RURAL BORDER INTERVENTION (RBI) PROGRAM Region 8 (Offices in Uvalde, Cotulla, Eagle Pass & Del Rio)

RURAL BORDER INTERVENTION (RBI) PROGRAM Region 8 (Offices in Uvalde, Cotulla, Eagle Pass & Del Rio) POLICIES AND PROCEDURES MANUAL FY2017-18 TABLE OF CONTENTS Policy Policy Page Number Name Number 001.. General Requirements 3 002.. Management and Organization.. 4 003.. Operational Plan & Policies and Procedures. 6 004..Organizational and Personnel Changes.. 9 005..Personnel Requirements and Documentation. 10 006..DSHS Logo. 12 007.. General Standards of Care.. 13 008.. Standards for Evidence-Based Programs... 18 009.. Limiting Barriers 20 010.. Specific Acts Prohibited 22 011.. Quality Management.. 24 012.. General Environment. 25 013.. General Documentation Requirements.. 26 014.. Client Records 27 015.. Hiring Practices. 29 016.. Students and Other Volunteers.. 31 017.. Staff Training. 32 018.. Client Rights... 35 019.. Complaints and Procedures 37 020.. Staffing... 39 021.. Standards of Conduct. 41 022..Participant/Client Eligibility Criteria.. 42 023..Non-Discrimination of Participants/Clients 43 1

024..Fee Policy 44 025..Participant/Client Rights and Safety. 45 026..Orientation for Participants/Clients 46 027..Participant/Client Grievances 47 028..Resolution of Participant/Client Grievances. 51 029..Participant/Client Record Security 53 030..Release of Confidential Information.. 60 031..Retention of Records.. 62 032..RBI Staff Member Orientation and Training. 63 033..Cultural Competency and Awareness 65 034..Drug-Free Workplace. 66 035..Program Design and Implementation 67 036..Documentation 69 037..Procedures for Prospective Participants/Clients... 73 038..Procedures for Engaging Participants/Clients... 74 039..Participant/Client Records (Admission & Consent) 75 040..Participant/Client Records (Screening & Assessment) 77 041..Participant/Client Records (Service Plans).. 78 042..Participant/Client Records (Progress Notes) 79 043..Performance and Activity Measures.. 80 044..Information Dissemination. 81 045..Problem Identification and Referral 82 046..Prevention Education/Skills Training. 84 047..Alternative Activities.. 85 048..Motivational Interviewing.. 86 049..Crisis Intervention.. 87 050..Service Completion 88 051..Participant/Client Follow-Up 89 052..Community-Based Process 90 053..HIV/AIDS Workplace Guidelines. 92 054..Child Abuse Reporting Procedures 93 055..Tobacco Products 94 056..Transportation. 95 057..Employee Performance Evaluations... 96 058..Staff Competencies. 97 059..CMBHS.. 98 060..Quality Improvement.. 103 2

001 GENERAL REQUIREMENTS POLICY: SCAN will establish and maintain effective internal programmatic and financial controls. Task 1: Programmatic and Financial Controls Responsibility: Chief Executive Officer Effective internal programmatic and financial controls will be established and maintained to ensure: 1) That the RBI Program is operated efficiently and effectively; 2) To maintain compliance with other funding and regulatory agencies; 3) Appropriate controls are in place to safeguard assets; 4) DSHS funds are properly spent; 5) DSHS funds are properly accounted for; 6) Clients receive appropriate services; and 7) Client services are adequately documented. FORMS: SCAN Financial Forms REFERENCE: N/A 3

002 MANAGEMENT AND ORGANIZATION POLICY: The Board of Directors of SCAN is the governing body that is legally responsible for the integrity of the fiscal and programmatic management of the RBI Program. It is a distinct business entity with legal authority to operate in the State of Texas. The program s staff members, including the Chief Executive Officer do not serve on the Board of Directors. Task 1: Facility Operation Responsibility: Chairperson of the Board of Directors The Board of Directors will: 1) appoint a chief executive officer to manage the day-to-day operations of the organization and to ensure that the organization has the programmatic, managerial, and financial capability to ensure proper planning, management, and delivery of funded services; 2) provide all members with information about the responsibilities and liabilities of the governing body and its individual members; and 3) ensure that all of its members are familiar with the provider s target population(s) and sensitive to the needs of the different cultures represented. Task 2: Meetings Responsibility: Chairperson of the board of Directors The Board of Directors will meet at least quarterly and maintain minutes that include: 1) date, time, and place of the meeting; 2) names of members present and absent; and 3) summary of discussion and action taken. Task 3: Responsibilities of the Chief Executive Officer Responsibility: Board of Directors The Chief Executive Officer will: 1) have documented education and/or experience in financial, administrative, and personnel management, and other areas needed to manage the organization effectively; 4

