Four Corners Community Behavioral Health Proceduresfourcorners.ws/documents/procedures.pdf ·...

Revised 8/25/2010

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH

ADMINISTRATIVE PROCEDURES

TABLE OF CONTENTS

ADMINISTRATION

AD01 Customer Comment Cards (Adopted 4/17/02)

AD02 Employee Recognition Values, Ideals, Principles (Revised 1/18/06)

AD03 Fire Safety (Revised 6/2/07)

AD04 Releasing Clinical Records (Adopted 2/16/05)

AD06 Compliance Plan for Fraud and Abuse (Revised 11/25/08)

AD07 Board Compliance Resolution (Revised 11/25/08)

AD08 Safety Management (Adopted 6/2/07)

AD09 Verifying PMHP Eligibility and Data Accuracy for (Adopted 8/17/10)

Initial Medicaid Requests

CLINICAL

CL01 Client Chart Format (Adopted 10/16/02)

CL03 COTT Clinical Records (Adopted 11/19/02)

CL04 Crisis Plan in ICA (Adopted 12/20/06)

CL05 Declaration for Mental Health Treatment (Revised 12/20/06)

CL06 Emergency / Crisis Services Notification (Adopted 12/18/02)

CL08 Intake Procedure Non‐Medicaid Mental Health

and Substance Abuse Treatment Services (Replacement) (Adopted 1/18/06)

CL09 Medicaid Client Education Handbook Protocol (Revised 4/26/07)

CL10 Quality Improvement Committee Program Peer

Review Quality Review Tool Protocols (Replacement) (Revised 12/21/05)

CL11 Service Priorities (Revised 5/16/07)

CL12 Clinical Supervision (Revised 5/16/07)

CL13 Targeted Case Management Record Keeping (Revised 4/26/07)

CL14 Wraparound Documentation (Revised 9/21/05)

CL18 Use and Documentation of AIMS (Adopted 8/11/04)

CL19 Individual Progress Notes for Groups (Adopted 8/11/04)

CL21 Emergency, Incident and Suicide Report Forms (Adopted 10/20/04)

CL22 Medication Only Protocol (Adopted 2/16/05)

CL23 CIAO (Revised 6/6/05)

CL24 Minimum Rent for Housing (Adopted 6/15/05)

CL25 Transporting Clients for Out of County Activities (Revised 2/21/07)

CL26 Hospitalizations (Revised 4/26/07)

CL29 Crew Criteria (Revised 5/16/07)

CL30 High Risk List (Adopted 1/18/06)

CL31 Referral Standards (Revised 4/17/06)

CL32 Unsigned and Missing Clinical Documentation (Adopted 8/22/06)

CL34 Emergency Responsiveness & Clinical Director Notification (Adopted 10/18/06)

CL35 Review of Involuntary Commitment under Court Order (Adopted 3/16/06)

CL36 DUI Screening and Assessment (Adopted 8/11/04)

Revised 8/25/2010

CL37 Supported Living Beds (Adopted 2/21/07)

CL38 Dual Relationships (Adopted 4/26/07)

CL39 Subpoena’s and Warrants (Adopted 4/26/07)

CL40 Utilization Review (Adopted 6/20/07)

CL41 OQ, YOQ Administration and Documentation (Adopted _/_/_)

CL42 Substance Abuse Assessment Scheduling (Adopted _/_/_)

CONTRACTS

CO03 Revenue Contracts Between Agencies and FCCBH (Revised 9/25/03)

INFORMATION SYSTEM

IN01 Access Message Board (Adopted 9/18/02)

IN02 Computer System Disruption or Troubleshooting (Revised 2/21/07)

IN03 Network Maintenance and Security (Revised 11/8/06)

IN04 Security Agreement for Laptop Computer Users (Revised 9/25/03)

IN05 Computer Equipments Requests (Adopted 10/18/06)

IN06 Transmitting Healthcare Data (Adopted 12/20/06)

IN07 Computer System Back Up (Adopted 1/18/06)

IN08 Coding Supervisor Non Clinical SA Time (Adopted 4/17/06)

IN09 Dashboard (Adopted 12/20/06)

IN10 Password Management (Adopted 12/20/06)

IN11 Access to Protected Health Information (Adopted 12/20/06)

OPERATIONS

OP03 Peer Helper Funds (Adopted 3/12/03)

OP04 Petty Cash (Adopted 3/12/03)

OP05 Property Held by Employee Acknowledgement (Revised 9/25/03

OP06 Telecommunications (Revised 7/16/03)

OP07 Client Payment Information Records Audit (Replacement) (Adopted 6/29/07)

OP08 Procurement (Revised 7/19/06)

OP09 Client Fees, Payments and Collections (Revised 11/8/06)

OP10 Travel and Reimbursement (Revised 7/1/08)

OP11 Surplus Equipment (Adopted 3/16/04)

OP13 Volunteer Requirements (Adopted 2/16/05)

OP15 Client Request for Fee Waiver or Reduction (Revised 5/24/06)

OP16 Single Case Agreements (Revised 11/8/06)

OP17 Advance Beneficiary Notice (Revised 10/20/05)

OP18 Fund Raising (Revised 5/16/07)

OP19 Approved Forms (Adopted 5/24/06)

OP20 Computer Replacement (Revised 6/21/06)

OP22 Discount Fees (Adopted 4/4/04)

OP23 Disseminating Changes in Policy (Adopted 12/20/06)

OP24 Record Retention (Adopted 1/17/07)

OP25 Vehicle Passengers (Adopted 4/26/07)

OP26 Detecting/Detouring and Reporting Potential Medicaid (Adopted 11/01/11)

Enrollee Fraud or Abuse

Revised 8/25/2010

PERSONNEL

PE01 Conflict of Interest Declaration (Adopted 8/22/01)

PE03 Drug Free Workplace (Revised 3/15/06)

PE04 Hiring Protocol (Revised 1/17/07)

PE07 Salary Increase at Licensure or Receipt of Degree (Revised 7/15/03)

PE08 Non Exempt Employee Overtime/Working Excess Hours (Adopted 1/17/07)

PE09 Requirements at Hiring (Revised 6/19/07)

PE13 Payroll Personnel Change Notice (Adopted 3/16/06)

PE14 Employee Certifications at Annual Evaluation (Revised 7/28/07)

PE15 Employee Appraisals and Merit Increases (Adopted 6/21/06)

PE16 New Employee Goal Setting (Adopted 7/19/06)

PE17 Other Trained Staff (Adopted 8/22/06)

PE18 Recording Time Worked (Adopted 7/19/06)

PE19 Sexual Harassment Investigator Qualifications (Adopted 10/18/06)

PE20 Unique Identifier (Adopted 11/17/06)

PE21 Signing and Approving Time Sheets (Adopted _/_/_)

PE22 Training and Conferences (Adopted 4/26/07)

Four Corners Community Behavioral Health Administrative Procedure

ADMINISTRATION PROCEDURE – AD01 – ADOPTED 4/17/2002 CUSTOMER COMMENT CARDS

1. Consumers of Four Corners programs and services shall have an opportunity to offer feedback on services through Customer Comments Cards available at all Four Corners clinics, clubhouses and the administrative office. The cards shall invite clients to comment on the services they receive and should be readily available in the customer waiting area. A box for customer comments shall also be placed conveniently to collect comment cards and allow for confidentiality of replies.

2. The clinic or program supervisor, or designee, shall collect the cards each Friday,

review them and forward all cards, with or without names, to the administrative office.

3. Every comment that includes a customer name shall receive a response from the

Executive Director. This includes comments that are concerns or that relate to issues about services as well as positive observations and compliments. Responses shall be sent within one week of receipt at the administrative office. The appropriate program supervisor shall be asked to follow up on specific complaints or concerns.

4. The program supervisor shall receive a copy of all customer comment cards

related to programs or staff under his or her supervision. Clinic staff should receive feedback on customer comments, both general and specific, in a timely manner. The Quality Improvement Committee shall receive a quarterly overview of customer comments prepared by the Assistant Director.

5. Office managers or program supervisors shall monitor the supply of customer

comment cards and contact the Assistant Director for additional blank cards when needed.

Adopted by the Executive Committee 4/17/002


ADMINISTRATION PROCEDURE – AD02 – ADOPTED 4/17/2002 EMPLOYEE RECOGNITION Recognizing Values, Ideals and Principles

1. Four Corners Community Behavioral Health, Inc. shall promote employee recognition that encourages staff engagement and acknowledges those who exemplify FCCBH, Inc. values and principles.

2. Employees are encouraged to acknowledge co-workers for exceptional work,

exemplifying values and principles or making a difference for other staff or Four Corners customers as one facet of Four Corners employee recognition.

3. “Recognize a VIP” cards shall be provided in an accessible location at each work

site. Employees may submit a “Recognize a VIP” card to acknowledge positive employee impact through values, ideals and principles.

4. “Recognize a VIP” cards shall be sent to the administrative office each Friday. A

copy of the Recognize a VIP card shall be retained in the administrative office and the original sent to the person being recognized. The clinic or program supervisor shall be advised of peer recognition at the monthly Executive Committee meeting.

Adopted by the Executive Committee 4/17/02, Revised 1/18/06


ADMINISTRATION PROCEDURE – AD03 – ADOPTED 8/27/2003 FIRE SAFETY

1. Inspections A. Every FCCBH, Inc. facility shall have a fire inspection conducted by the local fire

marshal the first month of each calendar year. The Business Manager or designee shall be responsible to ensure that fire inspections are carried out by the fire marshal.

B. FCCBH, Inc. shall conduct a fire safety self-inspection at each work site annually which

shall include: a. Identification of hazards, storage and clean up of flammable materials; service

and maintenance of electrical equipment and accessories; and safeguards for the network servers.

b. Ensuring that Fire Safety Evacuation Instructions and exit route maps are prominently posted.

c. Evidence of compliance with fire safety policies, procedures and rules d. Checking safety equipment including fire extinguishers, alarms, and other as

applicable e. Reviewing documentation of quarterly fire drills and ensure that exit routes are

clear and unobstructed.

2. Fire Drills All FCCBH, Inc. work sites shall conduct fire drills at least quarterly using emergency evacuation procedures and designated exit routes.

3. Fire Emergency Evacuation Instructions A. Fire Emergency Evacuation Instructions shall be developed for each work site and shall

be prominently posted in the facility. The Instructions shall include: a. A map of emergency exits including alternatives, emergency escape route

assignments; and b. Specific evacuation procedures including exit routes and conditions under which

an evacuation would be necessary; and c. A clear chain of command and designation of the person (s) authorized to order an

evacuation and communicate a fire emergency; and d. Procedures for assisting clients and visitors to evacuate including plans for any

individual with an ambulatory impairment or disability; and e. Employees’ assignments to take clients who are in their immediate vicinity and /

or clients in waiting or common areas and immediately vacate the premises; and f. Designation of an individual to oversee the shutdown of critical functions

including computers as appropriate; and

Adopted by the Executive Committee 8/27/2003; Revised

g. A means of accounting for employees, clients and visitors after an evacuation; and

h. Designation of a common predetermined area where employees, clients and others will meet once facilities are vacated; and

i. Instructions not to re-enter the facility until authorized to do so.

4. Exit Routes A. Evacuation routes to designated emergency exits (including alternatives) shall be

identified for each FCCBH, Inc. work site. B. A map of the building with exit routes, doors and windows clearly marked shall be posted

as a part of the Fire Emergency Evacuation Instructions.

C. Exit routes shall remain unobstructed and clear at all times.

D. Exit routes shall be reviewed with employees at least quarterly. The review may be in conjunction with the quarterly fire drill.

5. Training and Education

E. The FCCBH, Inc. Staff Development Institute shall include training on fire safety to be presented at the new employee orientation including:

a. Environmental controls such as proper storage and disposal of hazardous materials and other as described in I B above.

b. Means of reporting fires and other emergencies c. What to do in a fire emergency, evacuation procedures d. How employees will be alerted to a fire emergency e. How to exit a smoke- filled building safely f. What to do if exiting the building is not possible and how to establish visibility to

seek help g. A discussion of skills that enhance the protection of clients, employees and

property including client supervision h. Other as appropriate for each work site

F. Clients will be educated about how to respond to fire warnings or emergencies and safe

evacuation. a. Clients shall be made aware of Fire Emergency Evacuation Instructions and exit

route maps as a part of a program orientation, at the time of intake or other as appropriate.

b. Clients shall participate in fire drills, review exit routes and evacuation procedures quarterly.

6. Notification

The Executive Director shall be notified verbally of all fire related incidents within 24-hours of the incident and in writing, using the FCCBH, Inc. incident report form, within five days. The report shall include the estimated damage or injuries and the nature and / or cause of the fire.


ADMINISTRATION PROCEDURE – AD04 – ADOPTED 2/16/2005 RELEASING CLINICAL RECORDS Minors It shall be the FCCBH, Inc. procedure to only release clinical records (PHI) for deceased minors to their legal custodians at the time of death. For children not living with both biological parents, such legal custody shall be evidenced by a court order, divorce decree, or other legal evidence. Adults For deceased adult clients, FCCBH, Inc. shall release records (PHI) only to the legally appointed representative of the deceased client’s estate. A court order evidencing the appointment of the individual as representative shall be required. Adopted by the Executive Committee 2/16/2005


ADMINISTRATION PROCEDURE – AD06 –ADOPTED 10/18/2006; REVISED 11/25/08 COMPLIANCE PLAN FOR FRAUD, WASTE AND ABUSE (Previously Compliance Committee)

1. Four Corners Community Behavioral Health, Inc. shall develop and implement a written compliance plan to protect program integrity and guard against fraud, waste and abuse.

a. Policies and procedures shall reflect FCCBH, Inc.’s commitment to compliance with

applicable Federal and State standards designed to guard against fraud, waste and abuse. (Refer to Policies: 1.13 Reporting Suspected Child Abuse and Neglect, 1.20 Contract Provider Compliance, 1.21 Equal Employment Opportunity, 1.24 Interpreter Services, 1.25 Contracts Medicaid Subcontractors, 2.06 Conflict of Interest, 2.08 Unacceptable Employee Conduct/Disciplinary Action, 2.09 Drug and Alcohol Free Work Place, 2.27 Sexual Harassment Policy, 3.16 Purchasing, 7.01 Access for Non-Standard English Speakers, 7.04 Enrollee Client Grievances and Complaints 7.09 Confidentiality / Privacy, 7.10 Consumer Rights, 7.16 Human Subjects and Informed Consent, 7.26 Physical Restraint, 7.27 Provider Grievance Procedure, 7.40 Unethical Treatment or Conduct Grievance Procedure, 7.48 Protected Health Information General Policy, 7.49 Client’s Right to Access Records, 7.50 Accounting of Disclosures, 7.51 Amending Protected Health Information, 7.54 Medicaid Fair Hearing, 7.55 Service Authorization, 7.56 Selection of Out of Panel Providers, 7.59 Excluded Entities and Provider, 7.60 Provider non Discrimination, 7.61 Appeals, 7.62 Notice of Action, 7.63 Service Authorization for Employed Providers, 7.64 Initial Contacts)

b. FCCBH, Inc. shall appoint a Compliance Officer to oversee compliance program

planning, implementation of pre-emptive and corrective strategies, and monitoring. The Compliance Officer’s duties shall be outlined in the Corporate Compliance Officer Responsibilities Client Handout. Duties shall include (but are not limited to):

i. Provides leadership and technical assistance for policies and procedures ii. Establishes staff cooperation with compliance activities and a long term

commitment to effective internal compliance practices iii. Assists in the development and delivery of training iv. Tracks the Corporate Compliance Plan v. Coordinates activities, initiatives and strategies included in the plan vi. Reports directly to the Executive Director vii. Receives confidential client and employee compliance complaints viii. Has authority to hold employees accountable and direct personnel about 42

CFR and HIPAA policies and procedures. This includes creating mechanisms to hold management responsible for compliance in their areas of responsibility.

Approved by the Executive Committee on 10/18/2006; revised 4/26/2007, 11/25/08

ix. Assists management to minimize risk and liability x. Ensures that independent contractors and agents who furnish services to

FCCBH, Inc. are aware of the compliance program and provide acknowledgement of compliance

xi. Independently investigates and acts on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g. responding to reports of problems or suspected violations)

xii. Makes recommendations for discipline, corrective action and consequences for all employees, contractors and subcontractors resulting from complaints and that provide proper responsiveness to complaints.

xiii. Has the authority to review all documents and other information relevant to compliance including patient records, billing records and other documents involving employees, professionals on staff, independent contractors, suppliers, agents, and clinic-based physicians, etc. This includes ongoing monitoring and assessment for risk and operational issues.

xiv. Has the authority to review contracts and obligations (seeking the advice of legal counsel, where appropriate) that may contain issues that could violate HIPAA provisions and other legal or regulatory requirements

The Compliance Officer shall appoint a Compliance Committee with the following composition: Executive Director, Compliance Officer, Associate Director, and others as appointed by the Compliance Officer. The role of the Compliance Committee is to provide general oversight for corporate compliance planning, assessment, monitoring, correction and review of FCCBH, Inc. compliance activities and to report findings of such assessments, monitoring, corrections and review activities to the appropriate FCCBH, Inc. management staff for action. The Compliance Committee shall:

i. Be knowledgeable about all corporate compliance issues including 42 CFR

and HIPAA ii. Reflect the importance of effective internal compliance practices with

adequate controls iii. Maintain the FCCBH, Inc. compliance profile iv. Monitor and adjust timeline of activities v. Study documents, data and reports vi. Suggest areas that need to be reviewed for improved compliance vii. Discuss and evaluate priorities viii. Provide leadership for corporate culture issues ix. Assign tasks and responsibilities and promote a high level of cooperation x. Support peer reviews and audits and other internal assessments xi. Examine assessment findings xii. Make recommendations to the Executive Director xiii. The Executive Director will report directly at least annually to the FCCBH,

Inc. Board of Trustees xiv. Evaluate implementation activities

c. FCCBH, Inc. shall establish and maintain a training and education program for employed providers, non employed providers and the Compliance Officer.

i. The FCCBH, Inc. training and education program shall assure that employed

providers are aware of and informed about rules, regulations, policies, procedures, protocols and practices that affect civil rights, privacy, preferred practices, the management information system, record keeping standards, compliance, security and practices that constitute fraud, waste and abuse. (Refer to Personnel Policy 2.30 Training).

ii. Non-employed providers shall receive training and education in the following ways: (1) the clinical supervisor who approves the subcontracted services shall orient the provider to the expectations and requirements for serving PMHP Medicaid enrollees; (2) the subcontractor Letter of Agreement shall outline enrollee rights and responsibilities and the provider’s obligations; (3) policies, procedures, preferred practice guidelines and other training and educational materials shall be provided to the subcontractor on a compact disk and in alternative formats as requested.

iii. The Compliance Officer shall participate in training on laws, codes, rules and regulations to prevent fraud, waste and abuse including training provided by the Division of Substance Abuse and Mental Health, The Department of Health Division of Health Care Financing and others as required by contract or as assigned by the Executive Director.

d. The Compliance Officer shall communicate directly with employed providers and

non employed providers for credentialing, re-credentialing, attestations, certifications, education and training, audits, reviews and other methods of verifying the absence of fraud, waste and abuse. (See 1. b. above)

e. FCCBH, Inc. shall maintain an unacceptable conduct policy with sanctions that may

result in disciplinary action, including immediate termination. (Refer to Personnel Policy 2.08 Unacceptable Conduct) This policy shall warn against fraud, waste and abuse and shall be provided to every employee.

Grievances that include allegations of fraud or abuse shall be review by the Executive Committee. The disposition of allegations, complaints and / or grievances shall be determined by the provider’s supervisor, the Executive Director and the Compliance Officer as appropriate. (Refer to Clinical Policy 7.04 Client Grievance System Policy.)

f. An organizational assessment for internal monitoring and auditing shall be conducted at least every three years to identify areas of compliance, non compliance, fraud, waste and abuse. Interim reviews shall be performed by the members of the Corporate Compliance Committee based on recommendations of committee members or the Quality Improvement Committee, the Executive Committee or the Board of Trustees.

i. Peer reviewers shall conduct the assessments and provide verification of

findings based on the items being evaluated. ii. Review areas include (but are not limited to): (1) privacy, (2) security, (3) risk

evaluation, (4) liability issues, (5) policies and procedures, (6) quality assurance

/ internal controls, (7) administration, (8) hiring and compensation, (9) work and regulatory environment, (10) corporate culture, (11) emergency services.

g. FCCBH, Inc. shall establish and maintain provisions for prompt response to detected

offenses and development of corrective action plans.

i. The organizational assessment findings shall be reported to the Corporate Compliance Committee and the Executive Committee within thirty days of completion of reviews.

ii. The Compliance Officer shall prepare a report that includes: findings, an action plan with strategies, assignments and target date for response.

iii. Post assessment efforts to improve overall compliance may include changes in policy, procedure and/or protocol, training, adjustments to the management information system and other activities.

Supervisors shall submit a report summarizing grievances at each Executive Committee Meeting. When a preliminary investigation gives FCCBH, Inc. reason to believe that an incident of fraud or abuse has occurred a full investigation shall be conducted by the Compliance Officer. FCCBH, Inc. shall submit a full investigation report to the DOH within thirty days after the investigation. This shall include (1) the name and ID number, (2) the source of the complaint, (3) type of provider, (4) nature of the complaint, (5) approximate dollars involved, (5) legal and administrative disposition of the case.

2. All fraud, waste and abuse information shall be reported to the Department of Health as

required.


ADMINISTRATION PROCEDURE – AD07 Adopted 11/20/2002; Revised 11/15/08 BOARD OF TRUSTEES CORPORATE COMPLIANCE RESOLUTION

It is the policy of Four Corners Community Behavioral Health to follow the highest ethical standards. FCCBH, Inc. has an ongoing commitment to ensure corporate integrity, compliance with law and regulation and to prevent fraud, abuse and waste through effective internal compliance practices that provide adequate controls, privacy and security.

Statement of Purpose

To further this commitment to compliance and to protect its employees and other affiliated parties, FCCBH, Inc. will implement and sustain a Corporate Compliance Program as a framework for legal and corporate compliance. The Corporate Compliance Plan will establish: 1. Overarching principles 2. Key issues 3. The scope of concerns 4. Delegation of compliance oversight and 5. Priorities for action. Delegation of Compliance OversightThe Board of Trustees participates in corporate compliance activities through establishing policy associated with compliance and reviewing corporate compliance activity reports provided by the Executive Director. The Board is accountable for governing the corporation with knowledge of compliance expectations, practices, identified risk issues and plans for corrective action and the assurance of corporate integrity through the exercise of their fiduciary responsibility.

The Corporate Compliance Committee provides general oversight for corporate compliance assessment, planning, monitoring and evaluation and advises the Compliance Officer. The Compliance Officer appoints this committee. The Corporate Compliance Officer provides leadership and technical assistance for the review, revision and formulation of policies and procedures to guide all activities and functions of FCCBH, Inc. that involve issues of corporate compliance. The Compliance Officer also assists in the development and delivery of training, review of compliance issues, provides recommendations and reports, develops and tracks the Corporate Compliance Plan and coordinates activities, initiatives and strategies included in the plan. The Compliance Officer reports directly to the Board

Executive Director and receives confidential employee compliance reports.

Adopted by the Board of Trustees 11/20/2002; Revised 11/25/08

The Corporate Compliance Plan places priority on the regulatory issues likely to be of most consequence to FCCBH, Inc. operations. Specific strategies to respond to issues

Priorities

and ensure corporate integrity, compliance and prevention of fraud, waste and abuse include:

1. Research and understand industry risk. 2. Establish staff cooperation with compliance activities and a long-term

commitment to effective internal compliance practices. Survey staff and develop a training plan and schedule and other activities to meet needs and to create a corporate compliant culture.

3. Create a baseline and a gap analysis of areas related to clinical services and relevant areas of risk and inventory of existing or available resources.

4. Develop a FCCBH, Inc. baseline compliance profile. 5. Target factors contributing to and mitigate risk and liability. 6. Develop and implement an ongoing monitoring and assessment plan for risk areas

and operational issues. 7. Create mechanisms to hold management responsible for compliance in their areas

of responsibility and to hold employees accountable. 8. Establish a mechanism to receive and review employee compliance reports and

concerns. 9. Align policy and action for employee discipline, corrective actions and

consequences that provide proper responsiveness to complaints. 10. Consult with legal counsel when expert review is necessary to analyze risk issues.


ADMINISTRATION PROCEDURE – AD08 – ADOPTED SAFETY MANAGEMENT Four Corners Community Behavioral Health, Inc. safety management program shall include:

1st Safety requirements, practices and protocols established in procedure; 2nd Worksite analysis to identify existing and potential hazards / unsafe conditions; 3rd Prevention of accidents, abatement of potential hazards and control of unsafe

conditions; and 4th Safety training for employees.

1. Safety requirements, practices and protocols established in procedure:

A. The FCCBH, Inc. Business Manager (Finance Officer) shall serve as the organization’s Safety Officer or shall designate a Safety Officer in cooperation with the Executive Director.

B. Procedures on worker safety shall be posted where all employees can see them. C. The supervisor of the maintenance crew shall be responsible to ensure that safety

requirements are followed by members of the maintenance crew. D. All employees shall be held accountable for not following work rules designed to

promote safety and the prevention of accidents. 2. Worksite analysis to identify existing and potential hazards / unsafe conditions:

A. FCCBH, Inc. shall conduct a safety management self-inspection at each work site annually to: a. Identify potential hazards or unsafe conditions. b. Ensure that power equipment, office machines, electrical systems and facility

conditions are safe and appropriately maintained. c. Verify compliance with safety management requirements, practices and protocols

established in procedure. d. Formulate recommendations for improved safety, accident prevention, elimination of

potential hazards and employee compliance with safety requirements.

B. The scope of the safety management self-inspection shall be determined by the Safety Officer including but not limited to the following: storage, building and grounds conditions, waste disposal, tools, leakage, cleaning methods and materials and cleaning schedules, electrical equipment, circuits, special fixtures, grounding, lighting, heating and ventilation, machinery and the individual parts and features of machines, repair, maintenance, use and handling of equipment and machines, availability and use of personal protective equipment and safeguards, work practices, handling and storage of chemicals (as identified in 3.C. below), supervision, warning signs and available first aid supplies.

a. Inspections and safety assessments should be ongoing with timely response to concerns and issues.

b. The safety management self-inspection may be done in connection with the fire safety inspection and vehicle inspections.

c. A safety management self-inspection checklist shall be available for the work site supervisor or designee.

C. Safety management self-inspection-reports shall be reviewed and analyzed by the Safety

Officer, the Executive Director, the Compliance Officer and the work site supervisor. A post-inspection de-briefing shall be scheduled to review any recommendations if applicable.

D. Incident reports shall be completed for any on-the-job accident. The original copy of the

incident report should be submitted to the Human Resources Manager. E. All incident (accident) reports shall be reviewed by the Safety Officer, the Executive

Director, the Compliance Officer and the work site supervisor to help determine the causes and develop procedures to prevent a recurrence.

a. If appropriate an accident investigation may be initiated by the injured employee or the persons identified in 2. C. above.

3. Prevention of accidents, abatement of potential hazards and control of unsafe conditions:

A. Equipment shall be regularly maintained as determined by the work site supervisor and the Safety Officer.

a. A list of all major equipment shall be kept including the location of the equipment and inspection and or maintenance schedules / activities.

B. Electrical systems, power equipment, office machines, heating and ventilating

operations and building and property conditions shall be maintained to ensure the safety of employees and others in FCCBH, Inc. facilities. The work site supervisor shall be responsible to report concerns about areas listed to the Safety Officer.

C. Locked storage shall be used for hazardous or toxic chemicals and materials, flammable

agents, corrosive materials, substances that can be intentionally or deliberately misused (such as inhalants), compounds such as cleaning products that may cause eye or skin irritation, poisoning or respiratory damage.

D. To create a safer and hazard free environment, the following conditions are

unacceptable and must be cleaned up and cleared out of FCCBH, Inc. facilities: accumulated waste, empty containers, flammable materials unless properly stored, obsolete records or documents not in organized storage, unnecessary items, damaged property, broken equipment, furniture or machines, used rags, food or other products past the expiration date and garbage or other items that contribute to unclean, impeded, obstructed and/or potentially harmful conditions.

E. Employee reports of potential hazards or dangers shall be reviewed and action taken if

the report is substantiated.

F. First aid kits shall be available at each work site including any remedies necessary to counteract exposure to chemicals, corrosive materials or other potentially dangerous compounds or products used at that work site.

4. Safety training for employees:

A. General safety training shall be included in the new employee orientation. B. Required safety training modules for specific classifications of workers shall be

available on the FCCBH, Inc. web site or otherwise provided by experts in the field. a. It shall be the responsibility of the supervisor of specific classifications of workers to

ensure that employees complete required safety training. b. No employee, including employees working on the maintenance crew, shall be

expected to undertake a job until he or she has received adequate instructions on how to do the job in a safe manner.

c. No employee shall be expected to undertake a job that appears unsafe or without personal protective equipment if needed (e.g. protective eyewear, gloves, etc.)

d. Employees who handle / prepare food shall comply with R392-100: Food Service Sanitation Rule (U.S. Food and Drug Administration Food Code and Utah Amendments, effective Date: September 3, 2002) and shall complete training requirements for a food handler’s permit and receive ongoing consultation from a registered dietician on food safety requirements and practices.

C. Supervisors shall reinforce training with reminders, reviews, posted warnings or other

on a regular basis.

