MM-CAT-1 - Administrative Policy and Procedures Approved 10-2012

MONARCH, INC.
ADMINISTRATIVE POLICIES AND PROCEDURES TABLE OF CONTENTS POLICY # TITLE PAGE 3 4
MISSION, VISION, AND CORE VALUES. PHILOSOPHY AND PURPOSE..
MAP: 1001 GOVERNING AUTHORITY.. 5 MAP: 1002 LEADERSHIP. 7 MAP: 1003 LEGAL REQUIREMENTS MAP: 1004 CORPORATE COMPLIANCE.. MAP: 1005 ACCESSIBILITY 9 10 12
MAP: 1006 AMERICANS WITH DISABILITIES ACT (ADA).. 15 MAP: 1007 EQUAL EMPLOYMENT OPPORTUNITY & NON-DISCRIMINATION. MAP: 1008 SEXUAL HARASSMENT MAP: 1009 DRUG-FREE WORKPLACE. MAP: 1010 WORKPLACE VIOLENCE. MAP: 1011 CULTURAL COMPETENCY. MAP: 1012 DUTY TO WARN MAP: 1013 CODE OF ETHICS, CONFLICT OF INTEREST, & NEPOTISM MAP: 1014 REPORTING OF CRITICAL INCIDENTS. MAP: 1015 HUMAN RESOURCES MAP: 1016 APPLICATIONS FOR EMPLOYMENT. MAP: 1017 HIRING OF NEW EMPLOYMENT/ORIENTATION.. MAP: 1018 SIGN-ON BONUS.. 16 18 21 24 26 28 34 38 42 44 46 54
Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1019 VOLUNTEERS MAP: 1020 CLINICAL PRIVILEGING MAP: 1021 COMPENSATION. MAP: 1022 EMPLOYEE BENEFITS. MAP: 1023 PERSONNEL RECORDS.. MAP: 1024 HOLIDAYS, PAID TIME OFF, & OTHER LEAVE MAP: 1025 GENERAL EMPLOYEE ISSUES.. MAP: 1026 DISCIPLINE. MAP: 1027 PERSONNEL GRIEVANCE. MAP: 1028 EMPLOYEE ASSISTANCE PROGRAM (EAP) MAP: 1029 HEALTH AND SAFETY. MAP: 1030 EMERGENCY PREPAREDNESS PLAN.. MAP: 1031 TRANSPORTATION SERVICES FOR PERSONS SERVED BY THE ORGANIZATION. MAP: 1032 FACILITY ENVIRONMENT, VISITATION, PERSONAL PROPERTY, & BUILDING SECURITY MAP: 1033 INFECTION CONTROL.. MAP: 1034 SAFE HANDLING, STORAGE & DISPOSAL OF HAZARDOUS MATERIALS MAP: 1035 FINANCIAL POLICY AND PROCEDURES MAP: 1036 RISK MANAGEMENT 55 58 59 63 65 67 73 79 84 86 88 92 99 100 104 106 108 110
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES
MISSION STATEMENT We provide Hope and a New Beginning to women seeking recovery.
VISION STATEMENT To be the Regional Recovery Center of Choice for women in Oklahoma
CORE VALUES Commitment Service Relationships
Dedicated to providing compassionate, high quality services from intake to completion for our clients, their families, and the communities we serve.
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES PHILOSOPHY STATEMENT Chemical Dependency is a primary, chronic and progressive disease that, if not arrested, can be fatal. Addiction not only affects the individual but the family as a whole and disrupts all facets of the familys life. MONARCH stands on the belief that the individual and the entire family should be involved in treatment for a successful recovery. MONARCH provides a holistic treatment approach that includes direct supportive services to individuals and their families whose lives have been disrupted by this terminal disease. Services include a variety of proven therapeutic approaches as well as life skills, auxiliary services, referrals, AA and NA linkages and supportive groups. Chemical dependency is highly treatable when the dynamics are clearly understood. Abstinence cannot be a single goal. The development of facilitative skills and ego strength is crucial. It is also essential to recognize that although the addiction and/or dependency are not unique, each chemically dependent or addicted person is a unique individual. PURPOSE In working to support the mission, values and vision of MONARCH, the purposes are as follows: To stay informed and actively promote current, field-driven standards that improve the values and responsiveness of the programs and services provided to persons served. To continually seek input from persons served and other stakeholders and be responsive to the input so that better programs and services are available. To work to obtain and maintain recognition and/or certification from organizations such as CARF, ODMHSAS, and other accrediting authorities and organizations to assure that the programs and services are of the highest quality. To provide staff, consumers, stakeholders, vendors, and/or volunteers with information, educational and training opportunities that will allow them to stay informed of current standards, alternative programs and services and to obtain and/or maintain appropriate professional certifications and licensors; and so that MONARCH will continuously grow and develop to meet the needs of persons served.
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1001 - Governing Authority It is the policy of MONARCH to be an Equal Employment Opportunity employer, to comply with federal and state statutes governing equal opportunity employment, and to promote the recruitment, retention, and selection of the governing authority that reflect the cultural/ethnic diversity of the community. Governing Board In accordance with governing body bylaws and/or rules and regulations, the Executive Director is responsible for the overall day-to-day operation of MONARCH. This responsibility includes, but is not limited to, the control, utilization, and conservation of MONARCH physical and financial assets and the recruitment and direction of all employees. Board Members Criteria, Electing, Replacement, and Requirements or Procedures When it becomes necessary to replace and/or elect an individual to the governing board, the following guidelines will be followed: Recommendations for appointment to the Board will be taken from existing Board members, employees, and individuals in the community. Members of the Board will reside, or be employed, within the area served. The composition of the Board will reflect an equitable representation of the population distribution in the service area. Composition of the Board will also reflect a broad representation of the community, including minorities and consumers. Board members cannot be related to the Executive Management of MONARCH. The Board shall have a provision for the removal of individuals from the Board for non-attendance of Board meetings. The Board will meet at least quarterly. Board members are required to sign a Conflict of Interest Declaration and an Ethical Code of Conduct Declaration on an annual basis Employees of MONARCH are prohibited from participation as Board members. Board meetings shall comply with the Oklahoma Open Meeting laws. It is the intention of MONARCH to actively recruit individuals with disabilities and/or their personal representatives, as appropriate, as members of the governing authority. As needed, MONARCH will provide reasonable accommodations and support in order to promote equal opportunity for participation of the persons served, members of the governing authority, and/or employees. Executive Leadership and Development In addition to duties outlined within the Governing Authority By-Laws, the Board of Directors will be responsible for the development and evaluation of executive leadership within the organization. This process will include, but not be limited to:
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 1. A formal annual written evaluation of executive leadership in relation to a. The overall corporate performance verses target performance b. Individual performance verses target performance c. Professional development d. Professional accomplishments e. Professional opportunities 2. An annually reviewed executive leadership succession plan.
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1002 - LEADERSHIP POLICY The leadership of MONARCH embraces the values of accountability and responsibility to the mission of the organization and demonstrates corporate social responsibility. PROCEDURES Leadership at MONARCH guides the following: Establishment of the mission and direction of the organization Promotion of value in the programs and services offered Balancing the expectations of both the consumers and other stakeholders Financial solvency Compliance with insurance and risk management requirements Ongoing performance improvement Development and implementation of corporate responsibility Compliance with all legal and regulatory requirements MONARCHs Board of Directors is very diverse and represents the specific cultures the organization serves including but not limited to: Native American, Caucasian and African American members. Leadership at MONARCH responds to the diversity of its stakeholders with respect to: Culture Age Gender Sexual Orientation Spiritual beliefs Socioeconomic status Language Corporate responsibility efforts include: Written ethical codes of conduct that include but are not limited to the following areas: Business Marketing Service delivery Professional responsibility Human resources Any person who feels that there has been a violation of the code of ethics, will complete a complaint form and put it in a sealed envelope that will then be forwarded to the Human Resource Director. In the event that allegations of violations of ethical codes are made, the Human Resource Director will be responsible to investigate and act upon allegations of violation.
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Training provided to employees during orientation and other stakeholders, as appropriate, on ethical codes of conduct that is documented in personnel file. Written policies and procedures on waste, fraud, abuse and other wrongdoing that include: o A no-reprisal approach for employees reporting o The time frame for investigations Advocacy efforts for consumers Policies on contractual relationships Demonstrated corporate citizenship
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1003 - LEGAL REQUIREMENTS POLICY It is the policy of MONARCH that the confidentiality of current and former consumers be protected throughout all legal procedures which may involve verbal and/or written communication between employees of the organization and outside legal entities. The guidelines and procedures of this policy are followed with strict adherence to the legal requirements involved in the above noted communications. Employees will receive initial and ongoing training in the confidentiality guidelines of legal procedures to ensure that rights of the persons we serve are fully protected. MONARCH will comply with all legal and regulatory requirements of federal, state, county and city entities. PROCEDURE MONARCH will be responsible for ongoing reporting involving significant events at the time of occurrence to the appropriate government regulatory agency and/or funding source, and/or other entities, which includes, but not limited, to the following events: Litigation Allegations of wrongdoing Malpractice Violations of the codes of ethics. MONARCH complies with all legal and regulatory requirements, and ensures that the rights of the consumers are protected and advocates for their rights. Policy regarding the human rights and dignity of the consumers have been written and communicated to employees through the organizations code of ethics, and to the consumers in a manner understandable to them. Employees shall demonstrate knowledge of and compliance with all applicable laws through the orientation process and ongoing training (annually), including, but not limited to: Rights of the consumers Confidentiality requirements Reporting requirements Contractual agreements Licensing requirements Corporate status Employment practices Mandatory employee testing (as applicable) Privacy of the consumers and Debt Covenants
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1004 - CORPORATE COMPLIANCE POLICY MONARCH is dedicated to providing services that fully comply with all federal, state, and local regulations and applicable laws. PROCEDURE Rita Oakley is the Corporate Compliance Officer (CCO). The CCO will provide leadership and oversight of the Corporate Compliance Program. The CCOs duties shall include, but not be limited to: Serve as the organizations internal and external point of contact for overall corporate compliance issues. Develop, implement, and monitor the organizations Corporate Compliance Plan, including internal and external monitoring, auditing, investigative and reporting processes, procedures, and systems. Ensure that mechanisms for preventing, detecting, reporting, and resolving compliance issues are operating in a functional manner. Ensure that the organizations reporting mechanisms enhance and encourage active participation of all employees, and provide confidentiality in the reporting process. Ensure that all suspected violators and/or violations are handled according to policy and resolved in a manner that ensures integrity and compliance with applicable guidelines and laws. Submit an annual report to the Executive Director and/or Management Team that includes a summary of all allegations, investigations, and/or complaints processed, a complete description of all corrective actions taken, and any recommendations for changes to the organizations policies and/or procedures. Monitoring and Auditing MONARCH will utilize the CCO to ensure that it conducts business in an ethical manner and ensure that any questionable business practices are thoroughly investigated through the organizations written investigation procedures. All programs will implement internal controls, including monitoring activities to ensure compliance. Internal self-audits may include, but not be limited to: Fiscal services Marketing Contractual services Health and safety practices Use of agency resources Confidentiality Dual relationships Medical necessity
10
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Ongoing monitoring and auditing activities will be reported to the Executive Director and/or Management Team for review and appropriate actions, if necessary. MONARCH will provide mechanisms to employees and/or agents in reporting suspected violations of criminal conduct or violation of the organizational code of ethics by persons within the organization, without fear of retribution. Specific processes of reporting suspected violations include the following: Compliance Forms: All employees have access to Grievance forms for use in submitting information to the Corporate Compliance Officer concerning possible violations.
11
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1005 - ACCESSIBILITY POLICY MONARCH works to promote accessibility and the removal of barriers for employees, consumers and other stakeholders.
PROCEDURES The leadership at MONARCH will have a working knowledge of what needs to be done to promote an accessible setting and will be able to discuss plans to improve accessibility and remove barriers. MONARCH will address accessibility issues in an effort to:
Enhance the quality of life for consumers and other stake holders Implement nondiscriminatory employment practices Meet all legal and regulatory requirements Meet the expectations of all stakeholders in the area of accessibility. MONARCH will also address all requests for reasonable accommodations and determine the merit of the request to determine whether any remedial actions need to be taken. Requests for reasonable accommodations forms will be made available to all consumers, employees and other stakeholders. All requests will be reviewed by the Executive Director or designee and a written plan of response {accessibility plan) or reasons for denial of the request will be made within 10 days of the request. The Executive Director or designee will be responsible for arranging any reasonable accommodations such as large print materials for someone who is visually impaired or providing an interpreter for individuals who are deaf or hard of hearing or who speak in a language other than English. Larger projects may require some long-term planning with input from the Board of Directors. Evidence of conformance can be found in responses to requests for reasonable accommodations; meeting minutes where analysis, action planning and goals are established; in dialogue with stakeholders; during Focus Groups and Council meetings; in community events; in the various data collection methods, etc. The organization will have written documentation of identified barriers and accessibility action plans. The accessibility plan(s) will address issues such as the identification of barriers in: Architecture or physical barriers Environmental Attitudes Finances Employment Communications Transportation Any other barriers identified by the consumers, employees and other stakeholders. Time lines for the removal of any identified barriers
12
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Actions for removal or identification of barriers. A written status report will be prepared annually and will include information regarding the progress made in the removal of identified barriers and areas that are still in need of improvement. PLAN The following serves as MONARCH's Accessibility Plan. The purpose of this document is to provide a means to facilitate continual quality improvement in the area of accessibility MONARCH is committed to providing an organizational milieu that seeks to accommodate the needs of all consumers, employees, and stakeholders. Central to this commitment is the removal of architectural, attitudinal, employment, and/or other barriers that may impede full access to the services and programs of the organization. This Accessibility Plan corresponds to MONARCHs internal evaluation of barriers through the use of facility inspections, assessments of need, and consumer, stakeholder and/or employee feedback. The Accessibility Plan is an annual plan, reviewed and endorsed by Management. The Accessibility Plan is as follows: ARCHITECTURAL Architectural barriers will be identified through internal and external inspections, assessments of need, and employee, consumer, and/or stakeholder feedback. The Quality Improvement Committee and the Health and Safety Committee provide ongoing monitoring of conditions within the organization that serves to improve access. The organization's leadership conducts long and short range planning meetings that routinely include assessment of architectural needs and related costs analysis.
ATTITUDINAL
MONARCH seeks to reduce the stigma associated with persons who have physical disabilities, mental illness, mental retardation, and substance abuse problems, and to promote their inclusion within the community. FINANCIAL MONARCH seeks to reduce and/or eliminate financial constraints that may restrict the ability of all eligible consumers to access any services consistent with their needs and preferences.
13
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES ENVIRONMENTAL MONARCH believes that the environment in which services are provided reflect the cultures and cultural customs of the consumers, and in addition are conducive to providing a comfortable and confidential setting for consumers and employees to achieve their highest potential. EMPLOYMENT MONARCH strives to maintain a diverse workforce sensitive to the unique needs of consumers and representative of the community it serves. In addition, MONARCH strives to hire and maintain the highest quality of employees available in the labor market. COMMUNICATION MONARCH seeks to provide open channels of communication that allow consumers, employees, and stakeholders to access information that accurately represents the status of the organization's systems and outcomes. In addition, MONARCH seeks to facilitate communication among consumers and employees that provides a basis for personal and professional growth and well-being. TRANSPORTATION MONARCH seeks to ensure that consumers are not limited by a lack of personal transportation options or by options that may not accommodate their disabilities, and that transportation systems fully accommodate any community member seeking to access MONARCH services. OTHER AREAS In addition to the above specific accessibility goals and objectives, MONARCH is involved in many ongoing activities and procedures that enhance the accessibility of consumers, employees, and members of the community. Examples include personnel policies, ongoing outreach activities in all program areas, the utilization of consumer feedback/input processes such as satisfaction surveys, psychosocial assessments, and individual planning, participation in consumer advocacy groups, outcome studies, cultural competency education, and a multitude of other activities that directly facilitate the enhancement of accessibility. MONARCHs Executive Director develops and approves a revised Accessibility Plan each year. The plan is reviewed and approved by Management and the Board of Directors, and upon request, is made available to consumers, employees, and stakeholders.
14
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1006 - AMERICANS WITH DISABILITIES ACT (ADA) POLICY MONARCH welcomes applications from persons with disabilities. MONARCH fully supports the Americans with Disabilities Act of 1990 as Amended. Steps have been taken to make MONARCH facilities barrier free and accessible as defined by state and federal statutes. PROCEDURE MONARCH will reasonably accommodate otherwise qualified individuals with a disability unless such accommodation would pose an undue hardship, would result in a fundamental alteration in the nature of the service, program, or activity or in undue financial or administrative burdens. The term reasonable accommodation is used in its general sense in this policy to apply to employees, consumers, and visitors. Reasonable accommodation may include, but is not limited to: Making existing facilities readily accessible and usable by individuals with disabilities Job restructuring Part-time or modified work schedules Reassignment to a vacant position if qualified. Must complete and sign the Request for Reasonable Accommodation form and the Internal Application form Acquisition or modification of equipment or devices Adjustment or modification of training materials or policies Modifying policies, practices and procedures The Human Resource Department is the central point of contact to receive all requests for reasonable accommodation and to receive all documentation required to determine disability status under law.
15
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1007 - EQUAL EMPLOYMENT OPPORTUNITY AND NONDISCRIMINATION POLICY MONARCH endorses and supports the principles of equal employment opportunity. It is the policy of the company to provide equal employment opportunity to all qualified individuals without regard to race, color, age, religion, sex, sexual orientation, disability, marital status, veteran status, national origin, ancestry, or any other protective class under federal, state, or local law. In keeping with these principles, it is expressly against company policy to refuse to hire, discharge, or discriminate against a person in any manner on the basis of that persons actual or perceived age, race, creed, color, national origin, gender, disability, marital status, sexual orientation, lineage, citizenship status, or any other discriminatory reasons. The purpose of this policy is to ensure that all employment decisions are made on a non-discriminatory basis, whether at the time of employment, promotion, training, compensation, benefits, termination of employment, or any of the terms or conditions of employment with the agency. MONARCH expressly prohibits any form of harassment by its employees, agents, or independent contractors based on a persons race, color, religion, sex, age, disability, marital status, veteran status, national origin, ancestry, or other protected class. With respect to sexual harassment, MONARCH explicitly prohibits unwelcome sexual overtures, verbal or physical, requests for sexual favors and all other verbal or physical contact that could be construed as affecting employment decisions, including continued employment, salary, appraisal, and advancement. MONARCH also prohibits insults, offensive comments, jokes, innuendos, sexually oriented statements, and repeated unwelcome invitations to social or sexual activity, all of which can have the effect of creating an intimidating, hostile, or offensive work environment for individuals or can interfere with an individuals ability to perform his/her duties. Although responsibility is shared by all, the principal and direct responsibility for successful implementation of this policy in a uniform manner belongs to the Human Resource Director. Any employee who has a question or concern regarding any type of discrimination or harassment is encouraged to bring it to the attention of his/her immediate supervisor or the Human Resource Director. Supervisors are required to notify the Human Resource Director about any employees question or concern regarding discriminatory or harassing conduct. Conduct involving an employees immediate supervisor should be directed to the Human Resource Director. All complaints will be treated with confidentiality to the maximum extent possible and will be promptly investigated. If the result of the investigation indicates that
16
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES corrective action is called for, such action may include disciplinary measures up to and including termination of employment of the offender. MONARCH shall provide the following steps to assure equal opportunity: MONARCH shall be in voluntary compliance with any and all statutes, regulations and non-discrimination orders regardless of whether such statutes, regulations or executive orders are of federal or of state origin. MONARCH shall commit to offer culturally sensitive services; employees and/or consumer of the target area may be given preference over other persons with similar qualifications. MONARCH shall not employ any individual who is under supervision or jurisdiction of any parole, probation, or correctional authority. Persons with previous criminal convictions, but who are not under supervision, may be considered for employment; however persons with convictions involving neglect, abuse, sex offenses, firearms, or violence, and who will be working with children will not be considered for employment. A criminal history conducted through the Oklahoma State Bureau of Investigation shall be conducted on all potential employees, interns, and/or volunteers. All potential employees are required to undergo a drug test and background check as a condition of commencement of employment. Refusal to undergo drug testing or a confirmed positive drug test shall prohibit employment with MONARCH and, if requested, appropriate referrals will be made for treatment. Selection of potential employees will be made on the basis of interview evaluation, qualifications and job requirements.