2) ensure compliance with applicable laws and rules; 3) ensure that all staff are competent and trained; 4) establish mechanisms to ensure quality of services; and 5) maintain adequate financial records according to generally accepted accounting principles. Task 4: Organization Structure Responsibility: Chief Executive Officer The Chief Executive Officer will: 1) maintain a chart of the organization s structure and 2) document its staffing pattern to identify all staff positions, the individuals filling those positions, and current vacancies. 3) review and update the information (if necessary) at least annually. FORMS: Board Minutes, Chief Executive Officer s and Program Director/Supervisor s Job Descriptions, Organizational Chart REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.501 5

003 OPERATIONAL PLAN & POLICIES AND PROCEDURES Policy: In accordance with DSHS standards of care and to guide the performance of the programs, SCAN will function in accordance with the operational plan, as well as, maintain and implement a current manual that includes all policies and procedures required by DSHS. These Policies shall be approved by the SCAN Board of Directors, reviewed periodically, and revised as needed. Procedures shall be approved by the Chief Executive Officer, reviewed periodically, and revised as needed. SCAN will require that each employee reads the policies and procedures applicable to the position and maintain documentation signed by the employee that the policies and procedures have been read and understood. Task 1: Operational Plan Responsibility: CEO Procedures: SCAN s DSHS funded programs will operate according to an operational plan. The operational plan shall reflect: 1. The program s purpose or mission statement; 2. the program s services and how they are provided; 3. the program s description of the population to be served; and 4. the goals and objectives of the program. Task 2: Policies and Procedures Responsibility: CEO Procedure: SCAN will adopt and implement general written policies and procedures as well as program specific policies and procedures applicable to all DSHS funded programs as deemed necessary by the facility and as required herein. The policies and procedures shall contain sufficient detail to ensure compliance with all applicable DSHS rules. 1. The SCAN Board of Directors will approve all policies and procedures prior to implementation, review agency policies on a periodic basis, and revise them as needed. 2. The Chief Executive Officer will approve all policies and procedures, review them periodically, revise them as needed, and present them to the Board at regular Board meetings. 3. Minutes of the meeting will reflect that new policies and procedures and changes and revisions to existing ones were approved by the Board 4. The Program Directors will ensure that all program specific policies and procedures are current, consistent with program practices, individualized to the program, and easily accessible to staff. 5. The Program Directors will submit all program related policies and procedures to the Chief Executive Officer for review and approval. 6. Once approved, the program specific policies and procedures will be incorporated into the SOP Manual, bearing the signature of the Chief Executive Officer, the Board 6

Chairperson, and the date the procedures were implemented or revised. 7. Within 10 days of a general or program specific policy or procedure change, the Program Director will inform staff about any changes to the policy and procedure manual that are relevant to their job duties and document the notification. If training is needed, it will be provided and documented within 60 days. 8. The agency will ensure that each employee be required to acknowledge in writing that he/she has read and understood the agency s general policies and procedures as well as the applicable program specific policies and procedures and maintain this documentation in the employee s personnel file. 9. As applicable, the agency s policy and procedure manual will include policies and procedures for the following itemsa. Fiscal Policies to cover i. Revenue/Accounts Receivable ii. Billing/Payment Requests iii. Cost Allocation iv. Payroll v. Expenditures/Accounts Payable vi. Procurement of Goods and Services vii. Match and Program Income and Expenditures viii. Fixed Assets Inventory and Records ix. Petty Cash x. Cellular Phone Use xi. Travel xii. Subcontractor Fiscal Compliance Monitoring xiii. Financial Reporting b. DSHS Workplace and Education Guidelines for HIV and Other Communicable Diseases in order to meet requirements as specified in the ADA Act. c. Protections to safeguard client records and client-identifying information in accordance with 42 CFR Part 2 and the HIPAA Act of 1996. d. Prohibition of Discrimination e. Handling Complaints f. Employee Background Checks g. Standards of Conduct h. Tobacco Use i. Facility Access for People with Disabilities Task 3: Status of Policy and Procedure manuals Responsibility: CEO and Program Directors Policy: SCAN s general and program specific policy and procedure manuals will be current, consistent with DSHS rules, and easily accessible to staff members at all times. Procedure: Upon being employed with the agency, each employee will be issued a copy of the agency s policies and procedures. Additionally, during program specific orientation, employees 7

will review their program s policy and procedure manual, and be shown where the manual is kept for future reference. FORMS: Policy and Procedure Manuals REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.502 8

POLICY: 004 ORGANIZATIONAL AND PERSONNEL CHANGES SCAN will keep the DSHS informed on a timely basis concerning all significant organizational and personnel changes. The agency will notify the DSHS in writing within ten business days of - 1) Any changes to the agency s legal name, address, telephone number, official e-mail address, or legal status, and 2) Any changes in the following personnel: Certifying representative, board chair, chief executive officer, chief financial officer, security administrator and backup for the Behavioral Health Integrated Provider System, and project director/program director. FORMS: none REFERENCE: N/A 9