Adopted by the Executive Committee


ADMINISTRATION PROCEDURE – AD09 – ADOPTED 8/17/2010

Verifying PMHP Eligibility and Data Accuracy for Initial Medicaid Requests

1. When an initial contact is made for Four Corners services, PMHP eligibility will be checked as the Initial Contacts Performance Tracking (ICPT) record is created by :

a. If eligibility cannot be determined from the “Medicaid Eligibles” screen in ACCESS, the client can verify eligibility by presenting a current Medicaid card.

b. Checking the requestors PMHP Eligibility status from the “Medicaid Eligibles” screen on the Switchboard in ACCESS.

c. Medicaid Hotline 2. Once PHMH eligibility has been verified, the enrollee’s unique identifying

number will be entered on the initial screen of the ICPT form. 3. Only ICPT records with unique ID numbers validated by step 1 will be included

in the “Performance Measures” report. 4. Each front office worker who enters data into the Initial Contacts Performance

Tracking Tool will be required to attend a refresher workshop held each calendar year as part of the regularly scheduled Support Staff meetings. The refresher workshop will include:

a. Definitions of the emergency, urgent and non-urgent triages. b. Training on the electronic Initial Contacts Performance Tracking tool c. Any problem areas identified by the Data Manager or Administrator,

and/or changes to the electronic tracking tool 5. Four Corners will conduct a mini-audit at a minimum of once per calendar year,

per clinic, wherein a FCCBH staff member, or authorized person, will call into the clinic as if he/she were a Medicaid eligible enrollee, requesting services under the emergency, urgent, or non-urgent triage procedure. The offered and scheduled appointment times will be recorded and verified against what is entered into the electronic Initial Contacts Performance Tracking tool. Data from this audit will be recorded, evaluated and used for future FCCBH training.


CLINICAL PROCEDURE – CL01- ADOPTED 10/16/2002 CLIENT CHART FORMAT

A. A consistent format shall be used for all FCCBH clinical records. Files exchanged between clinical offices shall be provided in the required format.

B. The folder side tab shall include the following beginning at the top right corner:

1. Therapist number 2. Green dot for clients receiving alcohol and drug services 3. Red dot for clients who are Medicaid eligible 4. Folder label with client name and client number 5. First two letters of clients last name

Red dot for clients who are Medicaid eligible Folder label with client name and client number First two letters of clients last name

Therapist number Green dot for SA clients Red dot for Medicaid clients Folder label with client name and client number First two letters of clients last name

C. The contents of the file shall include documents specified in Policy 7.07 Clinical

Record Format. Adopted by the Executive Committee 10-16-02


CLINICAL PROCEDURE - CL03 - ADOPTED 11/19/2002 COTT CLIENT RECORDS

A. All non-electronic client information for individuals served by the Carbon and Emery Counties Community Outreach Treatment Team (COTT) shall be kept in one central file in the Psychosocial Services Office.

B. Files shall include all assessments, documentation, case management records and

other according to Policy 7.07 Clinical record Format.

C. All client information as specified in policy shall be maintained in the Access database including clients served by COTT.

Adopted by the Executive Committee 11-19-02


CLINICAL PROCEDURE – CL04 – ADOPTED 10/16/2002

CRISIS PLAN IN ICA

1. The ICA shall include a section for documentation of a Crisis Plan.

2. Updates to the client’s Crisis Plan shall be evidenced in a progress note and clearly labeled “Crisis Plan.”

3. Clients shall be provided with a copy of their Crisis Plan during their initial

appointment and whenever it is changed.

4. The Crisis Plan shall consist of a plan developed to safeguard the client’s safety.

a. The minimum standard shall be a review of the clinic’s 24-hour on-call system, including the appropriate telephone number to call and when to use it. Example: “Crisis Plan: Reviewed 24-hour on call system and provided dispatch telephone number. CT agreed to call if suicidal ideation became unmanageable.”

b. The Crisis Plan shall include a list of those individuals participating in its

development.

c. Clients who exhibit high risk of self-harm or harm to others may require more elaborate plans. Example: “Crisis Plan: Developed by Amy, Wendy, Harriet, Sandy and this therapist.

i. Amy will not be alone. ii. Amy’s sister Wendy, or her best friends Harriet or Sandy will be

with her at all times. iii. If Wendy, Harriet, or Sandy cannot stay at Amy’s house, Amy

will stay at one of their houses. iv. Amy agrees not to use illegal drugs. v. Wendy will accompany Amy to her appointments with her

therapist and doctor. vi. This plan will be reviewed in two weeks, or sooner if any of the

parties think it is not working. vii. A plan review may be called by any of the parties by calling this

therapist. Approved by Executive Committee 10-16-2002



DECLARATION FOR MENTAL HEALTH TREATMENT / ADVANCE DIRECTIVES

I. “Advance Directives” means oral and written instructions about a client’s mental health care in the event the individual is unable to communicate.

II. The Declaration for Mental Health Treatment, as established by law (UCA 62A-15-

1001-1004), shall allow clients to make decisions in advance about three types of mental health treatment: psychoactive medication, convulsive therapy and short term (up to 17 days) admission to a mental health facility. The instructions shall be followed if a court or two physicians believe that the client is incapable of otherwise making treatment decisions.

a. A declaration shall become operative when it is delivered to the declarant’s

physician or other provider and remains valid until it expires, or is revoked by the declarant.

b. When acting under authority of a declaration, a physician or other provider shall

comply to the extent possible, consistent with reasonable medical practice, the availability of treatments requested, and applicable law. If the physician or other provider is unwilling at any time to comply with the declaration, the physician or provider shall notify the declarant and the attorney-in-fact, and document the notification in the declarant’s record.

c. A physician or other provider may subject a declarant to intrusive treatment in a

manner contrary to the declarant’s wishes, as expressed in a Declaration for Mental Health Treatment if: (1) the declarant has been committed to the custody of a local mental health authority, or (2) in cases of emergency endangering life or health.

III. All adult Medicaid enrollees shall be provided with information on mental health

directives policies in the Medicaid Member Handbook, including a description of applicable state law. Information on advance directives in the Medicaid Member Handbook shall include:

a. A summary of enrollees’ rights under state law to develop a Declaration for Mental

Health Treatment, and

Adopted by the Executive Committee 4/16/2003, Revised 8/11/2004; Revised 12/20/2006

b. A reference to FCCBH, Inc. policies about the implementation of advance directive rights, including a statement of limitation regarding the implementation of the Declaration for Mental Health Treatment as a matter of conscience, if applicable.

c. Reflect changes in state law regarding advance directives no later than 90 days after

the effective date of the change.

IV. A completed, signed and dated declaration document shall be retained in the client record and remain in effect for a period of three years unless the client becomes incapable of participating in mental health decisions. If this occurs, the directive shall continue in effect until the client is no longer incapable.

V. All other rights associated with the Declaration for Mental Health Treatment as allowed

by law, including the right to revoke or change the document shall be upheld.

VI. Information about the Declaration For Mental Health Treatment shall be provided to all FCCBH, Inc. clinical staff as a part of the Staff Development Institute.

VII. A copy of the official Declaration for Mental Health Treatment form shall be available

on the FCCBH, Inc. web site.

VIII. Check boxes shall be included in the managed care plan to indicate “discussed”, “refused” and “completed.” The therapist shall check the appropriate box in the electronic record.



EMERGENCY / CRISIS SERVICES NOTIFICATION I. Four Corners Community Behavioral Health shall inform Medicaid enrollees about

access to emergency services.

A. The Intake Triage Protocol shall be followed to provide client education about emergency services on first contact.

1. Clients shall be informed that the after hours and weekends

emergency system can be accessed by calling the specified clinic office number and an answering machine will give the number to call or by calling dispatch at 911.

B. The Medicaid brochure will provide written notification about twenty-four-hour

crisis care as described above.

C. The Medicaid brochure shall explain what to do when an emergency occurs away from home. This includes getting help right away and notifying FCCBH within twenty-four-hours about care so payment can be approved and treatment coordinated.

II. FCCBH employees shall be advised of the Medicaid definition of emergency services.

A. Emergency means a psychiatric condition manifesting itself by acute symptoms of sufficient severity that a layperson could reasonably expect the lack of immediate medical attention to result in:

1. Placing health or safety of self or others in immediate jeopardy 2. Serious impairment to bodily functions 3. Respond within 30 minutes, face-to-face within one hour or as mutually

agreed. Approved by Executive Committee December 18, 2002


CLINICAL PROCEDURE – CL08- Adopted 1/18/2006 INTAKE PROCEDURE Non-Medicaid Mental Health and Substance Abuse Treatment Services I. The Secretary answers the phone and refers all Non-Medicaid and SA requests for

service to assigned mental health therapist/screener. For requests for SA services go to III below.

II. Mental health therapist/screener determines level of urgency or risk based on

current FCCBH OUTPATIENT NON-MEDICAID DECISION TREE.

a. Emergency requests (immediate risk individuals) to be seen within 24 hours or sooner at mental health therapist/screener’s discretion.

b. If caller is not at immediate risk and has insurance that is eligible for a single

case agreement, or agrees to pay full cost of services. Mental health therapist/screener staffs the case with clinical supervisor or at the weekly staff meeting.

c. If there is capacity as determined by the clinical supervisor to serve the

individual he/she is scheduled for an intake and referred back to support staff to arrange payment.

i. Office staff gathers insurance information, sends it to insurance specialist at business office, when eligibility is confirmed and required documents are executed the single case agreement is in place.

ii. Those with Medicare-only insurance are required to pay their co-payments at time services are received. A signature for Advanced Beneficiary Notice is required for any services not covered (e.g. Clubhouse).

iii. A signed Advanced Beneficiary Notice is required for anyone who wants to see a therapist or receive a service not authorized by their insurance company.

iv. Payment of the full cost of service is required at time of services. d. If the caller is not at immediate risk and needs a discount fee the case must be

staffed with the clinical supervisor or at the weekly clinical staff meeting to determine if the individual can be served under the 12% discount fee ceiling.

i. If he/she can be served a therapist is assigned to schedule an intake appointment.

e. If the individual cannot be served he/she is given information about private

providers from a list kept in each office for that area.

f. Services are suspended whenever a client has not paid for three visits. After payment is made, services can be resumed.

g. Support staff shall notify the therapist and clinical supervisor and the therapist shall either suspend services or fill out a patient assistance form or time payment contract for clinical supervisor’s approval.

III. Requests for Substance Abuse Treatment Services

A. DUI Screening

i. Court referred Level I DUI Screenings are given initial screening tools including the SASSI and other instruments as determined by the screener. BAL and basic information is collected by designated support staff member who schedules the screening appointment with an LSAC at the clinic. Insurance specialist at business office bills the courts $75 for the DUI screenings. (Code activity 1, NCC, Contract DUI/6)

ii. Court referred Level II DUI Screening and Substance Abuse Assessments

include the SASSI and other instruments as determined by the clinician, the ASI and an ICA completed after the individual has been seen by a mental health therapist. The individual is opened as a client on ACCESS and the Non-Medicaid individual who qualifies for a discount fee is charged $100 or $150 to third party payers (courts, DCFS, etc.). (Code as activity 1, client, contract DUI/6, or SA/1)

B. The PRI-DUI class series costs $250 and is self-paid or billed to the county if an

agreement is in place.

C. When Non-Medicaid people come for other substance abuse treatment services, they are charged a discount fee of no less than $100 for the initial intake assessment or 120% for out-of-area residents. a. Assessment procedure ii (above) is followed.

D. Subsequent appointments are charged for services based on ability to pay on the

discounted fee schedule or the IOP monthly schedule. Adopted by Executive Committee (Replaces previous CL08 Intake Triage Protocol) 1/18/06



MEDICAID CLIENT EDUCATION HANDBOOK PROTOCOL

1. Each adult Medicaid client and a guardian of each youth Medicaid client shall be provided basic information concerning FCCBH, Inc. and Medicaid services at his/her initial appointment.

2. This shall be accomplished by FCCBH, Inc. support staff as assigned by the

county supervisor.

3. Support staff shall provide each Medicaid Enrollee with a Medicaid Member Handbook at intake. Staff shall review the key information (noted below) and ask the Enrollee or his/her guardian if they have questions

4. Key information that shall be reviewed in the Medicaid Member Handbook shall

include: i. How to access emergency and transportation services ii. How to lodge a complaint iii. How to request the therapist (provider) of his/her choice

5. Support staff shall document that the Handbook has been reviewed and key

information explained to each new Medicaid Enrollee or his/her guardian by initialing the appropriate blank on the client’s FCCBH, Inc. intake form.

Approved by Executive Committee 12/18/02; revised 9/25/03; revised 2/21/07; revised 4/26/2007


CLINICAL PROCEDURE – CL10 – ADOPTED Replaces previous Record Review Protocol Adopted 11/19/2002 QAPI PROGRAM PEER REVIEW QUALITY REVIEW TOOL PROTOCOLS 1. The Quality Improvement Committee (QAPI) will function as the peer review committee and will

conduct clinical record reviews and service utilization reviews using the Quality Review Tool. Peer reviews will be conducted by licensed mental health providers or others appropriate for the review area.

2. The Quality Review Tool will address six main areas of quality improvement including:

a. Mental Health Evaluation b. Personal Recovery Plan c. Utilization Review to determine over- and underutilization d. Preferred Practice Guidelines to ensure adherence to the DSAMH guidelines, e. Availability and Accessibility to Services f. Cultural Competency to ensure that services were provided in a culturally competent manner g. Other areas that address completeness of documentation in the client record will be incorporated

3. The purpose of the QAPI peer review is to determine the accessibility, quality, adequacy and

outcomes of covered services being delivered to Medicaid enrollees. 4. Reviews will alternate between Carbon County, Emery County and Grand County; Carbon records

will be reviewed every other time. Peer review will be conducted every other month (at least 5 times a year)

5. A reasonable sampling (8-15 clinical charts) of Medicaid covered services will be reviewed. The QAPI Chair and Data Manager will select clinical records for the peer review through a computer generated sampling of records for open Medicaid clients with a completed Mental Health Evaluation and defined parameters (e.g. clinical focus, diagnoses or specific client data indicators.) Each clinician will have at least 2 cases reviewed each year.

6. The Scoring standards for Peer review are set at 80% accuracy. Records must meet a standard of 80% correct when being evaluated by the Quality Review Tool. Staff members with records below this standard will be referred to the supervisor for corrective action and or retraining.

7. The QAPI Committee member will meet with each clinic program director after each review to discuss findings and recommendations. The clinic program director will then meet with the individual clinician in supervision to discuss the review.

8. The QAPI Chairperson or designee will report to the QAPI and Executive Committee on review

findings including trends and systemic issues.

9. After the completion of each official peer review, the QAPI chairperson will meet with each clinical supervisor to report findings. This begins the process for any necessary corrective action. After each supervisor reviews peer review findings with each staff member the results and action plan (if there is one) are signed and return to the QAPI committee.

10. All treatment staff will be included in the peer-review process after one full center-wide review cycle. 11. The QAPI Committee will evaluate the Quality Review Tool and peer review process after one full

center-wide review cycle to identify areas needing improvement. Adopted by the Executive Committee Date 3/9/09

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH, INC. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM PEER REVIEW - QUALITY REVIEW TOOL

Date of Record Review: ___________ Reviewer: ___________________________ Client Name: __________________________

Medicaid Client: YES NO Therapist: __________________________ Client ID: __________ County: ____________________

REQUIREMENT YES NO NA COMMENTS I. Mental Health Evaluation / Assessment

The assessment was completed within thirty days There is documentation that the following were discussed: identification, chief complaint, psychiatric history, family psych history, family SA history, relevant past history

The assessment includes: mental status, formulation, note of other assessment tools used, recommendations

The Mental Health Evaluation is complete and the doctor and therapist assessment is consistent

The diagnosis is recorded and complete, (document diagnosis code in comments section), the assessment supports the DX, A&D codes completed

II. Managed Care Plan The Managed Care Plan addresses medically necessary services identified in the Mental Health Evaluation and the MCP has measurable goals

There is evidence that the client participates in TX planning The Managed Care Plan is reviewed/updated as required Note most recent review date: _______________ The services prescribed on the clinical managed care plan coincide with actual services being delivered

The necessary services for achieving the client’s individualized treatment objectives are offered and services are consistent with diagnosis (five axis DX listed)

Treatment alternatives and options are considered and noted as appropriate

There is a crisis plan in place

REQUIREMENT YES NO NA COMMENTS III. Utilization Review

The initial intake Mental Health Evaluation is staffed with the site multi-disciplinary team or site supervisor for appropriateness of diagnosis and assignment of treatment and there is a staffing note

If inpatient stay indicated, the amount, duration, and scope of services are adequate

If client record open over 6 months, documentation indicates that a peer consultation staffing has occurred

Documentation indicates that the client’s treatment is progressing

The modalities and duration are appropriate per standards IV. Progress Notes

Client contact is described according to GIO format There is a relationship to the MCP goals

V. Medical Medical assessment, DX and notes are complete There is a medical history form Appropriate records have been requested if applicable Explanation of the MH advance directive is noted

VI. Skills Development and Case Management There is a daily log, a monthly progress summary and a 180 day review for SDS

There is a TCM needs assessment and service plan There are relevant TCM progress notes and 180 day review

VII. Discharge Summary The summary of services is complete, there is an evaluation of goals

There is a post discharge plan with a final diagnosis Appropriate boxes are checked at discharge

REQUIREMENT YES NO NA COMMENTS VIII. Preferred Practice Guidelines (PPG)

Care provided is consistent with applicable guidelines.

IX. Availability and Accessibility to Services The following have been completed as evidenced by the Medicaid Member Handbook Review Acknowledgement 1. The client received transportation information 2. The client understands the right to have a choice of provider 3. The client received information about emergency services

Services are accessible to the client (there is a note about transportation issues being addressed, if applicable)

Service delivery hours meet the needs of the client (there is a note about after hours needs if applicable)

The client is receiving services in a timely manner that meets access standards

X. Cultural Competency The client’s cultural considerations were addressed in the assessment (language, ethnicity, cultural norms, issues specific to the client)

Language assistance was provided if requested Staff have been trained to recognize and respect cultural differences

X

XI. Substance Abuse (A&D) ASAM placement is reviewed every 60 days Primary DX SA client- not seen in 30 days is the client closed Client receiving SA services has a contact at least monthly Primary DX SA client- MCP updated every 60 days Primary DX SA client- MHT has signed off on assessments Compliance documents, paper files and other records are reviewed as a separate annual peer review – reported to the Compliance Officer

XII. Comments and Recommendations

Reviewer comments and recommendations: Therapist / counselor comments: Supervisor comments and proposed follow up: Reviewer signature: Date: Therapist/counselor signature: Date: Supervisor signature: Date:

Form Approved by Executive Committee 2/21/2007


CLINICAL PROCEDURE - CL11 ADOPTED 7/16/2003 SERVICE PRIORITIES 1. Individuals shall be provided services according to established priorities. The adopted protocols shall

be followed at each priority level. 2. The Outpatient Service Decision Tree outlines the range of services including: education classes,

clubhouse, case management, group therapy, individual therapy, medication, COTT, drug court, and residential / inpatient.

3. Inpatient placement shall be determined according to the established protocols for Medicaid enrollees,

individuals considered indigent and individuals with private insurance or Medicare.

4. All programs and services are provided without regard to race, color, national origin, disability or age. (See SERVICE PRIORITIES diagram included in this procedure) (See OUTPATIENT SERVICE DECISION TREE diagram included in this procedure) (See INPATIENT PLACMENT DECISION TREE diagram included in this procedure) (See OUTPATIENT NON MEDICAID SERVICE DECISION TREE diagram in this procedure)

Adopted by the Executive Committee 7/16/2003, Revised 12/20/2006; Revised 5/16/2007

FCCBH, INC. OUTPATIENT NON-MEDICAID SERVICE DECISION TREE

Is evaluation for civil commitment needed?

Evaluate

Is client under order of civil commitment?

Serve

Serve

Is individual at immediate risk of hospitalization, hx

of >1 suicide attempts*, psych hospitalization < 2 years ago?

*Or 1 previous suicide attempt with history sexual abuse

Is clinic mental health discount fee service load <12%

Is fee greater then or equal to cost of service and no wait list of immediate risk clients? IF YES

Refer out or wait list

Is individual SPMI/SED and at substantial risk of hospitalization?

Limited services

No

Yes

No

No Yes

Yes

No

No

Yes

Yes

No

FCCBH, INC. OUTPATIENT SERVICE PRIORITIES

Is individual SPMI/SED

and at substantial risk of hospitalization?

Refer out or wait list

SPMI or SED and civil commitment and/or at risk of hospitalization

Admit to service clubhouse, case management, group psycho-ed or therapy, COTT/wraparound, medication management, inpatient care

Substance abuse only

Admit to service or wait list, aftercare, education group (PRI), IOP, drug court, residential

Funding > 100% of cost, single case agreement, insurance IF NO

Capacity available IF NO

Authorize set number of sessions (<12)

Refer out

Medicaid and GAF >60

Authorize up to 6 sessions

No

No

No

Yes

Yes

Yes

Yes

Yes



CLINCIAL SUPERVISION The following protocol will be followed for clinical supervision.

A. A supervision file shall be established for each staff member being supervised. This file is to include the goal and training pages from the current annual evaluation, a brief statement of your supervision/ development goals for the supervisee and a schedule of supervision appointments. Required documentation includes:

1. Supervision file 2. A copy of the annual evaluation pages in supervision file 3. Development goals 4. Supervision schedule

B. All open cases shall be reviewed at least every 180 days using a printed caseload report.

Reviews shall include the following data on each case reviewed so that over and under utilization of services can be detected. A non-service note shall be entered in the clinical record to document any utilization review findings and changes in the services authorized.

1. Date of last service 2. Diagnosis 3. Progress toward treatment goals and appropriateness of services authorized and

provided to date 4. Funding 5. Authorization for additional services if any and follow up plan 6. Documentation of the review includes notes on caseload report and a non-service

note in the clinical record if any changes in services are authorized C. Quality of services and productivity shall be reviewed at least quarterly. Such reviews shall

include (as appropriate): 1. No show data 2. Productivity report 3. Assessment quality (review at least two randomly) 4. Managed care plan quality (review notes from MC plans approved) 5. Other data as appropriate

a) Activity code use b) P-code report c) Committee assignments d) Contract assignments e) Reports to other agencies

6. Documentation includes: a) Printed data reports b) Documents with supervisor’s notes in supervision file

D. Clinical supervision shall verify that services have been provided through review and approval of the employee time sheet.

1. The FCCBH, Inc. time sheet is the billing record for all services provided and

shall serve as the mechanism for service verification. 2. All time sheets shall be completed by 10 a.m. the following business day with

complete documentation of services provided. 3. The supervisor shall review each time sheet including activity codes, duration,

service hours and the electronic client record including progress notes as appropriate.

4. The time sheet shall be approved by the supervisor weekly. Approved by Executive Committee 10-16-2003; Revised 12 -21-2005; Revised 5-16-2007



TARGETED CASE MANAGEMENT RECORD KEEPING Required Documentation

1. Case managers must develop and maintain sufficient written documentation for each unit of targeted case management services. Documentation in the progress notes section of the client’s clinical record must include at least the following:

a. Name of client b. Date and actual time of service

c. Signature of the individual providing the service

d. Duration of service

e. Description of the targeted case management activity related to the Service

Plan

f. Setting in which the service was rendered

2. The following documents must be contained in each client's electronic record.

a. An electronic individualized needs assessment which documents the client’s need for targeted case management serviced.

b. An electronic, individualized targeted case management service plan that

identifies the services (i.e., medical, social education, and other services) the client is to receive and a general description of the targeted case management activities needed to help the client obtain or maintain these services; and

c. A review of the service plan every 180 days summarizing the client’s

progress toward targeted case management service-plan objectives. The service plan must be completed in the electronic record within the month due or more frequently as required by the client’s condition.

3. Time sheets shall reflect the exact amount of time worked. Access will convert time worked

to Medicaid units of service. (See Personnel Procedure PE13 Recording Time worked.) Adopted by the Executive Committee 1/16/02; revised 8/17/05, revised 7/19/06; revised 4/26/2007


CLINICAL PROCEDURE – CL14 – ADOPTED 10/16/2002; Revised 9/21/05

WRAPAROUND DOCUMENTATION The following protocol will be followed for documentation of wraparound services

A. Wraparound services to FCCBH clients shall be documented in the Four Corners Behavioral Health clinical record as follows:

1. If the primary therapist is present at the wraparound team meeting it is his or her

responsibility to document the session. a) The clinician will code his or her time as individual therapy (code 02 ),

collateral (04), family treatment (11), TCM (15) as appropriate. b) The clinician shall enter a progress note for this service

2. If their primary therapist is not present, documenting the session becomes the

responsibility of the Four Corners’ case manager. a) The case manager will code his or her time as targeted case management

(activity code 15) if the MC plan calls for such and there is a current TCM assessment and plan.

b) If the MC plan does not list targeted case management as a planned service code the service as 02 therapeutic behavioral services. The following are eligible to provide this service, psychologist, LCSW, CSW under the supervision of an LCSW, an APRN, MFT, LPC, supervised therapy student, RN, SSW or working toward SSW under the supervision of a licensed therapist. Enter a progress note for this service.

B. The progress note shall conform to the current FCCBH, Inc. progress not format and include:

1. The fact that this is a wraparound team meeting. 2. All members of the team present. (I) 3. The note should state any specific assignments given to any member of the team

including the child or family. (O) 4. The note should state when and where the next team meeting would be held. (O)

Adopted by the Executive Committee 10/16/02; Revised 9/21/2005



USE AND DOCUMENTATION OF AIMS Yearly Assessment for Clients Receiving Neuroleptics Each physician serving FCCBH, Inc. clients shall conduct a yearly assessment for involuntary movement for any client receiving neuroleptics for longer than six months. The AIMS shall be used to assess involuntary movement. Documentation The assessment shall be documented by stating in a medical note that an AIMS has been completed and by placing a copy of the AIMS in the client’s physical chart if the AIMS form is filled out. Adopted by the Executive Committee 8/11/2004



INDIVIDUAL PROGRESS NOTES FOR GROUPS Group Session Documentation 1. Individualized progress notes shall be documented for each group member at

every group session. a. Progress notes are required for every group participant for weekly groups.

b. Progress notes are required at least once per week for groups that meet more than one time a week such as IOP.

2. Therapeutic progress shall be noted under the outcome section of the progress

note. Adopted by the Executive Committee 8 /11/ 2004



EMERGENCY, INCIDENT, AND SUICIDE REPORT FORMS 1. The form for reporting non-client clinical emergency contacts described in Policy 1.10

Reporting Incidents, Emergencies and Suicides, is the Request for Services Tracking Form dated 7/03.

2. The form for documentation of client deaths that meet the criteria described in Policy

7.15 Fatality Review Procedure is the FCCBH Fatality Review form dated 2/02. In addition the Deceased Client Report required by the Department of Human Services, the Division of Substance Abuse and Mental Health must be submitted within three days if the fatality meets the eligibility requirements of the policy.

3. The form for documentation of a non-client completed suicide as described in Policy1.10

Reporting Incidents / Emergencies / Suicides is the FCCBH Suicide Staffing form dated 10/04. The form for use in the review process is the FCCBH QI Suicide Review Form dated 2/02 if required.

4. The form used to report incidents with injury or damage to property as explained in

Policy 1.10 Reporting Incidents / Emergencies / Suicides is the FCCBH, Inc. Incident Report (for clients or employees) dated 2/02. For vehicle accidents the correct form is the FCCBH Report of Accident dated 5/03. The driver must get a UA within twenty-four hours as described in Policies 1.17 and 2.09.

5. The FCCBH, Inc. Suicide, Emergency and Incident Response and Documentation flow

chart shall be provided to each clinical office to clarify responsibilities and documentation.




MEDICATION ONLY PROTOCOL For clients with receiving medication only services the following shall apply: 1. The case must be staffed with the treating physician and the clinic supervisor. 2. The client must be stable. Meds only is not a default mode for a client who requires

services but is non-compliant. 3. The chart must be current: signed psychiatric assessment within five years, current

managed care plan; congruent diagnosis. 4. The clinic supervisor shall decide on the caseload maximum for the RN. It may not be

feasible to transfer all eligible clients to the RN ‘s caseload. Adopted by the Executive Committee 2/16/2005


CLINICAL PROCEDURE – CL23 ADOPTED 7/2001 CIAO A. The Adult Probation and Parole (AP&P) officer makes a referral to FCCBH, INC. using the CIAO

Referral (attached) form to: Carbon: Carol Powell at 637-2358 Emery: Kari Alton at 381-2432 Grand: Gen Numaguchi at 259-6131 B. AP&P shall direct the client to make an appointment for intake with above named person. C. FCCBH, INC. staff shall conduct an assessment (ASI/ASAM) and notify AP&P and the Four

Corners business office of referral status (attached form). There shall be no co-pay charged for the assessment, but FCCBH, Inc. shall bill the Utah Division of Substance Abuse and Mental Health for the CIAO services. (The assessing therapist must send the intake sheet on CIAO assessments not opened marked “BILL CIAO FOR ASSESSMENT” to the business office.).

D. FCCBH, Inc. shall send all CIAO assessments to the referring AP&P officer. E. If referral accepted:

1. Client shall be opened as FCCBH, INC. client with CIAO listed as insurance, probation or parole as referral source and pay $100 pre-payment for residential. (The supervisor may waive or reduce the fees on a case-by-case basis using the FCCBH, Inc. Client Assistance form.)

2. Client receives indicated treatment and FCCBH, INC. provides AP&P monthly progress

report on CIAO Status Report (attached form). Four Corners staff shall telephone AP&P on all unexcused absences.

