director is a Qualified Credential Counselor (QCC). All staff conducting PPI programmatic services must meet minimum qualifications established by DSHS. PROCEDURES: 1. Director The PPI program director shall be a qualified credential counselor (QCC). 2. Intervention Staff

All staff conducting programmatic services shall meet one of the following minimum qualifications: bachelor’s degree or master’s degree in a behavioral health field of study; 2 years of case management experience in a behavioral health field; QCC; appropriately supervised LCDC or LPC intern, or LMFT associate, or similar license or certfications.

3. Trainings a. Prior to providing services, all PPI staff must have documented training in trauma-informed

systems of care. b. Prior to providing services all PPI staff must have documented training in the following:

clinical aspects of pregnant/postpartum care, including communicable diseases associated with substance use/abuse, and addressing health concerns and risks associated with substance abusing behaviors; trauma-informed service approaches; motivational interviewing techniques; and FASD through the FASD Center for Excellence.

FORMS: QCC designation document Training rosters REFERENCE: DSHS Contract, Statement of Work 2017-18

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058 CMBHS PROGRAM POLICES AND PROCEDURES Statement of Policy 1. Purpose.

The purposes of these policies and procedures are to regulate computer use of the CMBHS System at Serving Children and Adults in Need (SCAN), Inc. and to regulate the use and level of access within the program as necessary to protect individual privacy, client confidentiality, to provide an equitable sharing of limited resources, and to promote responsibility in the use of SCAN computer systems. All employees that will receive access to CMBHS must read and acknowledge in writing that they have read and understood the CMBHS policies and procedures prior to receiving access.

2. Policy. SCAN’s general policies for use of its computer systems and equipment are:

• The primary guiding authority regarding the use of the SCAN’s computer systems, Internet, and network is SCAN’s Internet Policy, which every employee has received a copy and is located in SCAN Operating Policies and Procedures.

• All users of the CMBHS System have the responsibility to use this system in an effective, efficient, ethical and lawful manner.

• The use of the SCAN computer facilities and of the CMBHS System is a privilege, not a right. SCAN may protect legitimate facilities users by imposing sanctions on users who abuse the privilege.

• CMBHS users shall:

1. Respect the intended use of accounts established for their use;

2. Respect the integrity of SCAN’s computer systems, the computer network, and the CMBHS System;

3. Respect and guard the information being documented as it is highly confidential;

4. Respect all TDSHS rules, regulations and procedures governing the use of the CMBHS System.

5. Respect the proprietary rights of software owners and comply with all copyright laws, treaties and compacts of the United States and all applicable state laws.

• Standards of common sense and common decency must be applied in determining what uses are proper when using the CMBHS System.

• SCAN shall not provide computer access to persons not employed or not affiliated with the organization.

• Code of Federal Regulations, Title 42, Part 2 shall govern the use of the CMBHS System and the information contained in the system.

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PROCEDURES 3. CMBHS Access in General.

All CMBHS Internet computer accounts shall be the property of SCAN. The privileges of such accounts shall be given by the organization’s Security Administrator and other authorized administrative level staff, for specific uses only. There shall be four types of levels, as set forth in paragraphs 4, 5, 6 and 7 below.

4. Administrative Level Access. Administrative Level use may be established only by the Security Administrator with the written authorization of the CEO and maintained only by virtue of an individual’s status as an executive director, and shall be used in conformance with these policies and procedures and all other policies and procedures of SCAN and the CMBHS System. Records related to each Administrative Account shall be kept by the Security Administrator.

• CEO, Executive Vice President, and Security Administrator have full access to view the CMBHS System, including client information, generate reports, and financial information, etc.

• Vice Presidents and Program Directors/Clinical Directors have access only to those individual programs that they manage/oversee. They can authorize and delete users within their program(s); view all client information pertaining to their programs, process unit cost billings, and input and generate program specific reports. They will not have access to the Business Office levels of CMBHS.