17
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1008 - SEXUAL HARASSMENT POLICY MONARCHs Management, employees, consumers, and stakeholders are responsible for assuring that the agency maintains an environment for work and treatment that is free from sexual harassment. Sexual harassment is unlawful and impedes on the rights of employees, stakeholders, and consumers. Sexual harassment violates the dignity of individuals and will not be tolerated. MONARCH seeks to eliminate sexual harassment through education and by encouraging employees, consumers, stakeholders, and/or volunteers to report concerns or complaints. Prompt corrective measures will be taken to stop sexual harassment whenever it occurs. PROCEDURE Sexual harassment includes unwelcome sexual advances, requests for sexual favors, and other physical or verbal conduct of a sexual nature when it meets any of the following: Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's employment status. Submission to or rejection of such conduct by an individual is used as the basis for employment or treatment decisions affecting such individual. Such conduct has the purpose or effect of unreasonably interfering with an individual's work or treatment performance or creating an intimidating, hostile, or offensive environment for working receiving treatment. Sexual harassment can occur between any individuals associated with MONARCH, (e.g., an employee and a supervisor; coworkers; a vendor, or contractor; or a person served). Examples of sexual harassment include, but are not limited to: Some incidents of physical assault. Direct or implied threats that submission to sexual advances will be a condition of employment, work status, promotion, or letters of recommendation. Direct propositions of a sexual nature and/or subtle pressure for sexual activity that is unwanted and unreasonably interferes with a person's work environment. A pattern of conduct that unreasonably interferes with the work environment including: o Sexual comments or inappropriate references to gender o Sexually explicit statements, questions, jokes, or anecdotes regardless of the means of communication (oral, written, electronic, etc.) o Unwanted touching, patting, hugging, brushing against a person's body, or staring o Inquiries and commentaries about sexual activity, experience, or orientation
18
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES o The display of inappropriate sexually oriented materials in a location where others can view them. Consensual Relationships No person involved in a consensual relationship will have direct responsibility for evaluating the employment performance or for making decisions regarding the promotion, tenure, or compensation of the other party to the relationship. Consensual romantic and sexual relationships between supervisor and employee are strongly discouraged. These relationships may be subject to concerns about the validity of consent, conflicts of interest, and unfair treatment of other employees or consumers. Further, such relationships can undermine the atmosphere of trust essential to the treatment process and/or the employment relationship. In the event of an allegation of sexual harassment, MONARCH will strictly scrutinize a defense based upon consent when the facts establish that a significant power differential existed within the relationship. Confidentiality and Non-retaliation MONARCH will make every reasonable effort to conduct all proceedings in a manner that will protect the confidentiality of all parties. Parties to the complaint should treat the matter under investigation with discretion and respect for the reputation of all parties involved. Agency policy and state and federal law prohibit retaliation against an individual for reporting sexual harassment, or for participating in an investigation. Retaliation is a serious violation that can subject the offender to sanctions independent of the merits of the sexual harassment allegation. MONARCH has a compelling obligation to address allegations and suspected instances of sexual harassment when it obtains information that would lead a reasonable person to believe that this policy has been violated. MONARCH is not precluded from taking any action it deems appropriate, including informing the alleged harasser of the complaint and pursuing an investigation even in cases when the complainant is reluctant to proceed. The complainant will be notified in advance when such action is necessary. Corrective measures When it has been determined that sexual harassment has occurred, steps will be taken to ensure the harassment is stopped immediately. Corrective measures consistent with the severity of the offense will be imposed consistent with applicable agency procedures and may include sanctions.
19
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Sanctions imposed on the harasser may include, but are not limited to, a reprimand, suspension, or dismissal. In the event that a record of such sanctions will become a part of the harasser's personnel records, prior notice will be given to the harasser. Sanctions also may be imposed on any individual with a duty to act (under this policy and associated procedures) who fails to respond to a complaint of sexual harassment in a manner consistent with the provisions of this policy and the associated procedures. The complainant will be informed of the corrective measures taken. False Allegations It is a violation of this policy for anyone to knowingly or with reckless disregard for the truth make false accusations of sexual harassment. Failure to prove a claim of sexual harassment is not equivalent to a false allegation. Sanctions may be imposed on individuals who knowingly or with reckless disregard for the truth make false accusations of sexual harassment. Use of Sexual Harassment Allegations in Employment Actions When making decisions affecting an individuals employment or status, allegations of sexual harassment may be considered only if they have been addressed through this policy or procedure, a court of law, or other administrative proceeding. Whenever such an allegation is discussed as part of a determinant in the terms and conditions of an employment status, the affected party should be given notice.
20
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1009 DRUG-FREE WORKPLACE MONARCH takes the issue of drug and alcohol abuse seriously and is committed to providing a workplace free of such substances. This policy applies to all employees, consumers, stakeholders, and/or vendors of MONARCH. No employee, volunteer, visitor, and/or consumer is allowed to consume, possess, sell or purchase any alcoholic beverage on any property owned by MONARCH or in any vehicle owned and/or leased by MONARCH. No employee, volunteer, visitor, and/or consumer may use, possess, sell, transfer or purchase any drug or controlled substance that may alter an individuals mental or physical capacity. The exceptions are aspirin, acetomenaphine or ibuprofen based products or any other legal prescription drugs that have been prescribed to that employee that are being used as prescribed by their doctor. In the event that an employee has to take prescribed/over-the counter medication during working hours, that medication must be kept in a secure environment, out of the reach of consumers (i.e., in a locked desk, Medication Station, etc.). For employees who do not have access to an office, their medication must be kept in the Medication Station or locked up in their vehicle. MONARCH will not tolerate employees that report to work who are impaired and/or under the influence of drugs or alcohol. In cases where the use of alcohol or drugs poses a threat to the safety of other people or property, an employee must report the violation. Employees who violate MONARCHs Drug Free Workplace policy will be subject to disciplinary action, up to and including termination. It is the policy of MONARCH to assist employees who suffer from drug or alcohol addiction. Employees with a substance abuse problem may be eligible for a leave of absence or other benefits and are encouraged to contact their supervisor for details and assistance. As of part of the policy to ensure a drug and alcohol free workplace, MONARCH employees will be asked to submit to drug and/or alcohol testing. Within the limits of federal and state laws, MONARCH reserves the right to test for drugs and/or alcohol. Some such situations may include but are not limited to, the following: All job applicants receiving a conditional offer of employment at MONARCH Where there are reasonable belief that an employee is under the influence of drugs and/or alcohol As a part of an investigation of a workplace accident and/or injury in which there is reasonable belief to suspect alcohol and/or drugs contributed to the accident On a random basis As a follow-up to a rehabilitation program
21
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Certain circumstances may give rise to reasonable belief. These circumstances may include: Drugs and/or alcohol on or about employees person or in employees vicinity Employee conduct that suggests impairment of influence of drugs and/or alcohol A report of drug and/or alcohol use while at work or on duty Information that an employee has tampered with drug and/or alcohol testing at any time Negative performance patterns, or Excessive or unexplained absenteeism and/or tardiness Any employee who refuses to submit to a drug and/or alcohol test, tests positive, fails to cooperate with testing, manipulates any drug and/or alcohol test, and or otherwise interferes with drug and/or alcohol testing will be subject to disciplinary action up to and including immediate termination from employment. MONARCH does not allow any illicit or licit drugs, unless listed above, on any of MONARCH properties or in any company owned vehicle. In the event that a person served, visitor or an employee brings illicit drugs, licit drugs and/or weapons on to MONARCH property, the following will occur: The item(s) will be confiscated if no immediate threat of violence exists. The local Police Department will be contacted. The Clinical Supervisor or Shift Supervisor or designee will be contacted immediately. If possible, keep individual(s) separate from others until police arrive and they will control the situation. If a potential threat of violence exists, remain calm and attempt to keep the individual away from others, and wait for the police to arrive and take control of the situation Possession of licit drugs by: A visitor will result in termination of visitation rights for a period of time (to be determined by the Clinical Treatment Team). An employee will result in a written supervision. Second offense will warrant further disciplinary action up to and including termination of employment. A consumer will result in an intervention and infractions being issued. Possession of illicit drugs by: A visitor will result in termination of all visitation rights. An employee will result in termination of employment. A consumer will result in discharge from the program.
22
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Tobacco Products It is the policy of MONARCH to promote good health among employees as well as provide a clean and safe working environment. MONARCH is a tobacco free facility. Tobacco products are not allowed on any MONARCH properties or in vehicles No one, including consumers, employees and visitors are allowed to use any form of tobacco while on MONARCH properties, inside or outside, or in any company vehicle. Possession and use of any tobacco product including cigarettes, electronic cigarettes, cigars, cigarillos, blunts, little cigars, roll your own, shisas tobacco (hookahs), dissolvable tobacco (orbs, sticks, strips), snus, cream or dry snuff, dokha, gutka, bidis, kreteks, topical tobacco paste, tobacco gel, tobacco water, tobacco gum (not to be confused with nicotine gum for cessation purposes), and any other product containing tobacco is strictly prohibited. In addition, all events supported by MONARCH will be tobacco free. These events include trainings, special event fundraisers and awareness events, and comparable activity. When possible, MONARCH will post signs to communicate the tobacco free event status. MONARCH will not accept financial support from the manufacturers or distributors of tobacco products, their affiliates, or any other entity controlling or controlled by such companies.
23
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1010 - Workplace Violence It is the policy of MONARCH to minimize the opportunities for violence in the workplace. Violence in the workplace can have many sources, including but not limited to: a consumer or former disgruntled employee, an angry customer, spouse, and/or relative of an employee. The violence can be a result of discipline or firing an employee, abuse of drugs, abuse of alcohol, harassment by co-workers, mental illness, and/or work-related stress. MONARCH prohibits: Any act or threat of violence made by an employee, consumer, and/or the public against another employee, consumer, and/or the public; Any act or threat of violence, including, but not limited to: intimidation, harassment, or coercion; Any act or threat of violence which endangers the safety of employees, customers, vendors, contractors, or the general public; Any act or threat of violence made directly or indirectly by words, gestures, or symbols; and/or Use or possession of a weapon on agency property. In an attempt to manage and avoid workplace violence, MONARCH has adopted the following policies: Weapons Weapons are not permitted on the agency premises, parking lots, or company vehicles unless the individual with the weapon is an official law enforcement officer. The consequences for possession of a weapon on MONARCH property will be considered on a case by case basis; however possession of a weapon by: A visitor may result in permanent ban from MONARCH property An employee may result in suspension for first offence and termination for second A consumer may result in an intervention and infractions being issued. Second offence will result in termination of treatment. Training All employees are expected to attend the annual training regarding security and safety in the workplace. Employees are expected to be familiar with the alarm system utilized during safety drills and the steps to take in order to maintain personal safety. Visitors All visitors are to check in at the Receptionists desk. Visitors are discouraged from roaming throughout the facility and should either be in the waiting area or with a MONARCH employee at all times.
24
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Company Vehicles Employees are not to pick up strangers, hitchhikers, and/or other individuals not well known to them in a company vehicle. Prosecution Any individual engaging in violence against the company, its employees, consumers, and/or property will be prosecuted to the full extent of the law. Discipline Employees exhibiting acts or threats of violence will be subject to discipline up to and including discharge. It is a requirement of continued employment that employees report any behavior that compromises the agencys ability to maintain a safe workplace. Any employee who engages in violence, fighting, loud arguing, threatening, and/or similar actions is subject to discipline, including immediate termination of employment. Such employees will not be eligible for future employment with MONARCH.
25
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1011 - CULTURAL COMPETENCY MONARCH fosters a diverse and competent cultural diverse leadership in order to achieve the goals set by the organization in an ever-changing environment through the strengths of our employees, consumers and the community. MONARCH realizes that specific characteristics of the populations served must be identified in order for the organization to have the foundations for culturally competent service delivery. Goals have been set to ensure a diverse pool of qualified and competent candidates, to make the organization a desirable place to work and to promote agency values. MONARCH is committed to creating an inclusive environment where diversity is valued so that individuals will be inspired to contribute fully to the success of the programs. MONARCH works to be seen as a positive place of employment and want the community to see it as an employer of choice. MONARCHs management philosophy fosters the creation of a fair and open environment. The equal opportunity employment philosophy reinforces the commitment that all persons regardless of race, color, national origin, sex, disability, religious affiliation or sexual orientation are welcome here and will enjoy equal opportunities in employment and/or service provision. The Cultural Competency plan for MONARCH is as follows: Recruitment Efforts Aggressively seek opportunities and methods to increase the available pool of qualified drug and alcohol counselors, other behavioral health professionals, direct care workers and/or skilled support staff and focus recruitment efforts to attract qualified women, minorities, veterans, persons with disabilities and people who reflect the communitys cultural diversity Develop a high-performance workplace that values diversity, recognizes outstanding achievements and promotes inclusion Utilizes internship programs as a diversity recruiting tool by recruiting students from a diverse group of candidates Explore changes in the companys benefits packages that could help attract and retain persons who are representative of the specific cultures served Staff Development and Retention Promote diversity on working committees and management level committees to ensure representation of diverse needs and points of view Establish upper management expectations toward managing diversity and communicate to all employees the definitions, purpose and key concepts related to valuing diversity Identify and assess issues and situations that either enhance or degrade the level of employee job satisfaction and morale
26
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Create an environment of equal opportunity that ensures that all employees with relevant skills, abilities and experience can achieve their full potential through advancements, promotions and career opportunities Develop and implement a process for recognizing and rewarding employees and supervisors for outstanding efforts to promote diversity Strive to recruit and maintain leadership, management, direct and support services employees that are representative of the specific cultures served Training MONARCH determines competency by the evaluation of employees at the onset of the hiring process. MONARCH ensures that all clinical staff is licensed/certified by a credentialing body that uses a competency-based process for issuing licenses and certification. Furthermore, evaluation of professional competencies is a part of an ongoing process of clinical supervision. The Clinical Supervisor and/or Executive Director arranges for competency based training of employees in the following areas: That reflect the specific needs of the consumers Clinical skills that are appropriate to the position Individual plan development Interviewing skills Program-related research-based treatment approaches
27
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1012 - DUTY TO WARN Definition: The duty to warn is defined as a person served revealing by any means a specific and immediate threat to cause serious bodily injury or death to an identified person(s), including self, and the person receiving the information reasonably believes that the person has the intent and the ability to carry out the threat immediately or imminently. The duty to warn supersedes all confidentiality laws. In situations which involve a substance abuse diagnosis, Federal Law 42CFR, Part 2, requires that the duty to warn does not include disclosure or any inference concerning information that a third party could use to identify the individual as having a substance abuse diagnosis or problem. If a public service employee is being requested to arrest, detain or transfer an individual known to have a communicable disease that may threaten the health of the public service employee, the following guidelines will apply: Public safety employees should be made aware of the potential risk or exposure to a communicable disease without revealing the specific type of disease the individual is known to carry. Communicable disease is defined as any airborne infection or disease as well as those transmitted by contact with blood or human body fluids. Public safety employees are defined as any person with law-enforcement authority under the control of state and/or local governing bodies. Employees involved in the situation should make every reasonable attempt to determine if the person served is known to be infected with a communicable disease by referring to the record, asking the individual directly, or consultation with other employees who have direct service contact with the individual. Public safety employees must be informed of the potential risk of exposure to a communicable disease by communicating the necessary information to alert the public safety employees of the risk, without disclosing the suspected or known condition. Response to Imminent Threat or Danger: In the event that a decision is made to take precautions to protect due to an imminent threat of harm, employees should take the following actions: Notify the Quality Assurance Coordinator and/or your supervisor for assistance, support, and consultation. Warn the intended victim or the victims parent if a minor. Contact law enforcement having jurisdiction in the area where the person served or intended victim live or work. Attempt to prevent, through verbal means, the individual from using violence until law enforcement can take custody.
28
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Continue the interaction with the person making the threat if you judge that by doing so the persons intention to cause injury or death to self or other may be diminished to the extent the duty to warn is no longer valid. If you judge the person to no longer be a threat requiring a duty to warn, immediately seek consultation with a supervisor following the interaction to assess the level of continued contact or care that may be necessary to assure the situation has been stabilized. Record the event in the individuals record and complete a Critical Incident Report. SUBPOENAS Definition: A subpoena is a mechanism for obtaining records from someone who is not a party to a legal case. It is a form of a court order that directs a person named to appear at a designated time and place to testify, produce documents, or both. In responding to subpoenas, MONARCH must balance our duty to protect confidential information against the duty to respond to the order of the court. A document subpoena or a subpoena duces tecum requires the person named in the subpoena to appear and produce documents. A subpoena to testify or a witness subpoena requires the person named in the subpoena to appear and give testimony. A properly executed subpoena will require a response within the time frame noted on the document. The recipient of a subpoena will immediately route it to the Quality Assurance Coordinator who will review the document and ensure that it includes the following: It is the original copy and is signed by the clerk of the court in which the action is pending. It states the full name and address of the recipients of the subpoena as well as the action number and names of both the plaintiff and the defendant. A document subpoena lists the documents to be produced as well as the time and place they are to be produced. An officer is authorized by law to execute the subpoena in the place where it is served. If the merit of the subpoena is questionable, the Quality Assurance Coordinator will contact the Clinical Supervisor for assistance. If the Clinical Supervisor requires assistance, the subpoena will be forwarded to the Executive Director. The Executive Director will determine if MONARCHs legal counsel will be consulted for assistance. If the merit of the subpoena is questionable, contact will be made with the party who issued the document to determine if the information sought can be obtained.
29
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES If a decision is made to contest the subpoena, MONARCHs legal counsel will pursue action to quash or modify the subpoena. If a notice is received indicating that a motion has been filed to quash the subpoena, the records should be sent only to the clerk of the court issuing the subpoena using the following procedure: Place the records in a securely sealed envelope. Attach a cover letter to the sealed envelope, which states that confidential health care records are enclosed and are to be held under seal pending the courts ruling on the motion to quash the subpoena. Place the sealed envelope and the cover letter in an outer envelope or package for transmittal to the court. If an individuals attorney issued the subpoena, the attorney should be asked to complete Consent for Release of Information form and have it signed by the consumer to protect both the consumer and the organization. Responding To a Subpoena All responses to subpoenas will be made with ongoing consultation with the supervisory employees and the organizations legal counsel, if appropriate. The Quality Assurance Coordinator will determine what records the subpoena seeks. If the subpoena seeks confidential records, the Quality Assurance Director will determine the statutes and regulations that apply to the records being sought. If the records being sought are covered by Federal Law 42CFR, Part 2, governing substance abuse records, they may only be released if the subpoena is accompanied by a court order that complies with sections 2.61 through 2.64 of the law. If the person is an active participant in services, they and/or their legal guardian will be notified of the request in order to ensure that the consumer has an adequate opportunity to assert his/her rights. After informing the consumer of the subpoena, the Quality Assurance Coordinator will determine if the consumer has an interest in waiving confidentiality. If the subject named in the document has consented to releasing the requested records, establish that all legal requirements have been met that permit the release of the records, and that specific details are available that communicate the exact documents or information that is to be released. If documents are not confidential or a release from the person served has been obtained, seek to excuse yourself from appearing by offering the records in advance of the proceeding. Never disclose any records in advance in which there are any questions concerning confidentiality Show up at the designated place and time noted on the subpoena. Produce the designated documents at the designated place and time.
30
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Refrain from disclosure of the records until you confer with the judge at the proceeding to determine whether the information should be released. In conferring with the judge, advise that the information sought is confidential and that the law prohibits you from disclosing it without a court order, and ask the judge to rule on whether records should be disclosed. Only if the judge orders you to disclose the information may you lawfully do so. When appearing at a deposition in which a judge is not present, MONARCHs Management and/or legal counsel will submit written objections to the release of confidential information in advance of the deposition if the consumer served has not consented to the materials release. Since the court may retain the originals while the case is pending, copies are to be made of all records sought by the court. These are to be maintained in the record until the original records are returned. If you are subpoenaed to a deposition, the party who issued the subpoena is responsible for having copies made and does not have the right to obtain the originals. SUBPOENAS, TESTIMONY, AND PRIVILEGED COMMUNICATION Definition: Privileged communication is conversation that takes place within the context of a protected relationship in which the disclosure of the content of that conversation may be deemed to do harm to the provider of the information. The concept of privileged as distinct from confidentiality is that it applies only to testimony in a judicial or quasi-judicial proceeding. If an employee is subpoenaed to testify in a judicial proceeding, and information is requested that the employee believes is confidential or privileged, the subpoena does not authorize the employee to disclose the information. The information may only be disclosed if a judge is present and rules that you must answer the questions. If subpoenaed for testimony in a deposition and questioned about what you know or believe to be confidential or privileged information, decline to answer the question. The party seeking the information bears the responsibility of seeking a court order (judges authorization) requiring the disclosure. Confessions of past crimes within a confidential relationship will only be reported if the crime is of such a nature that the public welfare is jeopardized. In civil matters, the parameters of privilege exist as defined by legal precedent and licensure requirements for licensed physicians and licensed clinical psychologist. Legal clarity is less defined for other mental health professionals and legal counsel will assist employees with preparation for testimony.