3. FCCBH, INC. must provide the probation officers and the State Division with monthly status

report on CIAO Status Report form. 4. FCCBH, INC. bills State for CIAO slot.

5. FCCBH, INC. business office notifies the county supervisors and AP&P when CIAO slots

have been exhausted for the year. F. CIAO requires that participants submit at least two drug tests per week. G. At a minimum the following outcome messages shall be collected for CIAO clients: 1. The number of offenders who complete the program successfully. 2. Measure the length of time in treatment. 3. Measure drug use within 30 days at both intake and discharge. 4. Measure employment at both intake and discharge. Adopted by Executive Committee 7/2001, Revised 6/6/2005

CIAO REFERRAL STATUS REPORT

Client Name: _____________________________________________ has completed a Substance abuse assessment on _________________________ at the ___________________ Office of FCCBH, INC., Inc. He/she has/has not been accepted for treatment. Based on this assessment, treatment is (Circle appropriate items)

Is recommended at ASAM Level (check one): ___ Level I General Outpatient ___ Level I Dual Diagnosis ___ Level II.1 IOP ___ Level III.5 High Intensity Residential

Substance Abuse Counselor:_________________________________________________ cc: Business office

Four Corners Community Behavioral Health

CIAO RELEASE OF INFORMATION

CLIENT’S NAME: ___________________________________ DOB _______/________/_______ ADDRESS:_______________________________________________________________________ I ________________________________________________________hereby authorize Four Corners (Client name) Community Behavioral Health, Inc. to release the information described below to my AP&P Officer and the Utah Division of Substance Abuse and Mental Health. I hereby authorize Utah State Corrections to release the information described below to Four Corners Community Behavioral Health, Inc. and the Utah Division of Substance Abuse and Mental Health. The purpose of and need for the disclosure is to inform the criminal justice agency listed above, Four Corners Community Behavioral Health, Inc. and the State Division of Substance Abuse and Mental Health of my attendance and progress in treatment and related information. The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, UA results, prognosis, employment and education status, living arrangements, parole/probation violations, criminal charges and the status of my financial obligations to the criminal justice system. I understand that this consent will remain in effect and cannot be revoked by me until: _____ There has been a formal and effective termination or revocation of my

release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment, or

_____ ___________________________________________ (Other time when consent can be revoked and/or expires)

_____________________________________________ ________________________ Signature of defendant/client Date _____________________________________________ ________________________ Parent or Guardian’s Signature if required Date _____________________________________________ ________________________ Witness Date NOTICE TO RECIPIENT: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations (42CFR Para II) prohibit you from making any further disclosure of it without specific, written consent from 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 paper.

9/00


CIAO REFERRAL FORM

Client Name: ________________________________ Date of Referral:_____________ Legal Status (check one): _____Probation _____Parole Client address: ___________________________________________________________

___________________________________________________________ Client phone:________________________________________________________________ AP&P Officer:____________________________________ Phone #:___________________ Offense:____________________________________________________________________ Incarceration history: ______________________________________________________ ________________________ ______________________________ ________________________ ______________________________ Issues/Reason for referral: _____________________________________________________ Financial hardship consideration requested: ______Yes ______ No Substance Abuse History: _________________________________________________

_________________________________________________ Substance Abuse Treatment History:_____________________________________________ ______________________________________________ Attached materials: _____Pre-sentence Report (Dated___________) _____Pri son Report (Dated__________) _____Other assessment material _____Release of Information 7/01



MINIMUM RENT FOR HOUSING A. A FCCBH, Inc. client who is a resident of a Four Corners sponsored housing facility and

who has no income shall be required to pay a minimum of twenty-five dollars per month in rent. 1. The required payment for a client with no income shall be thirty-five dollars per

month at the Willows housing unit in Grand County. 2. The client’s income shall be re-evaluated on a monthly basis. B. The Housing Authority rules regarding TE earnings shall apply for individuals living in a

Four Corners sponsored housing facility if the individual has no other source of income. C. Imputed income derived from investments, gifts, charity or other sources shall be

considered income for the purpose of establish the monthly rent. Adopted by the Executive Committee 6/15/2005



TRANSPORTING CLIENTS FOR OUT OF COUNTY ACTIVITIES

A. A current driver's license in good standing shall be required for all drivers transporting clients in Four Corners Community Behavioral Health, Inc. vehicles.

B. The FCCBH, Inc. Emergency Preparedness Trip Report form shall be completed when

clients are transported out of the county for a service or activity. The form shall include the following:

a. Date of service or activity b. The location of departure (work site) c. The staff members who will be on the trip d. Cell phone number (s) to reach staff e. Description of FCCBH, Inc. or State vehicle f. Time leaving and expected return time g. Names of participants, clients and other passengers

C. The completed trip report shall be faxed to the Administrative Office prior to departure

time. a. The cover sheet shall be marked “Emergency Preparedness.” b. The Administrative Secretary shall retain a file of trip reports c. The Clinic Office Manager shall retain a copy of trip reports

C. A parent permission from shall be completed and signed for all clients under the age of eighteen prior to traveling for an activity or program. Parent permission forms shall be submitted to the Associate Director prior to departure.

D. Adequate safeguards and reasonable steps shall be taken to maintain the confidentiality of

all Protected Health Information (PHI) including the identity of clients. Client activities shall be reserved for:

a. Clients b. Employees as assigned c. FCCBH, Inc. volunteers who have completed the required volunteer packet and

orientation d. Partner agency staff who have signed a Release of Information or a Non-

Employee Confidentiality Agreement

E. Incidents, accidents or other reportable conditions that occur during the trip shall be reported to the Administrative Office and the program supervisor within twenty-four hours. Incident forms shall be used as defined in Procedure CL21, Emergency, Suicide and Incident Report Forms.

Adopted by the Executive Committee 9/21/05; Revised 10/18/06; Revised 2/21/07

Related documents: Administration Policy 1.17 Travel Rules and Regulations, Release of Information, Non-Employee Confidentiality Agreement, Emergency Preparedness Trip Report, Operations Procedure OP25 Vehicle Passengers, Clinical Procedure CL21 Emergency, Suicide and Incident Report Forms

Four Corners Community Behavioral Health, Inc. Emergency Preparedness

Trip Report

Date ___________________________ Work Site ____________________________________

Staff member(s) who will be with the children/youth and/or adult clients________________

______________________________________________________________________________

Cell phone number (s) to reach staff_______________________________________________

What vehicle will be used to transport participants? _________________________________

Time Leaving ___________ Expected return time ___________ Planned Duration ________

Description of trip _____________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Names of participants

_____________________________________ ________________________________________

_____________________________________ ________________________________________

_____________________________________ ________________________________________

_____________________________________ ________________________________________

_____________________________________ ________________________________________

Other passengers

____________________________________ Status Trained Volunteer Signed ROI Confidentiality Agreement

____________________________________ Status Trained Volunteer Signed ROI Confidentiality Agreement

Additional information:

Fax completed form to administration, note Emergency Preparedness on cover-sheet.; copy office manager .

2/21/07



HOSPITALIZATION PROCEDURES AND PRIOR APPROVAL PROTOCOL Prior approval procedures for admission for acute inpatient psychiatric services shall be as follows: 1. During normal business hours prior approval must be obtained before any acute inpatient

psychiatric admission to inpatient hospital / organizational contractor or the Utah State Hospital Adult Recovery Treatment Center (ARTC). Admissions made after normal business hours and on non work days shall be approved the next business day.

A. The Medicaid Prepaid Mental Health Plan Contract requires that FCCBH, Inc. will pay for

Emergency Services where the presenting symptoms are of sufficient severity that a person with average knowledge of (mental) health and medicine would reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

2. The following criteria must be met for an individual to be admitted for acute inpatient

psychiatric services:

A. The patient has a DSM-IV psychiatric principal diagnosis; B. The patient requires active treatment of an intensity provided only in an inpatient hospital

setting; and C. The patient meets the requirements for voluntary admission or involuntary commitment to a

mental health authority pursuant to Utah Code Title 62A, Chapter 12, Part 2. 3. FCCBH, Inc. shall obtain the following patient information if it is available prior to referral for

admission to an inpatient facility;

A. demographic data including Medicaid number; B. current specific patient statements and symptoms; C. diagnosis (ses); D. current ability to function in life roles (work, school, home); E. current outpatient treatment including last appointment, medication, and whether the

therapist has been contacted and a summary of the therapist’s recommendations; F. previous inpatient, outpatient treatment; G. current danger to self or others, including response to offer of developing a no suicide

contract and outpatient plan for treatment; H. precipitant to seeking hospitalization; I. alcohol / drug problems last usage; J. medical problems and complications; K. current medications being taken;

Adopted by the Executive Committee 9/21/2005; revised 4/26/2007

L. perceived supports and degree to which they have been mobilized; M. relevant life experience including history of abuse and current stressors; and N. goals of this hospitalization and requested length of stay.

4. If this information substantiates that the individual has a DSM-IV psychiatric diagnosis and that

he or she requires active treatment of an intensity provided only in an inpatient setting the admission may be approved. The Managed Care Coordinator (MCC) shall review and approve inpatient placement prior to hospitalizations and work with staff to secure an inpatient bed.

5. Refer to protocols in Policy 1.26, Contracts Inpatient Hospital Services. The following client hospitalization procedures shall be followed; 1. Castle Dale (CD)

A. Staff shall evaluate individual for hospitalization using the Emergency, Crisis, Hospitalization and Diversion Guidelines and Strategies prepared by the Managed Care Coordinator (MCC) and prior approval procedures outlined in this procedure.

B. If staff making the evaluation determines that hospitalization is indicated staff are responsible to: a. make sure the client is open (all intake paperwork completed with allowance for

emergencies) ; b. staff the case with the CD supervisor and the MCC for appropriateness or diversion; c. work with the MCC to secure an inpatient bed; d. complete any required paperwork (pink sheet, hospital referral form, etc.)

i. Arrange for transportation to the Castleview Emergency Room (ER) for medical screening (and the inpatient unit).

ii. Alert the Castleview ER and Carbon on-call worker. C. Carbon on-call worker shall meet the client at the Castleview ER to facilitate the process of

medical screening and doctor to doctor transfer to the inpatient facility. i. The Carbon on-call worker shall notify the inpatient unit of the estimated time of

arrival (ETA) of the client when the screening is complete.

2. Price

A. Staff shall evaluate individual for hospitalization using the Emergency, Crisis, Hospitalization and Diversion Guidelines and Strategies prepared by the Managed Care Coordinator and prior approval procedures outlined in this procedure.

B. If staff making the evaluation determines that hospitalization is indicated staff are responsible to: a. make sure the client is open(all intake paperwork completed with allowance for

emergencies); b. (during business hours), staff the case with the Carbon supervisor and MCC for

appropriateness or diversion; c. (during business hours) work with the MCC to secure an inpatient bed; d. complete any required paperwork (pink sheet, hospital referral form, etc.); e. arrange for transportation to the Castleview ER for medical screening (and the inpatient

unit); f. alert the Castleview ER;

g. meet the client at the Castleview ER to facilitate the process of medical screening and doctor to doctor transfer to the inpatient facility; and

h. notify the inpatient unit of the ETA of the client when the screening is complete.

3. Moab

A. Staff shall evaluate individual for hospitalization using the Emergency, Crisis, Hospitalization and Diversion Guidelines and Strategies prepared by the Managed Care Coordinator and prior approval procedures outlined in this procedure.

B. If staff making the evaluation determines that hospitalization is indicated staff are responsible to: a. make sure the client is open (all intake paperwork completed with allowance for

emergencies) ; b. (during business hours), staff the case with the Grand supervisor and MCC for

appropriateness or diversion; c. (during business hours) work with the MCC to secure an inpatient bed; d. complete any required paperwork (pink sheet, hospital referral form, etc.); e. arrange for transportation to the Allen Memorial ER for medical screening (and the

inpatient unit); f. alert the Allen Memorial ER; g. meet the client at the Allen Memorial ER to facilitate the process of medical screening

and doctor to doctor transfer to the inpatient facility; and h. notify the inpatient unit of the ETA of the client when the screening is complete.


CLINICAL PROCEDURE – CL29- ADOPTED 3/15/2006 CREW CRITERIA 1. Can-Do-Crew services may be provided only to an individual who meets the following

criteria: a. Is an open client of FCCBH, Inc. b. Has a current Medicaid card with FCCBH, Inc. listed as the designated mental

health provider. c. Has a goal on their managed care plan for which Can-Do-Crew services are an

appropriate treatment method and psycho-educational services and / or vocational rehabilitation and / or psychosocial rehabilitative services group skills development is listed as a method on the current managed care plan

d. The ability to perform the required work and benefit from the services in the judgment of the individual’s therapist and the Can-Do Crew supervisor.

e. Willingness to work under the direct supervision of the Can-Do-Crew supervisor. f. Comply with the FCCBH, Inc. Drug Free Work Place Policy.

i. Crew employees who test positive will have 72 hours from the time of the positive test to request that a second test be done on the "split" portion of their drug specimen. The cost of the second test will be split equally between the employer and the employee as outlined in Section 34-41-103.

ii. If the second test is positive or if the Crew member waives the second test, the Crew member shall be suspended from employment with FCCBH, Inc. for a minimum of three months.

iii. If a Crew member tests positive a second time after reinstatement as a FCCBH, Inc. employee he or she shall be terminated and may not reapply for employment for 12 months.

iv. Psychosocial Program employment does not eliminate the client’s right to privacy. Protected health information related to drug testing, alcohol testing and sample collection, transmittal or reporting of test results shall be protected to the same standard as all client records.

2. A waiver for 1. b. (above) can be approved by the Carbon/Emery Psychosocial Team

supervisor under the following conditions: a. The individual agrees to purchase a Medicaid card by spending down the amount

required by Medicaid b. The Medicaid card must be purchased within one month of the start of Can-Do-

Crew services.



CLINICAL PROCEDURE – CL30- Adopted 1/18/2006 HIGH RISK LIST 1. Individuals on the High Risk list should meet the following criteria:

a. Hospitalization within 90 days b. Suicide attempt within 60 days c. Substantial risk of hospitalization (psychiatric, not SA) or on hospital diversion d. Civil Order of Commitment

2. A high risk list shall be staffed weekly and shall include:

a. Report on contacts within last week b. Report on assignments from previous week c. Scheduled contacts for week d. Any follow-up assignments

3. The staffing of a High Risk list shall be documented with:

a. Weekly staffing minutes b. Optional non-service note in chart c. Non-service note required when individual is moved on or off the High Risk list.

4. Maintenance and Review

a. High Risk file shall be kept in each office. i. The file shall include all High Risk staffing notes

b. On-call workers shall review file at start of rotation c. A copy of each weekly list shall be submitted to the Clinical Director

Adopted by the Executive Committee on 1/18/2006


CLINICAL PROCEDURE – CL31 – Adopted 3/16/2006 FCCBH, Inc. REFERRAL STANDARDS FCCBH, Inc. will provide high quality, responsive and professional services whenever a partner agency makes a formal referral. 1. Referrals will be formally acknowledged within two working days of receipt.

a. The staff member making the referral will be advised whether FCCBH can or cannot accept the referral. This decision will be based on the following factors:

i. Is the service requested medically necessary for the diagnosis or treatment of a mental or substance use disorder?

ii. If the source of payment for the service being requested is Medicaid, is the service being requested within the Medicaid scope of service?

01. Evaluations for the purpose of diagnosing an organic (neurologic) disorder or a developmental disorder/mental retardation are not covered by Medicaid and requests for them will not be accepted regardless of the source of payment.

02. Evaluations requested by a court or the Utah Division of Child and Family Services solely for the purpose of determining if a parent is able to parent and should therefore be granted custody or visitation rights, or whether the child should be in some other custodial arrangement are not covered by Medicaid and requests for them will not be accepted regardless of the source of payment.

iii. For referrals of non-Medicaid covered individuals, is there a source of payment that FCCBH accepts for the cost of the service being requested?

iv. Is the service requested within our expertise to provide? v. Has the referring agency made the referral in writing and provided adequate

background information in writing? 2. FCCBH will attempt to secure a release of information from each client referred if the

referring agency has not provided one. 3. If the client has signed a release, a written report will be provided to the referring agency

within 15 working days of the client’s first appointment. 4. FCCBH will provide a written report on the client’s progress within 10 working days of any

written request by the referring agency provided a release of information is in place giving permission to do so.

5. The referred individual’s primary therapist will answer any emails and return any phone calls from the referring agency within two working days.

6. FCCBH staff will activate out-of-office email messages for any period they are out of the office for more then two consecutive days.

7. FCCBH support staff will advise referring agencies calling to speak to a primary therapist whenever the therapist will be out of the office for more then two consecutive days.

Adopted by the Executive Committee 3/16/06, Revised 4/17/06


CLINICAL PROCEDURE – CL32 – Adopted 8/22/2006 UNSIGNED AND MISSING CLINICAL DOCUMENTION 1. Clinical supervisors shall monitor client records to identify blank or unsigned assessments,

evaluations and progress notes. 2. Progress notes cannot be deleted. Progress notes with no text may be amended with the

statement, “delete blank progress note.” 3. Clinical supervisors may request authorization to delete blank assessments, evaluations and

other clinical records except progress notes. a. A request shall be submitted to the Clinical Director to include:

i. Client # ii. Date of record

iii. Record type iv. Supervisor v. Reason for requested deletion

b. The Clinical Director shall review each request and on approval forward the request to the Compliance Officer.

c. The Compliance Officer shall review the request for compliance with law, rules and regulations.

d. The Compliance Officer shall advise clinical supervisors that authorization to delete has been approved or not approved.

4. Each clinic Supervisor shall establish procedures to insure that MD evaluations and progress

notes are completed and signed by the end of the physician’s next work day at that clinic. a. MD progress notes shall be created and / or entered at the time the service is

provided so that blank progress notes are not created for appointments not kept. 5. Only the individuals who provided the clinical service are authorized to sign assessments,

progress notes or Managed Care Plans.

Approved by the Executive Committee 8/22/2006


CLINICAL PROCEDURE – CL34 – ADOPTED 10/18/2006 EMERGENCY RESPONSIVENESS AND CLINICAL DIRECTOR NOTIFICATION I. In order to maintain a sound reputation for quality services and responsiveness the Four Corners

Community Behavioral Health, Inc. Clinical Director and the appropriate clinical supervisor shall be notified of problems arising in the operation of the FCCBH, Inc. emergency system including:

1. Problems with local or psychiatric hospital staff (e.g., lack of responsiveness, refusal to

admit, problems with medical clearance, etc.) 2. Difficulties with the Sheriff’s Office (e.g., refusal to transport, inappropriate demands, etc.)

3. Other significant problems

II. Staff observing any of the problems described above shall notify his or her supervisor and the

Clinical Director by the end of the next business day. Approved by the Executive Committee on 10/18/2006


CLINICAL PROCEDURE – CL35 – ADOPTED 3/16/2006 REVIEW OF INVOLUNTARY COMMITMENT UNDER COURT ORDER Review of involuntary commitment under court order. Utah Statute 62A-15-631 calls out different procedures for individuals under commitment for a determinate period (paragraph 11b) and those committed for an indeterminate period (paragraph 11c). The following procedure would align FCCBH with this statute. If an individual is under a 6 month (determinate) commitment the FCCBH supervisor will request that court clerk contact the local supervisor or designee about two weeks prior to the end date of the commitment and inform him/her of the approaching hearing date. After that contact, the supervisor or designee shall staff the case and determine if the reasons justifying the commitment still exist. If the supervisor, with staff input, determines that the commitment is justified, the supervisor shall identify two designated examiners and recommend those to the court clerk and write a Court Note using approved FCCBH format. Upon receipt of the DSAMH Form 36-6, the designated examiners appointed by the court shall schedule appointments with the individual and make a report on the appropriate document (Report of Designated Examiner-2003 revised). This report and the Court Note are distributed to the court, county attorney, and defense counsel prior to the hearing date. If the supervisor, with input from the staff, determines that the conditions justifying the commitment no longer exist, the supervisor shall discharge the individual from involuntary commitment and report this to the court, the individual and counsel with the appropriate document (DSAMH form 42) prior to the hearing date. If the order of commitment is for an indeterminate period, the case shall be staffed at the first adult staff meeting of the month every sixth month from the date of the initial commitment. Staff shall reexamine the reasons upon which the order of indeterminate commitment was based. If, with input from staff, the supervisor determines that the conditions justifying the commitment no longer exist, the individual and the court are informed by the appropriate document (DSAMH form 42) that the individual is discharged from the custody of FCCBH. If the supervisor, with input from staff, determines that the continued commitment is justified, the supervisor shall notify the court, the individual and the individual’s counsel of such with the appropriate document (DSAMH 36-14). This document also informs the individual of the right to a review hearing upon request to the court. If a hearing is requested, the court clerk will contact the supervisor and request two designated examiners be recommended. The examiners shall report their findings on the appropriate document as above (Report of Designated Examiner-2003 revised) and the supervisor shall write and distribute a Court Note (as above). Adopted by the Executive Committee: 3/16/2006


CLINICAL PROCEDURE – CL36 – ADOPTED 8/11/2004 DUI SCREENING AND SUBSTANCE ABUSE ASSESSMENT PROCEDURE

Service Content Product Cost Procedure DUI Screening

SASSI, MAST, BAL at arrest, Short interview (30 min./LSAC) ASI (optional per supervisor),

Form/ Report

$75 billed to county If out of county-self pay

Clinic bills county clerk with copy to Admin. Code as Non-client-01/NCC/Contract 1 (SA)

SA Assessment/ICA [DCFS, Court, AP&P, self referrals]

As above plus full ICA by MHT, ASI & ASAM

ACCESS ICA

$100 minimum discount fee plus insurance, or Medicaid. 120% for out of area.

Open as client. Code as activity 01.

DUI Class 8, 2-hour PRI classes $250 self pay Non-client service, Code as activity #34, PRI forms and PATS

Adopted by the Executive Committee 8/11/2004, Re-distributed 9/13/06

DUI SCREEN

No intervention

DUI CLASS

ICA, Treatment



SUPPORTED HOUSING BED DAYS The purpose of this procedure is to establish rules about supported housing bed days for clients that leave the facility for one or more days.

1. Residents who leave supported housing for fourteen days or more shall be discharged. a. Residents who are discharged may be eligible for re-admittance if the individual

is homeless and a bed is available.

2. Residents who leave supported housing for personal reasons for less than fourteen days shall be considered current residents and shall be required to pay the daily rate to hold the bed.

3. Individuals admitted to the State Hospital for inpatient care shall be discharged the day

following admittance. a. Residents who are discharged due to hospitalization may be eligible for re-

admittance if the individual is homeless and a bed is available.

4. Residents admitted to jail for less than fourteen days shall be required to pay the daily rate to hold the bed.

5. The census of the supporting housing facility shall be considered the number present at

home that day. Adopted by the Executive Committee 2/21/07

Four Corners Community Behavioral Health Clinical Procedure


DUAL RELATIONSHIPS Four Corners Community Behavioral Health, Inc. professional staff shall follow established guidelines when a therapist, counselor or physician engages in a secondary relationship with a client in addition to the clinical role. The secondary role may either be personal or professional.

1. Any dual relationship shall be considered: a. Unethical if it exploits the client or the therapeutic relationship; and b. Undesirable if it impairs the judgment or the performance of the clinician

within the therapeutic relationship. c. Undesirable if it impairs, or has the potential to impair the access to services

for the client or a family member.

2. When a dual relationship occurs therapeutic and professional boundaries shall be maintained. The professional therapeutic relationship shall have priority over any other role. No other relationship shall interfere with the integrity of the therapeutic relationship.

3. Employees shall declare any conflict of interest that results from a dual relationship. The following shall be considered inappropriate conflicts associated with a dual relationship.

a. Disclosing information acquired as an employee for another's personal benefit.

b. Accepting employment or volunteer responsibilities, which would impair independence of judgment in the performance of duties in the employee’s position.

c. Utilizing FCCBH, Inc.’s resources for another’s personal benefit. d. Involvement in an outside activity, which may require improper disclosure

or use of confidential information. e. Being a volunteer of another entity which has programs or activities that

directly relate to the employee’s clinical duties. f. Outside involvements, which could reasonably compromise FCCBH, Inc.

services to clients. g. Secondary relationships that could reasonably give rise to criticism or

suspicion of conflicting interests or duties Approved by the Executive Committee on 4/26/2007

4. The following dual relationships shall require that the client be transferred to another

clinician, therapist, counselor, physician or agency a. Personal friend or relative b. Business partner c. Teacher d. Supervisor e. Religious leader f. Co-worker

5. FCCBH, Inc. considers it a potentially inappropriate dual relationship for FCCBH,

Inc. to provide treatment for an employee or volunteer or the immediate family member of an employee or volunteer.

a. If the family member of an employee or volunteer is a Medicaid enrollee living in the FCCBH, Inc. catchment area he or she is considered eligible to receive services at FCCBH, Inc. In this situation the employee or volunteer must discuss the intent of the family member to seek services at FCCBH, Inc. and the dual relationship and appropriate boundaries.

b. Such treatment may be provided on approval of the FCCBH Clinical Director if the proposed client requires the comprehensiveness of services only reasonably available at FCCBH, Inc.

c. In the event that such treatment is authorized, all other safeguards enumerated in this procedure continue to apply.

6. It is the responsibility of the treatment provider to obtain informed consent from the

client when entering into a dual relationship. The boundaries of the treatment relationship should be discussed and agreed to as part of the informed consent process. Documentation of the discussion should be included in the clinical record.

7. Protection of life or client welfare supersedes any other guidelines concerning the

management of dual relationships.



SUBPOENAS AND WARRANTS Four Corners Community Behavioral Health, Inc. shall follow 42 CFR federal alcohol and drug treatment confidentiality-regulations for warrants and subpoenas. In general, the confidentiality regulations shall apply whether the person seeking the information already has it, is seeking it for a judicial or administrative proceeding, is a law enforcement or other government official or has a subpoena or a search warrant. Warrants / Subpoenas from Law Enforcement 1. An ordinary subpoena, arrest warrant or search warrant shall not provide authorization to disclose

client identifying information. FCCBH, Inc. shall not identify if: (1) an individual is a client or (2) the individual is known to the employee or FCCBH, Inc. or (3) the client is on the premises. Identification of a client may be allowed with proper written authorization to release information.

2. Attempts to get information that identifies a FCCBH, Inc. client or to enter the premises or

property where FCCBH, Inc. services are provided to question, arrest, find or identify a client shall be responded to as follows:

“I am sorry but I cannot help you. Our program is covered by federal substance abuse regulations that prohibit us from disclosing whether-or-not we even know this individual. I am afraid I have to ask you to leave.”

3. Law enforcement officers shall be treated as professionals trying to do a job. 4. If there is resistance to comply with the confidentiality regulations ask if the officer wants to speak

to your supervisor, the Executive Director or the Compliance Officer. 5. A copy of 42 CFR regulations shall be available and provided to law enforcement as needed. Court Orders 1. FCCBH, Inc. shall not disclose confidential patient-identifying information based on a court

ordered subpoena unless procedures and determinations specified in the regulations are met including:

a. Disclosure of a “confidential communication” that is necessary to protect against a threat to life or of serious bodily injury, is necessary to investigate or prosecute an extremely serious crime (see 42 CFR § 2.63 for list of crimes), or is connected with a proceeding in which the client has already presented evidence concerning the confidential communication.


b. A court finding that there is "good cause" for the disclosure. (A determination that the

public interest and the need for disclosure outweigh any adverse effect on the patient, doctor-patient relationship, or the effectiveness of services)

c. Notice to FCCBH, Inc. and the client of the application for the order and an opportunity to make an oral or written statement in response. (No notice is required if a criminal prosecution is involved. 42 CFR § 2.65 – 66) If no notice is required other regulations shall still be in effect.

d. Court order proceedings in connection with the application must be confidential unless the patient requests otherwise.

e. Use of a fictitious name for the application and any court order to protect a client’s identity.

f. If the information is available from another source, the court may not issue the order. g. Disclosure must be limited to the information essential to the purpose of the order. h. Information must be restricted to those persons who need it to fulfill the purpose of the

order 2. The program supervisor shall contact an officer of the court to explain that information will not

be forthcoming based on the subpoena unless the requirements in law are met. 3. FCCBH, Inc. may disclose information about a client if the client authorizes it by signing a

valid consent form. a. Whenever a disclosure is made based on a release of information it must be

accompanied by a written notice prohibiting re-disclosure. FCCBH, Inc. Initiated Crime Investigation 1. FCCBH, Inc. may release patient-identifying information to law enforcement where a client permits

or threatens to commit a crime on a program premises or against program staff. Staff may give law enforcement the client’s name, address and last known whereabouts. Staff shall not report other client crimes or information.

2. FCCBH, Inc. staff shall protect other clients’ identifying information while law enforcement is on

the premises to investigate a crime as described in #1 above. 3. Investigating officers shall be asked to sign a confidentiality agreement to respect the privacy rights

of clients present. 4. FCCBH, Inc. shall maintain a sign at each location that states: “Due to 42 CFR and HIPAA Privacy

Rule regulations FCCBH, Inc. cannot disclose client identifying information without client’s written authorization.”