Immediately upon an administrator having access to the CMBHS System is terminated or suspended his or her account shall be disabled by either the CEO or the Security Administrator. When an administrator that has access to the CMBHS System submits his or her letter of resignation or is retiring either the CEO of the Security Administrator shall terminate access to the CMBHS System two days prior to the effective date of resignation/retirement.

5. Financial Level Access. Financial Level use may be established only by the Security Administrator with the authorization of the CEO and maintained only for business office work. Authorizations for each Financial Level Account shall be made, and appropriate records of the account kept, by the appropriate manager or department head. Only the following will have access to the Business Office features of CMBHS:

• Executive Vice President, • Chief of Financial Services, • Senior Accountants

Immediately upon an employee having access to the CMBHS System is terminated or suspended his or her account shall be disabled by the Chief Financial Officer or Security Administrator. When an employee having access to the CMBHS System submits his or her letter of resignation or retirement the Chief Financial Officer or CMBHS Security Administrator shall terminate access to the CMBHS System two days prior to the effective date of resignation/retirement.

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6. Client Level Access. Client Level access (entering clients and client data) may be established only by the Security Administrator with the authorization of the Program Director for the respective program(s). Authorizations for each Client Level Account shall be made, and appropriate records of the account kept, by the appropriate manager or department head. Client level access will only permit limited access to one program. Only the following staff will have access to Client Level features of CMBHS:

• Designated Treatment Counselors • Designated Intervention Specialist Counselors

Immediately upon an employee having access to the CMBHS System is terminated or suspended his or her account shall be disabled by the Program Director or Security Administrator for the respective program. When an employee having access to the CMBHS System submits his or her letter of resignation or retirement the Program Director for the respective program shall terminate access to the CMBHS System two days prior to the effective date of resignation/retirement.

7. Unit Cost Billing Level Access. Unit Cost access may be established only by the Security Administrator with the written authorization of the Program Director for the respective program. Authorizations for each Unit Cost Billing Level Account shall be made, and appropriate records of the account kept, by the appropriate manager or department head. Client level access will only permit limited access to one program. Only the following staff will have access to Client Level features of CMBHS:

• Treatment Counselors • Treatment Program Directors/Supervisors/Coordinators • Treatment Clinical Directors • Treatment Administrative Assistants

8. Access Protection.

The integrity of the CMBHS System shall be maintained by protection of accounts through use of passwords. All computers having access to CMBHS shall be password protected. These passwords must be kept confidential. When the authorize user is leaving his/her office, the user must log off the CMBHS system to prevent unauthorized use of CMBHS. Additionally, authorized users should log-off their computers when leaving their office to prevent unauthorized use of their assigned computer. Any violation of the integrity of the CMBHS computer program shall be deemed to be a prohibited misappropriation of SCAN property and subject to termination.

• Attempts to perform any of the following acts are among such prohibited actions:

1. Make an account available to any person not authorized access by SCAN;

2. Defeat the security system of any computer;

3. Circumvent the accounting system;

4. Access and/or use an account without authorization;

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5. Use accounts for other than intended purposes;

6. Misappropriate the data or files of another person; or

7. Violate client confidentiality.

• Authorization for access to any account by someone other than the primary user is strictly forbidden.

• The account holder shall bear the responsibility and the consequences of allowing any access to his or her account by someone else.

• Gaining access to the system using someone else’s password is strictly forbidden. 9. Protection of the System.

Responsible continued use of the CMBHS System requires that each user: • Refrain from development or use of programs or utilities which:

1. infiltrate or modify the system or an account; or

2. damage the hardware or software components of the system.

• When requested, cooperate with systems administrators in investigations of systems abuse; and report suspected abuse, especially any damage to or problems with the user’s files.

10. Confidentiality.

SCAN recognizes that all client information is highly confidential and must be protected. Any suspected unlawful or improper activities must be immediately reported to the appropriate administrator. All client information on CMBHS System is to be considered highly confidential.