31
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES In all cases of testimony, employees should assert privilege by respectfully stating that he/she believes the information is privileged within the mental health provider/client relationship and allow the court to rule if he/she must respond to questions. Under no circumstances should an employee testify regarding substance abuse treatment unless the court has conducted a hearing and issued an order pursuant to Federal Law 42CFR, Part 2.61. The employee in this circumstance will be represented by MONARCHs legal counsel. If, during the course of testimony, a judge orders the employees to reveal substance abuse related information, the employee should inform the judge that special federal law applies to such information and request the opportunity to confer with legal counsel. SEARCH WARRANTS Definition: A search warrant is a written court order that authorizes law enforcement officials to search a specific place for specific persons or materials. The search is conducted under the belief that there is probable cause to suspect that criminal activity or evidence of a crime may exist. Persons or items may be seized if they fit the description within the written order. If a law officer presents a search warrant and demands to access records of consumers by the organization, the following guidelines should be followed: Immediately contact the Quality Assurance Coordinator and inform him/her of the search warrant Ask to see and read the warrant and determine if it contains the following: o The time and location of the search o The date of issuance of the search warrant o The scope of the search and the object (s) to be seized, if found o The reason for the search The Quality Assurance Coordinator will notify the Clinical Supervisor and request assistance with resolving the situation so that neither the consumers rights nor the programs integrity is compromised. Ask the officers for time to contact the prosecuting attorney or supervisory law officer so that clarification of the warrant and the situation can be further discussed. ARREST WARRANTS Definition: An arrest warrant is a written court order that authorizes law enforcement officials to arrest a specific person.
32
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES If a law officer presents an arrest warrant and demands to access to a consumer, the following guidelines must be followed: Hand the officer a copy of CFR 42 and Inform the officer that per CFR 42, you cannot admit or deny that the consumer is at MONARCH Contact the Quality Assurance Coordinator for further instructions, if any.
33
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1013 - Code of Ethics, Conflict of Interest, and Nepotism POLICY: It is the policy of MONARCH that certain rules and regulations regarding employee behavior and ethics are necessary for efficient business operations and for the benefit and safety of all employees. Conduct that interferes with operations, discredits the agency, or is offensive to consumers or coworkers will not be tolerated. MONARCH is dedicated to promoting and preserving the individual dignity and rights of consumers by the agency and of all employees and board members. PROCEDURE: This policy has been established to serve as a guideline for professional conduct. This policy reaffirms the application of MONARCH policy and belief that, as a principle of sound management, all business affairs and marketing practices be conducted within the spirit and intent of high business and professional ethics, honesty, and integrity. Exactly what constitutes an unethical business or professional practice is both a moral and a legal question. MONARCH recognizes and respects the individual employees right to engage in activities outside of his or her employment that are private in nature and do not in any way conflict with or reflect poorly on the company. Management reserves the right, however, to determine when an employees activities represent a conflict with the companys interests and to take whatever action is necessary to resolve the situation, up to and including, termination of employment. Code of Ethics During the Orientation process, all new employees are required to read and sign the MONARCH Code of Ethics. Once an employee has signed this document, the signed document will be retained in the employees personnel file. All new policies will be reviewed with employees during staff meetings and/or will be posted on the Employee Bulletin Board. In addition, employees are expected at all times to conduct themselves in a positive manner in order to promote the best interest of the agency. Appropriate conduct includes, but is not limited to: 1. Treating all consumers, families, visitors, and coworkers in a courteous manner; 2. Providing for the timely delivery of quality services to consumers, family members, and the community; 3. Refraining from behavior or conduct that is offensive or undesirable, or which is contrary to the agencys best interests; 4. Refraining from waste of agency resources, fraud, abuse of consumers, community members, and/or employees and/or other wrongdoing; 5. Reporting to the Corporate Compliance Officer suspicious, unethical, or illegal conduct by coworkers or suppliers;
34
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 6. Cooperating with agency investigations both internal and external. This includes outside, independent audit procedures and regulatory agencies with whom MONARCH has contracts; 7. Complying with all agency safety and security regulations; 8. Practicing ethical codes as outlined within ones professional discipline; 9. Wearing clothing appropriate for the work being performed; 10. Performing assigned tasks efficiently and in accordance with established quality standards; 11. Practicing ethical business and marketing techniques; 12. Reporting to work punctually as scheduled and being at the proper work station, ready for work, at the assigned starting time; 13. Giving proper advance notice whenever unable to work or report on time; 14. Smoking and use of smokeless tobacco only at times and in places not prohibited by agency rules or local ordinances; 15. Adhering to all applicable funding and/or licensing standards; 16. Abiding by the Drug Free Workplace policy; 17. Maintaining cleanliness and order to the workplace and work areas; and 18. Accurately reporting time worked and expense reports including mileage claimed; 19. Participating in and/or supporting advocacy and corporate citizenship efforts and/or activities. Any employee having knowledge of a coworkers unethical and/or unprofessional behavior should immediately report the behavior to the Corporate Compliance Officer. This report should be in written form, signed, and dated by the employee submitting the report. Once unethical and/or unprofessional behavior has been reported, the Corporate Compliance Officer will conduct an internal investigation within three (3) working days from receiving the report. The outcome of the investigation will be recorded in the employees personnel file. Any employee reporting suspected unethical and/or unprofessional behavior will be free from any type of reprisal. Conflict of Interest Any activity in the course of any agency business, marketing, and/or service delivery that would create a conflict of interest between an employee and consumer, resulting in actual, apparent, or perceived use of the employees position for private gain or complete loss of impartiality, is prohibited. Outside Employment: Outside employment of any nature is generally discouraged in that is tends to distract from on-the-job performance and efficiency. 1. No full-time regular employee shall engage in any other employment, in a private business or in the conduct of his/her profession during hours for which he/she is employed to work for MONARCH, or outside such hours, in a manner or to an extent, which adversely affects, or conflicts with, his/her service to MONARCH.
35
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 2. The offering of professional substance abuse services on a private fee basis for service and/or the public listing of ones professional services in a telephone directory or other such method of advertisement is incompatible with full-time employment at MONARCH. 3. Employees may not refer agency consumers or referrals to himself/herself or to any other MONARCH salaried or contract employee working at another agency or private sector without the approval of the Executive Director. 4. No employee may provide services for pay that could be considered in competition with services provided by MONARCH without obtaining written permission from the Executive Director. Business Transactions: There shall be no financial connections or business dealings between consumers and employees. Employees are not allowed to elicit or accept services provided by a current MONARCH consumer unless services rendered are paid for at a rate equal to or above what the employee could obtain the same services for within the community. Any financial or business relationship between consumers and employees should never result in, or any ways create the impression of, exploitation of the consumer. Exploitation of the agency/consumer relationship, or the appearance thereof, is prohibited. If evidence of non-professional, non-work related interaction between any employee and any person served is found, the Human Resource Director and the appropriate supervisor will conduct an investigation of the charges to determine if a policy violation has occurred. If a violation is established, the employee will be dismissed from employment, and a report will be filed with the appropriate authorities if vulnerable adults and/or children are also involved. Personal Relationships: No employee shall engage in an intimate relationship or participate in any activity that may create an impression of having an intimate relationship with any current or former MONARCH consumer. Any person requesting services who is currently involved or who has been involved within the past six (6) months in an intimate relationship with a MONARCH employee may be provided with referral assistance to obtain appropriate services from other agencies or providers. Gifts/Money/Gratuities: The exchange of gifts, money, and/or gratuities between employees and consumers is prohibited except in the following guidelines: 1. No employee shall accept a gift from any consumer other than of nominal value and then only if the acceptance of such a gift would in no way be countertherapeutic or, in any way, appear to be exploitative. 2. Under no circumstances will the acceptance or offering of any gift exceeding $25.00 in value be permitted. 3. No employee shall accept money from a consumer for any reason. Personal Beliefs: MONARCH recognizes that employees may hold a wide range of personal beliefs, values, and commitments. These beliefs, values, and commitments are a conflict of interest only when they prevent employees from fulfilling their job
36
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES responsibilities, if employees attempt to use agency time and facilities for furthering them, or if employees continue attempting to convince other employees, consumers, and/or the public of their personal beliefs after they have been asked to stop. Such practices will not be tolerated and may be subject to disciplinary action up to and including termination of employment. Nepotism/Favoritism 1. No person may be selected for or occupy a position, either as an employee or by contract, which would be directly supervised by a relative within the third degree of relationship by blood or marriage. Management should ensure that the employment of relatives does not interfere with the operation of the agency. In addition, supervisory employees must avoid placing themselves in a position, which would interfere with or create the impression of interfering with, the objective evaluation and direction of their subordinates. 2. No supervisor shall accept gifts from subordinates other than those of nominal value for special occasions. 3. No supervisor shall borrow money or accept favors from any subordinate. 4. Supervisory employees must avoid any action that might result in or create the impression of using his/her position for private gain, giving preferential treatment to any subordinate or losing complete impartiality in conducting MONARCH business. 5. No supervisor shall engage in an intimate relationship with a subordinate he/she directly supervises or participate in any activity that may create an impression of having an intimate relationship with a subordinate. 6. Should employees choose to date each other, their personal relationship cannot in any way affect their work or productivity. Such interference is cause for disciplinary action.
37
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1014 - Reporting of Critical Incidents POLICY: MONARCH will have written procedures regarding critical incidents that include prevention, reporting and remedial action, when necessary. Any incident that is potentially, or in fact, of a libelous nature will be reported and documented in written form. PROCEDURE: Any employee at MONARCH who is involved in or witnessing any of the following will complete a Critical Incident Report immediately. Critical incidents include, but are not limited to, the following: 1. Any injury to person (consumers, non-consumers, employees, etc) or property: (NOTE: Injury does not necessarily have to be a matter of physical injury, for example: unauthorized disclosure of privileged consumer information can cause injury to a consumer.) 2. Death from other than natural causes 3. Suicide and/or suicide attempts 4. Rape or attempted rape 5. Alleged or actual cases of consumer abuse and/or neglect 6. Any sentinel event 7. Medication errors 8. Elopement, AWOL, and/or wandering consumers 9. Violence or aggression 10. Theft or other illegal activities 11. Accidents in agency vehicles involving consumers 12. Use of seclusion and/or restraints 13. Use of any type of weapon on agency property 14. Fire, flood, or tornadoes 15. Accidents or incidents involving serious injuries or significant damage to facilities or agency vehicles 16. Any incident that disrupts the facilitys operating capacity 17. Any report that alleges maltreatment of consumers or poor administration of facilities 18. Use or possession of licit or illicit substances on company property 19. Bio-hazardous accidents 20. Any communicable disease that may pose a threat to other consumers and/or employees 21. Unauthorized use and/or possession of weapons 22. Other sentinel events Critical incidents will be reported in the following manner: 1. Notify immediate supervisor of the incident.
38
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 2. The Clinical Supervisor/Director is to be notified of the incident no later than end of the working day the incident occurred. 3. A Critical Incident Report is completed for documentation purposes and submitted to the Clinical Supervisor/Director within 24 hours after the incident occurred, unless the incident occurs on a holiday and/or weekend. In that case, the incident should be reported to the Clinical Supervisor/Director upon her/his return to work. 4. The Clinical Supervisor/Director will notify appropriate ODMHSAS employees of the incident if appropriate. In any case of an incident involving a consumer, a written report will be filed with the Clinical Supervisor/Director no later than the end of the workday in which the incident occurs. Documentation for a critical incident shall contain at least: 1. The name and signature of the person(s) reporting the incident; 2. The name of the facility reporting the incident; 3. The name of the consumer(s), employees (s), and/or others involved in the incident; 4. The time, place, and date of the incident; 5. The time and date the incident was reported and the name of the person to whom it was reported; 6. The type of incident which occurred; 7. A description of the incident; 8. The severity of each injury, if applicable. Severity will be indicated as follows: 9. No off-site medical care required or first aid administered on site; 10. Medical care by a physician or nurse or follow-up attention required; or 11. Hospitalization or immediate off-site medical attention required. 12. Resolution and/or action taken, date the action was taken, and signature of appropriate employees. After review and signature of the Clinical Supervisor/Director or designee in his/her absence, if appropriate, the Critical Incident Report will be faxed to ODMHSAS in conformance with the time frames and requirements determined by ODMHSAS as follows: 1. Critical incidents that require medical treatment by a physician or nurse or follow-up attention and incidents requiring hospitalization or immediate off-site medical attention will be delivered via fax or mail to ODMHSAS within 24 hours of the incident being documented. 2. Critical incidents involving allegations constituting a sentinel event or consumer abuse are reported immediately by phone or fax to ODMHSAS. If reported by telephone, the report shall be followed with a written report within twenty-four (24) hours.
39
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 3. The Critical Incident Report is placed in the master file for documentation purposes. If the Critical Incident Report has been faxed, the confirmation and the Critical Incident Report are both maintained in the master file. 4. Do not document in the Progress Note of a Clinical record that a Critical Incident Report was completed, submitted, etc. 5. All Critical Incidents will be reviewed during monthly Performance Improvement meetings and any recommendation(s) will be documented and returned to the original individual responsible for completing the Critical Incident. All child abuse and neglect laws and vulnerable adult regulations will be observed. In case of the following incidents, appropriate local authorities will be notified as necessary: 1. Child abuse or neglect 2. Death 3. Physical or sexual assault 4. Suicide attempts 5. Fire 6. Threats of Violence including bomb threats 7. Medical Emergencies that require immediate off-site medical attention or hospitalization In instances where debriefing is required by consumers and/or employees, MONARCH will provide this service through an agreement with Green Country Behavioral Health Services, a community provider of crisis response. Debriefings may include crisis or grief counseling. All other incidents (i.e., minor incident on playground requiring a bandage, etc.) will be recorded and submitted to the consumers primary counselor who will file the report in the consumers file. A written analysis of all critical incidents will be provided to the Executive Director who will provide a report to the Board of Directors annually. The analysis will include: 1. Causes 2. Trends 3. Actions for improvement 4. Results of performance improvement plan 5. Necessary education and training of employees 6. Prevention of recurrence 7. Internal and external reporting requirements Internal Accidents/Incidents Some accidents/incidents may involve issues that pertain to agency property and/or employees. These issues are internal to the operation of MONARCH and are to be reported as follows:
40
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Agency property 1. Any accident and/or incident resulting in the damage to company property, i.e., vehicles, machinery, equipment, buildings, etc., will be immediately reported to a member of Management by the individual witnessing the accident/incident as soon as possible. 2. The person involved in the accident must notify their immediate supervisor of the incident. 3. An Internal Accident/Incident Report is completed for documentation purposes and submitted to the Human Resource Director within 24 hours after the incident occurred. Employee Injury Any incident/accident resulting in an employees exposure to infectious diseases, biohazardous materials, needle sticks, etc., will be reported as follows: 1. If necessary, seek immediate medical attention. 2. Any accident and/or incident resulting in the injury of an employee will be immediately reported to the Human Resource Department An Internal Accident/Incident Report is to be completed for documentation purposes and submitted to the Human Resource Director within 24 hours after the incident occurred.
41
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1015 - Human Resources Overview MONARCH values our human resources within the agency. Employees are involved and engaged in the success of the organization and the consumers. MONARCH will assure that there are an adequate number of employees to: Meet the established outcomes of consumers Ensure the safety of consumers Deal with unplanned absences of employees Meet the performance expectations of the organization MONARCH strives to identify the necessary skills and knowledge that employees must attain to be successful in their positions within the agency. These skills, knowledge and competencies will relate to the type of program/services delivered and the consumers served by MONARCH. The Human Resources Department will be responsible for identifying the skills and characteristics needed by employees to assist the consumers of MONARCH in the accomplishment of their established outcomes and support the agency in the accomplishment of its goals and objectives. The Human Resources Director and/or Clinical Supervisor will also be responsible for identifying the current knowledge and competencies of employees; orientation and training needs of the employees and resources available to employees for learning and growth. The Clinical Supervisor is expected to collaborate with the Human Resource Department in regards to these responsibilities as necessary. Purpose MONARCH Administrative policies were developed to: 1. Facilitate consistent and equitable employment and personnel practices for all employees of the agency, and 2. Help employees familiarize themselves with important information about the agency, as well as information regarding their own privileges and responsibilities. It is not possible to anticipate every situation that may arise in the workplace or to provide information that answers every possible question. Also, future circumstances may require changes in the policies, practices, and benefits described herein. Accordingly, the agency reserves the right to modify, rescind, supplement, or revise any provision in MONARCH policies. The agency will make reasonable efforts to provide employees with advance notice of any modifications or revisions to policies and will update employees as revisions are made. Employment of Board Members To preserve the objectivity and integrity of the agency's Board of Directors, any member who wishes to apply for employment with the agency must first resign from the Board.
42
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Work Eligibility MONARCH seeks to comply with the requirements of federal law and employs only United States citizens and non-citizens who are lawfully authorized to work in the United States. All employment is conditioned on receipt of documentation establishing identity and authorization to work in the United States. MONARCH supports persons who have successfully overcome their addiction to drugs and alcohol. We encourage those individuals who meet the minimum qualifications for a vacant position to seek employment with the agency. If there are any questions regarding this issue, we encourage you to contact the Human Resource Director or the Executive Director for additional information.
43
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1016 - APPLICATIONS FOR EMPLOYMENT POLICY The Human Resource Department of MONARCH strives to always have a pool of qualified applicants for organizational jobs through an ongoing recruiting process. PROCEDURE The Application for Employment form is designed to comply with all state and federal enforcement agencies. Professionals and other applicants often apply for employment with a resume. Resumes appear to present candidates in their most positive light; therefore an Application for Employment form will be completed by each individual desiring employment with MONARCH to enable an objective evaluation to be made by the agency. Applications will be kept active for a period of three months and on file for a period of one (1) year. All applications that are one (1) year old or older will be properly destroyed. MONARCH supports the advancement of current employees that are in good standing with the agency and who qualify for vacant positions, therefore, at the discretion of MONARCH, a job/position vacancy may be posted internally before being advertised externally. MONARCH will utilize various methods to announce job/position vacancies internally and externally. Methods for announcing vacancies may include but not be limited to: Posting at all agency sites accessible to the public Local newspaper(s) Oklahoma Job link Website Local college bulletin boards Inter-Agency Position Transfer Where qualified applicants are available internally, MONARCH may seek to fill job openings by promoting from within. MONARCH may from time to time transfer employees from one position to another or from one location to another. An employees eligibility for transfer will be determined by Management and/or requirements of the new job. In addition, the employee must have held his/her current position for at least six (6) months, (unless moving the employee is in the best interest of the agency), and have both a satisfactory performance record and good attendance. MONARCH retains the right of discretion in the handling of employee transfers. Job openings and promotions, for which Management seeks candidates from within the agency may be posted on the Employee Bulletin Board and/or announced during staff meetings.
44
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Requests for inter-agency transfers will be handled as follows: 1. The employee will complete and submit an Internal Application Form to his/her supervisor. 2. The supervisor will forward the completed Internal Application Form to the Human Resource Department with a recommendation for approval or disapproval, subject to review by the Clinical Supervisor, if applicable. 3. The Human Resource Director shall determine whether the employee is eligible and/or appropriate for transfer. 4. The prospective supervisor will approve the final transfer decision, subject to the authorization of the Clinical Supervisor, if applicable. 5. If approved for transfer, the Human Resource Director will complete a Personal Action form and submit to the CPA. Position Openings and Interviewing In the event that no qualified applications are generated from the above methods, MONARCH may look to other methods for advertising vacancies such as non-local newspapers, professional journals, etc. All announcements will include at minimum: Title of Position Minimum qualifications Brief description of the position Agency contact information Closing date for the announcement The Human Resource Department will review all applications to assure the applicant meets the minimum qualifications for the position for which they have applied. All applicants who meet minimum qualifications will be forwarded to the appropriate Director/Designee.