UTILIZATION REVIEW Four Corners Community Behavioral Health, Inc. (FCCBH, Inc.) protocols for detecting under and over utilization of services for Medicaid Enrollees (hereinafter referred to as “clients”) shall be described in the Quality Assurance and Performance Improvement Plan (QAPI). FCCBH, Inc. shall conduct utilization reviews to detect under and over utilization of services through the following methods: 1. Multi-Disciplinary Team Staffings

a. All initial intake Mental Health Evaluations will be staffed with the clinic multi-

disciplinary team or clinic supervisor for appropriateness of diagnosis and assignment of treatment provider. Service and utilization authorizations will also be included. The psychosocial history and reported symptoms will be shared with the team.

b. The results of the staffing are reflected in the team’s development of the Managed Care Plan.

c. To ensure appropriate utilization of services and assignment of the primary treatment provider, decisions regarding treatment methods including frequency and duration will be made at the weekly clinical staff meeting held at each outpatient clinic under the direction of the clinic supervisor.

d. The clinic supervisors will provide a report to the QAPI Chairperson on relevant utilization issues from multi-disciplinary team case staffings monthly.

2. Inpatient Monitoring and Reviews

a. The Managed Care Coordinator (MCC) and the Executive Director or his/her designee

will review each client receiving inpatient hospital services on a regular basis. b. The MCC will ensure appropriate utilization of inpatient care through on-site visits and

telephone consultation with the hospital. c. The MCC will monitor the client’s progress and need for hospitalization through review

of the hospital’s case staffing, reviewing utilization, and through consultation with relevant treatment providers and the client.

d. The MCC will oversee the length of stay for appropriateness and will ensure that arrangement of outpatient services is timely and coordinated with the relevant FCCBH, Inc. staff and the hospital.

e. The Managed Care Coordinator will provide a report to the QAPI Chairperson on relevant utilization issues quarterly.


3. Peer Record Review Process

a. The Peer Review process will also be used to determine possible under or over utilization

for open clients who have been receiving treatment for longer than six months. b. The Quality Review Tool will look for documentation indicating that a peer consultation

staffing has occurred after six months of treatment to ensure that the client’s treatment is progressing.

c. The review will also determine if the Managed Care Plan is being utilized, if client progress on goals is indicated and the client’s participation in treatment is still appropriate. Efforts to ensure proper care is received and coordinated will be documented and monitored in the client’s clinical service records.

d. In the month prior to the clinic peer review the Committee, with assistance from the MIS staff, will run a computer generated sampling of records for open Medicaid clients with a completed Mental Health Evaluation and defined parameters. The utilization review will also be conducted at the same time as the peer record review to detect possible under or over utilization of services provided to the client.

e. The QAPI Chairperson or designee will summarize the review including utilization trends and systemic issues. The QAPI Chairperson will present the report to the QAPI Committee for recommendations and to the Executive Committee at the next scheduled meeting. The Executive Committee will give final approval on the report and recommendations and take action on policies and procedures for systemic issues.

4. Data Analysis

a. The Committee will review data for utilization issues. Relevant data indicators will be identified through the multi-disciplinary team process, service and utilization authorizations, inpatient reviews and the peer record review process.

b. The clinic supervisors will provide a report to the QAPI Chairperson on relevant issues and data indicators identified from multi-disciplinary team case staffings monthly.

c. The Committee will establish a list of data indicators to analyze for possible under or over utilization at least annually.

d. Reports will be generated by MIS staff for selected indicators and methods will be identified and implemented to track utilization indicators that are not currently collected.

e. Data and information will be examined by the Committee at the following Committee meeting. The Committee will also identify next steps for further analysis of the data indicators in order to determine any under or over utilization.

f. The QAPI Chairperson will summarize conclusions and findings related to under or over utilization and present a report and recommendations to the Executive Committee at the next scheduled meeting.

g. The Executive Committee will give final approval on the report and recommendations and take action on policies and procedures for systemic issues.

h. The QAPI Chairperson or designee will make recommendations for individual clinical supervision regarding possible under or over utilization.


CLINICAL PROCEDURE – CL41 – ADOPTED_____

OQ (Outcome Quality), YOQ (Youth Outcome Quality) Administration and Documentation Four Corners Community Behavioral Health, Inc. (FCCBH, Inc) in compliance with Utah State Division of Mental Health and Substance Abuse shall administer the OQ and YOQ to all clients and document the outcome scores as outlined below. 1. Administering the OQ and YOQ tool:

a. The OQ and YOQ tool will be available at each clinic on a PDA (Personal Data Devise),

computer kiosk, or by paper form. b. Clients are to complete the OQ or YOQ at time of initial assessment/intake and each

service for a maximum of once per week. c. If, in the clinician’s judgment a client is deemed too impaired, or otherwise incapable of

producing a meaningful result the administration of the OQ or YOQ will be omitted for that visit or service, and the client will be reassessed for appropriateness at their next visit or service.

d. Once the OQ, or YOQ is completed via PDA, computer or paper form, it will be given to the secretary who will upload it to the OQ website.

e. The clinician will review the OQ or YOQ results via the OQ website before, or at the beginning of the session or service and discuss the outcome/changes with the client, including this information in the client progress note.

f. For clients receiving a home visit, a PDA will be given to support staff from which the OQ, YOQ will be administered. The PDA will be returned to the office and it will be uploaded to the OQ Website for clinical reviewing with client at their next service visit. In the event that a PDA is not available a paper form of the OQ, YOQ will be administered in its stead.

2. Documenting OQ, YOQ scores:

a. The OQ or YOQ scores will be documented in the progress notes in Access each time the

OQ or YOQ is administered.

Adopted_________________________________________ Signed__________________________________________ Executive Director


CLINICAL PROCEDURE – CL42 – ADOPTED_____

Substance Abuse Assessment Scheduling

Four Corners Community Behavioral Health will provide timely appointments for clients needing a substance abuse assessment.

1. When a client calls to schedule an appointment for a substance abuse assessment they will be given the first available appointment by support staff.

2. Support staff will inform the client they will need to come into FCCBH to complete the Addictions Severity Index (ASI). Support staff will advise the client the ASI needs to be completed a minimum of 24 hours before their appointment and that failure to complete the ASI in this time frame will result in an automatic cancellation of their appointment.

3. Support staff will place the client on a cancellation list and notify them if an appointment comes available before their scheduled appointment.

4. If the client fails to keep their appointment support staff will contact the referral source, if a release of information has been signed by the client.

Adopted:______________________________________________ Signed:________________________________________________ Executive Director


CONTRACTS PROCEDURE – CO03 – ADOPTED 8/22/2001 REVENUE CONTRACTS BETWEEN AGENCIES AND FCCBH

A. Initiating Revenue Contracts

1. All contracts for which another entity is going to pay FCCBH, Inc. for services or programs must be written in the Four Corners contract template format unless the payer submits a proposed contract.

a. If the payer submits a proposed contract the compliance officer shall review the contract for required compliance language.

b. If the proposed contract needs additional or changed language the compliance office shall notify the Executive Director.

2. All revenue contracts prepared by FCCBH, Inc. staff must be submitted as

follows: a. A copy including the statement of work must be sent to the Executive

Director for program approval. b. A copy must be sent to the Business Manager for budget approval. c. A copy must be sent to the Compliance Officer for compliance language

approval.

3. Revenue contracts may be signed only after the required approvals are received.

B. Contract Tracking and Reports

1. The Associate Director shall provide the Contracts Specialist with a list of contract revenue sources and amounts at the start of the new fiscal year.

2. A spreadsheet / master list shall be prepared annually by the Contracts Specialist

that lists all revenue contracts between agencies and FCCBH that include anticipated (or confirmed) dollar amounts, date received, and executed, and status.

3. Contracts shall be tracked by the Contracts Specialist, using the spreadsheet /

master list, to ensure timely receipt, review and execution.

4. All contracts, initiating by any source, shall be forwarded to the Executive Director for review and approval.

5. The Contract Review Team will review an updated master list indicating the

status of contracts at least quarterly.

6. Reports, data and outcomes information required by the statement of work is the responsibility of the individual who has oversight for the contract within their assigned scope of responsibility.

7. The Executive Director should be notified by the Contracts Specialist or the

Business Manager if the contract is not received in a timely manner.

Adopted by Contract Review Team 8/22/01; Revised 9/25/03


INFORMATION SYSTEM PROCEDURE – IN01 – ADOPTED 9/18/2002 ACCESS MESSAGE BOARD

1. It is the intent of FCCBH to utilize the message board on the Access switchboard to post business related messages, announcements and reminders applicable to FCCBH client services, operations and / or administration under the direction of the Assistant Director.

2. All recommendations for switchboard messages shall be submitted to the

Assistant Director. Recommendations shall be acknowledged within two business days.

3. Reasonable consideration shall be given to all requests to post messages that

comply with the intent of this procedure. Announcements or reminders related to client services shall be given first priority.

4. No information shall be posted on the message board without prior approval of

the Assistant Director.

5. The Assistant Director shall provide content for the message board text by email to each office. The Office Manager or designee shall insert the text according to the established process within one business day.

6. Other uses of the message board are prohibited.

Approved by the Executive Committee on 9-18-2002


INFORMATION SYSTEM PROCEDURE – IN02 – ADOPTED 2/19/2003

COMPUTER SYSTEM DISRUPTION OR TROUBLESHOOTING

1. Supervisors shall report all urgent computer system disruptions to the Network Administrator. The following are considered urgent:

a. Network is down b. Access is down or will not perform a necessary function c. Schedule cannot be accessed and is needed to check for client appointments d. There is a system wide mail problem throughout the office e. Can’t sent (mail not dropping down from the Internet Service Provider) f. Can’t receive (mail getting hung up by the ISP) g. Error message that says, “Can’t find mail server” and the computer has been turned off and

re-booted and the problem still exists h. Virus protection concerns

2. The Supervisor or his or her designee shall call the business office to report urgent requests. The

report shall include: a. A specific description of the problem b. The extent of involvement including workstations affected c. Details of any efforts made to fix the problem.

3. A member of the IT team shall respond to urgent requests within one hour. 4. The administrative office secretary shall report the system disruption to other clinics, the

clubhouses, psychosocial office, the Lighthouse and administrative building staff. 5. The IT Team shall maintain a computer system disruption-log.

6. Program supervisors shall designate a staff member to post a system disruption notice

immediately. The announcement shall be posted in a visible, central location or multiple locations and the nature of the system disruption shall be brought to the attention of all employees at the worksite. Verbal notifications may also be given.

7. The worksite designee shall notify employees of system restoration.

8. Requests for non urgent computer system, troubleshooting, equipment or changes shall be submitted on the

Computer Request form. (See Procedure IN05 Computer Request Form)


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INFORMATION SYSTEM PROCEDURE – IN03 – ADOPTED 12/11/01 NETWORK MAINTENANCE AND SECURITY Designation of Responsibilities

1. The Computer System Programmer shall have responsibility for: a. Management Information System / Electronic Medical Records including development of

software and programming b. Responsiveness to FCCBH, Inc. Management Information System (MIS) needs c. Data base management and maintenance of individual health information d. Transaction auditing e. Technical assistance to protect system integrity f. System synchronization

2. The Executive Director shall provide oversight for the information system. All changes to the Management Information System / Electronic Medical Records shall be reviewed and approved by the Executive Director.

3. The Network Administrator shall manage:

a. Electronic transactions for payers in compliance with requirements for electronic transactions under HIPAA regulations.

b. Network, mail and scheduling functions c. Server and tape back-ups, preservation of back up and archived information d. Anti-virus maintenance and virus notification e. The Virtual Private Network (VPN) f. Required documentation and reporting g. Individual workstations h. Management Information System / Electronic Medical Records pending projects list i. Securing and safeguarding data j. Hardware maintenance k. Other technical support as needed

4. A Computer Committee shall be constituted consisting of such staff members as are deemed

appropriate by the Associate Director for Administrative Services and with the approval of the Executive Director. The committee shall review computer system issues and IT resources and receive training at least quarterly.

5. The Associate Director for Administrative Services shall act in the capacity of Information

Technology Director. The Computer System Programmer Network Administrator shall act as the Information System Security Officer and Privacy Officer.

System Integrity and Capacity Adopted by the Executive Committee 12-11-01; Revised 4-17-02, Revised 3/16/2004; Revised 6/15/2005; Revised 11/8/2006

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6. Standards for the network / information system are intended to protect the confidentiality, integrity and accessibility of Protected Health Information (PHI) and business records.

7. Employees are required to take reasonable and prudent actions necessary to assure the security of

PHI and to prevent unauthorized access to PHI transmitted over a communications network. 8. Employee utilization of the system and hardware shall be audited periodically for compliance with

privacy and security policies and standards. The Corporate Compliance Officer may initiate privacy and security audits.

9. Random audits shall be conducted at the discretion of the Executive Director to detect information

or material in the network that may violate policies, regulations or law.

10. A system evaluation shall be conducted at least once every three years to assess the viability, capacity, efficiency and effectiveness of the computer system.

Maintenance of Servers

11. All servers must be in a locked and / or monitored environment with controls that protect system viability and information confidentiality.

12. Only authorized users shall have access to servers. Any attempt by an unauthorized user to logon

shall be denied. The Network Administrator shall maintain a list of authorized server users.

13. Authorized personnel shall consult with the Executive Director prior to shutting down the server during normal working hours. The office supervisor shall designate a staff member to notify and instruct all office personnel when a shut down occurs.

14. Internet usage directly from a server is not permitted

Information Safekeeping

15. The database shall be updated continually with on-line synchronization using a specified synchronizing computer under the direction of the Computer System Programmer Network Administrator.

16. Information and data entered into lap top computers shall be synchronized to the server when the

computer is re-docked.

17. The Network Administrator is responsible for the response / recovery plan subsequent to server shut down or other incidents such as a corrupted database. The response / recovery plan shall be periodically tested for effectiveness under the direction of the Network Administrator or at the request of the Corporate Compliance Officer or the Executive Director.

18. Disaster recovery protocols shall be maintained using current disaster recovery protocols. A copy

of disaster recovery protocols shall be retained by the Network Administrator, the System Programmer and the Associate Director for Administrative Services

19. Management Information System / Electronic Medical Records, data folders, mail, schedule,

accounting, billing information and data shall be backed up daily through the current back-up

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system on each Exchange Server. The physical storage of back up tapes must be safeguarded and secured off site or in a fireproof container. Quarterly and annual back up tape records shall be archived and retained in a bank vault for a six-year period. Storage, security and retrieval of archived information are the responsibility of the Network Administrator.

20. All system related information must be removed from obsolete and surplus equipment prior to destruction,

disposal, surplus or sale. Virus Protection

21. Servers shall be protected at all times by adequate anti-virus software and firewalls in accordance with security configuration and procedures for implementing the proper Internet and network packet filtering requirements.

22. The Network Administrator may issue a virus warning if there is clear evidence of a virus and

shall notify the Executive Director or Associate Director of Administrative Services immediately. Instructions shall be given to employees at computer workstations to shut down individual computers when warranted.

Individual Users

23. Employee computer workstations are subject to automatic log off from the server after a two-hour period of inactivity.

24. Server capacity and job responsibilities shall determine the quantity and duration of file retention

allowed for each employee. Necessity shall determine employee access to the control panel, network neighborhood and other desktop functions. The Network Administrator shall maintain a master list of computer capacity, information access and software needs.

25. External access to the system for mail and schedule, the data base, a drug court data-base and/or

time sheets must be approved by the Executive Director. Necessity shall determine external access.

26. Employees may request a personal folder on the server to maintain confidential and restricted

information. Requests must be submitted on a computer request form. The Network Administrator shall install the personal folder if approved.

27. The assignment of passwords (a confidential numeric and / or character string used in conjunction

with a User ID to verify the identity of the individual attempting to gain access to a computer system) to individual employees shall be the responsibility of the Network Administrator and shall comply with all laws and regulations. Passwords changes shall be approved by the Executive Director. The master list of individual passwords shall be secured and protected.

28. The Network Administrator shall remove terminated employees from the system user list, mail,

and schedule and Management Information System / Electronic Medical Records user list. The Human Resources Specialist shall provide notification of termination immediately.


INFORMATION SYSTEM PROCEDURE – IN04 – ADOPTED 4/17/2002

SECURITY AGREEMENT FOR LAPTOP COMPUTER USERS

Security Agreement for Laptop Computer Users Agreement Amended 9/25/2003

It is the intent of Four Corners Community Behavioral Health to maintain the highest level of security and care for confidential client information and information technology equipment. The following standards are required for users of a laptop computer assigned for employee use by the Corporation.

1. The computer must be in a secure location or in the possession of the employee at all times. 2. Extra pre-cautionary measures must be taken to protect the computer and its contents in public areas, at meetings,

while traveling and in all other instances that may pose a security risk. 3. The computer is for the sole use of Four Corners Community Behavioral Health employees. 4. Protection, de-identification and confidentiality of Protected Health Information (PHI), or information that is a

subset of health information collected from any individual and information that describes care, services, or supplies furnished to an individual and related to the health of the individual must be paramount.

5. Laptop computers must be password protected. 6. Any incident of accidental exposure of confidential information or damage to the computer must be reported

within twenty-four hours to the immediate supervisor and the Computer Specialist. 7. Computer disks that have been elsewhere should never be used in a Four Corners’ laptop unless the disk is

subjected to a virus scan. 8. Non-server based laptop computer users shall use Outlook or Outlook Express and connect to an Internet Service

Provider (ISP), have an established email account and transmit reports, data, meeting notes and other documents by email as required.

9. Users shall comply with all established email and electronic transmission protocols. 10. Downloading anything from the Internet is prohibited unless pre-authorized. 11. Installation of any software must be pre-authorized. 12. Laptop computers shall not be checked as baggage for air travel. 13. It is the responsibility of the employee to take due care of the computer with regard to the investment of the

corporation in information technology equipment and to understand that resources may not be available to replace the computer for the employee’s use if it is beyond repair.

14. Users of FCCBH non-server based laptop computers must follow all instructions from the Network Administrator to update the anti-virus over the web.

I hereby acknowledge that I have received and reviewed the Security Agreement / Procedure for Laptop Computer Users. I fully understand that, as an employee, I have an obligation to fully adhere to these standards. ________________________________________________ ______________________ Name Date ________________________________________________ Position / Title ________________________________________________ _ _____________________ Supervisor Date

Amended 9/25/2003


INFORMATION SYSTEM PROCEDURE – IN05 – ADOPTED 3/16/2004 COMPUTER EQUIPMENT REQUESTS

1. All non-urgent computer requests shall be submitted in writing. For urgent computer requests see Procedure IN02, Computer System Disruption or Troubleshooting.

2. Purchases or installations of computer hardware, software, accessories and/or equipment on FCCBH,

Inc. IT property must be pre-approved. Changes and / or moving any computer equipment from one place to another must be pre-approved.

3. Requests for computer equipment, installations, changes or system modifications shall be submitted

on the Request for Non-Urgent Computer System Trouble Shooting, Equipment, or Changes Form. a. All computer request forms require the signature of a supervisor.

4. The Request for Non-Urgent Computer System Trouble Shooting, Equipment, or Changes Form shall

be submitted to the business office by email, fax, inter office mail or in person. Receipt of the form shall be logged.

5. The Computer Committee shall consist of the Associate Director for Administrative Services, the

Network Administrator, the Computer Technician or Specialist and the Associate Director for Operations and others as requested.

a. The Computer Committee shall review and evaluate computer requests including: the estimated time to provide the service, estimated cost, need, feasibility and available resources.

b. The committee shall approve or not approve and describe the reason in writing. i. All computer requests shall be responded to within ten business days.

ii. The committee may refer the request to the Management Team for review and consideration.

6. The designated Computer Committee representative shall respond to the individual who submitted

the request and provide the reason for approval or non-approval, note the response time and date. 7. Requests for changes to the electronic record system shall be submitted on the computer request form

with rationale for the change and shall be reviewed by the Executive Director and software design specialist for need, feasibility and capability.

a. A log of pending Access projects shall be maintained by the Network Administrator and the

status of each project noted.

8. Reasonable consideration shall be given to all requests within the constraints of the budget and available IT resources.

Approved by the Executive Committee on 3/16/2004; Revised 10/18/2006

Four Corners Community Behavioral Health, Inc.

COMPUTER REQUEST FORM Have you contacted your Computer Liaison?

If The Computer Problem Is Urgent Please Read:

Call the business office for urgent requests – You will receive a response within 1 hour URGENT = First steps – Has the computer been turned off and re-booted? Is the Computer Liaison aware of the problem? 1. Network is down 2. Access is down or will not perform a necessary function 3. Schedule cannot be accessed 4.There is a mail problem throughout the office 5. Can’t sent (mail not dropping down from the ISP) 6.Can’t receive (mail getting hung up by the ISP); error message that says “Can’t find mail server” 7. There is a virus protection problem

Request for Non-Urgent Computer System Trouble Shooting, Equipment, Changes

DO NOT CALL FOR NON-URGENT REQUESTS /USE THIS FORM – You will receive a response within 24 hours The following are examples of NON-URGENT: 1. No permissions to others’ calendars 2. Individual email not received or sent for less than 24 hours 3. Can’t run reports in Access 4. Information has been entered and is no longer there 5. Accessories don’t work 6. Can’t get on Internet 7. Want to add features to Outlook 8. Want equipment moved, installed, changed or reconfigured 9. Want approval for software or hardware purchase or installation

Worksite _____________________________________ Date _________________________ Time ___________________

CHECK ALL THAT APPLY Non-urgent Trouble Shooting

Problem or need ____________________________________________________________________________________ Describe efforts made to fix the problem ________________________________________________________________

Add new program Software requested __________________________________________________________________________________ Reason ___________________________________________________________________________________________

Add hardware or make changes or additions Addition or change requested _________________________________________________________________________ Reason ___________________________________________________________________________________________

Make changes to electronic record system /MIS / current program, configuration or features Change requested ___________________________________________________________________________________ Reason ___________________________________________________________________________________________

Request for permissions or privileges in clinical MIS program (Switchboard) Permission or privilege requested_______________________________________________________________________ Reason ___________________________________________________________________________________________

Other Request __________________________________________________________________________________________ Reason ___________________________________________________________________________________________

Computer Liaison __________________________________________

Person Submitting Request _____________________________________ Supervisor _____________________________

IT Committee Use Only IT Team member receiving request _____________________________________________________

Time/date received___________________ Fax ____ Email ____ Inter-office mail ____ Person ____ Estimated cost __________

Approved ______Not approved ______ Time/date of response _______________________

Form Revised 10/18/2006


INFORMATION SYSTEM PROCEDURE – IN06 ADOPTED12/20/2006 TRANSMITTING HEALTHCARE DATA 1. Confidentiality Notices

A. Email that includes Protected Health Information (PHI) or other sensitive or confidential information shall contain the following statement:

This email contains information from Four Corners Community Behavioral Health, which is confidential and/or legally privileged. All Personal Health Information is HIGHLY CONFIDENTIAL and is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to the specified individual. Any other use is a violation of Federal Law (HIPAA) and will be reported as such. The information is intended only for the use of the individual or entity named on this E-mail. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or the taking of any action in reliance on the contents of this information is strictly prohibited, and that the E-mail should be Deleted immediately. If you have received this E-mail in error, please notify us by return Email immediately.

B. Facsimiles that include PHI or other sensitive or confidential information shall include the following statement:

The documents contained in this facsimile contain information from Four Corners Community Behavioral Health, which is confidential and/or legally privileged. All Personal Health Information is HIGHLY CONFIDENTIAL and is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to the specified individual. Any other use is a violation of Federal Law (HIPAA) and will be reported as such. The information is intended only for the use of the individual or entity names on this transmission sheet. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or the taking of any action in reliance on the contents of this information is strictly prohibited, and that the documents should be returned to FCCBH, Inc. immediately. If you have received this facsimile in error, please notify us by telephone immediately so that we can arrange for the return of the original documents to us at no cost to you.


2. De-identified Information

A. Protected health information shall be de-identified including deletion, modified or blocked identifiers so that the remaining information cannot reasonably be used to identify a person.

i. Internal electronic transmissions that use the first initial of the person’s name and

the first three letters of the person’s last name shall be considered de-identified.

ii. External electronic transmissions that use the first initial of the person’s name and the first three letters of the person’s last name and client number (as necessary) shall be considered de-identified.

iii. Electronic transmissions may include client PHI as allowed by client permission

on the Release of Information / Acknowledgement of Disclosure form. 3. Transmitting PHI for Treatment Payment or Operations (TPO) Including Data Submission

A. Healthcare data shall be available to HIPAA compliant health plans, clearinghouses, intermediary systems, billing services and funders as required for treatment, payment and operations (TPO.)

i. Transmissions shall be assessed for applicable data, proper format and code validity.

ii. Authentication shall be required for external network users.

iii. Dial-in protections including encryption shall be maintained for payers to access

information. 4. Monitoring Transmissions to External Networks

A. The Network Administrator / Security Officer shall monitor transmission standards, software changes, format, code sets, and status of the intermediary system, transmission testing, physical and technical safeguards and adequacy of response.

B. Monitoring measures shall include audit logs, access reports and security incident

tracking reports.

C. Practices and procedures shall be evaluated and safeguards enhanced as appropriate to protect the confidentiality and integrity of PHI.

5. Mitigation

A. The Security Officer shall be responsible to identify and respond to suspected or known security incidents and mitigate to the extent practical; and document security incidents and their outcomes.

i. Documentation of incidents shall be retained for six years from the date of the occurrence.

ii. Documentation of incidents shall be made available to the Compliance Officer

and other persons responsible for implementing the procedures to which the documentation pertains.

iii. Documentation shall be reviewed periodically and updated as needed in response

to environmental or operational changes affecting the security of PHI.

B. Reasonable steps to cure the breach or end the violation shall be taken if an activity or practice that constitutes a material breach or violation of the transmittal agreement occurs.

6. Sanctions Appropriate sanctions shall be taken against employees who fail to comply with healthcare-data transmission policies and procedures. Purposeful disregard for the protection of PHI through external transmissions or other means shall result in disciplinary action and may be cause for termination. Related documents: Personnel Policy 2.18 Information Technology; Clinical Policy 7.48 Protected Health Information General Policy; Clinical Policy 7.05 Clinical Records; Administration Policy 1.22 Healthcare Data to External Networks; Operations Procedure OP23 Access to PHI; Personnel Policy 2.03 Unacceptable Conduct


INFORMATION SYSTEM PROCEDURE – IN07 Adopted 1/18/2006 COMPUTER SYSTEM BACK UP Back up Tape System Access, data folders, mail, schedule, accounting, billing information and data shall be backed up daily and data preserved on a Veritas back-up tape system. The Computer Technician shall be responsible to carry out and coordinate back up functions. The physical storage of back up tapes must be safeguarded and secured off site in a fireproof container. An additional back up tape shall be made at the main server quarterly and the tapes shall be stored in a bank vault in Price. An annual record back up tape shall be made at the close of the fiscal year and stored in the bank vault. Back up Failures Back up status reports shall automatically go to the Computer Technician in the administrative office. If the status says “failed” the Computer Technician shall advise the Computer Liaison at the server location. If it is a true “failed” the Computer Liaison shall perform a manual back up at the server location. If a server back up is unsuccessful for two consecutive business days, a back up shall be performed at the administrative office. Adopted by the Executive Committee on 1/18/2006


INFORMATION SYSTEM PROCEDURE – IN08 Adopted 4/17/06 CODING SUPERVISOR NON-CLINICAL TIME TO SUBSTANCE ABUSE /CONTRACTS I. Direct Service Clinical Time

A. Supervisors shall code direct service clinical time to the appropriate contracts i. Using the progress note MH / SA selection in the case of substance abuse

clinical services.

II. Non-Clinical Time A. Assignments that are specifically budgeted in the contract or grant budget

i. Using the contract codes for non-clinical services specifically budgeted in the grant or contract

ii. Time not specifically in the grant or contract budget, i.e., non-clinical, general overhead The following methodology shall be used: Supervisor’s non-clinical time not specifically assigned to a contract will be attributed to contracts based upon the percent FTE assigned to that contract in the supervisors work group. (For example, if a supervisor has ten FTEs reporting to him or her and two of them are assigned to contract “X”, then 20% of that supervisor’s non-clinical, not assigned time shall be attributed to contract “X.”



INFORMATION SYSTEM PROCEDURE – IN09 ADOPTED 12/20/2006 DASHBOARD I. Direct service hours are calculated by adding all of the time worked using direct service

activity codes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 31, 32, 36, and 51. Activity code 33 shall be calculated as direct service time when coded with contract codes 30, 58, 01 and others as approved by the Executive Director.

II. Data shall be reported in a Dashboard Report monthly for clinical, case management, prevention, nurses and clubhouse staff.

A. Mental Health Therapists and Licensed Substance Abuse Counselors Dashboard report shall include the following: 1. Direct service standards:

a. The standard for direct service is 100 hours per month per FTE clinical assignment.

b. Adjustments to supervisors’ direct service hour requirements shall be determined by the numbers of direct report employees:

• 1 to 3 employees = 94% of the standard • 4 to 9 employees = 70% of the standard • Program Director = 24% of the standard

2. The percentage of substance abuse hours is assigned by the employee’s direct supervisor.

3. The substance abuse direct service hours are calculated by adding all of the time worked using the substance abuse contract or providing a clinical service designated substance abuse on the progress note.

4. The percentage of assigned mental health hours is determined by the employee’s direct supervisor.

5. The number of mental health direct service hours is calculated by subtracting the number of substance abuse direct service hours from the total number of direct service hours.

6. The percent of total services that were Medicaid is determined by dividing the number of hours of direct services provided to Medicaid enrollees by the total number of direct service hours.

7. The percentage of Medicaid hours that were substance abuse is calculated by dividing the number of substance abuse direct service hours to enrollees by the total number of direct service hours to enrollees (as per 6 above).

8. The percentage of Medicaid hours that were mental health is calculated by subtracting the number of substance abuse direct service hours provided to enrollees from the total number of direct service hours to Medicaid eligible clients and dividing this by the total number of direct service hours to enrollees.

