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I N T R A N E T

Policies & Procedures

1.00 GOVERNANCE
01 Board of Directors Authority, Membership and Responsibility
01 Board of Directors Authority
02 Board of Directors Membership
03 Board of Directors Legal and Ethical Obligation
04 Board of Directors Orientation, Education and Training
05 Board of Directors Evaluation
06 Board Executive Committee Role and Responsibility
02 Board of Directors Operations
01 Policy Manual
02 Board Meetings
03 Board Committee Meetings
04 Board Member Reimbursement and Documentation
05 Board of Directors Public Relations and Communications Protocol
06 Guidelines for Appointment to LifeWays Board of Directors
07 Board of Directors Risk Management Policy
08 Board Appointment to Region 5 Entity
03 Management Operations
01 Role and Responsibility of Executive Administration
02 Leadership Team Meetings
03 Financial Audit Services
04 LifeWays' Communication Process
04 Management and Organizational Support
01 Policy and Procedure Management
02 Chief Executive Officer Supports
05 Conflict of Interest Policy
01 Regional Entity Board Member Conflict of Interest Guidelines
02 LifeWays Board Member Conflict of Interest Guidelines
06 Agency Records Management
01 Agency Record Retention Guidelines
02 Freedom of Information Act (FOIA) Requests
07 Delegation of Authority and Succession Planning
01 Executive Leadership Succession Planning
02 Executive and Director Level Delegation of Authority
03 Processing and Signing Legal Documents
08 Corporate Compliance
01 Corporate Compliance Committee & Corporate Compliance Officer
02 Detecting Non-Compliance
03 Investigating Reports of Suspected Non-Compliance
09 Whistleblower's Protection Policy
01 Whistleblower Protection Procedure

2.00 RECIPIENT RIGHTS
01 Protection of Recipient Rights
01 Protection of Recipients of LifeWays Services
02 Suitable Services, Treatment Environment, Person-Centered Planning
03 Recipient Rights Training
04 Communication, Mail, Telephone, Visits
05 Personal Property
06 Seclusion, Restraint, Freedom of Movement
07 Fingerprinting, Photographs, Audiotape, or Use of One-Way Glass
08 Admission and Discharge
09 Resident Labor
10 Sterilization, Abortion & Contraception
11 Code of Responsibilities
02Recipient Rights Committees
01 Recipient Rights Advisory Committee
02 Appeals/Appeals Committee
03 Protection of Recipient Information
01 Access to Case Records/Confidentiality
02 Subpoena
04 Recipient Rights Reporting
01 Death Reporting
02 Incident Report Process
03 Intervention Complaints
04 Abuse and Neglect Reporting
05 Investigation of Recipient Rights Complaints
06 Duty to Warn
07 Adverse Event Reporting and Review

3.00 FINANCIAL MANAGEMENT
01 Accounting
01 Cash Receipts
02 423 Funds
03 Accrual
04 Investment Policy
05 Schedules and Work Papers
06 Year End Financial Statements
02 Budget
01 Preparation and Reporting of Spending Plans, Budgeting and Financial Management Reports
03 Expenses
01 Credit Card
02 Petty Cash
03 Maintaining Hospitalization Payment, Accruals and Balances Owed
04 Disbursements (Other than Claims)
04 Billing and Claims
01 Billing Cycle - Claims
02 Authorizing Services in a Child Caring Institution Setting and Expense Allocation
03 Ability to Pay / Fee Determination
04 Claims Payment Schedule Instructions
05 Revenue Contract Monitoring
06 Claims Payment
07 Explanation of Benefits for Consumers/Guardians
05 Purchasing
01 Capital Asset Acquisitions
02 Pooled Funds
03 Purchase of Property for Residential Services
04 Purchasing Supplies, Equipment, and Other Program Materials
05 Purchasing Professional Services
06 Purchasing Process Permission Levels
06 Board and Staff Expenses
01 Travel and Training
02 Check Cashing and Lost Checks
03 EFT Payment Processing and Returned EFT
07 Rate Setting
01 Method for Estimating Costs/Rate Setting for Clinical Services or ASO Products
08 Financial Reports and Audits
01 Issuing Requests for Proposals (RFPs) for Annual Financial Auditing Services
02 Grant Writing, Reporting and Monitoring