45
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1017 - HIRING OF NEW EMPLOYEE/ORIENTATION Once all references, background checks, etc. have been satisfactorily completed, the selected applicant shall be offered the position. At the time of the offer, an employment start date will be established. The start date of the employee will also serve as his/her anniversary date for Human Resource Department purposes. On the first day of employment, the new hire will be required to acknowledge, read, sign and/or complete the following forms, which will be kept in his/her personnel file: Employment Application References Mission, Policy/Procedures, Affirmative Action, At-Will Statement, & Electronic Communications Acknowledgement Acknowledgement of Receipt of Emp. Handbook & Vehicle Safety Brochure Dispute Resolution Act, Reporting of Child Abuse/Neglect, & Statement Regarding Fraud CRF-42 Statement, HIPPA Statement, Rights of Persons Served, and Employment Confidentiality Statement Completion of Required Paperwork and Dress Code Employee Declaration Statement and Vehicle Insurance Disclosure Drug Free Workplace Act, Drug/Alcohol Tolerance/Testing Policy & Consent to Submit to Drug/Alcohol Testing Code of Ethics Receipt of Employee Identification Badge Copy of Training Certificates License, Certification, and/or Diploma Job Description Clinical Privileging Mandatory Annual Training DVDs Reviewed W4 Clinical Only Official Copy of Transcript Clinical Only copy of ASAM or ASI Training Certificate The following information will be maintained and/or filed outside of the Personnel File: Social Security Number Verified Authorization for Release of Information/Background Check Acknowledgement of Policies & Terms of Employment Affirmative Action Self-Identification EEO Census Survey Blue Cross/Blue Shield Dental Insurance Application/Declination Blue Cross/Blue Shield Medical Insurance Application/Declination VSP Application Dearborn Life Application Insure Oklahoma Application Health Insurance Verification
46
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Personal Action Form Emergency Contact Form/Authorization for Paycheck Pickup I9 Copy of Social Security Card Copy of Drivers License Copy of automobile Liability Insurance Verification OSBI Background Check Motor Vehicle Report Consent for On-Site Drug Screening form Drug Screening Results Competency-Based Test Results The employee will receive a copy of the following: Employee Handbook ( which contains the current Consumer Medication Policy), Consumer Handbook, and Vehicle Safety Brochure Job Description Insurance Booklet, Summary of Benefits, General Notice of COBRA Rights, etc. Staff Orientation, Development and Training MONARCH promotes the continued growth and development of its staff through the provision of opportunity for continuing education and training. Such training is provided to enhance individual as well as organizational performance. Staff development and in-service training shall consist of the following types of opportunities which will be made available to staff: Orientation programs In-service training and educational programs Continuing education programs Opportunities for affiliation with and participation in professional organizations Availability of professional reference materials Opportunities for participating in outside continuing educational programs New Employee Orientation The primary purpose of orientation is to acquaint new employees with agency rules, policies and procedures, and to complete all required paperwork. All new employees will receive orientation training during their first week of employment to acquaint them with the agencys policies and procedures, their jobs, and their internal and external working relationships. All new employees will meet with the Human Resource Director during their first week of employment. All paperwork and mandatory training will be conducted through the Human Resource Department. In addition, all new employees must complete all paperwork listed on the New Employee Checklist as part of the orientation process.
47
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Supervisors generally will be responsible for on-the-job training, as may be necessary, and instruction in duties normally expected of the employee. Non-supervisory employees may be assigned as on-the-job trainers, and such training will be conducted during regular working hours, whenever possible. All new employees will receive training required by their positions prior to the delivery of services. This training will be received annually thereafter. Employees will be advised of safety and health matters as necessary, and as required by federal and state law and will receive a copy of the MONARCH Drug-Free Workplace policy. In-service Training Program Periodic in-service training programs will be offered by the agency. Those in-service training programs may be conducted utilizing expertise of existing staff. General staff meetings will be held on at least a quarterly basis to afford opportunities for the provision of agency-wide dissemination of new policies and/or revision of existing policies and general agency information. Opportunity will also be afforded for input from staff regarding issues that may need to be addressed as part of an ongoing training program. Clinical staff meetings will be held on at least a weekly basis. Such meetings will be utilized to staff problem cases and to discuss pertinent clinical issues. Various clinical staff will assume responsibility for the provision of service training programs for the clinical staff. In-service and/or annual training will include, but not be limited to: Emergency Preparedness Health and Safety Practices Infection Control/Universal Precautions/HIV/AIDS Prevention of Infectious/Communicable Diseases Confidentiality Professional Conduct and/or Code of Ethics Person and Family-Centered Services Consumers Bill of Rights Public Law 99-401/Child Abuse Reporting Cardiopulmonary Resuscitation (CPR) and First Aid Training Cultural Diversity/Sensitivity Training Sexual Harassment Agency Policy and Procedures Prevention of Workplace Violence Use of Fire Equipment Age and Gender Specific Issues Transportation Safety/Procedures Reporting of Suspected/Actual Child/Elder Abuse
48
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Continuing Education Programs The agency will make administrative leave available to the professional staff for the purpose of pursuing continuing education training opportunities. The agency will underwrite the cost of such continuing education training to the degree that funds are available for such purposes, and if the continuing education meets agency needs. Such continuing education should include training required for licensure or certification. Determination of the continuing education needed to enhance specific individual skills and/or agency program requirements will be agreed upon between the individual and his/her immediate supervisor, with the final approval at the discretion of the Clinical Supervisor and/or Director. Introductory Period Employees are considered Temporary during the first two (2) months following the date of hire. During this period, performance will be carefully evaluated and a determination made regarding the employee's ability to perform the essential functions of their position. The Introductory period may be extended at the discretion of the employees supervisor with the approval from the Human Resource Director. Such an extension shall be for a specific period of time, but for no more than six (6) months unless circumstances indicate a need for a longer extension. Employee Classifications MONARCH employees are placed into classifications based on job description, consistent with the Fair Labor Standards Act and applicable state law. Employment status shall be defined as follows: Regular Employee Any employee who has been assigned to a regular, full time position. Temporary Employee Any employee who is hired for a limited time to fill a position, such as a vacation relief, positions vacant due to illness of a regular employee, etc. Temporary employees are not eligible for regular employee benefits, such as paid vacation, sick leave, holidays, etc. Exempt Employee Any employee who is not subject to the overtime provisions defined by the FLSA. Non-Exempt Employee Any employee who does not meet the qualifications for exempt status as defined by the FLSA. Employees may be classified as follows: 1. Full-Time Employee - Any employee whose regularly scheduled workweek covers forty (40) hours per week, exclusive of the five (5) hours per week allowed for lunch. Full-time employees are entitled to all employee benefits provided by MONARCH as outlined within this policy manual. 2. Part-Time Employee - Any employee whose regular work schedule is less than forty (40) hours per week. These employees may work specific days of the
49
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES week, or a specified number of hours on a given day, at the discretion of the employees supervisor, with final approval by the Executive Director. Part-time employees will not receive employee benefits. Temporary Employee An individual employed for a specified, limited period of time, not to exceed six months, either on a full- or part-time basis. Contract Employee - A person employed with the agency under contract, regardless of length of contract or hours worked per week. On-Call Employee: An employee who is not required to work a specified number of hours in any given workweek but who is scheduled to work on an asneeded basis Inactive Employee: An employee who is on a leave of absence and is not receiving pay from MONARCH.
3. 4. 5. 6.
In addition to the above-listed employment status, MONARCH has established position classifications for employees. These classifications are as follows: 1. Executive Management An employee who is promoted or assigned to oversee and/or supervise a significant component or program(s) within the organization. Appointees are selected by the Executive Director in conjunction with the approval of other Management Team and the Board of Directors. Appointees may not be terminated without prior approval from the Board of Directors. Perquisites may be provided for members of the Management Team at the discretion of the Executive Director. In addition, perquisites may be provided for the Executive Director with approval from the Board of Directors. Members of the Executive Management Team include the Executive Director, the Food Services Manager, the Employment Services Manager, and the Human Resource Director. Overall compensation packages for employees at this level will be approved by the Board of Directors and/or the Executive Director and may differ from other employees. 2. Mid-Management - An employee selected by a Management Team member to supervise and oversee a particular program component within the organization. Such an employee may be responsible for more than one program and/or component. Mid-management employees are responsible for the day-to-day operation of their particular program/component and the supervision of the employees within the program. Changes in Employee Classifications An employee's classification will not be changed due to a temporary change in work schedule. Changes in employee classification will occur when a job change, a promotion, or a change in work hoursprojected to be ongoing or last for more than four (4) monthstakes place. All employee/employment changes will be documented on the Personnel Action Request form.
50
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Personnel Action Request Form The Personnel Action Request Form is the only document used by the Human Resource Department to maintain and/or change an employees financial status and/or employment classification. Position Descriptions MONARCH maintains a written job description for all positions. In the event that new paid positions are created through expansion or reorganization, written job descriptions will be prepared and then approved by the Executive Director before the position is filled. A job description generally contains the following elements: title, summary of job duties, and definition of essential and nonessential functions, qualifications (education, experience, other), title of the immediate supervisor, employee's signature, Human Resource Director's signature, and date. Employees may occasionally be required to perform related duties not set forth in the job description. Job descriptions must be rewritten in the event of major new job responsibilities or other significant changes. All job descriptions will be reviewed and revised annually if necessary. Performance Evaluations Each employee's performance will be reviewed on a continual basis by his or her immediate supervisor. A formal 12 month performance appraisal will be conducted on an annual basis. Although the mechanics of the performance appraisal process may change from time to time, it will always include the components of planning, goal setting, measurement, communication, and feedback. The annual performance evaluation is intended as a means of measuring and enhancing employee performance, fostering professional development and career growth, determining merit increases and meeting the internal and external demands for documentation of individual performance. The individuals supervisor will evaluate the employee by anniversary or original date of hire and discuss as needed. The performance evaluation will be based upon review of the job description for the position. Annual performance appraisals, signed by both employee and supervisor, are placed in the employee's personnel file. Employees may keep a copy of their appraisal and have the opportunity to comment on it in writing. Performance appraisal also includes a discussion about career planning and development. For all clinical staff, the Clinical Privileging Form will be reviewed and updated. Additions and changes will be made during the year as they occur.
51
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Background Checks and Verifying Credentials MONARCH recognizes that the target population of the consumers served by our agency requires our agency to review certain criminal record checks on all employees hired. Therefore, when an applicant possesses the qualifications required to perform the duties of the vacant position most effectively, the Human Resource Department will proceed with checking references and conducting a background check. MONARCH assumes payment for such requests. MONARCH has established policies for actions to occur prior to delivery of services to consumers by our agency and throughout employment to verify the following: Credentials of employees through official transcripts, certifications, copy of diploma, etc. Currency of credentials as required by regulatory agencies Backgrounds of employees in the areas of criminal checks (Oklahoma State Bureau of Investigation - OSBI) Name searches (files maintained by the Oklahoma Department of Corrections under the Sex Offenders Registration Act) Motor Vehicle Report Drug Testing MONARCH will act accordingly to the information received in any and all of the background checks of employees conducted within the hiring process. MONARCH recognizes that qualified employees are critical to the success of the agency and consumers. It is essential that polices be established and implemented that ensure that those providing services in the agency are qualified and safe. Voluntary Resignation When any employee resigns from the agency, they are expected to give two (2) weeks notice prior to the termination date. Employees are not allowed to use Paid Time Off as their last two weeks of employment unless approval is granted by the Executive Director or designee. All terminating employees must return any equipment or property (keys, pagers, cell phones, music, policies and procedures manual, training modules, and etc.) belonging to MONARCH. Clinical staff is required to complete all required paperwork prior to their last day of work. Failure to return property is considered as a legal indebtedness to the agency for such property. Reduction in Force It is the intent of MONARCH to minimize the negative impact on employees if a reduction in force becomes necessary; however, from time to time, cutbacks or reductions may be unavoidable due to forces beyond our control. An employee may be separated for such reasons as lack of funds, curtailment of work, staff
52
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES reorganization, etc. All such reductions in force shall be done in accordance with the following reduction in force plan. Employees affected by reduction in force shall receive not less than two weeks notice of termination of employment or two weeks severance pay. Such termination of employment shall be without adverse effect on the employees eligibility for future employment with MONARCH. If significant reductions in personnel and/or program activities do occur, first consideration will be given to reducing/eliminating optional spending items in the current budget. Concerning personal deployment, MONARCH will make every reasonable effort to retain staff in their current assignments. However, the final decision concerning layoff determinations shall be the responsibility of the Executive Director. At the point where re-assigning or reducing staff becomes the option, the following criteria will be utilized: 1. Employees with high past performance, productivity, and good working relationships, reflected by notations in their Performance Evaluation, will be considered for retention. 2. Professional educational attainment and seniority of service will be considered in relation to criteria above. 3. Full-time employees shall be given priority for retention where their work performance is recorded to be superior to part-time employees. 4. Where the special talents of a staff member are deemed essential to mandated program activity, their retention shall be given priority over other full-time or part-time employees. 5. Staff with marginal performance, poor work attendance, poor attitudes or poor evaluations will be given least consideration for retention. Re-hiring When a former MONARCH employee has been laid-off due strictly to the availability of funds or has resigned as a regular status employee in good standing, she/he may be considered for re-hire, if approved by the Executive Director, and if a suitable position becomes available. Re-hired employees who have been absent for over six (6) months will be considered new employees and will be required to complete the two (2) month introductory period.
53
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1018 - Sign-On Bonus Clinical Only Policy A sign-on bonus is a lump sum payment that serves as a recruitment incentive to aid in the employment of individuals in critical positions that have labor market shortages which affects the business needs of MONARCH and which impair the delivery of essential services. Amount and Method of Payment The amount of the sign-on bonus shall be determined based on labor market data and available funds. An employee shall receive one-half of the bonus in their first paycheck and a second installment after successful completion of 6 consecutive months of employment provided the employee retains eligibility as outlined in this policy. Eligibility for Initial Sign-On Bonus A newly employed clinical employee who is employed to work 40 hours a week is eligible for the Sign-On Bonus. Eligibility for Final Sign-on Bonus Installment An employee is not eligible for the final sign-on bonus installment if: 1. The employees performance at any time is not at or above good or the employee has documented disciplinary actions for misconduct or performance 2. The employee changes from full time employment to part-time employment Repayment of Sign-On Bonus An employee who terminates employment with MONARCH, either voluntarily or involuntarily, before the completion of 12 months of consecutive employment shall repay a prorated amount of the sign-on bonus on months of service completed. The repayment shall be based on the following formula: 1. The amount of the initial Sign-on Bonus received divided by 12 months = Prorated monthly amount 2. Prorated monthly amount times (12 months Months worked) = Amount due The amount due shall be deducted in full from the employees final paycheck. If the amount deducted exceeds the final paycheck, the remaining balance shall be paid in full to the agency within 60 days from the last day of employment.
54
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1019 Volunteers/Interns/Contract Staff Purpose This policy is designed to enable MONARCH to accept volunteers, interns and contract staff and reduce risk and protect the interests of MONARCH, its consumers, volunteers, interns, contract staff, and the community we serve. Volunteers, interns, and contract staff generally provide support services to paid staff; work on special projects; or fulfill requirements of an outside agency for the purpose of providing community service. Volunteers, interns, and contract staff are expected to act in accordance with MONARCH policies and to reflect positive attitudes to all MONARCH employees, consumers, and/or vendors. Policy Responsibilities and Rights Volunteers, interns, and contract staff are expected to abide by MONARCH policies and procedures and external regulations that govern their actions including, but not limited to, those relating to ethical behavior, safety, confidentiality, protected health information, computer use, financial responsibility, and drug use. Volunteers, interns, and contract staff are not eligible for any MONARCH benefits as a result of this association. MONARCH employees who direct volunteer, intern, and/or contract staff activities are subject to non-discrimination laws and the MONARCH policy on discriminatory conduct. MONARCH employees shall not discriminate on the basis of race, color, religion, sex, national origin, disability, political affiliation, or sexual orientation in the selection or supervision of volunteers, interns, and contract staff. Volunteers, interns, and contract staff are asked to be reliable in their commitment to MONARCH and to notify MONARCH in advance if they are unable to work their regularly schedule time slot. Volunteers, interns, and contract staff are asked to wear a name badge that identifies them as a volunteer, intern, and/or contract staff while they are working at MONARCH. Volunteers, interns, and contract staff are expected to refer all requests for information to MONARCH staff, other than purely directional questions (e.g. where the bathroom is; where the Receptionists Office is, etc.). Training and Supervision When selecting/accepting a volunteer, intern, and/or contract staff, it is the responsibility of the Human Resource Director to be certain: 1. That the individual has adequate experience, qualifications, and training for the task he or she will be asked to perform; 2. Is assigned a direct supervisor; and 3. Is approved to work in the assigned department.
55
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Prior to engaging a volunteer, intern, and/or contract staff, the Human Resource Director must: 1. Ascertain whether the individual is at least eighteen years of age by reviewing appropriate proof of age presented by the volunteer. If individual is under eighteen years of age then written parental consent must be obtained. 2. Complete a criminal background check as appropriate, e.g., for all volunteers, interns, and contract staff who will be working with minors prior to their beginning service at MONARCH. Volunteers, interns, and contract staff who do not agree to criminal background checks in such assignments may be refused an assignment. 3. Provide appropriate orientation for volunteers, interns, and contract staff prior to commencing services, such as privacy policies and procedures review. Volunteers, interns, and contract staff will be assigned a supervisor and will receive specific training in their assigned duties from the MONARCH staff member who directly supervises their work. All reasonable care will be taken to ensure the safety of volunteers, interns, and contract staff. Individuals approved to be a MONARCH volunteer, intern, and/or contract staff will sign an agreement prior to being assigned to a department. Work Schedules Volunteers, interns, and contract staff shall only work during hours when adequate supervision is available. Individual work schedules and specific time commitments will be mutually arranged in advance by the volunteer, intern, and/or contract staff and the Director OF Human Resource or department supervisor. Community Service Persons who seek volunteer assignments at MONARCH in order to meet a requirement set by an outside agency for the performance of community service shall be subject to the above selection process and all other provisions of this policy. Who May Volunteer Individuals, including retirees, students, community service workers, or others may provide volunteer services to MONARCH, with the following restrictions: 1. A person who is under the age of eighteen may only become a MONARCH volunteer with written parental consent. 2. A current employee may not become a MONARCH volunteer at MONARCH in any capacity in which he or she is employed at MONARCH, or which is essentially similar to or related to the individuals regular work at MONARCH. A current employee may only volunteer for special events, such as community events. 3. An individual working with minors will pass a criminal background check.
56
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MONARCH volunteers, interns, and contract staff are prohibited from performing the following activities: 1. Operating heavy equipment 2. Operating vehicles except with the express permission of a MONARCH official. 3. Working with stored energy (e.g., steam, electricity, hydraulics) 4. Activity considered inappropriate for any employee 5. Entering into any contract on behalf of MONARCH Confidentiality Volunteers, interns, and contract staff are responsible for maintaining the privacy of any information to which they are exposed, whether this information involves staff, volunteers, interns, contract staff, consumers, or other persons in the overall agency business. Information regarding consumers should not be the subject of casual conversation either inside or outside the agency. Leaving Service A volunteer, intern, and/or contract staff selected for work on a special project will discontinue service when that project is completed or terminated, unless other arrangements have been made. In the event that a volunteer, intern, and/or contract staff is unable to adequately perform the duties assigned to him or her, and no other appropriate positions are available, that individual may be removed from service. In addition, the term of service for a volunteer, intern, and/or contract staff may be terminated at any time and without prior notice unless otherwise agreed upon.
57
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1020 - CLINICAL PRIVLEGING POLICY MONARCH maintains an organized method for documenting and verifying the training, experience, education, and other credentials of clinical staff prior to their providing clinical services. PROCEDURE All clinical staff will be documented as privileged prior to performing treatment services. The evaluation and verification of professional qualifications includes, but is not limited to, the review and verification of: Professional degree(s) via official college transcript(s) Professional licensure(s) Professional certification(s) Professional training Professional experience and Other qualifications as set forth in the position's job description Positions requiring privilege include: Clinical Supervisor/Director Counselors Case Managers Documentations shall be acknowledged and approved by the Clinical Supervisor and/or Director. Only those people providing documentation of requirements as according to job descriptions shall be considered for employment and appointed to provide clinical services. The Clinical Supervisor and Corporate Compliance Officer will conduct an annual review of credentials to assure maintenance of licensure and/or certification. Limited privileges will be given for new employees and/or employees wanting approval to increase privileges. When employees are working with limited privileges, specific conditions for their work and for approval to receive full privileges will be noted on the Staff Privileging Review form. Documentation that the conditions have been met will be provided before an employee may work with full privileges.