9. The percentage of client recipient hours that were Medicaid, billed to insurance and full pay is determined by adding the number of service hours serving Medicaid eligibles, the number of direct service hours paid by insurance and the number of direct service hours paid by first party payers and dividing this sum by the total number of direct service hours.

Adopted by the Executive Committee 12/20/2006 10. The percentage of the primary therapist’s clients seen in the last 90 days is

determined by the date of most recent encounter by the primary therapist with clients to whom he/she is assigned as primary therapist on the most recent Clinical Profile.

11. The percentage of all services that were SPMI/SED is determined by dividing the number of direct service hours provided to clients with a current SPMI/SED designation by the total number of direct service hours.

12. Percentage of complete ICAs is determined by dividing the number of the primary therapist’s clients’ whose ICAs are complete at the time of the report by the total number of that therapist’s assigned clients.

13. Percentage of ICAs that are current is determined by dividing the number of the therapist’s clients’ ICAs that were completed within 30 days of intake if the most recent admission is more than180 days after the most recent termination date and if the date of the ICA is within last five years by the therapist’s number of open clients.

14. Percentage of managed care plans complete is calculated by dividing the number of MCPs updated according to the MCP review schedule, or within 30 days of intake by the number of open clients assigned to that therapist.

15. Percent of no shows is calculated by dividing the number of “no show” notes by the total number of encounters.

16. Average managed care plan progress is determined by averaging the change in points on, “where client is now” over the most recent two MCPs or reviews.

17. Number of desired changes used to calculate the MCP progress is the total number of desired changes listed on the most recent of the pairs of MCPs used to calculate #16 above.

18. Other indicators may be added as approved by the Executive Committee.

B. Targeted Case Managers and Clubhouse Generalists Dashboard Report shall include the following: 1. The assigned hours of direct service

a. The standard for direct service is 125 hours per month b. Adjustments to supervisors’ direct service requirements hour shall be determined

by the numbers of direct report employees: • 1 to 3 employees = 94% of the standard • 4 to 9 employees = 70% of the standard • Program Director = 24% of the standard

2. The percent of total services that were Medicaid is determined using the methodology described in #II, A, 6 above.

3. The percentage of all services that were SPMI/SED is determined using the methodology described in #II, A, 11 above.

4. The percent of time spent providing personal services is calculated by dividing the number of hours of activity code 10 the number of direct service hours.

5. Number of assigned clients is calculated by counting the number of clients assigned to the case manager on the client’s most recent Clinical Profile..

6. The percentage of clients with case management listed in the current MCP is determined by dividing the number of assigned clients with TCM as a method in the most recent MCP by the total number of assigned clients to whom the individual provided case management services (activity codes #15 and #51).


C. Nurses Dashboard Report shall include the following:

1. The assigned hours of direct service a. The standard for direct service is 100 hours per month per FTE clinical

assignment. b. Supervisors’ direct service hours shall be determined by the numbers of direct

report employees: • 1 to 3 employees = 94% of the standard • 4 to 9 employees = 70% of the standard • Program Director = 24% of the standard

2. The percentage of substance abuse hours is assigned by the individual’s direct supervisor.

3. The number of substance abuse direct service hours is calculated using the methodology described in II, A, 3 above..

4. The percentage of assigned mental health hours are determined by direct supervisor assignment.

5. The number of mental health direct service hours are calculated using the methodology described in II, A, 5.

6. The percent of total services that were Medicaid is calculated using the methodology described in II, A, 6 above.

7. The percentage of all services that were SPMI/SED is calculated using the methodology described in II, A, 11.

8. The percentage of clients with medication management listed in the current MCP is determined by dividing the number clients with Medication Management listed as a method on the most current MCP by the number of clients served with medication management.

9. The percent of time spent providing personal services is calculated by using the methodology described in II, B, 4 above..

10. The number of encounters is the number of encounters recorded on the individual’s time sheet for the report period.


D. Prevention Specialists Dashboard Report shall include the following according to the calculation described: 1. The assigned hours of direct service

a. The direct service standard is 125 hours per month per FTE. b. Supervisors direct service hours shall be determined by the numbers of direct

report employees: • 1 to 3 employees = 94% of the standard • 4 to 9 employees = 70% of the standard • Program Director = 24% of the standard

2. The percent of time spent on non-client program consultation is calculated by dividing the number hours recorded with activity code 31 divided by the total number of direct service hours.

3. The percent of time spent on non-client education is calculated by dividing the number of hours recorded using activity code 32 by the total number of direct service hours..

4. The percent of time spent on other prevention consultation and education is calculated by dividing the number of hours of 33 by the total number of direct service hours. This is not direct service time.

5. The number of contacts is determined by the number of contacts recorded on the time sheet for the report period.

6. Other indicators may be added as approved by the Executive Committee. III. 1. Clinical staff who are assigned to a program that requires 75% or more of services to

be provided OUT OF THE OFFICE (i.e. COTT) shall calculate direct service hours by multiplying actual direct service hours by 1.25.

2. Hours of group therapy (activity code #3) shall be weighted as follows: a. For one therapist leading the group

i. <4 clients x 1.0 ii. 4 clients X 1.2 iii. 5 clients X 1.5 iv. => 6 clients X 1.8

b. For two therapists leading the group i. 1 client X 0.5 each ii. 2 or 3 clients X 1.0 each iii. 4 clients X 1.2 each iv. 5 clients X 1.5 each v. => 6 clients X 1.8 each

IV. Direct service requirements adjustments may be made for participation on certain

committees, for specific work assignments or necessary travel with prior approval. A. Committee assignments may include Quality Improvement, Cultural Competency,

Computer and others as approved. B. Adjustments based on travel may be approved for services provided in remote areas or at

alternate work locations.


INFORMATION SYSTEM PROCEDURE – IN10 ADOPTED 12/20/2006 PASSWORD MANAGEMENT 1. Four Corners Community Behavioral Health, Inc. employees shall be assigned a worker

identification number and a PIN number / password by the Human Resources Manager.

a. The worker identification number and PIN number / password shall be provided on the first day of employment.

2. Employee identifiers shall be retained in worker information in Access. Forgotten PIN numbers

can be provided by the Human Resources Manager or the Network Administrator after verifying the identity of the employee.

3. PIN numbers / passwords are confidential. Employees shall take appropriate and reasonable action

to safeguard passwords. 4. Passwords of terminated employees shall be deleted from the system within one business day of

the last day of employment. Adopted by the Executive Committee 12/20/2006 Related documents: Personnel Policy 2.18 Information Technology; Clinical Policy 7.48 Protected Health Information General Policy; Clinical Policy 7.05 Clinical Records; Administration Policy 1.22 Healthcare Data to External Networks; Operations Procedure OP23 Access to PHI; Information System Procedure IN06 Transmitting Healthcare Data; Personnel Policy 2.03 Unacceptable Conduct


INFORMATION SYSTEM PROCEDURE – IN 11 ADOPTED 12/20/2006 ACCESS TO PROTECTED HEALTH INFORMATION 1. Protected Health Information (PHI) contained in the Four Corners Community Behavioral Health,

Inc. clinical records, management information system, billing records or otherwise maintained shall be treated as confidential and private and shall be disclosed only with authorization as specified by law, rules, policies and regulations.

a. Protected Health Information (PHI) as defined in Public Law 104-191, shall mean any information, whether oral or recorded, in any form or medium:

i. That relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and

ii. That identifies the individual or reasonably may be used to identify the individual.

2. Four Corners Community Behavioral Health, Inc. shall implement procedures to determine that

employee access to electronic PHI is appropriate. a. FCCBH, Inc. employees may access PHI with the employee password which shall serve

as the unique user identification.

b. Accessing, viewing, reading, opening or printing client PHI shall be restricted to those persons and entities with a need for access according to the minimum necessary standard.

c. Minimum necessary is defined as the amount of PHI reasonably necessary to make a

decision on the matter under consideration, what is reasonable under the circumstances. 3. FCCBH, Inc. employees shall sign the IT Assurance and acknowledge that they will access PHI

only as authorized according to standards defined in policy and procedure. Inappropriate disclosure, access, alteration or destruction of PHI may be considered purposeful disregard and may result in disciplinary action or be cause for termination.

4. The Network Administrator and system users shall use reasonable safeguards to prevent

unauthorized users from accessing PHI on a workstation by: a. Logging off the computer when the workstation is left unattended for a period-of-time.

b. Implementing electronic procedures that terminate an electronic session after a

predetermined time of inactivity. Adopted by the Executive Committee 12/20/2006 Related documents: Personnel Policy 2.18 Information Technology; Clinical Policy 7.48 Protected Health Information General Policy; Clinical Policy 7.05 Clinical Records; Information System Procedure IN06 Transmitting Healthcare Data, Administration Policy 1.22 Healthcare Data to External Networks; Personnel Policy 2.03 Unacceptable Conduct


OPERATIONS PROCEDURE – OP03 – ADOPTED 3/12/2003

PEER HELPER FUNDS 1. A Peer Helper Fund up to three hundred dollars may be established for use in specified counties

with the approval of the Executive Director. 2. The staff member assigned to work with the Peer Helper Program in the specified county shall be

responsible to manage the fund and shall be accountable for all monies expended through this fund. 3. A completed Purchase Requisition or a Petty Cash Slip with an authorized signature must be

attached to any purchase. 4. Purchases over two hundred and fifty dollars require pre-approval and shall be requested through

the established purchase requisition process and shall be paid directly from the FCCBH, Inc. Business Office.

5. The following are required for all Peer Helper Funds:

a. Original receipts submitted within five days of the expense date b. Authorized signatures approving expenditure c. Compliance with all established purchasing and financial policies

6. The Peer Helper Fund Custodian must submit an accounting of expenditures to the Business Office

with required attachments. The accounting of expenditures shall include original receipts dated within five days of the expense date, completed Purchase Requisitions, completed Petty Cash Slips, authorized signatures and a written request for additional funds if applicable.

7. The business office shall track Peer Helper Fund expenditures and verify that unspent monies are

available prior to reimbursing the fund.




PETTY CASH A. A Petty Cash fund up to two hundred and fifty dollars may be established at each FCCBH, Inc.

office with the approval of the Executive Director. B. A Petty Cash Custodian shall be recommended by the Associate Director for Administrative

Services and appointed by the Executive Director. The Custodian shall be provided with the Petty Cash policy and procedure to clarify accountability for monies expended through the Petty Cash fund.

C. All Petty Cash monies shall be kept in a locked safe, cabinet or box. D. All monies expended through the Petty Cash Fund shall be accounted for on Petty Cash slips,

which shall indicate the purpose for the expenditure and the expense account number. Original receipts must be attached to the Petty Cash Slip to document expenditures.

E. The Petty Cash slip shall be signed by the individual receiving the money and shall be approved by

an employee authorized to make such approval. The Associate Director for Administrative Services shall maintain a current list of all FCCBH, Inc. employees authorized to approve Petty Cash expenditures.

F. When the Petty Cash fund is below one hundred dollars, the Petty Cash Custodian shall request

reimbursement of the fund from the Business Office and the fund shall be reimbursed up to the amount authorized for that Petty Cash fund.



OPERATIONS PROCEDURE – OP05 – ADOPTED 7/16/2003 PROPERTY HELD BY EMPLOYEE ACKNOWLEDGEMENT

1. All resources provided to carry out the responsibilities of an employee’s job are the property of FCCBH, Inc. This includes any item that is portable in nature and that may be used on or off a FCCBH, Inc. premises.

2. Employees shall be required to fill out and sign the FCCBH, Inc. Acknowledgement of Property

Held by Employee form at the time property is issued including but not limited to the following: laptop computers, all computer accessories, Palm Pilots and all PDA accessories and instruction manuals, hardware or software used off site, compact disks, DVDs and floppy disks purchased by FCCBH, Inc., cellular phones and accessories, books, manuals, training software, equipment or any other item belonging to FCCBH, Inc..

3. The new employee orientation shall include an explanation of the required acknowledgement.

4. The FCCBH, Inc. Acknowledgement of Property Held by Employee form shall record the date

property is issued, employee’s name, item description (including manufacturer, model, serial number, date of purchase if known and other identifiers.) The signed employee acknowledgement shall be retained in the employee’s personnel file. The supervisor shall also retain a copy.

5. It shall be the responsibility of the employee to submit and update the FCCBH, Inc.

Acknowledgement of Property Held by Employee form upon issuance of new or additional property as described above or upon return of property. The business office designee shall verify that property has been returned in the space provided on the form.

6. Employees shall be required to acknowledge that when employment with FCCBH, Inc. has

terminated all FCCBH, Inc. property assigned for use shall be returned to the Human Resources Office on or before the employee’s last working day.

7. The employee shall further agree to compensate FCCBH, Inc. for lost or damaged property at

replacement value and agree that the cost of lost or damaged property shall be deducted from my final paycheck.

8. Employee’s are responsible to safeguard and protect all property from damage or loss and may be

liable for loss or damage. Abuse, willful disregard for the protection or security of property that incurs additional costs to FCCBH, Inc. shall be considered the responsibility of the employee.

Approved by the Executive Committee 7/16/2003; Revised 9/25/03

Four Corners Community Behavioral Health Acknowledgement of Property/ Keys Held by Employee

All resources provided to carry out the responsibilities of an employee’s job are the property of FCCBH, Inc. This includes any item that is portable in nature and that may be used on or off a FCCBH premises. A Property Held by Employees form must be filled out for the following: all keys to FCCBH, Inc. facilities, vehicles or other, laptop computers, all computer accessories, Palm Pilots and all PDA accessories and instruction manuals, hardware or software used off site, compact disks and floppy disks purchased by FCCBH, Inc., cellular phones and accessories including leather covers and auto chargers, books or any other item belonging to FCCBH.

DATE: __________________________________________________________________________ EMPLOYEE: ____________________________________________________________________ Date Item Description (Include manufacturer, model, serial # Received date of purchase and other identifiers , for keys include Date Returned what doors in what facility) Business office must initial receipt

_____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ I hereby acknowledge that upon severance from FCCBH, Inc. I will return all FCCBH, Inc. property assigned for my use to the Associate Director for Administrative Services or his / her designee on my last working day. Upon termination I will return all FCCBH, Inc. property immediately. I also acknowledge that I am responsible to safeguard all property from damage or loss and that I am liable for loss or damage. I agree to compensate FCCBH, Inc. for lost or damaged property at replacement value. I agree that the cost of lost or damaged property shall be deducted from my final paycheck.

________________________________________ ________________ Employee Date Comments: _______________________________________________________________________ __________________________________________________________________________________ Original to Personnel Office ________ Copy to Supervisor _________ 8/2003


OPERATIONS PROCEDURE – OP06 – ADOPTED 12/18/2002 TELECOMMUNICATIONS

1. The new employee orientation will explain the procedure for allocating long distance calls with the assigned employee number as the long distance code.

2. All employees will be asked to read the Telecommunications Policy and sign the employee assurance,

which will be maintained in the employee’s file.

3. Information about personal long distance calls made from FCCBH, Inc. offices by employees will be submitted to the business office by email or other method as required. Employees will be notified of the amount owed for personal telephone calls.

4. To verify compliance with Telecommunications Policy 3.15, Business Office personnel will conduct

random reviews of telecommunications use. The random review will check for compliance with criteria for allowed occasional and minimal use as defined in policy and for activities not permitted by policy.

5. Supervisors shall be responsible to notify the Associate Director of Administrative Services of suspected

or substantiated abuse or non-compliance with policy immediately

6. Supervisors will submit a written request for employee cellular phone use for approval to the Associate Director for Administrative Services. The request will explain why use of a cellular phone is necessary to fulfill the assigned duties of the employee and a proposed usage plan that will reasonably accommodate the number of minutes needed for an average month.

7. The Associate Director for Administrative Services will review all cellular telephone use requests.

Approval or denial will be noted on the written request, the original request will be retained in the employee’s file and a copy returned to the supervisor.

8. Employees must fill out a Property Held by Staff form and the cellular telephone remains the property of

Four Corners.

9. All employees using a cellular telephone are allowed by policy to use no more than fifteen percent of the expected usage for personal telephone calls. At no time shall an employee be allowed to use over forty minutes for personal calls at company expense. All minutes used for personal calls over forty minutes shall be reimbursed to FCCBH, Inc. at twenty cents per minute.

10. The Business Office will provide employees with a statement of cellular phone usage and each employee

is responsible to identify all personal calls on the statement and return it to the business office within ten days with reimbursement if appropriate.

11. The supervisor requesting a cellular phone for an employee shall fill out a Request for Cellular Phone form.

The form shall include date submitted, program, name and title of employee to whom phone will be assigned, a description of how the cellular phone will be used to fulfill assigned duties, a proposed usage plan - expected number of minutes to reasonably accommodate needs for an average month and a supervisor recommendation for a $40 cell phone allowance or a FCCBH, Inc. cell phone to accommodate the need.

12. Employees will be required to sign the following acknowledgement if applicable: I understand that if I elect to receive a cellular phone allowance the total amount paid will appear as compensation on my W-2 form and I am solely responsible to report business expenses to the IRS

13. The employee’s supervisor is responsible to secure all telecommunications equipment assigned for use

upon the severance or termination of the employee on the last working day for which the employee is paid.

Approved by the Executive Committee 12/18/2002; revised 7/16/2003


Request for Cellular Phone Telecommunications equipment including cellular phones are intended to be used to conduct the business of Four Corners Community Behavioral Health, Inc. Cellular telephones may be provided to employees if necessary to fulfill their assigned duties and are intended for judicious business use. Date Submitted ___________________________ Program __________________________________________ Name/title of employee to whom phone will be assigned ____________________________________________ Describe how the cellular phone will be used to fulfill assigned duties ___________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Proposed usage plan - expected number of minutes to reasonably accommodate needs for an average month __________________________________________________________________________________________ Supervisor recommendation: _____$40 cell phone allowance _____FCCBH, Inc. cell phone to accommodate need I have explained the following to the employee: Employee use of cellular phones for personal calls shall not exceed fifteen percent of the total expected monthly usage to constitute occasional and minimal use (De Minimis Benefits as defined by the Internal Revenue Service). At no time shall an employee use over forty minutes for personal calls at company expense. All personal calls over forty minutes shall be reimbursed to FCCBH, Inc. at twenty cents per minute. The Business Office will provide employees with a statement of cellular phone usage and each employee is responsible to identify all personal calls on the statement and return it to the business office within ten days and with reimbursement if appropriate. The employee must read and agree to comply with the Four Corners Community Behavioral Health, Inc .Equipment Use And Return Assurance and the Employee Telecommunications Assurance. I understand that if I elect to receive a cellular phone allowance the total amount paid will appear as compensation on my W-2 form and I am solely responsible to report business expenses to the IRS ________________________________________________________ Employee ______________________________________________________ Date ___________________________________________________

Employee ________________________________________ Approved __________________________________________ Supervisor Associate Director for Administrative Services BUSINESS OFFICE ONLY Date approved _______________________ Date Received _______________ Cellular phone purchased ________________ Assigned Plan _____________________________________________________________________

Equipment Return Assurance Received Telecommunications Assurance Received 7/2003


OPERATIONS PROCEDURE – OP07 – ADOPTED Replaces Previous OP07 Client Income Verification Audit and OP12 Insurance Co-Pay Verification Audit CLIENT PAYMENT INFORMATION RECORDS AUDIT a. A client payment information records audit shall be conducted annually to assess:

a. Compliance with income verification practices b. Consistency in determining client eligibility for discount fees c. Appropriate verification of insurance / payment information d. Compliance with procedures for collecting insurance co-payments e. Updated AFS records f. Collections practices

b. The Network Administrator shall use the MIS to select fifty client records for each county that includes a

sampling of the following: a. Clients with insurance (including Medicare) b. Clients receiving IOP services c. Clients with a discounted fee d. Clients seen within the last sixty days e. Clients with an outstanding balance of $300 or more f. Clients with a single case agreement

c. The Client Payment Information-Records Audit Matrix shall be used to conduct the audit/review.

Documentation used to verify review areas described on the matrix shall be substantiated.

d. The records audit shall verify the following (as applicable): a. A Payment Information Form is on file for non-Medicaid clients. b. Insurance information is recorded on the AFS if the client has insurance coverage. c. Insurance information has been verified in the last six months. d. Insurance co-payment has been collected. e. Receipts have been provided for first party payments. f. An approved Single Case Agreement Request Form is on file. g. There is adequate documentation of the client’s income if the client has a discount fee. h. Income documentation substantiates fee based on the Four Corners Outpatient Services

Minimum Discount Fee Schedule and Uniform Discount Fee Schedule for Chronic clients. i. If a fee was not paid for three consecutive visits continuation of services was suspended. j. That there are no violations of FCCBH, Inc. financial policies and procedures. k. Clients with payment arrangements for balances owed have an approved Credit Application

and Agreement for Payment on file. l. AFS information is corroborated by other data including last date of service, if the client is

closed and/or changes in insurance if there have been any. m. That the client status records are accurately entered for Drug Court and IOP and the

corresponding AFS record reflects the appropriate fee information. n. That modifications to the client’s account have been properly performed and adequately

documented. e. The Finance Officer and the Compliance Officer shall review audit findings, identify trends and systemic

issues, training needs and recommendations for policy or procedure and provide a report to the Executive Director.

FCCBH, Inc. Client Payment Information Records Audit List the information requested in the boxes provided. Put NA if not applicable for this client. Use the back of this form if needed.

Client #

Date: Describe sources of documentation used to verify conclusions

Irregularities noted

Comments

Record / Document YES / NO NA

a. A Payment Information Form is on file if the client is non-Medicaid

b. Insurance information is recorded on the AFS if the client has insurance coverage

c. Insurance information has been updated in the last six months

d. Insurance co-payment was verified and is noted in the record

e. Insurance co-payment has been collected and is current

f. Receipts have been provided for first party payments

g. There is adequate documentation of the client’s income if the client has a discount fee

h. Income documentation substantiates fee based on the Four Corners Outpatient Services Minimum Discount Fee Schedule and the Uniform Discount Fee Schedule for Chronic Clients

i. If a fee was not paid for three consecutive visits continuation of services was suspended

j. Violations of FCCBH, Inc. financial policies and procedures

k. Clients with payment arrangements for balances owed have an approved Credit Application Agreement for Payment on file

l. An approved Single Case Agreement Request Form is on file

m. AFS information is corroborated by encounters, progress notes, last date of service, if the client is closed and/or there have been changes in insurance

7/2007


OPERATIONS PROCEDURE – OP08 – ADOPTED10/22/2003

PROCUREMENT I. The Four Corners Community Behavioral Health, Inc. Purchasing Policy 3.16 shall apply to all

purchases or contracts for which a bid is required as described in policy and procedure.

1. Fair practices and procedures for purchasing goods and services exceeding $2,000 shall include the following: a. A minimum of two competitive bids shall be secured if solicitation of bids is feasible. b. The Associate Director for Operations or the Executive Director may determine that bid

solicitation is not feasible and shall prepare documentation explaining the reason for vendor selection.

c. A Request for Proposal (RFP) for consultation shall be announced when it is likely that

more than one source can provide the precise consultation required at the quality, cost and timeliness required.

d. Bids submitted shall be reviewed by at least two management staff and others as applicable.

The review shall be conducted according to pre-established criteria.

2. A bid shall be initiated by an approved purchase requisition (PR) unless the Executive Director approves an exception according to policy.

a. The Administrative Secretary shall start and maintain a file for each bid. The file shall

contain: • The approved PR for the advertisement (if applicable) • Copies of print ads (if applicable) • The approved PR for accepted contractor (if a contract is not written) • Project specifications (bidding guidelines) • Copies of bids submitted • A copy of the approved bid • A completed and signed Contractor / Consultant / Bid Acceptance Form

b. The bid file shall be retained for five years and shall be attached to the PR or contract.

3. Print ads for bid solicitation shall be placed by the Business Office Administrative Assistant. Approved by the Executive Committee 10/22/2003; Revised 4/17/2006; Revised 7/19/2006

4. In the event that only one bid is received the Executive Director shall note on the accepted bid, “Only bid received.”

5. In the event that no bids were solicited the Executive Director shall describe the justification on

the Contractor / Consultant / Bid Acceptance Form.

II. A bid process is not required if one or more of the following conditions apply: a. The item being purchased is refurbished b. It is unlikely that more than one source can provide the precise consultation or service

required at the quality, cost and timeliness required.

• Likelihood of multiple sources shall be based on required expertise, services provided previously by consultant, need for continuity of consultation, previous response to requests for proposals, satisfactory service delivery from previous vendors, availability and remote location of service site.

• The Associate Director and the Executive Director shall have authority to approve sole source providers.

• Justification for sole sourcing goods or services shall be noted on the purchase requisition or Contractor / Consultant / Bid Acceptance Form.

III. Local vendors may receive preference if the following criteria are met:

a. There is an expectation of quality, service and acceptable delivery standards b. The bid is within ten percent of the lowest bid received

c. There is no prior experience of bad faith or poor workmanship

d. There is confidence in a positive outcome based on examples of prior work.

IV. Purchases can be made from State contracted vendors at the State price without a bidding process.

Contract prices can be used as a low bid price for comparison to vendor bid and selection. V. The Associate Director for Operations shall solicit bids for goods and services as required.

Four Corners Community Behavioral Health, Inc. Contractor / Consultant / Bid Acceptance Form

Date Submitted_______________________________ Contract time period _____________________ Name of bidder _____________________________________________________________________ Project or description of goods or services _______________________________________________ __________________________________________________________________________________ Bid amount / negotiated rate of pay _____________________________________________________ Reasons for bid acceptance (check all that apply): ___ Lowest Bidder ___ Best Qualified ___ Only Bidder ___ Local Vendor ___ Availability ___ Timeliness ___ Specifications ___ Sole Source ___ Quality ___ Continuity ___ Previous Vendor ___ Expertise ___ Refurbished ___ State Approved Vendor ___ Other ________________________________________________________________ Please describe the justification for not requesting bids: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Approved by ______________________________________ ________________________________ Executive Director Date

Date placed in bid file ___________________________ Administrative Assistant _____________

7/2006


OPERATIONS PROCEDURE – OP09 – ADOPTED 10/22/2003; Revised 9/21/05 CLIENT FEES, PAYMENTS AND COLLECTIONS I. At the Time Services are Requested:

A. A non-Medicaid request for service that is not an emergency requires payment information before scheduling an intake appointment. Individuals with a third party payer shall be advised of the insurance fee policy.

B. If an individual states they have Medicaid or Medicare make a copy of the current card. Verify

Medicaid eligibility on the Medicaid Eligibles Report in the management information system / electronic m records (MIS/EMR).

C. All non-Medicaid clients shall complete a Payment Information form. D. FCCBH, Inc. accepts PEHP, CHIP or other insurances approved by the Executive Director. Record insurance

information on the Insurance Information Verification Form. 1. If the insurance will only verify that the individual is covered until a diagnosis is provided, schedule an

assessment / evaluation and call the insurance after a diagnosis is available. 2. Provide the client with estimated co- pay. Enter insurance information on AFS and verify insurance every six

months. E. If a discount fee is requested verify income and retain documentation in file.

Discount fees must be approved by the clinic supervisor. 1. Enter “no insurance coverage” on AFS and the per session or per month fee amount and verify income

every six months. 2. The clinical supervisor is the only person who can authorize client assistance. (Refer to procedure OP 15

Client Request for Fee Waiver or Reduction) II. Payment Expectations

A. Clients shall be required to pay fees at the time service is received including: (1) discount fees, (2) full cost of services if the individual has insurance not accepted by FCCBH, Inc., (3) full cost of service if the client is not eligible for discount fee or has no insurance (4) full cost of service if no income is declared or documentation is not provided (5) the insurance co-payment for individuals with insurance accepted by FCCBH, Inc.

B. Clients shall be required to pay the following monthly fees no later than the first visit of the month or the 5th

day of each month: clubhouse plus outpatient monthly fee, IOP fee, indigent medications monthly fee, other fees as applicable.

C. The electronic record shall be checked to verify client fee, co-pay or balance due at the time service is provided. D. Drug court fees shall be collected according to established protocols.

III. Insurance

A. When a client has insurance not accepted by FCCBH, Inc. he/she shall be required to pay the full cost of services at the time services are received. FCCBH, Inc. shall provide a HCFA 1500 so the client can bill the insurance for reimbursement.

Adopted by Executive Committee 10/22/2003; Revised 7/12/2004; Revised to combine OP02, OP14 and OP09 9/21/2005; Revised 4/17/2006; Revised 11/8/2006

1. When a client has a primary insurance and a secondary insurance accepted by FCCBH, Inc. the client shall

pay the primary insurance co-pay and the insurance specialist shall bill both insurances. 2. When a client has a primary insurance accepted by FCCBH, Inc. and a secondary insurance not accepted

by FCCBH, Inc. the client shall pay the primary insurance co-pay. FCCBH, Inc. shall provide a HCFA 1500 so the client can bill the secondary insurance for reimbursement. The insurance specialist shall bill the primary insurance. (See C below)

3. When a client has a primary insurance not accepted by FCCBH, Inc. and a secondary insurance accepted by FCCBH, Inc. The client shall pay the secondary insurance co-pay. FCCBH, Inc. shall provide a HCFA 1500 for reimbursement from the primary insurance. The client needs to provide FCCBH, Inc. with an EOB so the secondary insurance can be billed. If the client fails to provide the EOB within 60 days he/she shall pay the difference between the secondary insurance co-pay and the full cost of services.