005 PERSONNEL REQUIREMENTS AND DOCUMENTATION POLICY: SCAN will maintain complete, accurate, and current documentation including documentation related to agency personnel. A) The agency will keep complete, current documentation. 1) All required documents shall be factual and accurate. 2) Authentication of documents shall include signature, credentials when applicable, and date. If the document relates to past activity, the date of the activity shall be recorded. 3) Documentation shall be permanent and legible. 4) When it is necessary to correct a required document, the error shall be marked through with a single line, dated, and initialed by the writer. B) The agency shall maintain current personnel documentation on each employee. Health related information shall be stored separately with restricted access as appropriate under Tex. Govt. Code Ann. Sec. 552.102 (Vernon 2000). Training records may be stored separately from the main personnel file, but shall be easily accessible upon request. Required documentation includes, as applicable: 1) A copy of the current job description signed by the employee. 2) Application or resume with documentation of required qualifications and verification of required credentials. 3) Verification of work experience. 4) Annual performance evaluations. 5) Personnel data that includes date hired, rate of pay, and documentation of all pay increases and bonuses. 6) Documentation of appropriate screening and/or background checks. 7) Signed documentation of initial and other required training, and 8) Records of any disciplinary actions. C) The agency will have an adequate number of qualified staff to comply with DSHS rules, provide the services described in the program description, and protect the health, safety, and welfare of clients/clients. D) Every program shall have an employee designated to serve as director. The individual must have appropriate education and training and at least two years of experience providing related services. 1) The director of a prevention program must have at least 2 years of experience in substance abuse prevention. 2) The director of an intervention program must have at least 2 years experience in substance abuse intervention. 3) Prevention programs shall employ program directors designated as Certified Intervention specialists or program directors who have completed 40 hours of intervention specialist training which must include- 10

history of prevention as a discipline, facts about drugs and drug terminology, prevention theory including risk/protective factors and resiliency, currently recognized prevention strategies and principles, role of media and environmental prevention approaches, promising, effective and/or model programs as designated by CSAP, cultural content and ethics of prevention, and assessment and evaluation as prevention tools. 4) Intervention programs shall employ program directors that are Qualified Credentialed Counselors (QCC). E) The program shall hire applicants who meet the minimum qualifications listed in the job description. FORMS: Employee Personnel File Checklist REFERENCE: N/A 11

006 DSHS LOGO AND SLOGAN POLICY: SCAN will not use the DSHS s logo and slogan in publications, electronic media, or video material unless the DSHS has given written permission. PROCEDURE: Prior to the use of DSHS s logo or slogan, the RBI Program Supervisor or designee will contact the DSHS via telephone, letter, or e-mail to request the use of the logo and/or slogan. FORMS: none REFERENCE: N/A 12

007 GENERAL STANDARDS OF CARE Policy: As a DSHS funded provider, SCAN adheres to all general standards of care as detailed in Chapter 448, Subchapter B. Responsibility: All Staff Standard 1: General Standard Procedure: SCAN will actively work to ensure that all program services provided to clients/clients are done so with integrity, and are adequate, appropriate, and consistent with best practices and industry standards. SCAN will strive to maintain objectivity in all matters concerning clients/clients, will respect every individual s dignity, and will not engage in any intentional actions that might cause injury or harm. Standard 2: Scope of Practice Procedure: SCAN s treatment programs will never provide services to clients/clients outside of their scope of practice nor allow staff members to use techniques that exceed their professional level of competence. Moreover, the agency will not make any claims that it possesses professional qualifications or affiliations to which it is not entitled. Standard 3: Competence and Due Care Procedure: SCAN will plan, adequately supervise, and evaluate all program related activities. All services will be rendered in a careful and prompt manner. SCAN will follow the technical and ethical standards related to service provision, strive to continually improve personal competence and quality of service delivery, and discharge its professional responsibility to the best of its ability. SCAN will always act in the best interest of its clients/clients and will ensure that services are designed and administered in such a way as to do no harm to them. Finally, SCAN will ensure that program services which are not beneficial, or are in any way detrimental, to clients/clients will be terminated in a timely manner. Standard 4: Appropriate Services Procedure: All SCAN treatment program services will be developmentally and age appropriate, culturally sensitive, non-exploitative, individualized to meet the specific needs and circumstances of clients/clients, and provided in a respectful manner. Standard 5: Accuracy Procedure: SCAN will report all information fairly, professionally, and accurately when providing services and when communicating with other professionals, the DSHS, and the general public. In published materials or public statements, SCAN will document and assign credit to all 13