58
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1021 - COMPENSATION Wages Wages shall be within the salary range that is assigned to the position based on the positions duties and responsibilities. All employees except those classified as executive, administrative, professional or other exempt status employees, are paid on an hourly basis and are considered non-exempt employees.
Adjustment of Wage Range/Merit Increase/Promotional Increases
To attract and retain employees, competitive wages and benefits will be provided. On an annual basis, the Executive Director and Management will review the base wages. Any necessary adjustments will be made in the salary schedule and included in the upcoming budget. Wage adjustments will be dependent upon the annual performance evaluation and budgetary considerations. The amount and method of payment of the compensation system will be determined by the Executive Director and budgetary consideration based upon an annual analysis. Wage increases may be granted upon promotion or upward reclassification. Each position in the agency shall have defined general responsibilities as outlined in the job description for the position and the availability of funds. A promotion or salary adjustment must be approved by the Executive Director and based on outstanding performance of job responsibilities and the availability of sufficient funds within the agency. When possible, MONARCH provides performance bonuses for achieving major organizational goals. In order to be eligible employees must be full time and not under disciplinary probation. Bonuses Individual bonuses and/or bonuses that will affect the agency as a whole, such as Christmas bonuses, will be presented to the Board of Directors for approval. Timesheets Each employee will keep a timesheet of hours and days worked each pay period. The timesheet will show if the time is for a regular workday, a holiday, Paid Time Off, Extended Illness Leave, etc. The employee will sign the completed timesheet and submit it to his/her supervisor. The supervisor will check the timesheet for accuracy. If it is accurate, the supervisor will approve the timesheet by signing it. If there are any discrepancies, the supervisor will deal with them immediately as to not delay the processing of payroll.
59
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Paydays and Paychecks A workweek at MONARCH will run from 12:00 a.m. Thursday until 11:59 p.m. the following Wednesday. A pay period will consist of two (2) workweeks. Paydays will fall every other Friday. All timesheets will be collected by 12:00 p.m. the Wednesday prior to the Friday payday. In the event that a Friday payday is a holiday, employees will be able to pick up their checks that Thursday. (NOTE: This may change the time that timesheets need to be turned in.) If an employee is unable to pick up his/her check, then their authorized representative may do so. Prior to the employees check being released to the Authorized Representative, the Executive Assistant will verify, through the Human Resource Department, that the person picking up the check is actually authorized to receive the employees check. The employee or person picking up the paycheck(s) will sign for the checks and will be held responsible for correct distribution. Travel/Expense Statements Reimbursement for approved mileage and business expenses incurred by the employee requires appropriate documentation and authorization. Employees may be reimbursed for approved mileage and expenses incurred in the course of providing direct care services or on behalf of the agency. Expense Statement All employees must obtain approval prior to incurring and obtaining reimbursement for any mileage and/or program expenses. An Expense Statement must be submitted to, and approved by, the employees immediate supervisor in order to receive reimbursement. The Expense Statement should reflect business expenses/mileage incurred from the first through the last day of the month. Original receipts must accompany the Expense Statement and include the following information: Amount Items Purchased Date Vendor Name Purpose of the Expenditure Signature of the Employee Expense reimbursement checks are issued once a month at the end of each month. In order to receive reimbursement, Expense Statements must signed by the employees immediate supervisor and submitted to the CPA no later than the 5th day of the following month in which the expense occurred. Expense statements submitted
60
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES later than the 5th day after the month in which the expense occurred will not be reimbursed unless approved by the Executive Director. Work Hours and Break Periods Employees are generally scheduled for a specific shift. The Clinical Supervisor and/or Executive Director or must approve any changes in the employees schedule. Break periods are paid time and need not be entered on the timesheet. Each employee who is scheduled to work an eight (8) hour work day is allowed one (1) 15minute break approximately two (2) hours after the beginning of his/her shift and another 15-minute break approximately six (6) hours after the beginning of his/her shift. At no time will an employee take a break from his/her duties without assuring that another employee is available cover services/needs of the consumers. Each workday includes a one (1) hour lunch break for all employees except the evening/night employees who work a straight eight (8) hour shift. All others will observe a one (1) hour lunch break unless other arrangements have been approved by the Clinical Supervisor. Work Schedules MONARCH is a 24-hour facility that is dedicated to the needs of the consumer. Due to these needs, or the needs of the agency, employees may be required, and must be willing, to work hours and/or other locations that accommodate the needs of consumers or the agency. Employees may be moved to another program and/or shift when agency and/or consumer needs so dictate. In addition, employees may be moved to another program and/or shift at the discretion of Management. MONARCH will adhere to the Federal Fair Labor Standards Act (Dept of Labor, 1991). This will provide for the payment of minimum wage and time and one-half for overtime hours to all employees except those having exempt status by qualification as professional, executive, or administrative employees. Under these guidelines, work schedules will be assigned as follows: 1. All employees may be required to work evenings and/or weekends as dictated by agency business hours and the needs of consumers. 2. The regular workweek for all employees will consist of forty (40) hours. On occasion it may be necessary for an employee to work more than the scheduled forty (40) hours in a one-week period. Authorization must be obtained in advance, whenever possible, and appropriate documentation is required. All overtime must be reported as worked. Falsifying time records will result in immediate termination for gross misconduct. 3. The workweek begins on Thursday morning at 12:00 a.m. and ends on Wednesday evening at 11:59 p.m.
61
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Tardiness Employees are expected to observe the hours that have been set for their position or shift. Repeated tardiness will make an employee subject to disciplinary action, up to and including, termination of employment. Every employee should provide notification to her/his supervisor if tardiness is foreseen at least 15 minutes before the shift or workday is to begin. Absence If an employee is unexpectedly absent due to illness or an emergency, the employee will notify the supervisor as soon as possible. Employees that work the evening and weekend shifts should notify their supervisor at least four (4) hours prior to the beginning of their scheduled shift so that a replacement can be found. Employees, who work regular office hours such as administrative employees and professional counselors, should notify their supervisor within 15 minutes prior to the beginning of their workday so that all duties and assignments can be re-assigned for the day. The supervisor should be kept informed of the probable duration of the absence so that necessary adjustments can be made. Once the employee has returned to work, the employee will complete a Leave Request Form and submit it to his/her supervisor. In the event the absence was for three (3) or more days, the employee will be required to obtain a Return to Work letter from their Physician outlining restrictions, if any. Failure to notify the supervisor of an absence is considered a no call, no show and will result in disciplinary action up to, and including, termination of employment. Overtime Only non-exempt employees are eligible for overtime under the Department of Labor Standards. Due to the funding structure of MONARCH, overtime pay creates an undue hardship on the organization. Therefore, the following will apply: 1. All overtime must be pre-approved by the Executive Director; 2. Overtime pay is calculated at 1 times the regular rate of pay for hours worked in excess of the 40 hours of actual work in a work week.
62
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1022 - EMPLOYEE BENEFITS MONARCH reserves the right to modify or amend, at any time, any or all provisions of the benefit plan. The Executive Director has the authority to amend or terminate any benefit plan. If an employee is scheduled to work less than 40 hours per week, she/he is considered ineligible for additional benefits such as PTO, Extended Sick Leave, etc. Workers Compensation All employees are eligible for workers compensation coverage. MONARCH pays for insurance to protect employees in the event of an on-the-job illness or injury. If an employee is injured while working or becomes ill as a direct result of employment at MONARCH, the employee must: 1. Contact his/her supervisor immediately regardless of how minor the illness or injury may seem. 2. Complete an Internal Incident/Accident report as soon as possible but no later than one (1) working day of the injury or illness 3. If medical treatment is required, the Human Resource Director will generate a referral for treatment 4. All medical advice/recommendations will be followed by the employee 5. Copies of all orders, reports, etc. will be forwarded to the Human Resource Director who will work with the insurance carrier on behalf of the employee. 6. Failure to report an illness or injury or comply with this policy may result in the denial of Workers Compensation. Medical/Dental Insurance All full time employees are eligible to immediately participate in the medical/dental insurance plan. The cost of an employees insurance will be partly paid by the agency. The employee will be expected to pay a pre-determined amount per paid period. Dependent coverage is offered to each employee and, if elected, shall be paid by the employee through payroll deduction. Once an employee has established health insurance with MONARCH, any change request must be made in writing and submitted to the Human Resource Director. A new employee has thirty (30) days from the date of employment to apply for insurance. If an employee does not apply in that time frame, the employee will have to wait until the next Open Enrollment date for application. In addition, once an employee has established insurance with MONARCH, any change request must be made in writing and submitted to the Human Resource Director. Continuation of Medical/COBRA Insurance Federal Consolidated Budget Reconciliation Act (COBRA) is the legislation that provides employees and their covered dependents the right to continue their group health care coverage after a qualifying event.
63
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES COBRA gives employees and their qualified beneficiaries the opportunity to continue health insurance coverage under THE MONARCH medical plan when a qualifying event would normally result in the loss of eligibility. Upon termination from MONARCH, an employee may choose to continue group medical coverage at group rates as long as the employee pays the required monthly premium in advance. Under COBRA, the employee will pay the full cost of coverage at the group rate and may pay an administration fee. MONARCH provides each eligible employee with a written notice describing his/her rights under COBRA when the employee becomes eligible for coverage under MONARCHs health insurance plan. Education/Training Monarch provides clinical training that supports employee growth and development needs. Monarch will provide training opportunity for employees in areas including but not limited to: Substance Abuse Counseling theory and techniques Age, Culture, and Gender specific issues Treatment of infants, toddler, preschool and school age children Identification of domestic violence, spousal/partner abuse Child abuse and neglect with special emphasis on failure to thrive and sexual abuse of children Normal and abnormal child development Dynamics specific to the multiple dysfunction of the substance abusing family Crisis intervention, crisis counseling Consumer care evaluation Suicide Awareness and Prevention/Intervention Children and suicide Charting procedures for adults and children Licensing/Accrediting Requirements, i.e., ODMHSAS, CARF, etc. Additional employee training shall be offered from time-to-time, with Monarch paying all necessary expenses of the training. Occasionally overnight, out of town travel will be necessary. After an employee has agreed to attend training and Monarch has committed funding, if the employee does not attend the training, the employee will be expected to refund Monarch the actual outlay of funds. When an employee or the employees supervisor request training, the employee must submit a request to the Clinical Supervisor. If the request for training is approved, the employee will contact the Executive Assistant for assistance with registration. Prior to attending the training, the employee will read and sign a Training/Continuing Education Agreement.
64
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1023 PERSONNEL RECORDS MONARCH shall keep a confidential file for each employee. It will be maintained and stored under double lock in the Human Resource Department. 1. Material in the file will be factual and objective. 2. The employee has a responsibility to report any and all changes in name, address, telephone number, marital status (for benefits and tax withholding purposes only), addresses and telephone numbers of dependents and spouse or former spouse (for insurance purposes only), beneficiary designation for any of the organizational insurance or disability plans, and persons to be notified in case of emergency. 3. All other personal, financial, and/or medical documentation will be maintained in a separate file. 4. Personnel records are to be kept private and confidential at all times. There are certain times when information may be given to organizations or persons outside of the agency in conformance with the Federal, State, and accreditation or licensing laws. Other circumstances would include the following: a. A response to a subpoena, court order or order of a contractual agency; b. In a lawsuit, grievance, or arbitration in which the employee and the agency are parties; c. To administer employee benefit plans; and d. To a health care provider for insurance purposes only. Personnel records are maintained in six sections with each section contents as follows: a. Section One: Orientation Form for New Employee Employment Application References Resume Mission, Affirmative Action, At-Will Statement, and Electronic Communications Acknowledgement Acknowledgement of Receipt of Employee Handbook and Vehicle Safety Brochure Dispute Resolution Act, Reporting of Child Abuse/Neglect, and Statement Regarding Fraud CRF-42 Statement, HIPPA Statement, Rights of Persons Served, and Employment Confidentiality Statement Completion of all Required Paperwork and Dress Code Employee Declaration Statement and Vehicle Insurance Disclosure Drug Free Work Place Act, Drug/Alcohol Tolerance/Testing Policy and Consent to Submit to Drug/Alcohol Testing Code of Ethics Receipt of Employee Identification Badge Copy of Licensure, if applicable
65
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Credentialing Packet (s) (as applicable) College Transcript (as applicable) Section Two: Job Description Section Three: Clinical Privileging Disciplinary Documentation Other Correspondence Section Four: Performance Appraisals Section Five: Training Records and Certificates Section Six: W-4
b. c.
d. e. f.
Memos are sent out as needed as a reminder of records needing updated such as licensure, drivers license, vehicle insurance, etc. Employee information sheets, licenses, and credentials are updated annually to ensure current information. For the health and benefit of each employee, MONARCH will ask employees to fill out an Emergency Contact Sheet. Employees should list person/or persons with telephone numbers to be contacted in cases of emergency. Other information should include blood type if known, any allergies, or other medical conditions which would be beneficial to the employee in case of an emergency, accident or illness. This information will be kept in the employees confidential file. Access to Personnel Files MONARCH employees shall have access to their personnel files for review and information. Confidential files for each employee are kept in a locked file in a locked room. Only the employees immediate supervisor, Executive Assistant, Human Resource Director and Executive Director will have access to the employees file. 1. An employee who would like review their file must submit a written request to the Human Resource Director. 2. The Human Resource Director will set an appointment with a date and time favorable to both the Human Resource Director and the employee. 3. Under no circumstance is the employee to be unsupervised or remove his/her files from the Human Resource office.
66
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1024 - HOLIDAYS, PAID TIME OFF, AND OTHER LEAVE POLICY MONARCH strives to provide all employees with the opportunity to have time off to observe holidays, take vacation, and tend to themselves or loved ones while sick as well as various other tasks and duties without creating a financial burden due to lost wages. PROCEDURE On all holidays there will be a clinical counselor on call, twenty-four (24) hours a day, for emergencies. Holiday Leave MONARCH will recognize ten official holidays during the calendar year during which the agency will be closed for business: New Years Day, Martin Luther King Day, Presidents Day, Independence Day, Memorial Day, Labor Day, Thanksgiving and the day after, Christmas Eve and Christmas Day. If a designated holiday falls on a Saturday, the agency will be closed on the Friday prior to the holiday. If a designated holiday falls on a Sunday, the agency will be closed on the following Monday. Unless otherwise arranged by their supervisor and/or department supervisor, all employees will observe these holidays. An Observed Holiday list will be posted and/or distributed at the beginning of each calendar year. This list is subject to change at the discretion of Management. Employees must be in active paid status (not on unpaid leave of absence) to receive holiday pay, and must work the regularly scheduled work day preceding and following each holiday to receive holiday pay. The only exception to this rule would be in the situation where an employee provides documented proof of personal (employee) illness or injury. If a pre-approved Paid Time Off day is taken before or after a MONARCH observed holiday, the employee will receive holiday pay. In addition, all exempt full-time employees are paid eight (8) hours' wages for each observed holiday in which the administrative and clinical offices are closed. Non-exempt Night/Weekend shift employees who are scheduled to work on a holiday observed by MONARCH will not be paid time and one-half; however, non-exempt/night/weekend shift employees that work the actual holiday will be paid time and one-half for time worked. Paid Time Off Regular full-time MONARCH employees will begin to accrue Paid Time Off (PTO) from the date of hire. No other classification of employee will earn PTO. An employee may wish to use this time for personal days, illness, to celebrate a holiday, take a vacation, spend time with family or sick children, or for taking mental
67
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES health days. The employee should always maintain a sufficient accrual of PTO to cover incidental illness. The amount of PTO earned is prorated each month as scheduled below. PTO accrual will not be earned on paid Extended Illness Leave, on-call hours, or during any other leave without pay period. Accrual of PTO is dependent upon the number of years of service to MONARCH during full-time employment. For every eligible month worked, the MONARCH employee will earn PTO as specified below: Years of Employment 0 through 2 years 2 through 5 years 5 through 8 years 8 through 10 years 10 years and up Accrual Rate 120 144 168 192 216 hours hours hours hours hours 15 18 21 24 27 days days days days days
Paid Time Off must be requested in writing two weeks prior to the requested starting date for consideration of time off exceeding one working day, unless emergency circumstances exist. Since many positions at MONARCH are related to the provision of services to consumers, it may not be possible to grant all days, or the exact days requested. The granting of PTO will be made by the direct supervisor and/or department supervisor, based on the needs of the agency and the timeliness of the request. Those requests submitted first for particular time off will be considered first. In the event of illness, the employee must notify their immediate supervisor and/or department supervisor of the illness before their regular time for reporting to work, as defined by MONARCH policy and procedures. Except when hospitalized, the employee is required to notify their supervisor each scheduled workday while ill. Failure to do so may disqualify the employee for Paid Time Off for which they are otherwise eligible, and may result in termination from employment. Paid Time Off (PTO) may not accrue beyond two hundred forty hours (240) accumulation. PTO is a benefit given so the employee may have more control over the amount and time he/she needs to take off, and is meant to be taken on a regular basis, with some reserve for illness. Any accrual of more than the maximum amount allowed will be forfeited, and no additional PTO will be earned until the number of PTO hours falls below the possible maximum accrual. Employees may not receive pay in lieu of Paid Time Off. PTO will not accrue when an employee is on Extended Illness Leave, on-call hours, or any other unpaid leave. Upon termination from employment, the full-time employee who has successfully completed one year of continuous employment will be paid for all earned PTO on record. An employee who voluntarily or involuntary leaves the agency before
68
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES completion of one year of continuous employment will not be paid for accumulated PTO. Paid Time Off of any kind is not mandated by law, but rather given at the discretion of the employer. MONARCH reserves the right to rearrange Paid Time Off schedules, to require employees to take Paid Time Off at certain times, and/or to shut down all or any part of the agency for Paid Time Off purposes as circumstances may prescribe. Further, MONARCH may alter this policy at any time. Employees Birthday/Floating Holiday Each full time employee is granted a Floating Holiday (8 hours) in observance of his/her birthday. The employee may use these hours on his/her actual birthday or use them as a Floating Holiday. This time must be used prior to the end of the calendar year. If this time is not used prior to the end of the calendar year, it will be forfeited. In addition, an employee who voluntarily or involuntary leaves the agency before taking their Floating Holiday will not be paid for the holiday. Extended Illness Leave After completion of one year of continuous employment, regular full-time MONARCH employees qualify for Extended Illness Leave. Extended Illness (sick) leave may not be used prior to this time for any reason. Regular full-time employees will accrue four (4) hours of Extended Illness Leave per qualified month. Extended Illness Leave may be accrued from year to year to a maximum of 240 hours. Extended Illness Leave time will not accrue when an employee is on Extended Illness Leave, on-call hours, or any other unpaid leave. To be eligible for Extended Illness Leave, the employee must have been absent from work for more than 40 consecutive work hours due to personal illness. The first 40 consecutive hours of each occurrence will come from the employees PTO accrual. Beginning with the forty-first (41) hour, the Extended Illness Leave benefits will begin, provided the employee has the necessary accrued Extended Illness hours and has furnished to the Human Resource Director documentation from the employees attending physician verifying the medical necessity of the employees time off. Failure to do so may disqualify the employee for paid Extended Illness Leave for which the employee may otherwise be eligible, and may result in termination from employment. Extended Illness Leave is a benefit which is provided to each regular full-time employee in addition to PTO, and must be used only for medically necessary, documented employee illness or in cases where the employee is required to attend to an immediate family member. Improper or fraudulent use of Extended Illness Leave may result in immediate termination from employment. Employees using Extended Illness Leave are required to furnish the Human Resource Director with a letter, or other certification, from the employees/family members
69
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES attending physician documenting the medical necessity of the illness and stating that the employee is unable to perform the duties of their job. Once the employee is released to return to work, he/she must furnish the Human Resource Director with a Physicians Release to Return to Work. This release must document the date the employee came under the physicians care, the date the employee is released to return to work, and any restrictions. The employees immediate supervisor, in conjunction with the Human Resource Director will make the final determination as to the employees ability to return to work and resume normal duties. Extended Illness Leave will not be granted for elected cosmetic surgery or procedures, or for any non-justifiable medical reason. Extended Illness Leave is provided for the benefit of the employee in the event of unforeseen or unavoidable catastrophic illness or crisis, to prevent or lessen undue financial hardship for the employee because of circumstances beyond the employees control. No employee should assume that Extended Illness Leave will be paid until formal written approval has been granted. Upon separation from employment from MONARCH, accrued Extended Illness Leave will be forfeited, and the employee will not receive pay for any Extended Illness Leave accrued. Bereavement Leave A regular full time employee may take up to five (5) Administrative days off in the event of a death in his/her immediate family. An immediate family member shall include husband, wife, mother, father, sister, brother, son, and/or daughter. A regular full time employee will be allowed one Administrative day leave of absence for an uncle, aunt, grandmother, grandfather, mother-in-law, father-in-law, daughter-inlaw, son-in-law and/or grandchild. Maternity/Paternity Leave Full time MONARCH employees who have been employed by MONARCH for twelve (12) consecutive months are allowed up to six (6) weeks of unpaid leave after the birth of a child or in conjunction with the adoption of a child. Upon returning to work, the employee will be required to submit a Release to Work form from the employees physician. Voting Leave Any employee who wishes to vote in the regularly held legal elections shall be allowed unpaid leave time up to two (2) hours to participate. Court and/or Jury Duty Employees required to serve on jury duty will receive compensation from the agency for each day of jury duty equal to eight (8) hours pay at their regular pay rate, or such lesser amount if the employee would not have otherwise worked an eight (8) hour day.