4.00 UTILIZATION MANAGEMENT
01 Service Authorization
01 Authorization of LifeWays Network Services
02 Clinical Competency
02 Clinical Program Management
01 Utilization Reviews
02 Autism Coordinator
03 Behavior Health Treatment Services for Children with Autism Spectrum Disorders
04 Self-Directed Services Guideline
05 Multisystemic Therapy (MST) Authorization and Eligibility
06 Housing Assistance
07 Enhanced Health Services Prescription Requirements
08 Supported Employment
09 Respite
10 Residential, Personal Care, and CLS In-Home Supports
11 Monitoring and Reassessment
03 Utilization
01 Utilization Management Criteria
02 Utilization Management Committee
03 Medicaid Fair Hearing Procedure
04 Utilization Review
04 Waiver Services
01 Serious Emotional Disturbance Waiver (SEDW) Services
02 Serious Emotional Disturbance (SED) Waiver Coordinator
03 Habilitation and Supports Waiver
04 Habilitation and Supports Waiver (HSW) Coordinator
05 Children's Waiver Service
06 1915i State Plan Amendment Waiver Services
05 Early and Periodic Screening, Diagnostic, and Treatment
01 Zero to Three (0-3) Infant Mental Health
03 Multisystemic Therapy (MST) Authorization and Eligibility


5.00 CLINICAL CARE SERVICES
01 Clinical Care
01 NARCAN (naloxone HCI) Nasal Spray
02 Clinical Staff Peer Record Review
03 Team Meetings | Clinical
04 Choice of Treating Providers
05 Patient Education Certified Electronic Health Record (CEHR) Clinical Summary
06 Trauma-Informed Care
07 Referral Process
08 Practice Guidelines
09 Advance Directives
10 Consent for Treatment | Participation
11 Culture of Gentleness
12 Improving Practices Leadership Teams
13 Coordination of Care
14 Special Treatment Procedures -- Electroconvulsive Therapy (ECT)
15 Crisis Plans
16 Behavior Treatment Committee
17 Financial Determinations
18 Providing Education to Consumers
19 Safety Plan
20 Medication Control
21 Use of Foam Blocks
22 Veterans and Active Military Personnel Seeking Services
23 Telehealth Service Provision
24 Recovery Oriented System of Care
25 Room Flags
26 Clinical Staff Development, Competency and Training
27 Priority Measures
28 Court Referrals
29 Pre- and Post-Booking Diversion
30 Private Duty Nursing (PDN) Assessments


6.00 CUSTOMER SERVICES
01 Consumer Relations
01 Consumer Advisory Councils
02 Planning and Supports for Persons with Communication Barriers
03 Advisory Councils/Committees
02 Customer Services
01 Grievance and Appeal/Fair Hearings
02 Customer Service Standards
03 Customer Services Department
04 Community and Conference Room Scheduling
05 Office Closure Appointment Management
06 Family Support Subsidy Program
03 Medical Record Management
01 Medical Record Release of Information
02 Consumer Access to Medical Records
03 Retention and Disposal of Medical Records