contributing sources. SCAN will not misrepresent directly or by implication any professional qualifications or affiliations to which it is not properly entitled. Standard 6: Documentation Procedure: SCAN will ensure that all treatment programs maintain required documentation of services provided and related transactions including financial records. Standard 7: Discrimination Procedure: SCAN will not discriminate against any individual on the basis of gender, race, religion, age, national origin, disability (physical or mental), sexual orientation, medical condition, including HIV diagnosis or because an individual is perceived as being HIV infected. Per DSHS rules, SCAN may consider economic condition and financial resources in admission criteria; however, once an individual is admitted, economic condition shall not affect services provided. Standard 8: Access to Services Procedure: SCAN will provide equal access to services, including providing information about other services and alternative providers, appropriately taking into account an individual s financial constraints and special needs. Standard 9: Location Procedure: SCAN will not offer or provide services in settings or locations that are inappropriate or harmful to individuals served, family members, or other persons. Standard 10: Confidentiality Procedure: SCAN s treatment programs will diligently work to protect the privacy of all individuals served and will not disclose confidential information without express written consent except as permitted by law. SCAN will work to ensure that its treatment program staff members remain knowledgeable of and obey all State and Federal laws and regulations relating to confidentiality of records relating to the provision of services. SCAN treatment programs will not discuss or divulge any information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes directly related to the case. Standard 11: Environment Procedure: SCAN will ensure that all of its treatment programs provide an appropriate, safe, clean, and well maintained environment. 14

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

(a) SCAN personnel shall not provide services, interact with individuals receiving services, or perform any job duties while under the influence or impaired by the use of alcohol, or mood altering substances, including prescription medications not used in accordance with a physician's order. (b) SCAN personnel shall not commit an illegal, unprofessional or unethical act (including acts constituting abuse, neglect, or exploitation). (c) SCAN personnel shall not assist or knowingly allow another person to commit an illegal, unprofessional, or unethical act. (d) SCAN personnel shall not falsify, alter, destroy or omit significant information from required reports and records or interfere with their preservation. (e) SCAN personnel shall not retaliate against anyone who reports a violation of these rules or cooperates during a review, inspection, investigation, hearing, or other related activity. (f) SCAN personnel shall not interfere with DSHS reviews, inspections, investigations, hearings, or related activities. This includes taking action to discourage or prevent someone else from cooperating with the activity. (g) SCAN personnel shall not enter into a personal or business relationship of any type with an individual receiving services until at least two years after the last date an individual receives services from the provider. (h) SCAN personnel shall not discourage, intimidate, harass, or retaliate against individuals who try to exercise their rights or file a grievance. (i) SCAN personnel shall not restrict, discourage, or interfere with any communication with law enforcement, an attorney, or with the DSHS for the purposes of filing a grievance. (j) SCAN personnel shall not allow unqualified persons or entities to provide services. (k) SCAN personnel shall not hire or utilize known sex offenders in adolescent programs or programs that house children. (l) SCAN personnel shall prohibit adolescent clients and clients from using tobacco products on the program site. Staff and other adults (volunteers, clients, clients and visitors) shall not use tobacco products in the presence of adolescent clients or clients. Standards 18: Standards of Conduct Procedure: SCAN and all of its personnel shall protect clients' and clients rights and provide competent services. (a) Any person associated with the facility that receives an allegation or has reason to suspect that a person associated with the facility has been, is, or will be engaged in illegal, unethical or unprofessional conduct shall immediately inform the DSHS's investigations division and the facility's chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported to the DSHS and the facility's governing body. (b) The facility and its personnel shall comply with TEX. HEALTH & SAFETY CODE ANN. ch. 164 (Vernon 2001 & Supp. 2003)(relating to Treatment Facilities Marketing and Admission Practices). (c) The facility shall have written policies on staff conduct that complies with this section. FORMS: SCAN policies and procedures 16

REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.201-448.218 17

008 STANDARDS FOR EVIDENCE-BASED PROGRAMS Policy: SCAN will design and implement evidence-based programs. Procedure: The evidence-based programs will meet the following criteria: 1) Programs are designed to enhance protective factors and move toward reversing or reducing known risk factors. 2) Program staff will be trained in risk factor and protective factor theory and research. 3) Programs are designed in a way that preserves the protective factors inherent in each culture and individual. 4) Prevention programs will be age, developmentally and culturally appropriate. 5) Programs that are able to determine the level of risk of the target population. More intense prevention programs are required for target populations with a recognized higher level of risk. 6) Programs that are appropriate for the target population(s) using universal, selective and indicated criteria. Programs have proven outcomes for the target population and are implemented with integrity and fidelity. 7) That when an evidence-based program is adapted to address the specific nature of the drug use or abuse problem in the local community, care is taken to adapt the program appropriately. The adaptation does not affect the integrity and fidelity of the program as it was designed. 8) Programs that teach skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency. Social competency skills, as they relate to reinforcement of attitudes against drug use, include skills related to communications, peer relationships, self-efficacy, and assertiveness. 9) Programs for adolescents include interactive methods, such as peer discussion groups, in addition to lecture-style teaching techniques. 10) Programs include a component which targets parents or caregivers. The parent/caregiver component reinforces what the youth clients are learning, such as facts about drugs and their harmful effects. This component opens opportunities for family discussions about use of legal and illegal substances and family policies related to their use. 11) That programs that are long-term, over the school career, including the repetition necessary to reinforce the original prevention goals. School-based efforts directed at elementary and middle school students, for example, include booster sessions to help with critical transitions from middle to high school. 12) That community programs that include media campaigns and policy changes, such as new regulations that restrict access to alcohol, tobacco, or other drugs, are accompanied by school and family interventions. 13) That community programs strengthen norms against drug use in all drug abuse prevention settings, including the family, the school, and the community. 18