70
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Employees required to serve on jury duty will give the agency any pay received from the governmental entity requiring their attendance. If an employee withholds such fee from the agency, the agency will reduce the employees paycheck for those days served for which the employee have received jury/witness pay. The employee may retain specific reimbursements for mileage, parking fees, and meals. If the jury is prematurely excused from duty during the time of its service, the employee is expected to report for work as usual. Employees who are released from jury duty three (3) hours or more before the end of their regular work shift will immediately report to work. Failure to report earnings from the court and/or failure to return to work after dismissal of court could result in disciplinary action up to and including termination. Military Leave An employee, who leaves a position to enter military service in time of war or any period of national emergency as declared by the President of the United States in connection with national defense or by reason of being drafted, shall be carried on the employment records in a Military Leave status. Upon an honorable discharge from military service, he/she shall be entitled to be restored to the same position or to a position equally acceptable for which he/she is qualified, provided he/she applies for re-employment within ninety (90) days after the discharge or before the expiration of any statutory right to re-employment, if later. A letter from the employees commanding officer certifying that the employee is required to fulfill military obligations will be allowed as Leave Without Pay shall be granted in accordance with state and Federal Laws in effect at the time that the leave is requested. Leave Without Pay (LWOP) Leave Without Pay (LWOP) is a temporary absence from duty in a non-pay status at an employees request. Leave without pay is not a right, but rather an option that may be administratively granted. Approval of leave without pay up to and including five (5) days requires the approval of the employees immediate supervisor and/or department head and a member of Executive Management. Leave without pay over five (5) working days requires the recommendation of the employees immediate supervisor, department head, and Management in conjunction with the approval of the Executive Director. Employees will not be granted leave without pay in excess of ten (10) consecutive working days in any case unless: There is a reasonable expectation that the employee will return to work at the expiration of the approved leave, and/or The employees leave does not interfere with the delivery of services to consumers and/or their children.
71
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Absence without proper authorization or approval may be considered sufficient cause for suspension or dismissal. Temporary Light Duty Assignment When a Monarch employee becomes medically or physically limited, a temporary light duty assignment may be considered. Any light duty assignment is temporary and reserved exclusively for the purpose of getting injured employees back to work as soon as possible. Temporary Light Duty assignments may be considered when: 1. The employee has a physicians written request for light duty assignment or when the agency has received notification from the employees physician that the employee may return to work in a light duty assignment; 2. The employee has a properly completed Physicians Statement. This statement must include dates of injury/illness a certification of when the employee can return to full performance duty and/or a specific statement of which specifies the duration of limited disability; 3. A vacant position exists and the needs of the facility and budgetary limitation are met; 4. The light duty assignment will not exceed a thirty (30) day period; 5. An employee with limited medical releases will not be allowed to work within direct consumer care areas which might require physical contact, unless the employee can demonstrate such placement will not pose an increased risk to the health, safety and welfare of consumers and/or other employees. If a vacancy exists in a non-direct consumer care area, consideration will be given to placing the employee temporarily in that position, pending receipt of a satisfactory medical release to return to the original position. The Executive Director and/or designee in such matters shall consult the agencys attorney; 6. An employee injured on the job shall be given priority placement over employees whose injury or illness is not work-related.
72
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1025 - General Employee Issues Supervision of all Staff All staff will receive on-going individual supervision by the respective immediate supervisor throughout their employment with MONARCH. Supervision will be provided as required, based on individual performance. Methods of supervision may consist of any of the following: 1. Case consultation 2. Evaluation of job performance and other issues concerning job functioning, which is intended to enhance job skills, attitudes, and maintenance of acceptable work standards and/or 3. Feedback to the employee regarding strengths and areas which need strengthening 4. The person conducting the supervisory session will keep written documentation of supervision session. Dress and Appearance Employees are expected to maintain MONARCHs professional image. Employees should promote a positive working environment and limit distractions caused by outrageous, provocative and/or inappropriate attire. It is expected that employees will report to work in a clean and neat fashion. Work attire should complement an efficient, orderly and professional environment. Therefore, employees are required to follow the guidelines below. While employees who work Monday through Friday from 8:00 a.m. through 5:00 p.m. may wear business casual clothes, they may not wear: 1. Denim jeans and/or T-shirts, except on Casual Friday; 2. Clothing that is stained, discolored, etc.; 3. Clothing that is offensive, such as clothing with nude or semi-nude pictures, offensive gestures, or suggestive cartoons; 4. Clothing with political slogans, derogatory words, Nazi, KKK, or gang-related regalia; 5. Clothing that displays and/or promotes the use of alcohol and/or drug products; 6. Revealing clothing such as short-shorts, crop, or halter tops, muscle shirts, spaghetti straps, or clothing showing the midriff. Sun dresses are allowed during the summer months; 7. Tank tops can be worn if the shoulder width is 2.5 inches; 8. See-through clothing that exposes underwear or inappropriate body areas; 9. Athletic shorts, cut offs, biking or spandex shorts, boxers or flannel shorts/pants/pajamas, jogging suits, sweat pants; however, RSA and Operations staff may wear sweatshirts with hoodies during winter weather; and/or 10. Offensive, explicit, graphic buttons, hats, caps, or other attire. 11. RSA staff may wear denim jeans and tee shirts. In addition, the following guidelines should be adhered to at all times: 1. Good personal hygiene is a daily necessity;
73
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 2. Tattoos that are obscene must not be showing; 3. Proper undergarments are to be worn at all times (and not exposed); 4. Clothing should be in good taste, neat, clean, and appropriate for the duties to be performed; and 5. Skirts, dresses, & shorts should be no more than 2.5 above the middle of the knee. All employees will be aware of their activities for the day and dress accordingly. For example, if an employee is scheduled to attend a meeting or training, she/he will dress professionally. Employees who appear for work inappropriately dressed, or an employee who has bad personal hygiene will be sent home and directed to return to work in the proper attire or improved personal hygiene. a. Under these circumstances employees will not be compensated for time away from work. b. Repeated abuse of the dress code will result in formal disciplinary action up to and including termination. All decisions regarding the appropriateness of the employees appearance will be made by Management and will be final. Off-Duty Conduct MONARCH reserves the right to take action when the off-duty conduct of an employee impacts the agencys business. Therefore, employees should become familiar with the companys policies regarding conflicts of interest and the code of ethics. For example, employees who are off-duty may not accept gifts from consumers, which is a violation of the agencys Conflict of Interest policy. In addition, employees who are traveling on agency business are expected to conduct themselves with decorum after hours. Employees on a leave of absence are subject to the same rules as employees regarding away-from-work conduct. Off-duty conduct, such as membership in organizations to promote civil rights, religious practices protected by law, and other lawful off-duty conduct is not a matter of concern to the agency. While it is impossible to list all the potential off-duty conduct that may impact the agencys interests, employees are to follow the guidelines listed below: 1. Sexual harassment of employees off-duty will not be tolerated. 2. Illegal conduct that indicates the potential for violence may be subject to discipline. 3. Illegal conduct on agency property while off-duty may be subject to discipline. 4. Illegal conduct off-duty that causes the employee to be unable to perform his/her essential job functions may result in termination of employment. 5. Disruptive actions while off-duty at a company-sponsored event may result in disciplinary action.
74
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 6. Disclosure of confidential information will not be tolerated. It is grounds for immediate termination. 7. Employees may not use agency equipment while off-duty. Children/Dependents in the Workplace Staff should avoiding bringing dependent children to the workplace unless extreme circumstances dictate the necessity for doing so, and staff should have the prior approval of their immediate supervisor before bringing dependents/children to the workplace. If an employee does bring a child to work, they are to follow the guidelines below: 1. Children shall be contained in the staff members immediate office area and not allowed to roam freely about the agency. 2. Children should be kept as quiet as possible and not allowed to disturb employees or consumers in the immediate or adjoining areas. 3. Children should not be left unattended or unsupervised. 4. The amount of time children are to be at the agency should be limited to only what is necessary. 5. At no time will it be acceptable for children to interfere with or disrupt services being provided to our consumers. 6. At no time is it acceptable for an employee to bring a sick child to work with them. 7. Children of employees are not allowed to attend groups, group outings, individual sessions, etc, with or without the approval of the consumers receiving such services. The only time children of employees are permitted to attend such functions is when the function is a community and/or agency-sponsored event, i.e. Easter egg hunt, Christmas party, etc. Cell Phones Employees who are assigned company cell phones are expected to respond to calls in a timely manner. In addition, employees are required to maintain company cell phones so that they are always in good working order. Employees who are on-call are to keep their cell phones on at all times. Employees may not use an agencyissued cell phone to conduct business for others or themselves. The MONARCH policy regarding communication system usage also applies to cell phones. For example, employees may not use cell phones to make harassing calls. All harassing calls received by an employee are to be reported to the Human Resource Director immediately. Agency cell phones are for business purposes. It is recognized that some personal calls may occur, but employees are encouraged to keep these calls to a minimum. Personal cell phone conversations must be kept to a minimum and cannot interfere with the employees ability to perform the essential functions of their position. In addition, cell phones are not to be used for any illegal activities.
75
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Employees should report problems with company cell phones to the Executive Assistant. In addition, company cell phones are agency property and are to be turned in to the Executive Assistant upon termination of employment. Use of Blue Tooth, Ear Pieces, and/or Use of Cell Phone Speaker The use of blue tooth, ear pieces, and/or use of my cell phone speaker is strictly prohibited in the workplace. Employees are requested to leave such devices in their personal vehicle and/or at home. Solicitation Disruptions in the workplace can be caused by the unauthorized sale of tickets, solicitation of contributions, or the distribution of announcements. Therefore, such activities shall not normally be allowed. In some instances, the collection of money for presents, flowers, parties, donations, or for cases of particular hardship can be considered appropriate. In these exceptional cases, such collections may be permitted with the approval of the Human Resource Director. All such approved solicitation should be made during regularly scheduled rest and lunch periods. In an effort to make clear the circumstances under which an employee may engage in solicitation, MONARCH has adopted a formal policy on collection and solicitation. These rules are designed to permit such activity only at those times and in those areas, which are compatible with the efficient and orderly operation of MONARCH business. The following rules shall apply throughout MONARCH: 1. No employee or organization shall engage in any solicitation of other employees for any purpose whatsoever during working hours or in work areas. 2. An employee may engage in solicitation or organization of other employees if both the soliciting employee and the solicited employee are: (a) On an authorized or scheduled work break; or (b) Have completed or have not yet begun their normal work hours. 3. No solicitation or organization of employees by a non-employee may take place on the MONARCH premises at any time under any circumstances. 4. The collection of money for flowers, parties, donations, gifts and/or undue hardships may be allowed provided the collection is coordinated through the Human Resources Department and one individual is assigned responsibility for the collection. Distribution of Keys 1. Employees will safeguard, and be held responsible for keys assigned to them, will not make duplicates of any keys assigned, and will return them to the Human Resource Director upon termination of their employment. 2. Each staff member will be assigned a key to his/her office. 3. The Operations Coordinator will retain a master key to all offices. 4. Employees will receive other keys as deemed appropriate to their work area.
76
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 5. Only those employees designated by the Executive Director shall have a key to the entrance of the main facility. 6. The Operations Department will retain a list of keys assigned to employees and obtain signatures of staff as keys are distributed, maintaining documentation. Inclement Weather Due to the fact that MONARCH is a facility that is operated twenty four hours a day, essential employees must report for work regardless of the weather. An essential employee is defined as one who works on the 4:00 p.m. to 12:00 a.m. and 12:00 a.m. to 8:00 a.m. The 8:00 a.m. to 5:00 p.m. shift will require one supervisory employee, one R.S.A., and the on-call Clinical Counselor. In the event of bad weather conditions, employees may call the main office at 918-682-7210. The person answering the telephone will respond to employees calls, notifying employees that the main office will open at its usual time, at a later time, or that the main office will be closed for the day. If the agency is open, employees will be expected to report to work. However, each employee must observe weather conditions in his/her area and determine whether it is unduly hazardous to attempt to drive to work when weather conditions are severe. Employees are not expected to take an unreasonable risk attempting to drive to work. 1. Should the agency be closed due to extremely bad weather, all employees will be expected to take a Paid Time Off day. 2. Employees reporting to work will be paid for time worked. 3. Those employees who do not report to work will not be paid for the day unless the employee takes a PTO day. 4. Employees that do not have PTO will be expected to take Leave Without Pay. 5. If the agency is closed early during the day to permit employees to leave work early, employees will be paid for actual hours worked. 6. Employees are provided an option to remain at home during inclement weather, and MONARCH will not be responsible for any personal injuries or property damage should an employee attempt to arrive at work. Employees should use their best judgment in deciding whether it is reasonable for the employee to attempt to travel during inclement weather. Animals in the Workplace To protect the health and safety of employees, consumers and visitors, and to maintain a professional and clean environment in which to work and provide services, animals are not allowed in any buildings owned by MONARCH with a few exceptions. MONARCH recognizes the important role pets play in the lives of many employees and consumers. We also recognize that some employees and/or consumers may have concerns regarding health especially allergies as well as safety as it relates to animals in the workplace.
77
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES For reasons of liability, safety, health and sanitation, no animals of any type are allowed in any MONARCH owned buildings with the following exceptions: 1. Service animals as defined by the Americans with Disabilities Act of 1990, for use by employees, consumers, and/or visitors. MONARCH recognizes the ability of persons with documented disabilities to utilize service animals as defined by the Americans with Disabilities Act 1990 (ADA). Employees or consumers of MONARCH who require a service animal should consult with the Executive Director and/or Human Resource Director for accommodation. 2. Law Enforcement animals professionally trained for search and rescue activities.
78
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1026 - DISCIPLINE POLICY It is the policy of MONARCH that employees are required to conduct themselves in a manner that is courteous, cooperative, competent and professional and in a manner which reflects well upon the agency, its employees, and is supportive of agency consumers, potential consumers, and the community. Additionally, MONARCH and its employees are subject to ethical codes and governmental rules, regulations, and statutes and accrediting/funding agency rules and regulations. It is each employees responsibility to keep informed of these and MONARCHs responsibility to ensure appropriate compliance. PROCEDURE: This list of prohibited conduct is not intended to be all-inclusive. Demonstration of these behaviors or violation of MONARCH policy may result in disciplinary action up to and including termination of employment. The following conduct is prohibited and may subject the employee to disciplinary action up to and including termination of employment: 1. Insufficient, unsatisfactory work performance, or lack of application or effort on the job 2. Failure to correct unsatisfactory work performance, poor attitude, or misconduct within a reasonable time 3. Failure to attend any scheduled meeting and/or training without prior permission from supervisor 4. Obtaining employment on the basis of false or misleading statements 5. Discrimination including, but not limited to, racial slurs, sexual harassment, and national origin jokes 6. Not reporting to work on time 7. Excessive or improper use of leave 8. Excessive tardiness, which is defined as reporting to work more than ten (10) minutes after scheduled work shift, two (2) or more times in any given pay period. 9. Lack of good attendance and punctuality 10. Failure to notify supervisor when more than 30 minutes late 11. Failure to report to supervisor after being late or absent 12. Leaving ones job or regular working environment during working hours for any reason without authorization from ones supervisor, except for lunch 13. Leaving work before the end of a regular workday, or not being ready to work at the normal starting time 14. Dishonesty 15. Use of abusive, threatening, or obscene language 16. Interference with work of others
79
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 17. Excessive use of personal and/or company cell phones for personal use/business during working hours 18. Disrespectful actions and/or attitudes towards consumers, MONARCH employees, supervisors, and/or the public 19. Not meeting the physical or educational requirement for the position 20. Creating or contributing to unsanitary conditions, which includes, but is not limited to, body odor, unclean hair, wearing clothing that is stained and/or unclean, unclean office, throwing trash on floor, etc. 21. Not completing required paperwork within assigned deadlines 22. Having a communicable or infectious disease that puts others at risk of contracting said disease, provided that if the person is on leave due to an illness he/she will not be subject to discipline only for having a disease. This does not prevent the agency from discharging the employee for not being able to perform his/her job 23. Excessive use of agency property for personal use, including stationary, personal phone calls and visits during working hours 24. Transporting unauthorized passengers and/or cargo in agency vehicles 25. Neglect of or mishandling of agency equipment, supplies, and/or property 26. Smoking in and/or on any MONARCH owned property, in agency vehicles, or while on duty and in the community with consumers 27. Failure to satisfactorily meet agency audit requirements 28. Conviction of a felony that substantially relates to the circumstances of ones particular job 29. Any other act(s) detrimental to the interests of the agency, its employees, and/or individuals served. 30. Other misconduct defined as, but not limited to, an act or course of conduct evidencing willful disregard of standard behavior which the employer has the right to expect, or in carelessness or negligence of such degree or recurrence as to manifest equal culpability, wrongful intent or evil design, or shows intentional or substantial disregard of the employers interest Disciplinary Actions MONARCH has several types of discipline that may be used in appropriate situations. They range in severity from an oral warning to termination and may be oral, written, and/or recorded. Serious offenses may require immediate termination. Employees are subject to discipline for violation of any of the policies or procedures contained in this manual. The following types of disciplinary actions are available: 1. Oral warning 2. Written reprimand a. The supervisor and the employee will sign documentation of written warnings. This documentation will be kept in the employees personnel file. b. If an employee refuses to sign the supervision, when possible, the supervisor will have a witness sign that the information was reviewed with
80
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES the employee. If an appropriate witness is not available, the supervisor will document on the supervision that the employee refused to sign the supervision. All reprimands will include the date of the violation, plan for improvement, and information concerning further disciplinary action that could result from failure to demonstrate improvement. 3. Suspension with pay, and/or 4. Suspension without pay a. The Human Resource Director may suspend an employee for disciplinary and/or investigation purposes with or without pay. The employee who is suspended will be given notice of the reason(s) for the action. b. Employees can be suspended, with or without pay, for incidents that merit termination, if the employees participation is suspected or questioned, but unclear. c. Supervisor(s) will meet with returning suspended employee(s) and define clearly and specifically the improvements in job-related behaviors required as a condition of the employees continued employment. The meeting will be documented and submitted to the Human Resource Director. A copy of the supervision record(s) will be kept in the employees personnel file. 5. Disciplinary Probation a. An employee may be placed on Disciplinary Probation by the supervisor in order to allow the employee to demonstrate improvement on the problem(s) specified at the time of probation. The disciplinary probation period begins when the supervisor provides the employee with a written and signed document which: b. Identifies the problem(s) c. Indicates the necessary improvements d. Specifies length of probation period (not to excess six months), and e. Informs the employee of further disciplinary action which could result from failure to demonstrate satisfactory improvement within the specified probation period. 6. Termination Termination of employment occurs when other disciplinary action has failed to achieve improvement or when the employee commits a serious offense. Some offenses warrant immediate dismissal. These include, but are not limited to: a. Theft, including, but not limited to, the removal of company property or the property of another employee from company premises without prior authorization and/or without the intent to return the property b. The use, possession, sale, purchase, and/or distribution of alcoholic beverages or illicit drugs and/or the possession of drug paraphernalia on agency property during working hours or reporting for work while under the influence of these. Should an employee be suspected of substance abuse, the supervisor and/or Management may request the employee be tested for such use.