11. Rules. In addition to these policies and procedures, SCAN has various specific rules, regulations and procedures which govern the use of the CMBHS System. Each authorized has an administrator level staff person who has the responsibility for the use of that site. Users shall abide by the rules, regulations and procedures of SCAN and the site and shall cooperate with the site administrator.

13. Consultation. Computer users are encouraged to consult with SCAN’s Computer person regarding computer use and with the Security Administrator regarding the CMBHS System.

14. Copyrights.

The Texas Department of State Health Services holds all copyrights to the CMBHS System. Computer users shall not copy software protected by copyrights except as specifically allowed by the licensing agreements or other stipulations of the owner.

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15. Sanctions. Failure to abide by the guidelines set forth in the foregoing policies and procedures shall subject any user of the CMBHS System to sanctions, which may result in denial of access, and/or disciplinary action, which could lead to termination, dismissal from a position, or legal action.

16. Administration.

These policies and procedures shall be administered by the CEO and the designated Security Administrator of CMBHS for SCAN. These polices will be reviewed and approved by SCAN Board of Directors annually.

• CMBHS user concerns not resolved by the appropriate Program Director may be appeal directly to the CEO.

REFERENCE: DSHS Contract, Statement of Work 2017-18 SCAN Policies and Procedures

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059 QUALITY IMPROVEMENT

POLICY: The Pregnant and Post-Partum Intervention Program takes part in an ongoing and coordinated quality improvement process to ensure that services are provided in accordance with DSHS rules and regulations and that fidelity is maintained. PROCEDURES: 1. Pregnant and Post-Partum Intervention Program clients that have completed all required

services will be asked to complete a service rating questionnaire at the conclusion of services to gauge their satisfaction with the program and the services they received.

2. This information will be recorded in an Excel spreadsheet and will be used to help determine if possible programmatic changes are warranted.

3. The PPI Program Director will maintain this spreadsheet and will share findings with the agency’s QA Coordinator and QA Team at regularly scheduled QA meetings.

4. The agency’s QA Coordinator and/or designee will contact randomly selected PPI Program clients receiving services from each Intervention Specialist to take part in a brief survey of program services at least 2 times a year. Information gleaned from these phone surveys will be presented to the PPI Program Director along with any recommended changes.

5. The PPI Program Director will send key collaborating agencies a Community Partner Questionnaire to obtain feedback about their experiences collaborating with the PPI Program.

6. The Community Partner Questionnaire will be sent to collaborating agencies in August or September of each fiscal year.

7. Information from the Community Partner Questionnaire will be entered into an Excel Spreadsheet and will be used to help determine if possible programmatic changes are warranted.

8. The PPI Program Director will maintain this spreadsheet and will share findings with the agency’s QA Coordinator and QA Team at regularly scheduled QA meetings.

9. The PPI Program Director will take part in the agency’s QA Program as a regular member, will attend all regularly scheduled meetings, and will submit a progress report at each meeting that provides a detailed overview of all activities and services provided to clients. The report will provide detailed information about PPI Program key performance measures as detailed in the program’s DSHS contract.

10. The PPI Program Director will perform monthly reviews of key performance measures by submitting a combined report for all services provided by staff members along with supporting documentation to the QA Coordinator. The QA Coordinator will verify the reports for accuracy prior to submitting the information in CMBHS.

11. The PPI Program Director will audit at least 2 client charts from each intervention specialist on a monthly basis and submit copies of these audits to the QA Coordinator for review. The focus of the audits will be to ensure that all required services are being provided, that services are being appropriately documented, and that all required CMBHS components are being used correctly. a) Client Profile

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b) PPI Screening c) Open Case d) Close Case e) Consent for Release of Information f) Service Plan g) Referral and Referral Follow-up h) Psycho-Educational Note i) Progress Notes for Counseling and Case Management j) Administrative Notes

FORMS: CMBHS Forms listed above REFERENCE: DSHS Contract; Chapter 448 (§448.504); Standard of Care PPI Policies and Procedures 2017-18 DSHS Contract – Statement of Work 2017-18