B. FCCBH, Inc. shall accept Medicare as an insurance payer. A therapist providing Medicare services must have a

Medicare PIN number. Medicare will reimburse for clinical services provided by physicians, psychologists and LCSWs with PINs. The client is required to pay the Medicare co-pay at the time of services. 1. An Advance Beneficiary Notice (ABN) shall be provided for any services received and not covered by

Medicare. 2. Individuals with Medicare insurance have an annual deductible. The deductible start date and amount

shall be confirmed with the client and noted on the AFS in the comments box.

C. When a client has Medicare and another insurance the insurance specialist shall bill both insurances. Collect the Medicare co-payment at the time services are received.

D. If an individual has insurance not accepted by FCCBH, Inc. and he/she requests a single case

agreement refer to procedure OP16 Single Case Agreements.

E. If a drug-court client has insurance that covers substance abuse treatment and pre-approval has been received the insurance shall be billed the full cost of service. The drug-court client shall pay the required insurance co-pay not to exceed the discount fee schedule. A list of drug court clients and all insurance information shall be sent to the insurance specialist and updated as new clients enter the system.

F. The full cost of services shall be billed for an IOP participant with insurance not accepted by FCCBH, Inc. if

pre-approved by insurance. The full cost of services shall be billed for all IOP participants with insurance accepted by FCCBH, Inc. The client co-pay shall not exceed the discount fee schedule. Adolescent clients shall not be charged out of pocket for substance abuse services. 1. Clients enrolled in IOP will be charged the monthly discount fee on a calendar month basis. The billing

system does not pro-rate IOP fees.

G. Clients with insurance coverage shall not be eligible for a discounted fee unless the client meets the FCCBH, Inc. acuity criteria and one or more of the following apply: (1) insurance benefits are exhausted, (2) client has Medicare and the recommended treatment is not a covered Medicare benefit and the client chooses to receive the service and receives an Advance Beneficiary Notice.

H. Clients with insurance shall be provided with information to assist them in billing their insurance company.

This shall include but not be limited to a verbal explanation of how to inquire about submitting a bill / invoice, giving contact numbers for their insurance and offering the handout Billing Your Own Insurance.

I. Insurance Panels

Employees shall not apply to serve on an insurance panel on behalf of FCCBH, Inc. without approval from the Clinical Director or Executive Director.

IV. Credit and Non Payment A. Clients who request payment arrangements for balances owed shall complete the Credit Application and

Agreement for Payment for review which shall be approved by the clinic supervisor. The monthly fee due shall be entered in the electronic record.

B. Non-payment of fees or failure to comply with an agreement for payment shall be reported to the client’s therapist or physician and supervisor for resolution. If a fee has not been paid for three consecutive visits continuation of services shall be suspended. A Credit Application and Agreement for Payment or Client Assistance Form and approval by the clinic supervisor may restore services.

C. The business manager shall review client account credit balances twice yearly and make recommendations to

the Executive Director for refunds if appropriate. D. The business manager shall review client account indebtedness and unpaid insurance balances twice yearly

and make recommendations for adjustments or write-offs. (Refer to Policy 3.62 Client Fee Write-offs)

E. A list of outstanding client indebtedness shall be submitted to the Associate Director for Operations on December 15th and June 15th each year.



TRAVEL AND REIMBURSEMENT I. Rates for employee mileage reimbursement, per diem and lodging shall be set by the Finance

Director. The Executive Committee shall review all rates annually. A. MEALS

1. The approved rates effective July 1, 2008 shall be: In state meals • Breakfast - $9 • Lunch - $11 • Dinner - $16 Out of state meals • Breakfast - $10 • Lunch - $14 • Dinner - $21 • Premium cities Chicago, New York, Washington DC, Atlanta, San Francisco, LA,

Boston – out of state per diem or actual receipts up to $59 per day

2. Employees may be provided with a meal per diem if there is a substantial business reason to do so. Employees may be eligible for meal reimbursement if the employee travels at least fifty miles one way from his or her home office.

3. Employee reimbursement for meals shall be determined on the basis of the time of

departure and arrival. • Breakfast – leave before 6:00 a.m. or return after 10:00 a.m. • Lunch – leave before 11:00 a.m. or return after 2:00 p.m. • Dinner – leave before 5:00 p.m. or return after 7:00 p.m.

B. MILEAGE-EMPLOYEES

1. The approved mileage reimbursement rates for employees effective July 1, 2008 shall be: • No FCCBH, Inc. car available $.50.5 per mile • Chose to drive own vehicle $.36 per mile

C. LODGING • Private residence - $25 per night • Event site – actual cost (Must have prior approval and must document event site rate

(conference brochure) • Out of state - $80 per night (Note: Ask motel/hotel for State rate or if that is not

available ask for corporate rate.) • In state:

Utah City Per diem

rate Altamount $70 plus tax Boulder $70 plus tax Bryce $70 plus tax

Green River $70 plus tax Kanab $75 plus tax Layton $70 plus tax Logan $75 plus tax

Mexican Hat $70 plus tax Moab $80 plus tax Ogden $70 plus tax

Panguitch $70 plus tax Park City $90 plus tax

Heber City/Midway $90 plus tax Price $70 plus tax

Provo/Orem/Springville/Lehi $75 plus tax Metropolitan Salt Lake City

(Draper to Centerville), Toole $90 plus tax

St. Geoge/ Washington/Springdale $70 plus tax

Vernal/Roosevelt $90 plus tax All Other Utah Cities $65 plus tax

• Lodging is reimbursed actual cost up to the rates listed above for single occupancy only.

For double employee occupancy, add $20, for triple state employee occupancy, add $40, for triple employee occupancy, add $40, for quadruple employee occupancy, add $60.

• Non-event site (in and out of state) – cost up to event site hotel rate (Must have prior approval and must document conference site rate - conference brochure)

• Campground - $30 Approved by the Executive Committee 3/16/2004; Revised 8/22/2006; Revised 7/1/2008

D. VOLUNTEER, MEDICAID OR FEMALE SUBSTANCE ABUSE CLIENTS WITH DEPENDENT CHILDREN. Rates for volunteer or Medicaid client mileage reimbursement shall be set by the Associate Director for Administrative Services.

• $.16 per mile – regular Medicaid appointment • $ .31 per mile – hospital transportation • $ .10 mile – frequent travel for IOP – women with dependent children or club (more

than once a week. II. Out of state travel beyond 100 miles from the Utah border must be pre-approved by the Executive

Director or his / her designee.

III. The Finance Director or his or her designee shall be notified of vehicle malfunctions or problems. Repairs and maintenance must be authorized in advance.

IV. A Training Authorization form shall not be required for non-training travel. Verbal approval is required from the employee’s supervisor for all travel. Non-training related travel reimbursement shall be requested on the current FCCBH, Inc. Travel Report Form.



SURPLUS EQUIPMENT A. Any staff member, with supervisory approval, may submit a Request for Equipment Surplus Status

form if FCCBH, Inc. property is not reasonably usable at any FCCBH, Inc. work location. Property shall not be deemed as surplus without approval by the Associate Director of Operations. (See Policy 3.07 Disposal of Surplus Property)

a. The Request for Equipment Surplus Status form shall be submitted to the Administrative Secretary at the business office by email, fax, and inter-office mail or in person. Receipt of the form shall be logged.

i. The Associate Director for Operations shall respond to requests within five business days.

b. Requests involving computers shall include the processing speed, memory, hard drive capacity and other pertinent information related to usability or value.

B. Property shall be declared surplus, usable or of no value by the Associate Director for Operations.

a. The Associate Director for Operations shall set a minimum bid or sale price on surplus equipment with a value greater than $2,000.

i. All surplus items with a value greater than $2,000 shall be posted in the clubhouse and all other work sites for a minimum of one week and must be sold on a bid basis.

b. All vehicles shall be sold through a bidding process. c. Property declared as having no value shall be donated to a governmental or charitable

organization and/or discarded as determined by the Associate Director of Administrative Services.

d. After computers have been declared surplus they shall be made available to FCCBH, Inc. employees and Clubhouse members through a Clubhouse bid process prior to a public sale.

C. The sale of any surplus property by the Clubhouse serving the county in which the property is located

requires a declaration of surplus status by the Associate Director for Operations. a. All FCCBH, Inc. computer equipment must be cleared of all data, documents and

programs that are the property of FCCBH, Inc. prior to sale or donation. Approved by the Executive Committee 3/16/2004

Four Corners Community Behavioral Health, Inc. Request for Equipment Surplus Status

Someone will contact you within Five Business Days

The following FCCBH, Inc. property is not reasonably usable at ____________________________.

This is a request to declare the property surplus with a determined value.

Worksite _________________________________________________ Date __________________

Person Submitting Request _____________________________________________________________

Description of the equipment and recommendation: (More than one piece of equipment may be included) Office Use Only

Description of Equipment / Property and Recommendation Surplus

Status Value

($2,000 +)

Can be used

within FCCBH

No value

Surplus to NEW HEIGHTS __________ INTERACT __________

Administrative Office Use Only Date Received ____________________________________________Reviewed by ______________________________________

Surplus approved _____ Yes _____ No Name of person notified_______________________________ Notification date ____________

11/8/2006



VOLUNTEER REQUIREMENTS Four Corners Community Behavioral Health, Inc. volunteers, mentors or student interns shall be directly supervised by a program staff. The program supervisor shall ensure compliance with this volunteer requirements procedure. Section 1. Volunteer Packet 1. New volunteers are required to: (See section 6 of this policy for exceptions)

a) Review and sign the Driver’s Information Sheet, if licensed to drive. b) Provide a copy of a current driver’s license. c) Read and sign the Utah Department of Human Services Code of Conduct. d) Take a TB test or provide results of a TB test taken within the last twelve months. The fee

for a TB test taken at the Southeast Utah Health Department will be refunded upon presentation of receipt. Results of the test must be provided in writing to the HR office.

e) Review the Policy on Controlled Substances and Alcohol and sign the required acknowledgement.

f) Submit to a urine analysis which must be negative for substances as described in policy. g) Submit to a background screening (BCI) unless the volunteer is under the age of eighteen

years old or enrolled as a student in High School. The background screening shall be renewed annually. Any fees arising from this process are the responsibility of the volunteer. The volunteer is responsible to submit any information requested by the Office of Licensing to complete the screening. If a background screening is denied the individual shall not be allowed to work as a FCCBH, Inc. volunteer.

h) Read the Information Technology (IT) Acceptable Use Policy and sign the IT acknowledgement.

i) Read the Telecommunications Policy and sign the telecommunications acknowledgement. j) Agree to the provisions in the Non-Employee Confidentiality Agreement and sign the

required agreement. k) Agree to the provisions in the Sexual Harassment Prevention Policy and sign the required

acknowledgement. l) Sign the Volunteer Agreement / Acknowledgement (included in this procedure).

Section 2. Volunteer Handbook A volunteer handbook shall be provided to all employees who utilize volunteers. The handbook shall include information about 42 CFR Part 2, privacy rules and regulations, FCCBH mission, customer service standards, code of conduct, safety, pertinent policies and procedures and other information as appropriate. Section 3. Volunteer Duties It is the responsibility of the program supervisor to insure that a written description of duties is provided for all program volunteers. Section 4.

Training 1. Individuals who provide volunteer service shall review the following web-based training modules with

the program supervisor or designee: (The Supervisor/designee shall acknowledgement in writing (email) that training has been provided.

a) HIPAA Privacy and Confidentiality for volunteers or youth mentors; and b) Sexual Harassment prevention for Volunteers and Youth Mentors; and c) Safety Training

2. Additional safety training shall be provided for volunteers according to need and in consultation with the

training officer. The program supervisor shall exercise due caution to minimize the risks associated with fire, exposure to hazardous materials and other conditions or situations to minimize the loss of life, injury and property.

Section 5. Tracking Volunteers 1. Employees who utilize volunteers, of any age and in any capacity, must maintain a list of all volunteers

including mentors. The list must be submitted to the HR office and updated when volunteers sign the agreement form or cease to be active FCCBH, Inc. volunteers.

2. The training officer shall be provided with a list of all volunteers by the HR office. Regularly scheduled

trainings shall be used whenever possible and special trainings scheduled as needed. The training officer will send training notices to the program supervisor. It is the responsibility of the program supervisor to ensure that volunteers receive mandatory trainings.

Section 6 Mentors and/or Volunteers Under 18 Years of Age AND Individuals of Any Age Who Volunteer Five Hours or Less During a Calendar Year 1. Youth mentors (under the age of eighteen or still enrolled as a student in high school) who are under the

supervisor of a FCCBH, Inc. employee and individuals of any age who volunteer five hours or less during a calendar year shall be considered FCCBH, Inc. volunteers with limited requirements. The requirements of this procedure shall be modified for youth mentors who perform service on public school property or who mentor younger students on occasional activities supervised by adults or adults who participate in clinical observations or other limited activities under the supervision of a licensed mental health professional.

a) A list of all mentors must be submitted to the HR office and updated quarterly. b) The program supervisor shall ensure that due care is provided for the safety and well being of

all youth and clients. c) Employees and volunteers supervising youth mentors, student observers or others are

expected to use good judgment at all times and to abide by all FCCBH, Inc. policies and procedures, the code of conduct and laws and statutes regulating Sexual Harassment.

d) Youth mentors shall receive an appropriate orientation approved by the program supervisor, which shall review privacy rules and regulations, sexual harassment prevention, the code of conduct as appropriate to the mentor’s role and relationships, safety procedures and other issues as deemed necessary.

e) Student observers or other volunteers with limited activity shall sign the Non-Employee Confidentiality form and shall be instructed about the importance of privacy and protected health information.

f) The youth mentor shall sign the Youth Mentor Acknowledgement / Agreement, which shall be forwarded to the HR office within one week of the mentoring start date.


This agreement is between Four Corners Community Behavioral Health and ______________________________, hereinafter referred to as VOLUNTEER. This agreement is for the purpose of (include description of program and the role of the VOLUNTEER). ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Either party may terminate this VOLUNTEER AGREEMENT by sending written notice to the other party at least thirty days in advance of the desired termination date in accordance with the conditions described in this agreement. VOLUNTEER shall work under the direction of _____________________________________________. VOLUNTEER agrees that his / her service to the program described is voluntary, and he / she shall not receive compensation for services. VOLUNTEER shall have no claim against FCCBH, Inc. for compensation for hours worked, reimbursement, annual leave, sick leave, retirement benefits, Social Security contributions, overtime payments or other benefits unless specified. VOLUNTEER acknowledges that in the course of volunteer service Worker’s Compensation Coverage is not in effect according to the rules and regulations of Worker’s Compensation of Utah. The following have been reviewed and signed:

Code of Conduct Information Technology Acknowledgement Telecommunications Acknowledgement Non-employee Confidentiality Agreement Sexual Harassment Policy Acknowledgement VOLUNTEER also agrees to submit to a BCI check, to the Drug Free Work Place Policy required testing, to participate in HIPAA Privacy and Security training as required and Sexual Harassment Prevention training and any other FCCBH, Inc. requirements to perform the described volunteer duty.

VOLUNTEER is required to strictly adhere to the requirements of federal law as detailed under 42 CFR Part 2, HIPAA (Privacy Rule) and State Law, rules and regulations to provide adequate security for patient records, to protect the privacy of patient’s medical information and to appropriately maintain patient information. I ACKNOWLEDGE THAT I HAVE READ AND AGREE TO ALL THE REQUIREMENTS CONTAINED IN THIS AGREEMENT. ______________________________________________________ ____________________ VOLUNTEER Signature Date ______________________________________________________ Supervisor Signature 2/2005

Four Corners Community Behavioral Health, Inc. Volunteer Agreement /Acknowledgement

This agreement is between Four Corners Community Behavioral Health and ______________________________, a

YOUTH MENTOR / VOLUNTEER working under the supervision of ___________________________________ for

the purpose of (include description of program and the role of the YOUTH MENTOR).

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

YOUTH MENTOR / VOLUNTEER agrees that his / her service to the program described is voluntary, and he / she shall not receive compensation for services. YOUTH MENTOR / VOLUNTEER shall have no claim against FCCBH, Inc. for compensation for hours worked, reimbursement, annual leave, sick leave, retirement benefits, Social Security contributions, overtime payments or other benefits unless specified. VOLUNTEER acknowledges that in the course of volunteer service Worker’s Compensation Coverage is not in effect according to the rules and regulations of Worker’s Compensation of Utah. I acknowledge that I have received an appropriate orientation which included a review of privacy rules and regulations, sexual harassment prevention and the code of conduct. I ACKNOWLEDGE THAT I HAVE READ AND AGREE TO ALL THE REQUIREMENTS CONTAINED IN THIS AGREEMENT. ______________________________________________________ ________________________ YOUTH MENTOR / VOLUNTEER Signature Date _________________________________________________________________ _____________________________ Supervisor Signature Date Date of Birth ___________________________ Emergency Contact ________________________________________ Address _____________________________________________ Telephone __________________________________

2/2005

Four Corners Community Behavioral Health, Inc. Youth Mentor/Volunteer Agreement /Acknowledgement


OPERATIONS PROCEDURE – OP 15 –ADOPTED 6/15/2005 CLIENT REQUEST FOR FEE WAIVER OR REDUCTION A. Requests for client fee reduction or waiver must be made on the Client Assistance Form using the

regular procedure. B. A Payment Information Form, required for all non-Medicaid enrollees, must have been completed

and filed. C. Unless special circumstances exist, clients requesting help with fees owed should be offered

payment arrangements for account balances and should be asked to complete the Credit Application and Agreement for Payment for review and approval by the clinic supervisor.

D. If the amount to be waived is $50 or more a Purchase Request must accompany the Client

Assistance Form. E. FCCBH, Inc. is considered the vendor in an instance of fee reduction or waiver; send the white

copy of the Client Assistance Form to the business office so the client’s account balance can be adjusted.

F. The yellow copy of the form is placed in the client’s paper file in the financial tab. G. Client fee waiver-reduction shall be reviewed quarterly if the client has received assistance two or

more times during the quarter. The client shall be asked if there is a change in his or her financial status.

H. Changes to the amount of assistance provided shall require a new Client Assistance Form. Adopted by Executive Committee on 6/15/2005; Revised 5/24/2006


OPERATIONS PROCEDURE – OP 16 – Adopted 10/20/2005 SINGLE CASE AGREEMENTS A. Requests for Single Case Agreements (SCA)

If an individual has insurance not accepted by FCCBH, Inc. and he or she requests a single case agreement for their insurance to pay for services, the following steps shall be taken:

1. Fill out the insurance information verification form. Clinic support staff

Verify what services the client wants to receive Support staff needs to ask Supervisor

2. Ask the client to call the insurance and request a SCA Clinic support staff

3. Assign a therapist and/or physician Clinic Supervisor

4. Complete the SCA approval form and send to insurance Clinic support staff Specialist

5. Call the insurance company to negotiate a SCA Insurance Specialist Provide the insurance company with required information

6. Fax the preliminary approval from the insurance company Insurance Specialist to the clinician

7. Fax signed preliminary approval to insurance company Insurance Specialist with copy of clinician’s license and FCCBH, Inc. m alpractice insurance

8. Send/Fax completed SCA form to clinic supervisor, Insurance Specialist clinic support staff and clinician

9. File SCA in client chart under insurance/financial Clinic support staff

10. Advise clinician of approved SCA and service limitations Clinic Supervisor

11. Collect co-pay (if any) from client at time of services Clinic Support Staff 12. Bill insurance companies Insuranc e Specialist

Adopted by Executive Committee 10/20/2005; Revised 7/19/2006; Revised 11/8/2006

13. Maintain spread sheet with current SCA’s and provide Insurance Specialist

Provide to Associate Director of Administrative Services.

14. Review SCA report with staff monthly (# sessions used) Clinica l Supervisor 15. Submit SCA treatment report to insurance per schedule Clinician

16. Make decision about continuing services when sessions Clinician

are exhausted (Insurance specialist can request more services)

B. If the insurance will not establish a preliminary agreement for a SCA without a diagnosis, verify that the individual is covered until a diagnosis can be provided. Ask if a single case agreement is probable and advise the insured that he/she must pay for the intake/evaluation so a diagnosis can be provided to negotiate a SCA.

C. If the full cost of service will not be covered the client must agree to pay the difference between the insurance

payment and the full cost for a SCA to be accepted. The insured must pay at the time the service is provided.


OPERATIONS PROCEDURE – OP 17 – Adopted 10/20/2005 Advance Beneficiary Notice Medicare I. Four Corners Community Behavioral Health, Inc. shall provide an Advance

Beneficiary Notice (ABN) to a Medicare beneficiary or insured of any insurance FCCBH does not accept when furnishing a service for which Medicare or the insurance is expected to deny payment. The client or their guardian shall have the option to decline the service. If an ABN is signed it is an agreement for the recipient to pay for services.

II. The notice shall say in part, “We expect that your Medicare or insurance company

will not pay for service(s) that are described below…..It is your choice whether or not to receive the services and to accept responsibility for full payment.”

Single Case Agreements III. For all services and providers not specifically listed on a single case agreement an

Advance Beneficiary Notice must be provided. The service recipient or guardian must sign the ABN before services are provided.

Adopted by Executive Committee 10/20/2005



FUND RAISING

1. Fund raising may only be undertaken by FCCBH, Inc. staff with prior supervisory approval. 2. Supervisory approval may be given only based on a fund raising proposal that contains the

following elements: a. Statement of goal or purpose, e.g., to subsidize members’ travel to and registration for

the club house regional conference; b. Amount to be raised; c. Methods to be used, e.g., bake sales, solicitation of contributions from local businesses; d. Proposed cost center and budget line to which the funds to be raised are to be applied;

and e. Need for funding.

3. When a fund raising proposal has received supervisory approval, a copy shall be forwarded to the business office for review.

a. The Associate Director for Administrative Services shall review all approved proposals to insure that the proposal follows proper financial procedures.

1. The Administrative Office Secretary shall retain files of approved fundraising plans.

b. A copy of the approved proposal shall be retained in the business office and a copy evidencing the Associate Director’s review returned to the supervisor.

4. All monetary contributions shall be deposited within three business days, except money from the Clubhouse snack bar and vending machine which shall be deposited weekly. All money shall be receipted to the miscellaneous account with a detailed description at the local office. A copy of the receipt shall be retained and the original receipt sent to the business office, attention Accounts Payable/Insurance Specialist.

5. Monies collected from fund raising activities shall be spent in the same fiscal year as the

activity for which funds were raised or shall be held in a designated account for ongoing activities and/or projects.

6. Tax deductions for contributions to charities require a contemporaneous written

acknowledgement. Individuals or businesses that make a contribution of cash or property shall be provided with substantiation of charitable contributions of $250 or more. The Acknowledgement of Charitable Contribution form shall be completed and sent to the contributor prior to the end of the calendar year in which the gift was received.

Adopted:____________________________ Signed___________________________________ __________________________________ Executive Director Board Chairperson

Approved by the Executive Committee 4/17/2006; Revised 6/21/2006; Revised 8/22/2006; Revised 5/16/2007

Four Corners Community Behavioral Health, Inc.

Acknowledgement of Charitable Contribution

Date ____________________ Name ______________________________________ Thank you for your important contribution of _____________________to Four Corners Community Behavioral Health, Inc. and the ___________________________________ program on the following date (s)____________________________________________ FCCBH, Inc. is a tax exempt charitable organization and your contribution is tax Deductible to the extent allowed by law. This acknowledgement also confirms that you

received nothing in return for your donation.

We appreciate your contribution and it will make a difference. Sincerely, 6/2006

Purpose of Fundraising Activity:

Four Corners Community Behavioral Health, Inc. Fund Raising Approval Request Form

Date _____________ Name of Requester _________________________________ Program /Work Site______________ Estimated staff time involved ____________ Estimated current expenses to be used ____________________________________

Subsidize clubhouse members’ conference costs Pay for youth field trip (group skills development) Help support youth prevention activity Help support graduation party Finance community awareness (e.g. Mental Illness Month) Scholarships for program participants Training Parent Involvement / Education Enhance treatment (e.g. drug court) Other _______________________________________

Estimated amount to be raised: _________________________________________________________________________ Earnings will be applied to the following cost center: _______________________________________________________ Earning will be applied to the following budget line: ________________________________________________________ Fundraising Methods:

Soliciting money from businesses* Soliciting in-kind contributions from businesses Soliciting money from individual donors Grants for general purposes Pledges (e.g. walk-a-thon) Selling goods (yard sale, bake sale, other items) Auctions Meals (Health Department approved kitchen) Other _________________________________

*If soliciting money from businesses please list the business you intend to contact on the back of this form. ATTACH COPIES OF ANY PRINT MATERIALS THAT WILL BE USED INCLUDING FLYERS, LETTERS, ETC. Other comments: ____________________________________________________________________________________ __________________________________________________________________________________________________ I have reviewed this fund raising activity and give my approval:

_________________________________________________________________ ________________________________ Supervisor Date I have reviewed the approved proposal to insure that it follows proper financial and operational procedures: _________________________________________________________________ ________________________________ Associate Director Date 8/2006


OPERATIONS PROCEDURE – OP 19 ADOPTED 5/24/2006 APPROVED FORMS I. Four Corners Community Behavioral Health, Inc. forms shall be used to support quality clinical

services, sound fiscal and business practices that decrease organizational risk and enhance operational consistency.

II. All Four Corners Community Behavioral Health, Inc. forms shall be approved by the Executive

Committee prior to use including forms used to carry out FCCBH, Inc. programs, activities, services and / or official business or otherwise used by a Four Corners’ employee in the performance of his or her job.

a. The Executive Committee may require forms to be reviewed by other FCCBH

committees (QI, Cultural Competency, Compliance, etc.) prior to consideration by the Executive Committee.

b. Use of unapproved and unauthorized forms is prohibited.

c. Employees shall use approved FCCBH, Inc. forms when required or indicated.

III. Forms shall be made available on the FCCBH, Inc. web site. Adopted by Executive Committee on 5/24/2006


OPERATIONS PROCEDURE – OP 20 ADOPTED 6/21/2006 COMPUTER REPLACEMENT 1. Staff computers shall be replaced every four years, or as determined by the Associate Director for

Operations who shall maintain a replacement schedule. 2. An inventory of all computers purchased by FCCBH, Inc. shall be maintained to include inventory

tag number, description of equipment, model, processor speed, installed memory and operating system, and serial number, date of manufacture, location and current user.

3. Computers may be replaced with older computers as needed. 4. Servers shall be replaced on the same schedule as workstation computers. 5. Special requests for replacement of computers shall be considered. Adopted by Executive Committee on 6/21/2006


OPERATIONS PROCEDURE – OP22 –Adopted 4/2004 DISCOUNT CLIENT FEES

In compliance with the State of Utah Division of Substance Abuse and Mental Health Administrative Rule R523-1-5, Fee for Service, FCCBH, Inc. clients shall be charged the actual cost of services rendered to them based on the most recent FCCBH, Inc. cost study.

A minimum discount fee schedule shall be adopted by the Carbon, Emery and Grand Local Substance Abuse and Mental Health Authority. It shall be maintained for individuals who meet the established priorities for service as outlined in Clinical Procedure CL11, Service Priorities, and for whom “a fee would result in a financial hardship for the recipient of services,” R523-2-C.