81
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES c. Reporting to work after having ingested alcohol, legal (prescribed) drugs, and/or illegal drugs, in a condition that adversely affects the employees ability to safely and effectively perform his/her job functions, or which could imperil the safety of consumers and/or other employees
d. Initiation or participation in a non-therapeutic, social and/or intimate, relationship with a current MONARCH client or with any individual who has been a client of MONARCH within the past two years. This includes social networking; i.e. Facebook, MySpace, etc.
e. Falsifying or altering company records, including Time Records, Medical Records, Expense Statements, etc. f. Fraudulently billing and/or recording services not rendered, or any other act of willful misrepresentation of services rendered g. Willful destruction or damage to MONARCH property, theft, or misuse of MONARCH or another employees property h. Walking off the job i. Sleeping on the job j. Gross neglect of duty k. Unexcused absence (i.e., no call, no show, not reporting to work scheduled shift) l. Sabotage and/or undermining the efforts of ones supervisor, the agency, and/or another employee m. Acts of insubordination and/or refusing to carry out the order of a supervisor and/or a Management Team member n. Physical assault, verbal threats, or verbal harassment of a fellow employee, consumer, or client o. Creating a hostile work environment p. Sexually harassing a co-worker, vendor, consumer, and/or the general public q. Absence for two consecutive working days without notice to the agency, which will be deemed a voluntarily resignation r. Working for another employer while on leave of absence without written consent of the agency s. Possession of firearms, fireworks, explosives, or any other potentially lethal weapons or devices in agency vehicle and/or facility t. Violation of general health, safety and/or security rules and/or endangering the general health and safety of ones self or others u. Breach of confidentiality, which could include information involving consumers and/or the agency. v. Attempting to influence a Board member to change agency policy for personal benefit w. Unauthorized and/or misuse of agency and/or consumer funds x. Participation in or solicitation of bribery or kickbacks relating to consumer and/or agency programs/funds
82
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES y. Displaying unbecoming behavior that brings serious discredit to the agency The above types of discipline are not necessarily progressive or in order of severity and do not have to be preceded by any other type. For example, termination for a severe violation may occur without any other disciplinary action first applied. Formal discipline of any type, except termination, shall not be used as part of the basis for further formal discipline after the expiration of one year from the date of the formal discipline. Prior to reviewing a Written Reprimand, issuing Leave Without Pay, placing an employee on Disciplinary Probation, etc., the incident, written reprimand, and/or documentation pertaining to the action must be in written form, reviewed, and approved by the Human Resource Director. The original reprimand and/or written action must be placed in the employee's personnel file.
83
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1027 PERSONNEL GRIEVANCE POLICY: It is the policy of MONARCH to encourage employees to resolve their grievances at as low a level as possible. Employees will be allowed to present their complaints and grievances in a formal, structured system that includes specific rights of appeal. All complaints and grievances will be resolved fairly and promptly. A grievance is defined as an employees expressed feeling of dissatisfaction concerning conditions of employment or treatment by management, supervisors or other employees. PROCEDURE: Employees are informed of the grievance process during Orientation. Staff is to assist employees in resolving grievance as soon as possible through open communication and conflict resolution. If an employee is not able to resolve the grievance, or feels that she/he is being treated unfairly, the employee shall be directed to follow the steps in the grievance process below: 1. If an employee feels she/he is being treated unfairly by or has a conflict with any staff, the employee should discuss the issue with the staff member involved. If the employee is not comfortable in approaching the staff member, the employee should discuss her/his concerns with her immediate supervisor who will assist the employee in resolving any issues. 2. Within three (3) working days following the incident/problem, the employee shall verbally present the problem to his/her supervisor and request the supervisors help in resolving the problem. 3. If the employee is not satisfied with the outcome, the employee will complete a written statement of her/his grievance on the Grievance Form and present her/his grievance in writing to Rita Oakley, Human Resource Director. The Human Resource Director will assist the employee in working out an acceptable solution to her/his grievance and/or will respond to the grievance in writing within five (5) working days after receiving notification of the grievance. 4. In the event that a satisfactory solution is not reached at this level or if the grievance pertains to the Human Resource Director, the employee may present her/his grievance in writing to Rachel Neighbors, Executive Director who will respond in writing within five (5) business days after receipt of the grievance. 5. There will be no adverse, biased or prejudicial treatment toward an employee during or following any grievance process. 6. The decision of Rachel Neighbors, the Executive Director shall be final. 7. In the instance where the Executive Director is the subject of the grievance, the decisionmaking authority shall be delegated to the Board of Directors.
84
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 8. No grievance, petition, or compliant should be filed in any court until all administrative remedies have been followed. No appeal of any grievance decision may contain new or additional claims, facts or allegations other than those stated in the original grievance. If any such claims, facts or allegations are contained in any appeal, they shall be disregarded. Employees are encouraged to use the grievance procedure, if needed, and will not be penalized for so doing unless the grievance is unsubstantiated and/or based on a personal bias. Any grievance based on a personal bias and/or issue will not be allowed to proceed through this process. In addition, employees filing frivolous and/or unwarranted grievances may be subject to disciplinary action. Decisions on grievances will not be precedent setting or binding on further grievances. Any employee involved in the grievance process (those filing the grievance and/or those filed against) shall have information and access to the grievance process throughout the grievance procedure. In addition, all employees will have the same appeal process. A failure to strictly adhere to this procedure may result in forfeiture of the grievance and appeals process (i.e., not following the chain of command, openly discussing the grievance with other employees members, etc.). The grievance procedure shall be posted on the Employee Bulletin Board at each location.
85
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1028 - Employee Assistance Program (EAP) MONARCH has established a short-term Employee Assistance Program (hereinafter referred to as EAP) with a local provider to provide professional assistance for any type of personal problem. The program is designed to encourage employee awareness of such problems and to offer assistance at the earliest opportunity. Employees are responsible for their performance and for taking constructive action to resolve any personal problem that affects or threatens to affect their on-the-job behavior. The EAP provides a confidential, professional resource for assistance in resolving personal problems. Employees are encouraged to seek assistance through the EAP on their own, before performance has been negatively affected. Procedure: Employees who work more than twenty hours per week are eligible to participate in the EAP. MONARCH encourages employees with personal problems to take advantage of the professional services provided through the EAP. The Human Resource Director is available to answer any questions about the EAP and the scope of available services. Use of the EAP can be voluntary or involuntary. For voluntary utilization of the EAP program, employees are responsible for seeking admittance to the EAP. Supervisors are responsible for offering assistance through the EAP to employees who have personal problems which affect their work performance. For involuntary utilization of the EAP program, instances where the employee is offered use of the EAP and refuses the offer, the supervisor may make participating in the EAP program a condition of continued employment. An employee's decision to seek assistance through the EAP will not adversely affect the employee's job security or advancement opportunities. Also, participation in the EAP does not relieve an employee of the responsibility of meeting acceptable work performance and attendance standards. 1. Time off will be provided to eligible employees, consistent with the current Paid Time Off (PTO) policy. 2. Benefits for treatment expenses (i.e. counseling and Medication Clinic) will be provided for eligible employees consistent with applicable group health insurance coverage. 3. Employees may receive up to four counseling sessions. Any additional services will be the responsibility of the employee and is not considered part of the EAP agreement. 4. Upon discharge from employment, (i.e. resignation, termination, etc.), an employee receiving EAP services will be referred to an outside provider.
86
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Referral Guidelines: Employees may obtain professional assistance through the EAP in one of the following ways: 1. Self-referral: An employee who desires confidential assistance for a personal problem should call 918 682-7210 and ask to speak to the Human Resource Director. 2. Supervisor's Recommendation: When an employee brings a personal problem to the attention of his/her supervisor, the supervisor should encourage an employee to use the EAP, explain to an employee how the EAP works, and offer assistance in making the first appointment. 3. Supervisor's Referral: Any supervisor who is in doubt about the appropriateness of making an EAP referral should contact the Human Resources Director for consultation. The following are some of the situations in which a supervisor should make a referral to the EAP: 1. A request from an employee for assistance with a personal problem; 2. A decline in work performance on the part of an employee; or, 3. An on-the-job incident or an observation by a supervisor which indicates the possible presence of a personal problem for an employee. Incidents of willful misconduct which require other immediate disciplinary action are not appropriate for supervisory referral to the EAP. When a supervisory referral is appropriate, a supervisor should review the EAP policy with an employee and advise him/her of the availability of confidential professional assistance for any personal problem. Although the final decision to use the program must be an employee's decision, a supervisor should emphasize the importance of the EAP. A supervisor may arrange the first meeting between an employee and the Human Resource Director.
87
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1029 - HEALTH AND SAFETY POLICY MONARCH is committed to maintaining an environment that is an accessible, healthy, clean, and safe environment in all facilities it controls through both external and internal safety reviews and detailed health and safety procedures in the event of emergency situations. All policies and procedures regarding health and safety conform to all legal, regulatory and accreditation health and safety requirements. PROCEDURE In an effort to maintain an accessible, healthy, clean and safe environment in all facilities controlled by MONARCH, designated employees will maintain constant attention to safety practices, reduction of health and safety risks and an overall concern for the health and safety of the consumers and employees. The Safety Officer will be responsible for planning, implementing and overseeing a comprehensive organizational wide health and safety program. She/he serves to develop, oversee and monitor the organizations health and safety policies and procedures and ensures that all regulatory requirements are carried out within the day-to-day operations of the organization. Procedures will focus on the identification, monitoring, evaluation, reduction and/or elimination of risks as well as planning and preparation to maximize the health and well beginning of individuals in the event of disasters or emergency situation. The Safety Officer will provide on-going reports to Management, serve as the organizational health and safety point-of-contact regarding regulatory or third party inquires, issues and/or inspections, and provide leadership in maintaining a strong and dynamic health and safety environment within all areas of the organization. The Safety Officer reports directly to the Executive Director and will communicate all information related to health and safety practices, concerns and/or issues in a manner that ensures the health and safety of all consumers, employees and other stakeholders is upheld to the highest degree. The Safety Officer and/or designee is charged to provide guidance in the following areas: Policy and procedure development, implementation and monitoring Orientation, education and training for employees in health and safety issues Incident reporting and use of information Infection control Facility safety monitoring, correction and improvement Accessibility for persons with disabilities Vehicle safety Medical and emergency procedures Food preparation and storage Emergency preparedness drills and documentation Emergency response and documentation
88
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Inspections A comprehensive inspection by a qualified external authority will be conducted annually at all MONARCH controlled facilities. The written report from the inspector will include: Identification of each area inspected Recommendations for area needing improvement Actions that need to be taken to respond to the recommendations A self-inspection will be conducted at least twice each year at all facilities controlled by MONARCH and will be completed by designated employees. A written report will identify: What areas are inspected Recommendations for areas in need of improvement Areas requiring improvement. Emergency Procedures MONARCH will have written emergency procedures for each location under the control of the organization that address: Fire Bomb Threats Natural Disasters Utility Failures Earthquakes Medical emergencies Safety during violent or other threatening situations These procedures will be provided to every employee during orientation and to every person served upon admissions to the program. These procedures will also be located in the Medication Station, on each floor/wing of residential areas, main reception area and other offices deemed appropriate for instant access in the event of an emergency. In addition, all MONARCH employees will be CPR/First Aid Certified and will keep certification current. First aid kits are located in the Medication Station, the main reception areas, the kitchen area, all vehicles, and at other designated areas. Designated employees will assure that items in the kits are adequately stocked and not expired. Tests/Drills Emergency procedures will be tested at least once a year on each shift and in all facilities where MONARCH provides administration and/or delivers services on a regular basis. The test/drill may include actual or simulated physical evacuations. The alarm company and/or local fire department must be notified prior to a planned test with the date and time of a fire drill. Each test of emergency procedures will be
89
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES documented on appropriate forms and the information will be analyzed for performance improvement and will result in improvement of or affirm satisfactory current practices. Training/Education All employees are expected to perform their jobs in a safe and healthy manner. Employees are primarily responsible for their own health and safety as well as for the health and safety of persons in their care. This responsibility includes: Proper hand washing Proper storage and use of chemicals Control of body fluids/blood borne pathogens Emergency evacuation procedures Use of protective gear Managing behavior to prevent violence and reacting to the potential for violence with appropriate interventions. All employees are responsible for immediately correcting conditions or practices that are unsafe or unhealthy. Unsafe or unhealthy practices and/or conditions must be reported immediately to Management. Employees are required to promptly report any accident, injury or incident. Any condition or practices which cannot be corrected by an employee should be reported in accordance with the organizations incident reporting procedures. All employees will be provided training during orientation and then annually regarding: Health and safety practices Identification of unsafe environmental factors Emergency procedures Evacuation procedures Identification of critical incidents Medication management, if appropriate All general training for all employees will address: Individual roles and responsibilities Information about threats, hazards and protective actions Notification, warning and communication procedures Means for locating family members in an emergency Emergency response procedures Evacuation, shelter and accountability procedures Emergency Shutdown Procedures An employee, who is certified, will provide CPR and First Aid training. If this individual is unavailable and no one else on staff is eligible to provide the training, MONARCH will contact other agencies for referrals to possible instructors. The Recovery Support
90
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Specialist ll or designee will provide training in areas of health and safety such as but not limited to: Universal Precautions Blood-borne Pathogens Medication Management, if applicable The Quality Assurance Coordinator will provide training in the areas of: Critical Incidents/Identification Reporting requirements for emergencies When necessary, MONARCH will access the local Emergency Medical Services, Muskogee Fire Department and Muskogee Police Department for training in areas such as response to fire, natural disasters, threats of violence, etc.
91
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1030 - EMERGENCY/CATASTROPHIC PREPAREDNESS PLAN POLICY: MONARCH will assure the orderly evacuation of employees and consumers in the event of an emergency and/or catastrophic event and will provide shelter to those in the building during the threat of tornado and/or severe weather. PROCEDURE: A Safety Officer, with the assistance of a Safety Coordinator, will oversee and document compliance with an emergency/catastrophic preparedness program, and ensure that the facility and grounds provide a safe environment for consumers, employees, and visitors. All facilities owned, leased and/or operated by MONARCH will be inspected on an annual basis by designated fire and/or safety officials in order to insure safe operations at each location. It is the responsibility of the Safety Officer to post diagrams noting emergency evacuation routes in case of fire and shelter locations in case of severe weather. In-service training is held annually by the Safety Officer or designee to update and remind employees of the preparedness program, evacuation routes, and policies. Diagrams noting emergency routes to be used in case of fire and severe weather are posted in each building of the main facility and in all other facilities operated by the agency. The Safety Officer and/or designee will also be responsible for educating employees on the exact location, contents, and use of first-aid supply kits and fire-fighting equipment. Operations personnel will properly maintain fire-fighting equipment in each building, and the RSA ll will properly maintain each first-aid kit. The Safety Officer will appoint building monitors who will ensure that the safety plan is followed in their building. In the event of an emergency, building monitors will make sure all areas of their assigned buildings are evacuated, when necessary, and will notify employees and consumers of severe weather or any other procedures employees and consumers should follow. The principal danger to occupants will result from panic and the spread of smoke and fumes. The Safety Committee will meet at least quarterly to discuss procedures which will include reports pertaining to the safe evacuation in case of fire, bomb threat, hostage or sniper situations, power failure, and/or workplace violence/threat situations. Designated shelter locations will also be reviewed in case of severe weather. Building monitors will be trained to: 1. Participate in the annual in-service training if needed 2. Participate in all emergency drills 3. Know location, contents, and the use of first-aid equipment 4. Notify their back up of any planned leave
92
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES At least once per quarter, different portions of the emergency plans will be tested at all locations where services are provided. Facilities with multiple shifts will have emergency evacuation conducted and recorded annually on each shift. An adequate number of fire extinguishers are located throughout the facilities, are clearly identified, and are included on a regular maintenance program. A record of maintenance shall be maintained by the Operations Department. Instruction for use of equipment is included in annual in-service training. In all types of emergencies, employees should remain calm. In the event of fire, the following procedures will be followed: 1. Fire alarms within each building have visual signals (lights) for the deaf and hearing impaired. 2. If fire or smoke is seen, alert the Receptionist, who will alert consumers and employees of the fire. The Receptionist will then alert the Fire Department. 3. Feel doors for heat before opening, and then open the door carefully. 4. Upon hearing the alarm, employees will assist consumers to the nearest ground floor exit and exit the building. 5. Broadway employees and consumers will meet on the west end of the St. Paul Methodist Churchs parking lot. 6. Fredonia employees and consumers will meet on the sidewalk across the street in front of the Fredonia building and will await further instructions. 7. The Safety Officer/Clinical Supervisor and/or designee will bring the consumer list and complete a roll call. In the event of severe weather or tornado warning, the following procedures will be followed: 1. The Safety Officer or designated person will be responsible for monitoring severe weather/tornado reports. If a severe weather/tornado warning is issued, the Safety Officer/Clinical Supervisor and/or designee will alert consumers and employees of the warning. 2. Employees and consumers will proceed to the designated shelter areas clearly marked on diagrams posted in each building. 3. Building monitors will check all rooms in their buildings for employees and/or consumers unaware of the warning. 4. The Safety Officer/Clinical Supervisor and/or designee will bring the consumer list and complete a roll call. 5. Employees/consumers will stay in the designated shelter until the Safety Officer/Clinical Supervisor and/or designee determines and communicates to employees that threatening weather has left the area.
93
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES In case of bomb threat and/or explosion, the following procedures will be followed: 1. The Receptionist will notify 911, the Executive Director, and the Safety Officer/Clinical Supervisor and/or designee. 2. The Receptionist will then announce over the intercom, May I have your attention, please? I need all employees and consumers to evacuate the building immediately. 3. Upon hearing this announcement, employees will assist consumers to the nearest ground floor exit and exit the building. 4. Broadway employees and consumers will meet on the west end of the St. Paul Methodist Churchs parking lot. 5. Fredonia employees and consumers will meet in the parking lot of the Divine Love Church. 6. If an explosion has already occurred the following procedures will be followed: 7. Be prepared for possible additional explosions and crawl under a table or desk. 8. Stay away from windows, mirrors, overhead fixtures, filing cabinets, bookcases, and electrical equipment and watch for falling objects. 9. Do not move seriously injured persons unless they are in obvious immediate danger of fire, building collapse, etc. 10. Feel doors for heat before opening, the open door carefully. Do not use matches or lighters. 11. If upstairs, proceed downstairs with extreme caution. 12. If requested, accompany individuals with disabilities. 13. Limit use of telephone calls to emergency services. 14. Evacuate the building if the fire alarm sounds. 15. The Safety Officer/Clinical Supervisor and/or designee will bring the consumer list and complete a roll call. In the event an employee is placed in a dangerous/unsafe position, hostage and/or sniper situation, and/or threatened with workplace violence, the following procedures will be followed: 1. A distress code will be used to notify others where and when an employee needs protection or assistance from others. This type of assistance may be simply another employee standing near or checking into the room where the volatile situation is present. 2. The employee in danger will call the Receptionist or call over the intercom and say: Fred, hold calls in _______s (your name) office. 3. This message will be relayed to other employees available to go to the employee making the in need of help call. 4. If needed, the Receptionist will call 911, the Executive Director, and the Safety Officer/Clinical Supervisor and/or designee. 5. The area or building where the violent/threatening and/or hostage/sniper situation is located should be secured by the Building Monitors to prevent others from harm or danger.
94
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 6. If necessary, the Safety Officer/Clinical Supervisor and/or designee will initiate the evacuation of the building. 7. Employees will await further instructions from the Safety Officer/Clinical Supervisor and/or designee. 8. MONARCH does not utilize seclusion and/or restraint, nor does MONARCH utilize any emergency intervention as defined per CARF. Therefore if any MONARCH employee feels that a consumer will be a threat to herself or others, law enforcement will be contacted. In the event there is Imminent Threats of Violence in the area (neighborhood), the following procedure will be followed: 1. If information is received on potential threat in vicinity of agency, the Safety Officer/Clinical Supervisor and/or other authorized person makes decision to lock down agency. 2. The Safety Officer/Clinical Supervisor and/or designee will communicate Lockdown Status by announcing, MAY I HAVE YOUR ATTENTION. AT THIS TIME, I NEED FOR YOU TO TAKE SHELTER IN YOUR BUILDING. DO NOT LEAVE YOUR BUILDING UNLESS OTHERWISE NOTIFIED. IF POSSIBLE, SECURE YOUR BUILDING. THIS IS NOT A DRILL (repeat) 3. The Safety Officer/Clinical Supervisor and/or designee will assess the need for police or other assistance and assign responsibilities to others. If needed 911 will be called and assistance requested. 4. All outside doors will be locked if possible. Entry will be restricted to known persons, movement of employees/consumers between buildings will not be allowed, and consumers will be brought in from outside areas if safe to do so. 5. Contact each building for report once assigned building is secured 6. BROADWAY 7. A building meets in the downstairs A hallway 8. B building meets in the downstairs B hallway 9. C building (Sanctuary) goes to play area 10. D building meets in D building hallway 11. FREDONIA Meets in the Counselors hallway 12. Give ALL CLEAR signal when the safety of the agency has been assured. 13. Assess the need for aftercare, counseling, or Critical Incident Stress Debriefing. Allow consumers time for physical activity or verbal stress relief. In the event of power failure, the following procedures will be followed: 1. The Safety Officer/Clinical Supervisor and/or designee will assess the situation (i.e., reason for power failure, length of time power is expected to be unavailable, etc.). 2. Employees and consumers at both facilities will gather in the dining room. 3. The Safety Officer/Clinical Supervisor and/or designee will bring the consumer list and complete a roll call.