7.00 INFORMATION SERVICES
01 Information Systems Infrastructure, Strategy and Management

02 Information Security and Risk Management
01 Business Continuity and Disaster Recovery
02 Information Access and Security
03 Data Backup and Restore
04 Virus Protection, Detection and Removal
05 Use and Disclosers of Protected Health Information
06 Virtual Private Network (VPN) Remote Access
07 Acceptable Internet Use
08 Email Guidelines and Requirements
09 Generative Artificial Intelligence (AI) Chatbot Usage Policy
03 Computer Systems
01 Information Technology Asset Management
02 Information Systems Service Desk
03 Software Standards and Compliance
04 Technology Equipment Requests
05 Computer Lifecycle and Replacement Schedule
04 Telecommunication Systems
01 Telephone Usage
02 Employee Cellular Telephone Assignment and Usage
05 Health Information Management
01 Behavioral Health Treatment Episode Data Set (BH-TEDS)
02 Health Information Technology & Management
03 Data Validation and Management
04 Report and Data Requests
05 Use of Multiple Data Platforms
06 Encounter Data Reporting Process
07 Electronic Medical Record Documentation
08 Accessing Medical Records using Break the Glass

8.00 QUALITY MANAGEMENT
01 Quality Improvement Program
01 Quality Improvement Plan
02 Quality Improvement Council
02 Performance Management
01 Quality Management Role in Strategic Planning
02 Performance Indicator Development and Monitoring
03 Mission Based Performance Improvement Systems (MIMBPIS) Reporting
04 National Core Indicators
05 Service Fidelity and Outcomes Monitoring
06 Quality Improvement Role in Behavior Treatment Committee
07 Sentinel Event and Root Cause Analysis
08 Provider Guidance Reviews
03 Quality Improvement
01 Stakeholder Input and Customer Satisfaction
02 Quality Improvement Process Facilitation
03 Volunteers, Students and Interns
04 Accreditation
01 Behavioral Health Accreditation

9.00 PERSONNEL MANAGEMENT
01 Staff Qualifications and Hiring
01 Hiring Practices
02 Job Descriptions
03 Credentialing of LifeWays Staff
04 Background Checking
05 Workplace Accommodations
06 Employer of Choice
07 Staff Motor Vehicle Use
08 Onboarding and New Employee Orientation
09 Equal Opportunity Employer
02 Salary, Benefits and Payroll Administration
01 Compensation Philosophy and Program Guidelines
02 Exemption Status
03 Teleworking
04 Family Friendly Workplace
05 Benefits Coordination
06 Paid Time Away from Work
07 Leaves of Absence
08 Holidays
09 Bereavement Leave
10 Jury Duty
11 Work Related Injury and Illness
12 Personnel Files
03 Competency and Training
01 Required Training
02 Performance Evaluation
03 Training & Conference Attendance
04 Supervision
05 Training Reciprocity
06 Cross Training Procedure
07 Licensing Links
08 Succession Planning & Career Development
04 Workplace Conduct
01 Appropriate Workplace Conduct and Expectations
02 Ethical Standards
03 Conflict of Interest/Secondary Employment
04 Dress Code
05 Drug-Free Workplace
06 Anti-Harassment
07 Counseling and Discipline
08 Attendance
09 Employee Problem Resolution
10 Work Schedule and Break Time
11 Mental Health Treatment of Employees
12 LifeWays After Hours On-Call
13 Termination/Exit
14 LifeWays Employees and Social Media
15 Community Event Participation
05 Employee Recognition
01 Annual Board & Staff Appreciation Event
02 PERKS Committee
03 LifeWays Retirement Recognition
04 Staff Celebrations
05 Employee Support During Critical Events
06 Diversity, Equity, Inclusion, and Belonging
01 Diversity, Equity, Inclusion, and Belonging Procedure


10.00 CONTRACTS MANAGEMENT
01 Provider Network Management
01 Provider Manual
02 Auditing Certification and Accreditation
03 Network Development and Capacity Evaluation
04 Delegating Managed Care Functions
05 Person-Centered Planning
06 Self Determination and Self-Directed Services
07 Primary Case Holder Services
08 Environment of Care Standards for Residential Providers
09 Community Based Services
10 Recovery Based Services
11 Transition/Discharge Planning
02 Contract and Agreement Management
01 Procurement of Vendors
02 County of Financial Responsibility (COFR)
03 Out of Network Contracting
04 Contract Development and Distribution
05 Disclosure of Ownership Control and Criminal Conviction
06 Publications and Research Projects
03 Credentialing
01 Credentialing and Privileging
02 Credentialing Application
03 Credentialing Committee
04 Suspending, Limiting, and Terminating Credentialing
05 Provider Training Requirements
04 Provider Relations
01 Provider Orientation
02 Provider Resolution Process
03 Provider Communication
04 Provider Performance Monitoring
05 Provider Claims Processing and Verification