14) That schools offer opportunities to reach all populations and serve as important settings for specific sub-populations at risk for drug abuse, such as children with behavior problems or learning disabilities and those who are at risk of leaving school before graduation. 15) Programs will use formal and informal structures to receive and incorporate input from service recipients in the development, implementation and evaluation of prevention services. 16) Programs will be evaluated to determine outcomes and impact on the clients. Responsibility: board of Directors, CEO, Executive Vice President, Vice President, and Program Director(s). REFERENCE: DSHS Chapter 448.301 19

009 LIMITING BARRIERS & GENERAL ENVIRONMENT Policy: SCAN does not discriminate in any of its practices. Task 1: Prohibition of Discrimination and Identification of Deficiencies Responsibility: All Staff Procedures: SCAN will: 1) implement and enforce a written policy prohibiting discrimination against any individual on the basis of gender, race, religion, age, national origin, disability (physical or mental), sexual orientation, medical condition, including HIV diagnosis or because an individual is perceived as being HIV infected. SCAN may consider economic condition and financial resources in admission criteria, but economic condition shall not affect the services once an individual is admitted; 2) ensure that no person or group of persons is restricted from receiving the same services or the same quality of services available to others; 3) make all facilities and programs accessible to persons with disabilities as required by the Americans with Disabilities Act; 4) ensure that the facility maintains documentation that it has conducted a self-inspection to evaluate compliance and implemented a corrective action plan, as necessary, with reasonable time frames to address identified deficiencies; 5) ensure that the facility has a certificate of occupancy from the local authority that reflects the current use by the occupant or documentation that the locality does not issue occupancy certificates; 6) ensure the site, including grounds, buildings, electrical and mechanical systems, appliances, equipment, and furniture shall be structurally sound, in good repair, clean, and free from health and safety hazards; 7) ensure that the facility provides a safe, clean, well-lighted and well-maintained environment; 8) ensure that the facility has adequate space, furniture, and supplies; 9) ensure that the facility has private space for confidential interactions, including all group counseling sessions; 10) ensure that the facility prohibits smoking inside facility buildings and vehicles and during structured program activities. If smoking areas are permitted, they shall be clearly marked as designated smoking areas and shall not be less than 15 feet from any entrance to any building(s) and comply with local codes and ordinances. Staff shall not provide or facilitate client access to tobacco products; 11) ensure that the facility prohibits firearms and other weapons, alcohol, illegal drugs, illegal activities, and violence on the program site; 12) Animals shall be properly vaccinated and supervised; 13) maintain documentation that it has conducted a self-inspection to evaluate compliance and implemented a corrective action plan to address identified deficiencies; and 14) maintain documentation of formal agreements and contracts to address identified deficiencies in access to program services for people with disabilities. 20

FORMS: none REFERENCE: DSHS Chapter 448 Standard of Care 448.207, 448.505 21

010 SPECIFIC ACTS PROHIBITED Policy: SCAN and all its agents will protect the health, safety, rights, and welfare of clients/clients. It will provide adequate and appropriate treatment as described in the program description and will comply with all applicable laws, regulations, policies, and procedures. It will also maintain required licenses, permits, and credentials, and will comply with professional and ethical codes of conduct. Additionally, the facility and its personnel shall comply with Chapter 164 of the Texas Health and Safety Code (relating to Treatment Facilities Marketing and Admission Practices). Task 1: Specific Acts Prohibited Responsibility: All Staff, Volunteers, and Board Members Procedures: Neither SCAN or any of its personnel will: 1) provide services, interact with individuals receiving services, or perform any job duties while under the influence or impaired by the use of alcohol, or mood altering substances, including prescription medications not used in accordance with a physician s order; 2) commit an illegal, unprofessional or unethical act (including client abuse, neglect, or exploitation); 3) assist or knowingly allow another person to commit an illegal, unprofessional, or unethical act; 4) knowingly provide false or misleading information; 5) falsify, alter, destroy or omit significant information from required reports and records or interfere with their preservation; 6) retaliate against anyone who reports a violation or cooperates during a review, audit, inspection, investigation, hearing, or other related activity; or 7) interfere with DSHS reviews, inspections, investigations, hearings, or related activities. This includes taking action to discourage or prevent someone else from cooperating with the activity; 8) enter into a personal or business relationship of any type with an individual receiving services until at least two years after the last date an individual receives services; 9) discourage, intimidate, harass, or retaliate against individuals who try to exercise their rights or file a grievance; 10) not restrict, discourage, or interfere with any communication with law enforcement, an attorney, or with the DSHS for the purposes of filing a grievance; 11) not allow unqualified persons or entities to provide services; 12) not hire or utilize known sex offenders in adolescent programs or programs that house children; 13) prohibit adolescent clients and clients from using tobacco products on site at the treatment programs and staff members and other adults (volunteers, clients, clients, and visitors) from using tobacco products in the presence of adolescent clients or clients. 14) display favoritism or preferential treatment of one client, or group of clients/clients, over another. 15) deal with any client except in a professional relationship that will support the approved goals of the program; specifically, employees, volunteers or board members must never accept for themselves or any member of their family, any personal gift, favor or service 22