The Executive Committee shall review the client discount-fee schedule bi-annually. The following shall be considered at the time the discount fee schedules are reviewed: the client’s ability to pay, fees for specific programs, the cost of services, number of dependents and first party receipts. In exceptional circumstances the Client Assistance Request may be used to provide temporary assistance in meeting fees. The discount fee schedule shall be available on the Four Corners Community Behavioral Health, Inc. web site. (Reference - Finance Policy 3.03 Client Fees; Operations Procedure OP15 Request for Fee Waiver) Approved by the Executive Committee 4/2004

Page 1 of 6 – Discount Client Fees Procedure

Based on Household Income - Before Taxes

FAMILY GROSSMONTHLY INCOME 1 2 3 4 5 6 7 8

$0 - $100 $0 $0 $0 $0 $0 $0 $0 $0$101 - $200 $9 $9 $9 $9 $9 $9 $9 $9$201 - $300 $10 $10 $10 $10 $10 $10 $10 $10$301 - $400 $10 $10 $10 $10 $10 $10 $10 $10$401 - $500 $10 $10 $10 $10 $10 $10 $10 $10$501 - $600 $10 $10 $10 $10 $10 $10 $10 $10$601 - $700 $10 $10 $10 $10 $10 $10 $10 $10$701 - $800 $10 $10 $10 $10 $10 $10 $10 $10$801 - $900 $10 $10 $10 $10 $10 $10 $10 $10$901 - $1000 $10 $10 $10 $10 $10 $10 $10 $10$1001 - $1100 $12 $10 $10 $10 $10 $10 $10 $10$1101 - $1200 $15 $10 $10 $10 $10 $10 $10 $10$1201 - $1300 $18 $10 $10 $10 $10 $10 $10 $10$1301 - $1400 $21 $11 $10 $10 $10 $10 $10 $10$1401 - $1500 $24 $13 $10 $10 $10 $10 $10 $10$1501 - $1600 $28 $15 $10 $10 $10 $10 $10 $10$1601 - $1700 $31 $17 $11 $10 $10 $10 $10 $10$1701 - $1800 $35 $20 $12 $10 $10 $10 $10 $10$1801 - $1900 $40 $22 $14 $10 $10 $10 $10 $10$1901 - $2000 $44 $24 $16 $11 $10 $10 $10 $10$2001 - $2100 $49 $27 $17 $12 $10 $10 $10 $10$2101 - $2200 $54 $30 $19 $13 $10 $10 $10 $10$2201 - $2300 $59 $33 $21 $14 $10 $10 $10 $10$2301 - $2400 $65 $36 $23 $16 $11 $10 $10 $10$2401 - $2500 $71 $39 $25 $17 $12 $10 $10 $10$2501 - $2600 $77 $42 $27 $19 $14 $10 $10 $10$2601 - $2700 $83 $46 $29 $20 $15 $11 $10 $10$2701 - $2800 $89 $49 $31 $22 $16 $12 $10 $10$2801 - $2900 $96 $53 $34 $23 $17 $13 $10 $10$2901 - $3000 $103 $57 $36 $25 $18 $14 $11 $10$3001 - $3100 $110 $61 $39 $27 $19 $15 $12 $10$3101 - $3200 $118 $65 $41 $28 $21 $16 $12 $10$3201 - $3300 $118 $69 $44 $30 $22 $17 $13 $11$3301 - $3400 $118 $74 $47 $32 $24 $18 $14 $11$3401 - $3500 $118 $78 $50 $34 $25 $19 $15 $12$3501 - $3600 $118 $83 $53 $36 $27 $20 $16 $13$3601 - $3700 $118 $88 $56 $38 $28 $21 $17 $14$3701 - $3800 $118 $93 $59 $41 $30 $23 $18 $14$3801 - $3900 $118 $98 $62 $43 $31 $24 $19 $15$3901 - $4000 $118 $103 $65 $45 $33 $25 $20 $16$4001 - $4100 $118 $109 $69 $47 $35 $26 $21 $17$4101 - $4200 $118 $114 $72 $50 $36 $28 $22 $18$4201 - $4300 $118 $118 $76 $52 $38 $29 $23 $19$4301 - $4400 $118 $118 $79 $55 $40 $31 $24 $19$4401 - $4500 $118 $118 $83 $57 $42 $32 $25 $20$4501 - $4600 $118 $118 $87 $60 $44 $33 $26 $21$4601 - $4700 $118 $118 $91 $63 $46 $35 $28 $22$4701 - $4800 $118 $118 $95 $65 $48 $36 $29 $23$4801 - $4900 $118 $118 $99 $68 $50 $38 $30 $24$4901 - $5000 $118 $118 $103 $71 $52 $40 $31 $25

OUTPATIENT DISCOUNT FEE SCHEDULE

FAMILY SIZE

$5001 - $5100 $118 $118 $107 $74 $54 $41 $33 $26$5101 - $5200 $118 $118 $112 $77 $56 $43 $34 $27$5201 - $5300 $118 $118 $116 $80 $59 $45 $35 $28$5301 - $5400 $118 $118 $118 $83 $61 $46 $37 $30$5401 - $5500 $118 $118 $118 $86 $63 $48 $38 $31$5501 - $5600 $118 $118 $118 $90 $66 $50 $39 $32$5601 - $5700 $118 $118 $118 $93 $68 $52 $41 $33$5701 - $5800 $118 $118 $118 $96 $70 $54 $42 $34$5801 - $5900 $118 $118 $118 $100 $73 $56 $44 $35$5901 - $6000 $118 $118 $118 $103 $75 $57 $45 $37$6001 - $6100 $118 $118 $118 $107 $78 $59 $47 $38$6101 - $6200 $118 $118 $118 $110 $81 $61 $48 $39$6201 - $6300 $118 $118 $118 $114 $83 $63 $50 $40$6301 - $6400 $118 $118 $118 $117 $86 $66 $52 $42$6401 - $6500 $118 $118 $118 $118 $89 $68 $53 $43$6501 - $6600 $118 $118 $118 $118 $91 $70 $55 $44$6601 - $6700 $118 $118 $118 $118 $94 $72 $57 $46$6701 - $6800 $118 $118 $118 $118 $97 $74 $58 $47$6801 - $6900 $118 $118 $118 $118 $100 $76 $60 $49$6901 - $7000 $118 $118 $118 $118 $103 $79 $62 $50$7001 - $7100 $118 $118 $118 $118 $106 $81 $64 $52$7101 - $7200 $118 $118 $118 $118 $109 $83 $66 $53$7201 - $7300 $118 $118 $118 $118 $112 $86 $67 $55$7301 - $7400 $118 $118 $118 $118 $115 $88 $69 $56$7401 - $7500 $118 $118 $118 $118 $118 $90 $71 $58$7501 - $7600 $118 $118 $118 $118 $118 $93 $73 $59$7601 - $7700 $118 $118 $118 $118 $118 $95 $75 $61$7701 - $7800 $118 $118 $118 $118 $118 $98 $77 $62$7801 - $7900 $118 $118 $118 $118 $118 $100 $79 $64$7901 - $8000 $118 $118 $118 $118 $118 $103 $81 $66

Shaded area indicates poverty levels

Effective 4/1/09Prepared by Jeanie WillsonThis guideline was developed using the 2009 HHS Poverty Guideline.

IOP DISCOUNT FEE SCHEDULE

FCCBH, Inc.IOP Discount Fee Schedule

*Please remember that this includes the gross monthly income from all family members living in the household. Use the income verification form to document income information. INCOME* FEE

up to $750 $150

$751-$999 $200

$1,000-$1,499 $300

$1,500-$1,999 $400

$2,000-$2,499 $500

$2,500-$2,999 $600

$3,000-$3,499 $700

$3,500-$4,000 $800

$4,000-$5000 $1,000

Over $5,000 full cost of services Adopted 4/2004 Effective 7/1/04


INPATIENT DISCOUNT FEE SCHEDULE

FCCBH, Inc.

Inpatient Discount Fee Schedule

This includes the gross income from all family members Number of Dependents Income* Inpatient fee 1 person at or below poverty Up to $775 per mo $10 per day 1 person over poverty level Over $775 per mo $10 + 10% of excess income 4 person family at or below poverty Up to $1,570 per mo $10 per day 4 person family over poverty level Over $1,570 per mo $10 + 10% of excess income 5 person family at or below poverty Up to $1835 per mo $10 per day 5 person family over poverty level Over $1,835 per mo $10 + 10% of excess income 6 person family at or below poverty Up to $2,100 per mo $10 per day 6 person family over poverty level Over $2,100 per mo $10 + 10% of excess income 7 person family at or below poverty Up to $2,365 per mo $10 per day 7 person family over poverty level Over $2,365 per mo $10 + 10% of excess income


CLUBHOUSE PLUS OUTPATIENT DISCOUNT FEE SCHEDULE

FCCBH, INC.

Club House Plus Outpatient Monthly Discount Fee Schedule *Please remember this includes the gross monthly income from all family members living in household. Use the income verification form to document income information. Number of dependents------------>

1 2 3 or more

Income* up to $550 $24 $17 $12

$600 $27 $21 $16 $650 $31 $25 $20 $700 $35 $28 $24 $750 $39 $32 $27 $800 $42 $36 $31 $850 $50 $40 $35 $900 $100 $60 $45 $950 $150 $60 $60

$1,000 $200 $60 $60 $1,050 $250 $60 $60 $1,100 $300 $60 $60 $1,150 $350 $100 $60 $1,200 $400 $125 $60 $1,250 $450 $175 $60 $1,300 $500 $225 $60 $1,350 $550 $275 $60 $1,400 $600 $325 $100 $1,450 $650 $375 $150 $1,500 $700 $425 $200 $1,550 $750 $475 $250 $1,600 $800 $525 $300 $1,650 $850 $575 $350 $1,700 $900 $625 $400 $1,750 $950 $675 $450 $1,800 $1,000 $725 $500 $1,850 $1,050 $775 $550 $1,900 $1,100 $825 $600 $1,950 $1,150 $875 $650 $2,000 $1,200 $925 $700 $2,050 $1,250 $975 $750 $2,100 $1,300 $1,025 $800 $2,150 $1,350 $1,075 $850 $2,300 $1,500 $1,225 $1,000 $2,350 $1,550 $1,275 $1,050 $2,400 $1,600 $1,325 $1,100 $2,450 $1,650 $1,375 $1,150 $2,500 $1,700 $1,425 $1,200 $2,550 $1,750 $1,475 $1,250 $2,600 $1,800 $1,525 $1,300

above $2,600 full cost of service Adopted 4/2004 Effective 7/1/04


of 6 – Discount Client Fees Procedure

INDIGENT MEDICATION FEE SCHEDULE

FCCBH, Inc.