11.00 FACILITIES MANAGEMENT
01 Safety and Security
01 Building Access, Safety, and Security Management
02 Behavioral and Medical Emergency
03 Emergency Preparedness
04 Equipment Management Plan
05 Fire Safety Management Plan
06 Hazardous Materials Management Plan
07 Medical Waste Management Plan
08 Tobacco-Free Campus
09 Service Animals
10 Vandalism or Theft
11 Utilities Management Plan
12 Workplace Safety
02 Space Management
01 Inspections of LifeWays Buildings
02 Facilities Coordination
03 Division of Responsibility in LifeWays Owned or Leased Facilities
04 Space Management
03 Maintenance and Custodial Services
01 Maintenance and Repair
02 Unwelcomed Insect Sightings
04 Agency Vehicle/Transport Services
01 Agency Vehicle Use
02 Vehicle Safety and Security
03 Vehicle Accident Reporting
04 Vehicle Safety and Maintenance
05 Vehicle Refueling
06 Use of Personal Vehicle for Transport


12.00 COMMUNITY RELATIONS
01 Public Relations
01 Media Contact Guidelines
02 Newsletters and Process Alerts
03 Brand Management
04 Information Dissemination
05 Readability
06 Annual Report
07 Corporate Responsibility
08 Consent for Use of Images/Personal Stories/Video/Audio Recording
09 Communication Efficiency
10 Communications Standards
11 Public Relations and Marketing Requests
02 Community Benefit Policy
01 Requests for Community Financial Support

13.00 ACCESS SERVICES
01 Functions of Access
01 Welcoming
02 Open Access
03 Rapid Access
04 Post Hospital Follow-up
05 Warm Handoffs
06 Outreach
07 Access Services Follow Up
08 Callback Queue
09 First Service Appointments
10 Engagement Team
02 Access Screening
01 Conducting an Access Screen
02 Eligibility Determination
03 Prison Release Request for Services
04 County of Financial Responsibility (COFR) Presentations to LifeWays Access
05 Waiver Eligibility Identification and Referral
03 Substance Use Disorder (SUD) Screenings
01 Regional Electronic Medical Information (REMI) Brief Screening and Level of Care Determination
02 Priority Populations
03 Screening, Assessment, Referral, Follow-Up (SARF)
04 Initial Assessment
01 Conducting an Initial Assessment
02 Interim Plans
03 Orientation to Services
04 Wait List for Community Mental Health Services
05 Autism Screening
01 Autism Eligibility and Evaluation
06 Serious Emotional Disturbance (SED) Screening for Foster Care

13.08 CENTRAL MICHIGAN 2-1-1
08 Central Michigan 2-1-1 Services
01 Inclusion/Exclusion Criteria
02 Data Backup
03 Donations
04 Entering Transactions
05 Follow-Up
06 Performance Monitoring Plan
07 Program Effectiveness
08 Resource Management - Standardization
09 Responding to Calls
10 Specialized Information & Referral Programs
11 Taxonomy
12 Unmet Needs
13 Updating Records
14 Volunteers
15 Challenging Callers
16 Live Chat Response/Text Messages
17 Hearing/Speech-Impaired Callers
18 Welcome Message Recording
19 Domestic Violence/Sexual Assault Calls
20 Medical/Police/Fire Emergency
21 Mental Health Crisis Calls
22 Community Announcements and Updates (2-1-1 Email Blasts)
23 Technology
24 Central Michigan 2-1-1 Training Procedure
25 Financial Procedure for Central Michigan 2-1-1 Program
26 Social Media
27 Database Audit Procedure
28 Central Michigan 2-1-1 Confidentiality Policy
29 Advocacy
30 Email and Social Media Response
31 Information & Referral Call Monitoring
32 Program Coverage
33 Emergency Succession Planning
34 Community Disaster/Emergency 2-1-1 Response
35 Responding to Access Line Calls
09 Health and Social Care Coordination (Jackson Care HUB)
01 Jackson Community Health Innovation Users (Jackson Care HUB)