from a client or from any client s family or close associate, no matter how trivial the gift or service may seem. In addition, no employee, volunteer or board member shall give gifts, favors or services to clients/clients, their families or close associates. 16) have any contact with a client or ex-client except for those activities which are an approved, integral part of the program and a part of the employee s job description. Employees, volunteers and board members are expected to maintain this role-appropriate relationship with former clients/clients until at least two years after the service recipient s discharge from services. Task 3: Orientation of Staff and Volunteers to Standards of Conduct Responsibility: Program Director Procedure: The Program Director will ensure that: 1) all staff and volunteers are provided with a thorough explanation of standards of conduct during orientation; 2) all staff and volunteers will sign the Standards of Personal Conduct; and 3) the signed Standards of Personal Conduct are placed in the personnel file. Task 4: Reports of Violations Responsibility: Program Director Procedure: SCAN and all of its employees shall protect client rights and provide competent services. Any person associated with the facility that receives an allegation or has reason to suspect that a person associated with the facility has been, is, or will be engaged in illegal, unethical or unprofessional conduct shall immediately inform the DSHS s investigations division and the facility s chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported to the DSHS and the facility s governing body. FORMS: Credential Verification Form, Standards of Personal Conduct Form REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.217 & 448.218 23

011 QUALITY MANAGEMENT Policy: SCAN utilizes a formal, comprehensive, and ongoing quality management process to monitor the effectiveness of all DSHS Substance Abuse Services funded programs (prevention, intervention, and treatment). The agency will develop, update, implement, and submit a Quality Management Plan (QMP) to the TDSHS annually. The agency s Quality Assurance Program members meet on a regular basis throughout the year to review the performance of all DSHS Substance Abuse Services funded programs and conducts regularly scheduled Client chart audits and performance measure binder audits. All agency program directors meet as a group at least 4 times a year to review the progress of each program in meeting contractual goals and obligations. The agency s prevention, intervention, recovery, and other non-substance abuse treatment program directors meet separately throughout the year for the purpose of monitoring contractual goals and obligations and to conduct and review random Client chart audits and performance measure binder audits. The agency s substance abuse treatment program directors meet on a monthly basis to monitor the completion of contractual goals and objectives as well as to ensure that therapeutic services are being provided in accordance with DSHS rules and standards of care. Responsibility: CEO, Executive Vice President, Vice President, and Program Directors Procedures: SCAN s Quality Management Plan will describe methods to measure, assess, and improve the implementation of evidence-based practices and research-based approaches, client satisfaction with services, service capacity, and access to services, client continuum of care, and accuracy of data reported to the state. Additionally, SCAN s Quality Assurance Program will establish and maintain: 1) goals and objectives that relate to the programs purpose or mission; 2) methods to review the progress toward the goals and a documented process to implement corrections of changes; 3) a mechanism to review and analyze incident reports, monitor compliance with rules and other requirements, identify areas where quality is not optimal and procedures to analyze identified issues, implement corrections, and evaluate and monitor their ongoing effectiveness; 4) methods of utilization review to ensure appropriate client placement, adequacy of services provided and length of stay; and 5) documentation of the activities of the quality management process. FORMS: Chart Audit Forms REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.504 DSHS FY 2017-18 Performance Contract Service Requirements 24

012 GENERAL ENVIRONMENT Policy: SCAN will provide a safe, secure, and well-maintained environment. It makes every concession and takes all measures to protect the public health, safety, and welfare of clients/clients and their families, and to ensure that chemically dependent individuals receive adequate treatment. Included in this policy is the regulation of tobacco products. Task 1: Facility License Requirements Responsibility: Program Director Procedure: SCAN will: 1. comply with the Americans with Disabilities Act. It will maintain documentation that it has conducted a self-inspection to evaluate compliance and implemented a corrective action plan within reasonable time frames to address identified deficiencies. 2. have a certificate of occupancy from the local authority that reflects the current use by the occupant or documentation that the locality does not issue occupancy certificates. 3. SCAN, including grounds, buildings, electrical and mechanical systems, appliances, equipment, and furniture shall be structurally sound, in good repair, clean, and free from health and safety hazards. 4. provide a safe, clean, well-lighted and well-maintained environment. 5. have adequate space, furniture, and supplies. 6. have private space for confidential interactions, including all group counseling sessions. 7. prohibit smoking inside facility buildings and vehicles and during structured program activities. If smoking areas are permitted, they shall be clearly marked as designated smoking areas and shall not be less than 15 feet from any entrance to any building(s) and comply with local codes and ordinances. Staff shall not provide or facilitate client access to tobacco products. 8. Staff and other adults (volunteers, clients, clients, and visitors) will not use tobacco products in the presence of children or adolescent participating on the program site. 9. prohibit firearms and other weapons, alcohol, illegal drugs, illegal activities, and violence on the program site. 10. Animals shall be properly vaccinated and supervised. FORMS: Facility Incident Report Form REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.505 25