Indigent Medication Fee Schedule Set-up fee per medication $20 Monthly fee per medication $10 Adopted 4/2004 Effective 7/1/04

```````````


OPERATIONS PROCEDURE – OP23 ADOPTED 12/20/2006 DISSEMINATING CHANGES IN POLICY AND PROCEDURE 1. Policies adopted by the FCCBH, Inc. Board of Trustees and administrative procedures approved

by the FCCBH, Inc. Executive Committee shall be:

a. Posted on the FCCBH, Inc. web site within fifteen business days of adoption or approval b. Distributed electronically to all employees within ten business days of adoption or

approval

2. Training on new policies and procedures shall be provided by the team supervisor and by other staff as assigned.

3. Changes in existing policy and/or procedure shall be explained at the time of electronic

distribution. 4. The date of revision shall be recorded on policies and procedures. Approved by the Executive Committee 12/20/2006


OPERATIONS PROCEDURE – OP24 ADOPTED 1/17/2007

RECORD RETENTION The purpose of this procedure is to specify how long Four Corners Community Behavioral Health, Inc. shall retain or keep records to comply with record keeping laws. Record retention for those records not specified shall be retained as deemed appropriate by the Executive Director. Clinical Services / Confidentiality Medical records in their original form shall be retained in the electronic record system for a minimum of six years from the date of last entry. Records must also be retained for two years after a client’s death. Documentation is required that an individual is an executor, administrator or personal representative authorized under applicable law to act on behalf of the decedent’s estate to have the right to control deceased individual’s protected health information. Documents related to uses and disclosures, authorization forms, business partner contracts, notice of information practices responses to a client who wants to amend or correct their information, the client’s statement of disagreement and a complaint record shall be retained for six years. Medical records for minors shall be retained for three years after the client reaches the age of majority, or twenty-one years of age, or for a minimum of six years from the date of last entry, whichever is longer. Billing and Protective Payee Records Records related to third party payers including Medicaid, Medicare and private insurance shall be retained for at least six years. Contracts and documentation of contractual transactions shall be retained for six years. Employment / Personnel Records related to wages and wage-rate tables, hours, occupation, conditions of employment, payroll and earnings records, employment information and certificates, work time schedules, job evaluations, merit system descriptions, deductions from or additions to pay and other documents that explain wages differences shall be kept for at least three years. Any employment and personnel records of hiring, promotion, demotion, termination, transfer, layoff, pay raises et al must be retained for six months from the making of the record of personnel action involved to comply with the Civil Rights Act. Taxes Copies of employment tax records shall be kept for at least four years after the due date of the tax. The summary of the employee pension plan filed with the Department of Labor shall be retained for six years. Adopted by the Executive Committee 1/17/2007


OPERATIONS PROCEDURE – OP25 ADOPTED 4/26/2007

VEHICLE PASSENGERS The purpose of this procedure is to specify the Four Corners Community Behavioral Health, Inc. procedures for use of vehicles and for non-employee drivers in FCCBH, Inc. and State vehicles. Use of Vehicles FCCBH, Inc. vehicles shall be used to conduct the business of Four Corners Community Behavioral Health, Inc. Access to and use of vehicles shall be given to employees as needed and required. The following shall not be permitted:

1. Unauthorized use 2. Use of a vehicle for personal activities that interfere with the need and requirement for use 3. Personal mileage that is not reimbursed to FCCBH, Inc. 4. Allowing non employees to drive a vehicle except as allowed in #12 below. 5. Failure to secure prior approval for child passengers not attending an activity as a participant of

a FCCBH, Inc. program 6. Driving a vehicle without a valid driver’s license 7. Driving without the use of a seatbelt or allowing passengers to travel without the use of a

seatbelt 8. Unlawful activities 9. Unreasonable distractions from non client passengers that endanger vehicle occupants

The following shall be permitted with the stipulations described:

10. Child passengers properly secured in an approved child safety seat (a child is defined as “someone less than 4 feet 9 inches tall or under the age of twelve”)

11. Child passengers in the front passenger seat properly secured in an approved booster seat (see definition in #10 above)

12. Approved client drivers or bona fide volunteers with prior authorization 13. Service dogs as required for client safety and restrained as necessary

Non-Employee Drivers Individuals who are not employed by FCCBH, Inc. may volunteer to drive a FCCBH, Inc. vehicle after meeting the volunteer requirements as described in Operation Procedure OP13 Volunteer Requirements. This includes completing the Volunteer Agreement and Acknowledgement Form and submitting other required documents. Client drivers are not required to meet the volunteer requirements. Violation of the vehicle passengers’ procedure may result in corrective action up to and including termination. Adopted by the Executive Committee on 4/26/2007


PERSONNEL PROCEDURE – PE01 – ADOPTED 8/22/2001 CONFLICT OF INTEREST DECLARATION

1. It is the intent of this procedure to establish safeguards for employees and FCCBH, Inc. and to provide documentation for funders to clarify any potential employee involvement in situations that may compromise the best interests of FCCBH, Inc. or the purchasers of the Four Corners’ services.

2. All employees are required to submit a Conflict of Interest / Related Party Declaration Form

annually on July 1st. Employees engaged in outside employment or volunteer activities shall disclose such activities. Outside activity that may constitute a potential conflict of interest must be approved/disapproved by the Executive Director.

3. If the status of an employee's outside activities changes, a form shall be filed within 30 days of

such change. Approved forms and Executive Director approval/disapproval to requests for involvement in outside activity shall be filed in the employee's personnel folder.

4. Upon receipt of signed Conflict of Interest /Related Party Declaration Forms, the supervisor shall

forward forms, with recommendations for approval or disapproval of relevant outside activities, to the Executive Director.

5. The Executive Director shall approve or disapprove an employee's request to participate in such

outside activity, based on the guidelines described in this policy. If the Executive Director disapproves a request , he/she will discuss such with the supervisor and/or the employee.

6. In cases where the situation is not covered by the guidelines or other considerations described

herein the Executive Director shall bring the request to the Executive Committee at the next regularly scheduled meeting and invite the employee to present his/her case to the Committee at which time the Executive Committee shall consider the request.

7. The employee has the right to seek resolution through the formal grievance procedure after the

above steps have been taken.

8. If an employee fails to disclose requested information on the proper forms described in this policy, and is subsequently determined to be engaged in an outside activity which should have been disclosed , FCCBH, Inc. will take disciplinary action. The disciplinary action will be consistent with the FCCBH, Inc. Disciplinary Policy and Process.

9. The following list includes factors, which constitute conflict of interest. It is not all-inclusive but

will guide what is submitted on the Declaration form.

a. Being engaged in volunteer or other service for an agency or employer during the same hours the employee is scheduled to be working for FCCBH, Inc..

b. Receiving pay for providing services that would compete with the services FCCBH, Inc. provides for remuneration.

c. Disclosing information acquired by reason of the employee's position for personal or another's private gain or benefit.

d. Using or attempting to use the employee’s position to secure special privileges or exemptions for self or others.

e. Accepting employment or volunteer responsibilities, which would impair independence of judgment in the performance of duties in the employee’s position.

f. Being employed or affiliated for financial gain with other persons, agencies, or entities which have contractual relationships with FCCBH, Inc. in which there may be real or perceived undue influence.

g. Not being able to perform at full capacity in the employee’s position because of fatigue, anxiety, burnout, or other impairments caused by outside employment.

h. Utilizing the FCCBH, Inc.’s resources and/or materials for purposes other than those required in the position held by the employee.

i. Involvement in an outside activity, which may require improper disclosure or use of confidential information.

j. Having outside employment, which exceeds 20 hours per week. This must be evaluated with G above.

k. Receiving compensation for any transaction involving Four Corners and a business in which the individual has a substantial interest.

l. Having outside employment which involves providing services to a current client of Four Corners, or one who has been a client within the preceding six months, for a fee when such fees are paid directly to the employee, a relative of the employee, or a business owned wholly or in part by the employee, or when the employee benefits financially in any way from the provision of such service.

m. Being a volunteer member of a policy making board of an agency, institution, or other entity which does business with Four Corners or with a business providing services or products similar to those offered by Four Corners.

n. Receiving outside compensation for the performance of the employee’s duties with FCCBH, Inc. except in cases of pre-approved honoria or expenses paid for papers, talks, demonstrations, or appearances made by employees on their own time and not at Four Corners’ expense.

o. Outside involvements, which could reasonably compromise FCCBH, Inc. services to consumers.

10. In addition to the conflict of interest guidelines, the following criteria shall also be considered in the approval/disapproval process.

a. Does the outside activity interfere with the effective performance of the employee's responsibilities?

b. Is the outside interest the type that could reasonably give rise to criticism or suspicion of conflicting interests or duties?

c. Would the outside interest provide a proven benefit to Four Corners? d. Would failure to approve the outside activity be considered an extreme hardship for a

client or consumer?



PERSONNEL PROCEDURE – PE03 – ADOPTED 2/19/2003 DRUG FREE WORK PLACE 1. SAMPLING PROCEDURES

Drug tests, sample collections, alcohol test and reporting of results will be done in conformity with Four Corners Community Behavioral Health (FCCBH, Inc.) policy and shall be conducted in accordance with the requirements of Title 34, Chapter 18 of the Utah Code Annotated.

All drug tests, alcohol tests and sample collection procedures shall be performed under reasonable and sanitary conditions and in such a manner as to ensure the privacy of the individual being tested. All drug tests will be split specimen tests. All collections will be done by an entity independent of and approved by FCCBH, Inc. and in conformity with Title 34, Chapter 18 of the Utah Code Annotated.

2. CONFIDENTIALITY OF TEST RESULTS

In all drug testing, alcohol testing and sample collection, transmittal or reporting of test results shall be conducted with due respect for the confidentiality of the test results.

Drug and alcohol test results will be reported directly by a certified lab, third-party administrator or a MRO to a designated FCCBH, Inc. official. Drug test results will be kept in a separate locked file.

3. PAYMENT FOR TESTS

Random, reasonable suspicion and post accident drug and alcohol tests will be conducted while employees are on FCCBH, Inc. time and will be paid for by FCCBH, Inc. Pre-employment test will be conducted on prospective employees on their own time. Pre-employment tests will be paid for by FCCBH, Inc. Employees may be required to pay for drug and alcohol tests under a return to work option according to the conditions of the return to work agreement.

Employees who fail to submit to a required drug test within twenty-four hours or who fail to comply with a corrective action plan may be responsible to pay for additional tests.

4. APPEAL PROCESS AND CONTESTING TESTS

As per Title 34, Chapter 18 or the Utah Code Annotated, any employee or potential employee will have the right to explain a positive drug or alcohol test. Under the conditions set forth in Section 34-41-103 an employee who has a positive drug test will have 72 hours from the time of the positive test to request that a second test be done on the "split" portion of their drug specimen. The cost

of the second test will be split equally between the employer and the employee as outlined in Section 34-41-103.

5. TESTING CATEGORIES AND PROCEDURES

a. REASONABLE SUSPICION TESTING Reasonable suspicion testing will be done when a supervisor observes an

employee actually using a Controlled Substance, in possession of a Controlled Substance, when a supervisor observes a set of documentable actions and circumstances that would lead them to believe that an employee may be using a Controlled Substance, non-prescribed prescription drug or, alcohol while on Four Corner's business, property or, during on-duty time or when a report of reasonable suspicion is received.

Supervisors should fill out the form "Observed Behavior-Reasonable Cause

Record" before requesting a reasonable suspicion test. A reasonable suspicion test will be conducted at the third-party administrator's testing facility, unless provisions are made for the testing to occur on-site. To request an on-site test, telephone the third-party administrator during normal business hours.

All employees required to submit to a "reasonable suspicion" test will be

taken to the testing facility by a supervisor or another designated employee. No employee will be allowed to proceed to a "reasonable suspicion" test on his/her own.

Following the testing procedure, if results are positive or unknown the

employee will be taken home by a supervisor or sent home by public transportation. If the results are negative the employee may be allowed to return to work immediately.

If the employee is no longer in violation of this policy (i.e. no longer having

any prohibited substances in his/her system), the employee may be allowed to return to work the next day, pending the results of the test. If the test is positive, disciplinary action will be taken. If the test-result in negative, no further action will be taken, and any written reference to the reasonable suspicion circumstance and the referral for testing will be destroyed.

Any employee who is requested to take a reasonable suspicion test, and who

leaves a Four Corners’ facility will be reported to proper authorities and disciplinary action will be taken.

b. POST -ACCIDENT TESTING

Post-accident drug and alcohol tests should be conducted within 8 hours of an accident. . If a post-accident drug or alcohol test is not conducted within the required time limits it should not be conducted. Any employee who is


required to take a post-accident drug or alcohol test is prohibited from consuming any drug or alcohol (except under the care of a physician) prior to taking a post-accident drug or alcohol test. If a post-accident test is needed, a third-party administrator should be contacted immediately. Post-accident tests can be conducted either at a third party administrator's testing facility, Four Corners Community Behavioral Health facility, or if the parties are injured and admitted to a hospital, at the hospital.

The employee involved in an accident that requires post-accident testing shall

have responsibility to submit to a drug and alcohol test within 8 hours at one of the designated locations in Carbon, Emery or Grand Counties or if the employee is out of the area at a certified lab or hospital according to the specifications in numbers 1 and 2 above.

c. PRE-EMPLOYMENT TESTS

Pre-employment tests are conducted at a third-party administrator's facility or on-site. Pre-employment tests are paid for by FCCBH, Inc.

d. RETURN TO WORK TESTING

Any employee who returns to work after a positive drug or-alcohol test will be subject to return to work testing under the terms and conditions of a return to work agreement.

e. OBSERVED TESTS

Any suspicion of an attempt by an employee to adulterate, contaminate or otherwise change a test result will be reported to their supervisor. If requested by the FCCBH, Inc., a second test will be conducted where the collector observes the individual. Observed tests will only be conducted at the request of FCCBH, Inc.

f. RANDOM TESTING

All employees shall be subject to random selection for a drug and alcohol test. The Human Resources Specialist shall do a blind selection of an employee or employees and shall notify the individual of the requirement to submit to a urine breath, or blood test within 24 hours and of the location of the drug and alcohol test.

Any employee who is required to take a random drug test and fails to do so

within 24 hours shall be participate in a mandatory meeting with his or her immediate supervisor to discuss appropriate action.

Three percent of the employee census shall be randomly selected for

unannounced drug or alcohol testing quarterly.

6. FORMS AND DOCUMENTATION

a. The following forms shall be provide official documentation of employee or potential employee notification, consent, and drug and alcohol related incidents:

Acknowledgment Of Having Read And Understanding The Four Corners Community Behavioral Health Policy On Controlled Substances And Alcohol

Four Corners Community Behavioral Health Consent For Pre-Employment

Drug And Alcohol Screening

Four Corners Community Behavioral Health Observed Behavior -Reasonable Suspicion Record.

7. CONTROLLED SUBSTANCE SCREENING CUT -OFF LEVELS

a. Screening and Confirmation Test Cut-off Levels for the Controlled Substances or their metabolites being tested are as follows:

Screening Confirmation Marijuana 50 NG/ML 15 NG/ML Cocaine 300 NG/ML 150 NG/ML Opiates 300 NG/ML 300 NG/ML Amphetamines 1,000 NG/ML 500 NG/ML Phencyclidine 25 NG/ML 25 NG/ML Barbiturates 300 NG/ML 200 NG/ML Benzodiazepines 300 NG/ML 200 NG/ML Methadone 300 NG/ML 300 NG/ML Propoxyphene 300 NG/ML 300 NG/ML Alcohol .01% .01% (.04% if employee is on-call status)

ACKNOWLEDGMENT OF HAVING READ AND UNDERSTANDING THE FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH

POLICY ON CONTROLLED SUBSTANCES AND ALCOHOL I, the undersigned employee or prospective employee of Four Corners Community Behavioral Health, hereby acknowledge that I have read the drug and alcohol policy of Four Corners Community Behavioral Health, and I understand it. I also agree to comply with the drug and alcohol policy as a condition of employment with Four Corners Community Behavioral Health. Further, I also understand that this agreement does not create an obligation or contract of employment between Four Corners Community Behavioral Health and myself. I also further consent to any request under the Policy for a urine or breath specimen for the purposes of detecting the presence of drugs, including the presence of such drugs as a metabolite, or alcohol and authorize its designated third-party administrator to collect the specimen. I also understand and consent to the test result being given to a Medical Review Officer (MRO), an authorized agent of Four Corners, and/or a third-party administrator. Further, I understand that appropriate action may be taken in conformity with the drug and alcohol policy, if the test result is positive. Name (Please Print) _________________________________________ Signature ______________ ___________________________ Social Security Number _________________________________________ Date ______________ ___________________________ Supervisor's Signature _________________________________________ 12/2001

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH CONSENT FOR PRE-EMPLOYMENT DRUG AND ALCOHOL SCREENING

I, the undersigned in accordance with Four Corners Community Behavioral Health drug and alcohol-free workplace policy, acknowledge that I have read the policy and I understand it. I also understand that as a condition of being offered a position with Four Corners Community Behavioral Health, I will have to take and pass a drug test. If a position is offered with Four Corners Community Behavioral Health, I understand that I will have to comply with its terms for employment. I submit voluntarily to the Four Corners’ request for a specimen for detecting drugs or alcohol or other Controlled Substances and authorize Four Corners Community Behavioral Health to have its third-party administrator collect the specimen for the purpose of the test. Further, I understand that those tests may be given to a Medical Review Officer and/or Four Corners Community Behavioral Health for review. I understand that failure to submit to providing a specimen, or if the sample reveals the presence of non-prescribed drugs, or other Controlled Substances, including their presence as a metabolite, it will preclude me from being offered a position with Four Corners Community Behavioral Health. I have read this form in full and understand the above statements. Name (Please Print) ___________________________________ Signature ________ ___________________________ Social Security Number ___________________________________ Date ____________ _______________________ Witness ____________ _______________________ 12/2001

Four Corners Community Behavioral Health Observed Behavior -Reasonable Suspicion Record

_______________________________________ _______________________________ ________________________ Employee Name Social Security Number Date of Birth _________________________________________ From: __ a.m. /p.m. To: __ a.m. /p.m. ______________________________ Location Observation Time Observation Date Reasonable suspicion of current use or impairment by: Alcohol Drugs Both

Cause for Suspicion Appearance

Normal Flushed Puncture Marks Disheveled Bloodshot Eyes Tremors Dilated/Constricted Pupils Profuse Sweating Dry-mouth Runny Nose/Sores/Frequent Sniffing Inappropriate Wearing of Sunglasses Other: ___________________________________________________________________

Behavior: Speech

Normal ( Incoherent ( Slurred ( Silent ( Confused ( Slowed ( Whispering ( Loud ( Other: ____________________________________________________________ Behavior: Awareness ( Normal ( Confused ( Mood Swing ( Euphoria ( Lethargic ( Disoriented ( Lack of Coordination ( Aggressive/ Violent ( Paranoid ( Other: _______________________________ Motor Skills: Balance ( Normal ( Swaying (Falling ( Staggering ( Head Bobbing ( Other: _________________________________________________________________________________________ Motor Skills: Walking and Turning ( Normal (Swaying ( Arms Raised for Balance ( Stumbling ( Falling ( Reaching for Support ( Other: _________________________________________________________________________________________ Motor Skills: Other ( Dropping Things ( Lack of Coordination ( Slowed Reaction Time Other Observable Actions of Behavior (Specify): ________________________________________________________ Check if the following conditions are met, (test only if both conditions are met): (Observations are specific, contemporaneous, and can be articulated on the appearance, behavior, speech, or body odors of the individual. ( For alcohol testing, observations are made during, just preceding, or just after the individual is required to be in compliance (performing safety-sensitive functions) with DOT/FHWA regulations. If unable to test in 2 hours of reasonable suspicion determination, state reasons: _______________________________ ________________________________________________________________________________________________ If unable to test within 8 hours of reasonable suspicion determination, cease attempts to test and state reasons: ________________________________________________________________________________________________ _____________________________________ ____________________________________ ________________ Supervisor / Official’s Name Signat ure Date

________________________________________________ Comments and/or corroboration by a second supervisor or official: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ______________________________________ ____________________________________ ________________ Supervisor / Official’s Name Signat ure Date 12/2001


PERSONNEL PROCEDURE – PE04 – ADOPTED 4/3/2003

HIRING PROTOCOL All supervisors shall follow the procedure outlined as the hiring protocol for recruitment and hiring of new employees. 1. All vacant positions that result from employee resignations, terminations or new programs shall be

reviewed and approved by the Executive Director prior to recruitment. The program supervisor shall indicate to the Executive Director whether an open or in-house recruitment is requested.

2. The Human Resources (HR) Manager will draft a recruitment notice for the Program Directors to review

and revise if necessary. 3. The HR Manager shall send a copy of the announcement to the Chair of the Cultural Competency

Committee, The Network Administrator and the Administration Secretary for posting. 4. The HR Manager shall advertise the position externally including the DWS website. 5. All recruitment announcements shall include the following:

a) Job title b) Work location c) Brief summary of duties / outcomes / expectations d) Minimum requirements for the position (including licensure) and competencies e) Salary information; FTE f) Deadline for submitting applications g) Who to contact and how to obtain an application h) The statement: “FCCBH, Inc is an equal opportunity employer (EOE) and a drug free workplace

(DFW). Special consideration will be given to individuals with experience working with diverse populations or who speak a second language.”

i) The following statement shall be added for in-house recruitment only: “Recruitment for this vacancy is offered to FCCBH, Inc. employees only at this time.”

6. Completed applications shall be returned to the HR Manager. The HR Manager will screen out applicants

that do not meet the required qualifications and provide copies to each of the Screening Committee members once the application period has ended.

7. Once the application period has closed, the Program Director shall recommend a screening committee. The

Screening Committee will select candidates to interview and notify the HR Manager who will contact applicants to schedule the interviews.

8. When appropriate, the Screening Committee will select a primary and an alternate candidate. In no case does this

mean an alternate candidate must be selected.

9. After interviews have been conducted the Program Director shall complete and document a minimum of two reference checks on the candidate being considered for employment.

10. The Program Director shall recommend hire to the Executive Director including compensation and terms

of employment prior to discussing compensation with candidate.

11. The Executive Director shall authorize the Human Resources Manager to issue a formal written offer of

employment over the hiring supervisor’s signature and with a signature block for the employee to note his/her acceptance of the offer. The employee offer shall include the mandatory pre-employment UA and BCI clearance paperwork, request for current licensure and debarment status (Medicaid / Medicare) and license status in other states. Employment is conditional upon status of information as defined in policy and procedure.

12. The conditional candidate shall be provided with new hire paperwork to be completed prior to start date.

13. Once the HR Manager receives the supervisor hiring checklist and all new hire paperwork the HR

Manager will contact the Program Director with authorization for the employee to start work.

14. The HR Manager shall notify the office managers and Program Directors when the position is no longer open.

15. All new hires shall be provided with the orientation workbook and Employee Handbook and shall be required to

complete the checklist within 30 days of start of work. New hires shall submit the completed checklist to the Human Resources Specialist.

16. The HR Manager will send a letter to applicants not hired and inform them that their application will be

considered current for three months.

Four Corners Community Behavioral Health, Inc. SUPERVISOR HIRING CHECKLIST

Please fill out, attach the documents listed and send to the Human Resources Office: ______ Hiring authority, Date __________ ______ Job description ______ Screening committee selected and notified (list names/affiliations)

____________________________ ___________________________

____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ______ Pre-employment phone reference checks (must have a minimum of 2 references

documented)

Mentor assigned to work with new employee ____________________________ Name

1/17/2007



SALARY INCREASE AT LICENSURE OR RECEIPT OF DEGREE

1. All salary increases may be granted only within established policies and procedures.

a. Increases shall not differ from the terms of employment described in the letter of hire.

b. Increases may be granted according to an individual plan for obtaining a degree or licensure as approved by the supervisor and the Executive Director in advance.

c. The most recent performance evaluation must be at least satisfactory and the employee may not be on corrective action.

2. An employee who receives the professional license related to their assigned duties and

field of practice may be eligible for a salary increase. 3. An employee who receives a degree related to their assigned duties and field of practice

may be eligible for a salary increase.

4. Under filled positions, i.e., positions that required certification, licensure or a degree as a condition of employment shall be granted increases based on the letter of hire.

5. Monies shall be budgeted at time of hire for a professional level position with licensure.

6. Receipt of a salary increase based on obtaining a professional license or degree does not

make an employee ineligible for merit increases based on outstanding performance.




NON EXEMPT EMPLOYEE OVERTIME / WORKING EXCESS HOURS

1. Hourly employees (non-exempt) who work excess time must request pre-authorization from his or her supervisor. The supervisor shall notify the payroll office of the approval before the close of work on Friday.

a. The supervisor is not required to notify the payroll office if an hourly

employee works less than 60 minutes overtime in a week.

2. It is the employee's responsibility, along with his or her supervisor, to assure that excess hours are worked only when there are no other options available to get required work done. The supervisor should schedule the employee’s work hours so that no excess hours are worked during a one-week period, Sunday to Saturday.

3. If an employee consistently requests overtime pre-authorization the supervisor

must meet with the employee and review the job description, how time is being spent and discuss priorities and solutions to avoid working excess hours.

4. The overtime pay standard requires that overtime be compensated at a rate not

less than one and one-half times the regular rate at which the employee is actually employed.

a. Employees who are less then one FTE must have pre-authorization as

above and do not qualify for 1.5 times their regular hourly rate for up to 40 hours per week. Only hours worked over 40 in one week will be paid at 1.5 times their regular hourly rate.

b. Non-exempt employees attending training must pre-plan the workweek

not to exceed a total of forty hours, including the time spent in training and travel to and from the training unless approved in advance by the supervisor on a Training Authorization form.

i. Only those hours actually spent in a training session may be entered on the time sheet as hours worked.

ii. The training agenda and workshop handouts shall be provided as documentation for hours worked beyond an eight hour work day.




REQUIREMENTS AT HIRING Background Screening Background screening shall be conducted on all new hires. Background screening shall be renewed annually on all active employees. Any fees arising from this process are the responsibility of the employee. The employee is responsible to submit any information required to complete the screening. A denied background screening will result in immediate termination or suspension from FCCBH, Inc. Employees who are under the age of eighteen or who work on the Crew are not required to have a background screening. New Hire Packet The New Hire Packet must be completed before a start date can be negotiated with a potential employee. The packets are as follows:

Full-Time Employee Packet Employees who work 20 hours/week or more shall be required to review and/or sign off on the following: 1. Employee data record 2. I-9 and a copy of a current driver’s license and one other acceptable form of identification 3. IRS w-4 4. Drivers information sheet 5. Code of conduct 6. Exemption sheets (if applicable) 7. TB test, (FCCBH, Inc. will reimburse individuals for the cost of the TB test if receipt and test results are

submitted) 8. Resume and application 9. Copy of diploma or transcripts, copy of license and/or copy of certificate as appropriate 10. Job description 11. Payroll change notice 12. Cafeteria plan form (accept or waive) 13. Utah retirement / 401k enrollment form 14. Drug free workplace and UA 15. Background screening form (BCI) 16. New hire registry 17. IT acceptable use policy 18. Direct deposit information 19. Conflict of interest / related party transaction disclosure form 20. Employee confidentiality agreement 21. Telecommunication policy 22. Acknowledgement of property/keys held by employee 23. FCCBH, Inc. insurance enrollment forms (medical, dental, vision, and life) Approved by Executive Committee 4/14/2004; Revised 3/16/06; Revised 7/19/06; Revised 10/18/2006; Revised 6/19/2007

24. 403b form (if interested) 25. Performance management tool with pages for goal setting 26. Emergency contact information 27. Health insurance acknowledgement 28. NPI application or documentation (licensed mental health therapists, physicians, nurses and licensed or

trainee substance abuse counselors ) 29. Certification concerning licensure (if applicable) 30. Credentialing and Privileging Application for Employees (if applicable) 31. Copy of driving record obtained from the Utah state drivers license division (FCCBH, Inc. will reimburse

individuals for the cost of the driving record if receipt and record are submitted) Part-Time Employee Packet Employees who work19.5 hours/week or less or temporary employees (who work any amount of hours for a time-limited period) shall be required to review and/or sign off on the following: 1. Employee data record 2. I-9 and a copy of a current driver’s license and one other acceptable form of identification 3. IRS w-4 4. Drivers information sheet 5. Code of conduct 6. TB test (FCCBH, Inc. will reimburse individuals for the cost of the TB test if receipt and test results are

submitted) 7. Resume and application 8. Copy of diploma or transcripts, copy of license and copy of certificate 9. Job description 10. Payroll change notice 11. Utah retirement statement of ineligibility 12. Drug free workplace and UA 13. Background screening form (BCI) 14. New hire registry 15. IT acceptable use policy 16. Direct deposit information 17. Conflict of interest / related party transaction disclosure form 18. Employee confidentiality agreement 19. Telecommunication policy 20. Acknowledgement of property/keys held by employee 21. Performance management tool with pages for goal setting 22. Emergency contact information 23. NPI application (licensed clinicians or LSAC trainees only) 24. Credentialing and Privileging Application for Employees (if applicable) 25. Copy of driving record obtained from the Utah state drivers license division (FCCBH, Inc. will

reimburse individuals for the cost of the driving record if receipt and record are submitted) Crew Employee Packet Employees working for the Can Do Crew shall be required to review and/or sign off on the following: 1. Employee data record 2. I-9 and a copy of a current driver’s license and one other acceptable form of identification 3. IRS w-4 4. Drivers information sheet if appropriate 5. Code of conduct 6. TB test (FCCBH, Inc. will reimburse individuals for the cost of the TB test if receipt and test results are

submitted)

7. Job description 8. Payroll change notice 9. Utah retirement statement of ineligibility 10. Drug free workplace and UA 11. New hire registry 12. IT acceptable use policy 13. Direct deposit information 14. Employee confidentiality agreement 15. Telecommunication policy 16. Emergency contact information 17. Copy of driving record obtained from the Utah state drivers license division (FCCBH, Inc. will

reimburse individuals for the cost of the driving record if the receipt and record are submitted) Summer Work Programs FCCBH, Inc. shall follow the minimum age standard set by the U.S. Department of Labor which sets fourteen as the minimum age for employment. Employees must meet this standard before the first day of work. Supervisors may offer employment, collect documentation and otherwise verify eligibility for employment prior to the fourteenth birthday but the job candidate must be at least fourteen years of age before he or she starts work as a FCCBH, Inc. employee. Summer Teen Worker Employee Packet Summer Work Program employees must review and/or sign the following: 1. Employee data record 2. Form I-9 3. Copy of two forms of acceptable identification 4. IRS w-4 5. Code of conduct 6. Application 7. Job description 8. Payroll change notice 9. Utah retirement statement of ineligibility 10. Drug free workplace and UA 11. New hire registry 12. IT acceptance use policy 13. Telecommunications policy 14. Employee confidentiality agreement 15. Sexual harassment policy 16. Emergency contact information


PERSONNEL PROCEDURE – PE13 ADOPTED 3/16/2006 PAYROLL / PERSONNEL CHANGE NOTICE 1. The Four Corners Community Behavioral Health, Inc. Payroll Personnel Change

Notice shall be the official notification to the payroll and accounting department that the employee’s personnel information or status be changed.

A. A Payroll/Personnel Change Notice shall be submitted by the employee’s

supervisor when any of the following change:

i. FTE ii. Non-exempt status to exempt status iii. Title or position or supervisor iv. Work site v. Hours / FTE paid by a grant or contract vi. Wages / Salary vii. Quartile placement viii. Licensure ix. Degrees x. Work Schedule xi. Direct Service (Clinical FTE)

B. The change notice is required for newly hired or re-hired employees, for a leave

of absence, a resignation, discharge, demotion, layoff or retirement. 2. A change in grant or contract assignment, promotion, demotion and increase or

decrease in FTE shall require a review of the job description for necessary changes. The supervisor shall attach information for job description changes to the Payroll Personnel Change Notice.

i. An updated job description shall be prepared by the HR Specialist and shall be sent to the supervisor to obtain the employee’s signature.

ii. The employee shall sign the new job description which shall be submitted to the HR Specialist.

3. The worker record on Access shall be reviewed when a Payroll Personnel Change

Notice is submitted which affects FTE, clinical FTE or other worker data. Adopted by the Executive Committee on 3/16/2006


PERSONNEL PROCEDURE – PE14 ADOPTED 5/24/2006 EMPLOYEE CERTIFICATIONS / DECLARATIONS AT THE ANNUAL EVALUATION All FCCBH, Inc. employees shall be provided the following certifications / declarations annually; certification and declarations shall be attached to each employee’s annual performance evaluation and shall be signed at the time the evaluation is presented.

1. Certification Concerning Fraud and Abuse A. Each Four Corners Community Behavioral Health, Inc. employee shall be required to

provide a written certification that he or she has no knowledge of any fraud or other abuse committed by any employee of FCCBH, Inc. during the previous year.

B. The certification shall contain the language and required signature as included in this procedure.

C. Signed certifications shall be considered a true and valid statement of fact and shall be retained on file by the FCCBH, Inc. Compliance Officer.

2. Conflict of Interest / Related Party Declaration Form

A. Each Four Corners Community Behavioral Health, Inc. employee shall be required to provide a signed Conflict of Interest / Related Party Declaration Form as prescribed in Personnel Procedure PE01 and Personnel Policy 2.06.

B. Signed declarations shall be retained by the FCCBH, Inc. Human Resources Specialist.

3. Code of Conduct A. Each Four Corners Community Behavioral Health, Inc. employee shall be required to

provide a signed Code of Conduct as prescribed by the Utah Department of Human Services.

B. The Code of Conduct shall clarify the expectations of conduct for providers of contracted, licensed and certified programs and their employees, which includes administrative staff, non-direct care staff, direct care staff, support services staff and any others while interacting with clients.

C. Signed Code of Conduct documents shall certify that the employee understands the expectations outlined in the Code and will strive in good faith to comply with the provisions therein. The signed documents shall be retained by the FCCBH, Inc. Human Resources Specialist.

Adopted by Executive Committee on 5/24/2006, Revised 8/22/2006; Revised 5/16/2007; Revised 7/25/2007

4. Employee Job Description A. All FCCBH, Inc. employees shall be provided a copy of his or her current job description

annually, shall be required to certify that the job description was received and there was an opportunity to discuss assigned duties, and required competencies with the supervisor.

B. A signed job description shall be considered certification that the employee is aware of his or her responsibilities and performance expectations.

C. Signed job descriptions shall be retained by the FCCBH, Inc. Human Resources Specialist.

5. Re-credentialing Declaration A. All FCCBH, Inc. licensed professionals shall complete the Employed Provider

Credentialing Form annually to certify that his or her license and credentials are current and valid according to the requirements of Personnel Policy 2.39 Credentialing and Recredentialing Employed Providers.

FCCBH Inc’s Corporate Compliance Plan

Four Corners Community Behavioral Health Center wants to create a value-based organizational culture built on continuing quality improvements and high ethical standards. A corporate compliance program is required by both state and federal authorities. Our State Medicaid Contract specifically requires that our Center have a corporate compliance program to prevent Fraud, Waste and/or Abuse within the organization. We have an obligation to investigate Fraud, Waste, and Abuse issues if they come up.

Fraud-any intentional deception that violates Federal/ State criminal or civil law. This includes but isn’t limited to; theft, acceptance of bribes or gratuities, making false statements, misrepresentation of material facts, accepting kickbacks. Waste- extravagant, careless needless expenditure of public funds caused by deficit policies, procedures, system controls, decisions or programs. Abuse- is the intentional wrongful or needless expenditure of funds that causes loss or misuse of center resources. It also includes physical, sexual or other inappropriate mistreatment of clients.

Reporting Compliance Issues All employees, contractors, members of the public etc. are encouraged to discuss operational and compliance issues first with the service supervisor where compliance questions may occur. However, anyone within or outside the organization can contact the Compliance Officer directly with questions or concerns. All reports will be investigated unless inadequate information is provided. Anyone reporting a compliance issue will be protected from retaliation or harassment to the fullest extent possible. Complainant confidentiality will be protected unless their identity must be disclosed according to law, regulation, or policy. _______________________________________________________________________________

Certification Concerning Fraud and Abuse Check One:

I hereby certify that I have reported to my supervisor any fraud, waste or abuse committed in the

past 12 months by any employee or other person connected with FCCBH, Inc. about which I have

any knowledge:

Such reports are (list all)

o ___________________________________________________________

o ___________________________________________________________

Or

I hereby certify that I have no knowledge, nor have I witnessed any fraud, waste or abuse

committed by any employee or other person otherwise connected with FCCBH, Inc. during the

past 12 months.

________________________________________________ _________________ Employee Signature Date

Compliance Officer Karen Dolan [email protected]

105 West 100 North 1-435-637-7200 ex 1314 2/2009

Re-credentialing reviewed by Compliance officer Date ____________________ Signature

Administrative Office 105 West 100 North

Price, UT 84501 (435) 637-7200

Employed Provider Annual Re-credentialing Date _______________________ This re-credentialing declaration is for professional providers currently employed by: Four Corners Community Behavioral Health, Inc. Address: Business Office, 105 West 100 North, Price, UT 84501; Phone (435) 637-7200. Name________________________________________________________________________________ Last First Middle 1. Please list your professional license (s) __________________________________________________ (LCSW, CSW or SSW); LSAC, SAC; LPC, PC Intern; MFT, MHT-Externship, MHT-Internship; Clinical Psychologist (Ph.D. or Psychology Resident); Physician and Surgeon, Controlled Substance, Osteopathic Physician (MD, Intern, Resident); PA; RN, APRN, LPN; CCS) 2. Is your license current in the state of Utah? ___Yes ___ No 3. Has your personal data/information changed? ___Yes ___ No If yes have you notified FCCBH, Inc. Human Resources? ___Yes ___ No 4. Have you submitted new/changed certifications/license renewals from the last 12 months? ___Yes ___ No 5. Over the last 12 months: have you been sanctioned, censured, disciplined, had your membership revoked or

been suspended by any licensing body or payer; had an unfavorable judgment in a malpractice suit; been convicted of a felony or involved in charges relating to moral or ethical turpitude; been the defendant in any felony proceeding; or been fined or expelled by Medicare or Medicaid? ___Yes ___ No

If yes please describe: _____________________________________________________________________________________ _____________________________________________________________________________________ I certify that all information provided to Four Corners Community Behavioral Health, Inc. (FCCBH, Inc.) is true and correct to the best of my knowledge and belief. I agree to notify FCCBH, Inc. promptly if there are any material changes in the information provided. I understand and agree that if FCCBH, Inc. discovers that this or previous declarations or applications contain any significant misstatement, misrepresentations, or omissions, FCCBH, Inc. may void, in its sole discretion, any provider agreements. I understand that FCCBH, Inc., as a condition of payer contracts, will check state and national data banks for debarment status. ___________________________________________ ____ __________________________ Professional Provider’s Signature Date 5/16/2007


PERSONNEL PROCEDURE – PE15 ADOPTED 6/21/2006 PERFORMANCE APPRAISALS AND MERIT INCREASES 1. The FCCBH, Inc. performance management system shall be guided by the Work Performance Management

Guidelines and the Performance Appraisal Tool to promote fairness, objectivity, excellence, recognition, a learning environment and shared responsibility for quality.

2. At the time of the annual performance appraisal each supervisor shall make a recommendation for a quartile

placement for each employee based on performance and the criteria listed on the quartile chart. The supervisor shall insert each employee’s recommended quartile placement into the Quartile Placement Salary Matrix spreadsheet provided by the Human Resources Manager (HR) and sign the appraisal. After the one-up review (3, below) the supervisor shall submit the appraisal form and spreadsheet to HR (as below, 3).

a. The job description shall be signed by each employee annually and shall be submitted with other required forms.

b. Employees not eligible to receive a merit raise: i. Employees promoted to a new pay grade within six months prior to the

scheduled date of merit pay increases. ii. Employees hired within six months prior to the scheduled date of merit pay increases

c. The following shall not be factored into the merit pool: i. The salary or wages of promoted employees as described above

ii. The salary or wages of new hires as described above iii. Vacant positions

3. A one-up review shall be conducted on each performance appraisal to insure fairness and

consistency. The review is intended to provide another perspective on each evaluation. The Executive Director shall appoint one-up reviewers, usually the appraiser’s supervisor.

a. Prior to meeting with the supervisor the one-up reviewer shall review all appraisals and complete the Performance Management One-Up Reviewer Checklist on each perform ance appraisal.

b. The one-up reviewer shall assess for consistent ratings, check to see if goals have measurable outcomes, review progress on work related goals listed in sections 1 and 2 of the appraisal and look for evidence that supports ratings on training and professional development goals. The one-up reviewer will validate that there is fairness within the work group (i.e. point totals correspond to recommended activities) and that documentation is attached to support conclusions.

c. The one-up reviewer shall verify that the required criteria to be considered for a merit increase have been met. If an employee does not meet merit standards but a merit increase is recommended clear justification is provided.

d. The one-up reviewer shall meet with the supervisor to review the appraisals, checklist and matrix.

e. When the one-up reviewer and supervisor agree, both shall initial the Quartile Placement Salary Matrix and give a copy to HR.

f. The supervisor shall review the completed appraisal and quartile placement with the employee. Adopted by Executive Committee on 6/21/2006; Revised 7/25/2007



NEW EMPLOYEE GOAL SETTING 1. New employees shall be given a copy of the Four Corners Community Behavioral Health, Inc. Work

Performance Management Guidelines and his or her Performance Appraisal Tool within thirty days of the employee’s start date.

2. Within two-months of the new employee’s start date he or she shall meet with his or her supervisor to

discuss the performance evaluation process and to, at the supervisor’s discretion, collaboratively set work related goals and professional development / training goals for the current appraisal year

a. Work related goals shall relate to outcomes, competencies and engagement as listed on the

Performance Appraisal Tool. They may be designed to build on strengths or address opportunities for improvement.

b. Professional development / training goals may involve taking on new tasks, increasing capacity, reaching new standards of excellence or otherwise enhancing job performance, and/or keeping current with new verified developments, techniques, treatments, or practices.

c. Goals must be specific, measurable and identify documentation of accomplishment.

3. New employees who have worked for FCCBH, Inc. for more than six months prior to the end of the current fiscal year may be eligible for a merit increase if all required criteria are met including one or more points given on professional development / training goals.

Adopted by Executive Committee: 7/19/2006


PERSONNEL PROCEDURE – PE17 – Adopted 8/22/2006 OTHER TRAINED STAFF

1. Employees who meet the FCCBH, Inc. training requirements (below) shall be considered “Other Trained Staff.”

2. Staff Development Institute (SDI) Training requirements shall be:

a. At least 100 hours on the job training under the supervision of a licensed mental health staff (e.g. RN, SSW, Mental Health Therapist) or under the supervision of a Licensed Substance Abuse Counselor.

b. At least twelve hours direct supervision staffing cases with a licensed mental health therapist

c. Completion of FCCBH, Inc. SDI Targeted Case Management training (three hours) and knowledge assessment with passing score d. Completion of FCCBH, Inc. SDI case manager training (six hours) on:

i. Skills development interventions ii. Strengthening social, interpersonal and living skills iii. Crisis intervention iv. Relationships and boundaries with clients v. Understanding mental illness vi. Managed care plans vii. Writing progress notes

e. In the event of training delays, self study modules shall be made available for items c. and d. above to include a tutorial session with the supervisor or the Training Officer.

3. Completion of at least five independent SDI training modules as assigned by supervisor and two

additional modules each year thereafter, including but not limited to: i. Medicaid Member Handbook ii. Mental Health Advance Directive iii. Recovery and Prevention iv. First Aid Training v. CPR vi. Mediation and Conflict Resolution vii. Coaching the Experienced Driver viii. Cultural Competency ix. 42 CFR / Confidentiality x. Job Safety xi. Living with Bipolar Disorder xii. Strengthening Families xiii. Break Through Listening xiv. Time Management xv. Social Security Disability xvi. Anxiety Disorders xvii. Schizophrenia


4. Employees working on “other trained staff” certification by FCCBH, Inc. shall use the Other Trained Staff Certification Tracker to document completion of all requirements.

i. Supervisors shall sign off core requirements a. and b. above. ii. Trainees and / or supervisors may access other training modules by contacting the

Training Officer and shall sign off each upon completion.


PERSONNEL PROCEDURE – PE18 – ADOPTED 7/19/06 RECORDING TIME WORKED Time sheets shall reflect the exact amount of time worked. For example if an employee provides eight minutes of service, the employee shall record eight minutes on his or her time sheet. If a mental health therapist provides individual psychotherapy for thirty-eight minutes, employee shall record thirty-eight minutes on his or her time sheet. ACCESS converts time sheet entries into Medicaid units. Some are per encounter (not time/duration), others are by time. ACCESS rounds to the nearest Medicaid unit when the service is counted based on time/duration. Adopted by the Executive Committee: 7/19/06


PERSONNEL PROCEDURE – PE19 Adopted 11/8/2006 SEXUAL HARASSMENT INVESTIGATOR QUALIFICATIONS

1. A complaint of sexual harassment may be submitted in accordance with the FCCBH, Inc. Personnel Policy 2.27 Sexual Harassment Prevention. Complaints may be submitted to the Executive Director, Associate Director, Medical Director, Carbon Clinic Supervisor, Carbon/Emery Psycho/Social Team Supervisor, Emery Clinic Supervisor, Grand Clinic Supervisor, Grand Psycho/Social Team Supervisor or the Chairperson or Vice Chairperson of the FCCBH, Inc. Board of Trustees.

2. The Executive Director shall maintain a list of qualified individuals to conduct preliminary

reviews and formal investigations of sexual harassment complaints.

A. Qualified individuals shall: i. Complete training in investigations procedures including “anticipation of litigation” (training

and certification provided through the FCCBH, Inc. Staff Development Institute.) ii. Be knowledgeable about FCCBH, Inc. policies and procedures (rated as “understands and

practices” competency of knowledge of policies and procedures – properly interprets and applies to job responsibilities on annual performance appraisal.)

iii. Exhibit competence in interviewing techniques (training and certification provided through the FCCBH, Inc. Staff Development Institute.)

iv. Have a reputation for impartiality and credibility

B. The Executive Director shall appoint a qualified investigator to conduct a review or investigation. The investigator shall:

i. Protect those involved by directing persons interviewed to keep matters discussed confidential ii. Detail all findings and preserve documents and evidence

iii. Prepare an investigation strategy and an outline of issues iv. Identify witnesses v. Examine allegations in compliance with FCCBH, Inc. policies and procedures

vi. Formulate recommendations vii. Seek resolution of issues as appropriate

viii. Submit written recommendation to Executive Director (if the complaint is against the Executive Director see Personnel Policy 2.27 Sexual Harassment Prevention)

3. The intent of all sexual harassment complaint investigations is to (1) protect the agency, clients,

staff and witnesses, (2) to resolve complaints, (3) to improve the factual basis for decision making, (4) to assemble and preserve all documentation and (5) to develop a thorough record in anticipation of litigation.

4. Employees have the right to complain to the Anti-Discrimination and Labor Division (UALD) or

other appropriate state or federal regulatory agencies. Adopted by the Executive Committee 11/8/2006



UNIQUE IDENTIFER 1. All FCCBH, Inc. employed providers and subcontractor providers who provide clinical services

shall obtain a National Provider Identifier (NPI). 2. The Insurance Specialist shall assist with NPI compliance in the following ways:

a. Assist with completing the NPI application as needed. b. Verify taxonomy numbers before submitting applications. c. Submit NPI applications to the National Provider System (NPS). d. Maintain a copy of all NPI notifications including the assigned number. e. Provide clinical staff with a copy of his or her notification including assigned number. f. Track applications for which no response has been received. g. Maintain NPIs in Access. h. Verify NPIs for subcontractor providers. i. Submit application(s) for agency NPIs for FCCBH, Inc. j. Notify the compliance officer if clinicians fail to obtain an NPI.

3. The Human Resources Manager shall assist with NPI compliance in the following ways:

a. Obtain a copy of the notification including assigned number from the Insurance Specialist. b. Ensure that an NPI application is included in new clinical employee packets.



PERSONNEL PROCEDURE – PE21 – ADOPTED SIGNING AND APPROVING TIME SHEETS 1. Time sheets shall be entered and signed by 10:00 a.m. the following business day. 2. Supervisors shall review and approve all time sheets in Access by the close of business each

Monday or the next business day. 3. If the supervisor is not available to review and approve time sheets as explained in # 2 above

he or she shall review and approve time sheets that are pending approval by the close of the first business day after returning to work.

4. If the supervisor is not available to review and approve time sheets within five business days,

the second supervisor, as designated in Access, shall review and approve time sheets that are pending approval by the close of the fifth business day following the date of the time sheet.

5. Time sheets that have been signed and approved cannot be deleted without authorization

from the Executive Director or designee. This includes any time sheet entry for clinical services. (Clinical services are billed and/or encounters submitted in real time.)

Adopted by the Executive Committee



TRAINING AND CONFERENCES I. Four Corners Community Behavioral Health shall support training and professional

development to increase employee competencies, to promote current and new verified techniques, treatments and practices, to enhance proficiencies and expertise or otherwise expand knowledge and skills related to the employee’s job responsibilities.

II. The attendance of FCCBH, Inc. employees at out-of-town training is considered time

worked. Employee participation in outside training and conferences shall require: A. Prior approval from the employee’s supervisor. B. That the cost be included in the approved budget. C. That subject matter relate to the employee’s job and specific duties. D. A signed and approved Training Authorization form submitted to the business office

prior to the training. III. Employees shall be required to attend mandatory training as required by contract or the

supervisor may appoint a designee to attend the training as allowed by contract. IV. Non-exempt employees requesting time to attend training must pre-plan the workweek to

avoid exceeding the number of work hours assigned (i.e. 19.5 hours per week). If more then the assigned number of hours will be required, including the time spent in training and travel, written approval must be submitted in advance to HR by the supervisor. A. Non-exempt employees may exceed the number of work hours assigned for

mandatory training required by contract. B. A printed conference program and workshop agendas shall be provided to document

more then eight hours worked in one business day. C. FCCBH, Inc. is not required to count the time an employee spends for lunch and

dinner as time worked unless the employee is required to spend the time working. D. FCCBH, Inc. is not required to count time spent in a hotel at night, sleeping,

attending entertainment or voluntary socializing as time worked. V. Employees who attend training or conferences as time worked for FCCBH, Inc. shall not

have a minor child in his or her care during the work day. VI. Outside training on topics available through the FCCBH, Inc. staff Development Institute

shall be discouraged. VII. The employee shall provide a report on the training to the supervisor and other

appropriate staff members and shall assist in the implementation of change as requested. Approved by the Executive Committee on 4/26/2007 Related documents: Performance Management Guidelines, Training Authorization, personnel Policy 2.30 Training, Legal Opinion Nielsen and Senior April 2001, FLSA

Four Corners Community Behavioral Health Proceduresfourcorners.ws/documents/procedures.pdf ·...

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