14.00 CRISIS SERVICES
01 23-Hour Crisis Living Room
01 23-Hour Living Room Eligibility and Exclusionary Criteria
02 23-Hour Living Room Services and Programming
03 Utilization of the 23-Hour Living Room
04 Follow Up Post 23-Hour Living Room
05 23-Hour Living Room Peer Services
02 Mobile Crisis Team for Adults
01 Eligibility, Exclusion and Transition Criteria
02 Mobile Crisis Team Response Protocols
03 Consumer Care
04 Mobile Crisis Services and Provider Expectations
05 Removal of Consumer Access to Medications and/or Sharps
06 Mobile Crisis Services Debriefing
07 Screening Questions for In-Home Response
03 Intensive Crisis Stabilization Services (ICSS) for Children
01 Components of Service Delivery for Intensive Crisis Stabilization Services (ICSS)
02 Referral Process for Intensive Crisis Stabilization Services (ICSS)
03 Criteria for Children's Crisis Response
04 Intensive Crisis Stabilization Services (ICSS) Plans
05 Intensive Crisis Stabilization Services (ICSS) and Family Needs
06 Intensive Crisis Stabilization Services (ICSS) Follow Up Services
07 Intensive Crisis Stabilization Services (ICSS) Staff Training and Supervision
04 Crisis Residential Unit (CRU)
01 CRU Risk Levels
02 CRU Treatment and Services
03 CRU Admission and Discharge
04 CRU Shift Responsibilities
05 CRU Facility Requirements
06 CRU Guest Care
07 CRU Hazardous Material and Waste
08 CRU Staff Requirements
09 CRU Health Care Provision
10 CRU Guest Rights
11 CRU Records and Documentation Requirements
12 CRU Medication Administration & Management
13 CRU Facility Licensure
14 CRU Utility Systems
15 CRU Emergency Preparedness and Evacuation Plan
16 CRU Security
17 CRU Therapeutic Environment
18 CRU Elopement and Escalating Behaviors
19 Psychiatry Services in the Crisis Residential Unit
20 Health Care Appraisal & Withdrawal Management
21 Crisis Residential Unit (CRU) Discharges
22 CRU Medication Administration Procedure
23 CRU Nicotine Use
05 Crisis Line
01 Phone Crisis
02 Crisis Line Call Response
03 After Hours Crisis Line
06 Crisis Intervention
01 Face-to-Face Crisis
02 Assisting Law Enforcement Officers
03 Provision of Emergency Services
04 Critical Incident Stress Management (CISM)
05 Potential Threats of Violence in Schools
07 Pre-Admission Screening to Inpatient
01 Conducting a Pre-Admission Screening
02 Placement Logs
03 Inpatient Screenings at Hospital Emergency Departments
04 Inpatient Screenings at Hillsdale Hospital
05 Courtesy Screens
06 Petitions
07 Diversions
08 Acute Care Services
01 Inpatient Hospitalization
02 Assisted Outpatient Treatment Monitoring
03 Involuntary Commitment Court Proceedings
04 Involuntary Admission Deferral of Hearing
05 Voluntary vs. Involuntary Inpatient Admissions of Adults
06 Assisted Outpatient Treatment (AOT) Deferral Referral Process
07 Diversion Committee
08 Inpatient Hospitalization Step-down and Transition Planning