013 GENERAL DOCUMENTATION REQUIREMENTS Policy: SCAN shall keep complete and current documentation. Task 1: Factual and Accurate Information Responsibility: Program Director, all Employees, and Volunteers Procedure: All required documents will be factual and accurate. Task 2: Signing and Dating of Documents Responsibility: Program Director, all Employees, and Volunteers Procedure: All documents and entries will be dated and authenticated by the person responsible for the content. 1) Authentication of paper records shall be an original signature that includes at least the first initial, last name and required credentials. 2) Initials may be used if the client record includes a document that identifies all individuals initialing entries, including the full printed name, signature, credentials, and initials. 3) Authentication of electronic records shall be by a digital authentication key. Task 3: Legibility Responsibility: Program Director, all Employees, and Volunteers Procedure: Documentation will be permanent and legible. Task 4: Corrections Responsibility: Program Director, all Employees, and Volunteers Procedure: When it is necessary to correct a client record, incident report, or other legal document, the error shall be marked through with a single line, dated, and initialed by the writer. Task 5: Abbreviations Responsibility: Program Director, all Employees, and Volunteers Procedure: The records shall contain only those abbreviations included on the facility s list of approved abbreviations. FORMS: none REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.507 26

014 CLIENT RECORDS Policy: SCAN will protect client records and other client-identifying information from loss, tampering and unauthorized access or disclosure. All active client records will be stored at the different program sites. Task 1: Client Records Treatment, Intervention, and Prevention Programs Responsibility: Program Director, all Employees, and Volunteers Procedure: The facility will establish and maintain a single record for every client at the time of admission. The content of client records shall be complete, current, and well organized. Task 2: Security of Client Records Responsibility: Program Director, all Employees, and Volunteers Procedure: SCAN will protect all client records and other client-identifying information from destruction, loss, tampering, and unauthorized access, use or disclosure. It will comply with the following: 1) All active client records shall be stored at the facility and inactive records in off-site storage shall be fully protected. All original client records shall be maintained in the State of Texas. 2) Information that identifies applicants shall be protected to the same degree as information that identifies clients/clients. 3) Electronic client information shall be protected to the same degree as paper records and shall have a reliable backup system. 4) Access to records is restricted to staff whose job duties require use of the records 5) Client records are kept in a secure room, a locked file cabinet or other similar container when not in use. Records are locked at all times unless an authorized person is continuously present in the immediate area. 6) SCAN will ensure that all client records can be located and retrieved promptly at all times. 7) SCAN will comply with Federal and State confidentiality laws and regulations, including 42 C.F.R pt. 2 (Federal regulations on the Confidentiality of Alcohol and Drug Abuse Patient Records), TEX. HEALTH & SAFETY CODE ANN. ch. 611 (Vernon Supp. 2004)(relating to Mental Health Records) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The facility shall also protect the confidentiality of HIV information as required in TEX. HEALTH & SAFETY CODE ANN. 81.103 (Vernon 2001)(relating to Confidentiality; Criminal Penalty). 27

8) SCAN will not deny clients/clients access to the content of their records except as provided by TEX. HEALTH & SAFETY CODE ANN. 611.0045 (Vernon Supp. 2004) and HIPAA. Clients requesting copies of their records must first complete a Consent for Disclosure Form prior to staff making copies and providing the copies to the clients. 9) Treatment Program Client records shall be kept for at least six years. Records of adolescent clients shall be kept for at least five years after the client turns 18. 10) If client records are microfilmed, scanned, or destroyed, SCAN will take steps to protect confidentiality. SCAN will maintain a record of all client records destroyed on or after September 1, 1999, including the client s name, record number, birth date, and dates of admission and discharge. FORMS: none REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.508 28