15.00 INTEGRATED CARE SERVICES
01 Integrated Health Services
01 Nurse Practitioner Services
02 HEDIS Measures and Monitoring (Risk Reduction of Metabolic Syndrome)
03 Addition of LifeWays Psychiatric Services
04 Integrated Health Clinic Program
05 OBRA Coordination
06 Infection Control and Exposure Response
02 Prevention Policy
01 Mental Health Education
03 Prevention and Health Promotion Plan
03 Community Health & Wellness
01 Wellness Programs
02 Wellness Coaching
03 Community Health Workers
04 Integrated Health Clinic Services
01 General Medication Prescribing Guidelines
02 Adverse Medication Reaction Reporting
03 Prior Authorization - Medications and Services
04 LifeWays Psychiatric Service Referrals from Access Services
05 Clozaril Process
06 Injection Clinic
07 Medication Assisted Treatment for Substance Use Disorders
08 Laboratory Reporting
09 Prescribing Provider Service Expectations
10 Prescribing Provider Monthly Meetings
11 Prescribing Medications for Behavioral Control/Management
12 Children in Waiting Areas
13 Post-Crisis Residential Unit and Post-Hospital Psychiatric Appointment Process Flow
14 Clinical Scope of Practice
15 Providing Psychiatric Services to Intoxicated Patients

16.00 OUTPATIENT SERVICES

16.01 Case Management
01 Targeted Case Management
01 Targeted Case Management Features
02 Targeted Case Management Service Expectations
03 Wraparound Implementation

16.03 Outpatient Therapy
03 Outpatient Therapy
01 Criteria for LifeWays' Outpatient Therapy
02 Outpatient Therapy Service Expectations
03 Parent Management Training-Oregon Model (PMTO) Outpatient Service
04 Trauma Focused Cognitive Behavioral Therapy (TF-CBT)

16.04 Jail Services
04 Incarceration Services
01 Criteria for Inmate Services
02 Documentation for Services to Inmates
03 Care Coordination and Discharge Planning During Incarceration
04 Jail Services Provider Process
05 On Call Jail Services

16.05 Outpatient Substance Use Disorder Services
05 Outpatient Substance Use Disorder Services
01 Substance Use Disorder Program Requirements
02 Co-Occurring Mental Health and Substance Use Disorders
03 Substance Use Disorder Outpatient Methodology
04 Outpatient Substance Use Disorder Authorizations and Claims
05 Outpatient Substance Use Disorder Admission Requirements
06 Gambling Disorder Protocol
07 Outpatient Substance Use Disorder Transportation
08 Outpatient Substance Use Disorder Medicaid Verification
09 Outpatient Substance Use Disorder Individualized Treatment Planning
10 Outpatient Substance Use Disorder Progress Reviews
11 Outpatient Substance Use Disorder Progress Notes
12 Communicable Disease Screenings
13 Outpatient Substance Use Disorder Discharge Planning
14 Outpatient Substance Use Disorder Aftercare and Follow Up
15 Outpatient Substance Use Disorder Client Satisfaction
16 Outpatient Substance Use Disorder Reporting Requirements
17 Outpatient Substance Use Disorder Performance Indicators
18 Court Ordered Individuals
19 Culturally Competent Substance Use Disorder Services

16.06 Outpatient Substance Use Disorder Services
06 Outpatient Substance Prevention Community Education

18.00 POLICYSTAT TRAINING
   
01 Introduction to PolicyStat for Provider Users
02 Introduction to PolicyStat for LifeWays Users
03 Supervisors | To Create a Policy
04 Supervisors | To Approve a Policy
05 Supervisors | To Revise a Policy or Procedure
06 Supervisors | To Review Proposed Revisions to Policies & Procedures
07 Annual Policy & Procedure Review Process
08-A Board Approval of Reviewed and Revised Policies
08-B Posting Board Facilities Committee Reports
08-C Posting Board Finance Committee Agenda Items
09 Policy/Procedure Owner Training

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