015 HIRING PRACTICES Policy: SCAN complies with all applicable laws and DSHS requirements regarding background checks and drug tests for employees and volunteers and the disclosure of employee and volunteer information. The agency s employment and volunteer applications require that applicants inform the agency of any legal involvement including misdemeanors. All positions are filled by individuals who meet minimum qualifications specified in the job description as evidenced by an application or resume and documentation of current status for credentials required by the job description. The agency s drug prevention programs require that background checks and preemployment drug testing be conducted with all potential paid and volunteer staff prior to their delivering services and/or having direct contact with youth and/or their family clients. Task 1: Guidelines for Personnel Hiring Responsibility: Chairperson of Board of Directors, Chief Executive Officer, Executive Vice President, and Program Directors Procedure: SCAN will comply with the following requirements: 1) The facility employs counselor interns; therefore, it is registered with the DSHS as a clinical training institution and complies with all applicable requirements. 2) The facility verifies the current status of all required credentials with the credentialing authority by Internet, phone, or letter. 3) The facility complies with all applicable laws, including the Texas Civil Practice and Remedies Code 81.003, which relates to employment reference checks. 4) The facility obtains and assesses the results of a statewide criminal background check from the Department of Public Safety on all staff within four weeks of the date of hire. It uses the criteria listed in the Texas Occupations Code 53.022 and 53.023, to evaluate criminal history reports and make related employment decisions. Additionally, employees pending the results of a background check will be prevented from having any client contact. 5) The facility will not hire an individual who has not passed a pre-employment drug test that meets criteria established by the DSHS. SCAN may conduct random checks on its employees as permitted by law. 6) The facility shall develop a job description which outlines job duties and minimum qualifications for all personnel. 7) The facility maintains a personnel file for each staff member with documentation demonstrating compliance with this section. FORMS: Application for Employment, Volunteer Application, Verification of Credentials Form, Criminal Background Check 29

REFERENCE: DSHS Substance Abuse Services Chapter 448 Standard of Care 448.601 DSHS Contract - Statement of Work 2017-18 30

016 STUDENTS AND OTHER VOLUNTEERS Policy: SCAN will use students and other volunteers to augment treatment services and will ensure that all students and other volunteers comply with standards of performance and conduct. Task 1: Selection of Volunteers Responsibility: Program Director Procedure: SCAN will ensure that volunteers are appropriate and qualified to perform assigned duties. It will: 1) require an application from prospective volunteers; 2) students and volunteers will be qualified to perform assigned duties; 3) screen volunteers through an interview process; 4) complete a reference check on all volunteers; 5) complete a background check and drug test for those working with drug prevention, intervention, and treatment programs; 6) provide a job description or written agreement for each volunteer position; and 7) maintain documentation in the volunteer s file. Task 2: Training and Use of Volunteers Responsibility: Program Director Procedure: SCAN will: 1) ensure that volunteers receive orientation and training appropriate to their qualifications and job responsibilities; 2) monitor and evaluate volunteers work performance; 3) ensure that volunteers follow all required policies and procedures; 4) ensure that volunteers are appropriately supervised by staff; and 5) ensure that direct care volunteers in residential programs without CPR certification will have immediate supervision from certified staff. FORMS: Job Description, Training Table or Roster, Verification of Credentials Form, Counselor Competence Form, Direct Clinical Supervision Documentation Form REFERENCE: DSHS Standard of Care Chapter 448 Standard of Care 448.602 31

017 STAFF TRAINING - ALL PROGRAMS Policy: All staff will receive all required training within the time frames required by the Texas DSHS on Alcohol and Drug Abuse and other funding or regulatory agencies. The length and type of training for contract personnel shall be based on the amount of time spent at the facility, degree of client contact, and individual qualifications and responsibilities. Unless otherwise specified, video, manual, or computer-based training is acceptable if the supervisor discusses the material with the staff person in a face-to-face session to highlight key issues and answer questions. SCAN may accept documented training from another organization completed during the year prior to employment if it meets DSHS requirements. SCAN maintains documentation of all required training for each staff person. All staff members working in adolescent treatment programs will receive appropriate training according to DSHS s rules and contract requirements. The program shall ensure also that there are procedures for quality assurance for staff training. Task 1: Modality of Trainings. Persons Responsible: Training Coordinator and Program Directors Procedure: Unless otherwise specified, video, manual, or computer-based training is acceptable if the supervisor discusses and documents the material with the staff person in a face-to-face session to highlight key issues and answer questions. Task 2: Documentation of required training. Persons Responsible: Training Coordinator and Program Directors Procedure: SCAN will: (1) Keep documentation of external training shall include: (A) date; (B) number of hours; (C) topic; (D) instructor's name; and (E) signature of the instructor (or equivalent verification). (2) Maintain documentation of all internal training. For each topic, the file shall include: (A) an outline of the contents; (B) the name, credentials, relevant qualifications of the person providing the training, and (C) the method of delivery. (3) For each group training session, SCAN will maintain on file a dated attendee sign-in sheet. Task 3: Orientation Training Responsibility: Program Director, and Training Coordinator Procedure: Prior to performing their duties and responsibilities, SCAN will provide orientation to staff, volunteers, and students. This orientation shall include information addressing: (1) DSHS rules; (2) SCAN s policies and procedures; (3) client rights; 32