95
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 4. If power is expected to return in a short period of time, consumers and employees will be notified of this time frame. 5. If power is not expected to resume within a reasonable amount of time (more than two hours), staff on duty will contact the Executive Director, Safety Officer and/or Coordinator for further instructions. Employees and consumers will be notified of anticipated time for power to resume and generators will be utilized if necessary. 6. At no time will an employee remain in a dark room with a consumer. In the event of an earthquake, the following procedures will be followed: 1. Upon the first indication of an earthquake, staff will use the PA system and direct consumers and other staff to DROP, COVER, and HOLD. 2. DROP to the ground; take COVER by getting under a sturdy table or other piece of furniture; and HOLD ON until the shaking stops. If there isnt a table or desk near you, cover your face and head with your arms and crouch in an inside corner of the building. 3. Stay away from glass, windows, outside doors and walls, and anything that could fall, such as lighting fixtures or furniture. 4. Stay in bed if you are there when the earthquake strikes. Hold on and protect your head with a pillow, unless you are under a heavy light fixture that could fall. In that case, move to the nearest safe place. 5. Do not use a doorway except if you know it is a strongly supported, loadbearing doorway and it is close to you. Many inside doorways are lightly constructed and do not offer protection. 6. Stay inside until the shaking stops and it is safe to go outside. Do not exit a building during the shaking. Research has shown that most injuries occur when people inside buildings attempt to move to a different location inside the building or try to leave. 7. When the shaking stops, instruct consumers to evacuate their buildings and proceed to the A building downstairs hallway. 8. The Safety Officer/Clinical Supervisor and/or designee will bring the consumer list and complete a roll call. 9. The Safety Officer/Clinical Supervisor and/or designee will check for injuries and provide appropriate first aid. 10. The Safety Officer/Clinical Supervisor and/or designee will determine if additional actions are deemed necessary. In the event of a medical emergency at a MONARCH facility, the following procedure(s) will be followed: 1. The first employee to arrive on the scene of a medical emergency will be responsible for implementing the following medical emergency procedures. 2. Employees trained in CPR or First Aid will take appropriate action, as per training. The employee in charge will enlist assistance from others and delegate responsibilities whenever possible.
96
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 3. Notify the Receptionist. Inform the Receptionist that there is a medical emergency; give the location, and action taken. If deemed necessary, request an ambulance at this time. 4. Call 911 for emergency medical assistance, if needed. 5. Request additional assistance as needed. 6. All MONARCH employees involved in the incident will be responsible for completing a Critical Incident Report, to include a description of the incident, actions taken by employees (including CPR or First Aid rendered and/or medical treatment offered), and names of witnesses. The original must be turned in to the Clinical Supervisor no later than 4:00 p.m. the same day. If an incident occurs after office hours, or on a weekend or holiday, the Critical Incident Report must be turned in within the first two (2) hours of the next day the agency is open for business. 7. Direct care staff supervising the activity, as per CPR and/or First Aid training, will handle medical emergencies occurring during activities away from agency offices. 8. Medical emergencies occurring outside of regular office hours will be handled in accordance with CPR and/or First Aid training. The Clinical Supervisor will be notified immediately. In the event of a disaster or catastrophic circumstance, or in the event that a MONARCH facility is destroyed, or damaged as to disrupt normal services, the following procedures will be followed: 1. Consumers housed at the Broadway site will be temporarily housed at the St. Paul Methodist Church. 2. Consumers housed at the Fredonia site will be temporarily housed at the Broadway site. 3. Data Processing employees will report to designated data entry location to be determined by the Executive Director or designated employee at time of disaster. 4. Full data access and data entry services will resume in accordance with the Disaster Recovery Plan. 5. Employees and consumer records are saved to an external hard drive every month to facilitate immediate communication as to status of disaster recovery and alternate service locations. 6. In the event of a disaster or catastrophic circumstances, the Executive Director, or his designee, is responsible for immediately contacting the Safety Officer/Clinical Supervisor and/or designee. 7. The Safety Officer/Clinical Supervisor and/or designee will then contact the local American Red Cross at 918-682-1366 to activate the agency plan. 8. The Safety Committee will report to the base of operations site, which will be the MONARCH Halfway facility. In case of power failure, no phone lines, etc, Safety Committee will always report to the Halfway facility. If this site is destroyed, the base of operations will be at the Fredonia site.
97
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 9. A current list of each employee assigned to the Safety Committee is located in the Receptionists office and Human Resource office. Each member of the Safety Committee will be provided a list. 10. In the event of a disaster, the Executive Director will contact the local radio and television stations to announce the emergency services available. Announcements of alternative service locations will be submitted to the local newspapers for publication, as well as to local law enforcement agencies. 11. All other employees not assigned to the Safety Committee, both clinical and administrative, will report to the Halfway facility and work at that site. Medical Records personnel will immediately report to the Medical Records department at the unaffected site and secure client records. The Human Resource Director, or designee, will immediately report to the Human Resource Department at the Halfway facility and secure personnel records.
98
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1031 -TRANSPORTATION SERVICES FOR PERSONS SERVED BY THE ORGANIZATION
POLICY MONARCH will provide safe, legal transportation to consumers. PROCEDURE 1. Transportation services provided by MONARCH will be in compliance with all applicable federal, state, provincial, county and city requirements. 2. All vehicles will be in good repair including lights, window wipers, etc. with seatbelts for the number of passengers to be transported. 3. All employees who drive a MONARCH vehicle will be have a valid Oklahoma drivers license, which is verified by Human Resources upon hire. 4. All employees driving records are subject to review by the organization upon hire and at anytime Administration feels necessary (i.e. after an accident in company vehicle, after report of accident by an employee in local newspaper, etc.) to verify continued eligibility to drive a company vehicle and/or to travel or transport consumers in a private vehicle. 5. Texting is not allowed while driving a MONARCH vehicle and/or transporting consumers in personal vehicle. 6. Use of cell phones should be kept to a minimum. 7. All MONARCH vehicles and personal vehicles used for travel or for transportation of consumers will be insured according to local requirements and will provide coverage to any eligible driver and passengers. 8. Seatbelts will be worn at all times and by all passengers in MONARCH vehicles and/or when transporting consumers. 9. All children riding in a MONARCH vehicle or in an alternate vehicle will be restrained in appropriate safety seats at all times. 10.Each MONARCH vehicle is equipped with a first aid kit, fire extinguisher, flashlight, emergency warning cones, jack, spare tire and equipment to change it. 11.Should a consumer require accommodations related to transportation i.e. wheelchair lift, MONARCH will assist the person served in securing appropriate transportation from community providers such as Volunteers of America who already have adaptive aids in its vehicle(s). 12.All employees who will be providing transportation services to consumers will be trained regarding transportation requirements. 13.Each vehicle will have Emergency Procedures that give specific instructions in the event of an emergency. 14.All MONARCH vehicles will be maintained according to the manufacturers recommendations and recorded in a Maintenance Log which is kept in the Operations Department. 15.No smoking, eating, and/or drinking in MONARCH vehicles or while transporting consumers in personal vehicle. 16.All employees providing transportation services to consumers are responsible for ensuring that all consumers and/or children are safely out of the vehicle and accounted for prior to locking and/or leaving the vehicle.
99
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1032 - Facility Environment, Visitation, Personal Property, and Building Security POLICY: The Americans with Disabilities Act of 1990 mandates, among other things, accessibility to services, goods, facilities, privileges, advantages, and accommodations for individuals with disabilities in the United States. It is the intention of MONARCH to comply with the Americans with Disabilities Act in the provision of an accessible facility and safe environment for consumers, employees, and the community. PROCEDURE: MONARCH meets accreditation, inspection, safety, and building code regulations required by local, state and federal authorities and laws. In addition, MONARCH has been designed to allow employees, consumers and the community easy and safe access to treatment areas, which include: 1. The facilitation of travel by providing walkways and curbs accessible to individuals using wheelchairs; 2. Accessible fountains, toilets, and hand washing facilities for handicapped individuals; 3. Parking spaces set aside and identified specifically for handicapped individuals; and 4. Facility grounds maintained in a manner to provide a safe environment for employees, consumers, and visitors. Employees are responsible for maintaining their work areas in a clean and orderly fashion. To fulfill this responsibility, each employee should, at a minimum, do the following: 1. Place coats, umbrellas, and other items of clothing in areas so that work stations are not unnecessarily cluttered; 2. Consume food or beverages in areas away from computer, keyboards, etc, in order to minimize damage to these items; and 3. Prior to the end of the workday, straighten work areas and secure any items, papers, or information of a confidential nature. Supervisors are responsible for ensuring their employees maintain their work areas according to the requirements of this policy. Each supervisor should: Make sure that floors and walls are free of debris and other unnecessary items; Monitor their work areas and equipment and request maintenance where appropriate; Arrange for the removal of any items from the work place that are not needed for the operation of the business or the enhancement of employee comfort; and Immediately report to the Operations Coordinator any existing or potential workplace hazards and safety violations. MONARCH will attempt to maintain the temperature, lighting, and noise level of its facilities at a level that is comfortable for employees yet appropriate for the nature of
100
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES its operations. Employees should inform their supervisors of any concerns about working conditions. Facility Visitation for Professional or Educational Reasons Facility visitations for professional and educational reasons must be approved by the Executive Director, Clinical Supervisor, or Director of Human Resources. Visitation may be considered if the following four conditions are met: 1. Every effort will be made to maintain the protection of the clients rights and privacy during facility visitation; 2. Group visits will be permitted only when the purpose of the visitation is educational or professional; 3. Visits must provide limited interruption of the routine therapeutic or rehabilitative programs and activities; and 4. Consumers shall have advanced knowledge of such visitations and will not be referred to or identified by name. Personal Property Employees are allowed to bring personal items on the premises in order to decorate their workspace as long as the items are not offensive or do not create clutter. MONARCH specifically prohibits any items that are sexually suggestive, offensive, or demeaning to protected individuals or groups. MONARCH also prohibits firearms and other weapons on the premises. Employees are expected to respect and safeguard the property of consumers, visitors, coworkers, and MONARCH. MONARCH reserves the right to limit personal items brought onto/into the premises. In addition, employees, their possessions, and any containers or equipment under their control are subject to search and/or surveillance at all times while on the companys premises or while conducting facility business. MONARCH reserves the right to question employees and anyone entering and/or leaving our facility and to inspect any possessions or articles carried to and from this premises in order to: Safeguard the property of the agency, employees, and the consumers we serve, and Help prevent the possession, sale and/or use of illegal drugs on the premises. In addition, MONARCH reserves the right to search any employees members desk, office, file or any other areas or article on the premises. Searches may be conducted at any time at the discretion of MONARCH. MONARCH recognizes that employees may need to bring certain personal items to work. However, personal property that is not related to the employees job performance may be disruptive to the flow of work or may pose a safety risk to other employees. Employees are expected to exercise reasonable care to safeguard personal items brought to work. Personal property brought onto MONARCH premises is done at the
101
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES risk of the owner and MONARCH accepts no responsibility for lost, damaged, or stolen employee property, and employees are advised not to carry unnecessary amounts of cash or other valuables with them when they come to work. MONARCH may assign desks or file cabinets to employees for the safekeeping of small personal effects during working hours. Employees are responsible for maintaining their desks and/or file cabinets in a clean manner. In addition, MONARCH may supply employees with keys to these desks or file cabinets and will retain a passkey to desks, file cabinets, and workstations. Employees may not place their own locks on any storage facility. To maintain security and protect against theft, MONARCH reserves the right to inspect all personal property brought on the companys property, including, but not limited to, vehicles, packages, briefcases, back packs, purses, bags, and wallets. In addition, the company may inspect the contents of storage areas, file cabinets, desks, and work stations at any time and remove company property and other items which are in violation of company policies and procedures. Articles of personal property found on the premises should be returned to the owner, if known, or turned in to the Operations Coordinator. Inquiries regarding lost property should be directed to the Operations Coordinator. Security MONARCH places a strong emphasis on reporting security-related incidents so that proper action can be taken. Internal Incident/Accident reports should be prepared by employees and submitted to a member of Management immediately after a securityrelated incident has occurred or has been discovered. The report should cover any and all information relating to who, what, when, where, why, how, and aspects of the incident. If time is a critical factor, the report should be made first over the telephone and later confirmed in writing. The following types of incidents must be reported: 1. Criminal acts on company property, including possession, sale, and/or use or narcotics and/or illegal drugs; 2. Bomb threats via telephone, mail, etc, or actual bomb incidents; 3. Theft or misappropriation of company assets; 4. Loss, theft, and/or suspected theft of proprietary information; 5. Personal use of company facilities; 6. Breach of Conflict of Interest policy; 7. Damage to MONARCH property and/or an employees personal property while on MONARCH premises involving actual or suspected mischief, vandalism, and/or criminal negligence; 8. Natural and/or man-made disasters; 9. Attempts by persons to misrepresent themselves as employees or agents of MONARCH; 10. Actual or suspected subversive activity;
102
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 11. Any illegal action proposed by a purchasing agent, contract representative, and/or employee thereof; 12. Any breech of computer security; 13. Any breech of the MONARCHs contraband policy; and 14. Any intoxication. Any employee who violates security rules is subject to disciplinary action up to and including termination of employment. To ensure that employees, visitors, and the agency property are secure, the following procedures will be followed: 1. It is the responsibility of the Human Resource Director to conduct a background check on all potential employees of MONARCH. This check includes both professional and personal references. In addition, an Oklahoma State Bureau of Investigation (OSBI) criminal background check is requested for all employment positions. 2. MONARCH has made every effort to safeguard and secure all electronic equipment and communications, confidential files and/or information, and the release of sensitive information. 3. Theft and/or vandalism occurring on MONARCH premises or involving MONARCH property will be investigated. Law enforcement officials may be requested to help conduct this investigation. 4. MONARCH property and/or equipment may not be removed from the premises without written authorization. Employees requesting to take MONARCH property and/or equipment off premises must have their supervisors written approval and authorization from the Executive Director. 5. Employees may be subjected to search, surveillance, and/or interrogation whenever MONARCH feels such action must be taken to maintain security. This includes, but is not limited to, inspections of all personal property brought on the MONARCHs premises, such as vehicles, briefcases, backpacks, purses, bags, and wallets. In addition, MONARCH may inspect the contents of storage areas, file cabinets, desks, and work stations at any time and may remove all MONARCH property and other items which are in violation of policy and procedures. 6. Employees may be asked to take a polygraph examination when MONARCH is investigating economic losses such as those resulting from theft, embezzlement, sabotage, or similar economic injury. No disciplinary action will be taken against any employee solely on the basis of the results of a polygraph examination or for refusal to take a polygraph examination. 7. Employees who have not been issued a key to the main facility may request special permission to work after hours and/or on weekends. Such employees must have authorization from their immediate supervisor. 8. Employees are expected to exercise reasonable care for their own protection and for that of their personal property while on MONARCH premises and while away from the premises on business. MONARCH assumes no responsibility for loss, damage, or theft of personal property.
103
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1033 - INFECTION PREVENTION AND CONTROL POLICY MONARCH will provide training and information to employees and consumers in order to promote an effective Infection Prevention and Control Plan. PROCEDURE "Universal precautions," as defined by the CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), Hepatitis B virus (HBV), and other blood-borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all employees, consumers, and/or the public are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Universal precautions apply to blood, other body fluids containing visible blood, semen, and vaginal secretions. Universal precautions also apply to tissue and to the following fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomit unless they contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable. Universal precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the employees skin or mucous membranes to potentially infective materials. In addition, under universal precautions, it is recommended that all employees take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. Hand washing is the number one method of infection control. Hands should be washed: Before and after potential exposure to blood borne pathogens When gloves are removed After touching face or wiping nose After coughing or sneezing After using the restroom Procedures for proper hand washing will be posted in the restrooms and at other areas where consumers and/or employees may wash his/her hands. Gloves are to be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all consumers if performing vascular access (medication injection) procedures. Gloves are for single use only. Gloves will be available at each work site for use by employees. Hands are to be immediately washed after the gloves are removed.
104
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES Safety goggles will be provided for any employee who anticipates a risk of splashes, spray, spatter, or droplets of potentially infectious materials. Warning labels shall be affixed to containers and refrigerators that contain regulated waste, or samples of potentially infectious materials. Labels will clearly indicate a biohazard. Red bags or containers may be used in place of a label. Employees will decontaminate working surfaces and equipment with an appropriate disinfectant (one part bleach to ten parts water) after potential exposure to blood. Employees will clean any surface that becomes contaminated, after any spill of blood or other potentially infectious materials, and at the end of each work shift if contamination might have occurred. If surfaces or equipment are draped with protective coverings such as plastic wrap or aluminum foil, these coverings should be removed or replaced if they become potentially contaminated. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in all work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials. Food and drink will not be kept in refrigerators, freezers, shelves, cabinets, or counter-tops where blood or other potentially infectious materials are present. All employees will be provided training regarding the use of universal precautions during Orientation and annually. Training can occur in group workshops and through handout materials. Education for consumers regarding the prevention and control of infection or communicable diseases will occur upon admission. In addition, consumers will be provided with training based on individual needs such as risk-taking behaviors, drug use, and long-term involvement in services or greater potential risk of exposure. The additional training can occur in group and individual sessions and through written materials.
105
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1034 - SAFE HANDLING, STORAGE AND DISPOSAL OF HAZARDOUS MATERIALS POLICY MONARCH will adhere to the regulations set forth by OSHA (Occupational Safety and Health Administration) to assure a safe environment for consumers and employees that include the safe handling, storage and disposal of hazardous materials and the storage and administration of medications for consumers. PROCEDURE To ensure the safe handling, storage and disposal of hazardous materials, MONARCH will have copies of this policy available to consumers and employees. A copy will be located in the Medication Station, in main reception areas, in kitchen area and other appropriate places. The following are examples of applications of OSHA standard to MONARCH: 1. Spills: All body fluid spills (regurgitation, diarrhea, urination, bleeding, sputum, etc.) will be cleaned promptly and the contaminated area disinfected. The area will be cleaned with a fresh solution of one (1) part bleach to ten (10) parts water. 2. Waste Disposal: All items that contain liquid or semi-liquid blood or other bodily fluids, or items that would release blood or other infectious material if compressed (cleaning rags, tissues, dressings, gloves, gowns, masks, etc.) are to be discarded in labeled biohazard red bags. These bags are to be closed to prevent spillage or protrusion of contents during handling, storage, transport or shipping. In some instances, double bagging may be necessary. These bags will be coded with the regulated waste insignia and taken to a local hospital for appropriate disposal or removed from the premises by a contract waste disposal provider. 3. Sharps: All employees shall take precautions to prevent injuries by needles and other sharp instruments or devices during procedures that are likely to generate droplets of blood or other body fluids and prevent exposure to mucous membranes of the mouth, nose, and eyes. Broken glass is to be picked up using mechanical means such as a brush and dustpan or other devices that reduce the risk of accidental puncturing of the skin during the clean-up process. To prevent needle stick injuries, needles will not be recapped, purposely bent, or removed from disposable syringes. Needles should be placed in puncture resistant containers for disposal. 4. Collecting and Processing: If urine is collected for urine drug screens, it will be collected in a special plastic wide-mouth bottle. The consumer will be given the bottle, which has been labeled prior to the collection. The consumer is asked to void into the bottle and place the leak-proof lit tightly on the bottle. The consumer then gives the bottle to the employee witnessing the collection. The employee will then test the specimen for substances.
106
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES 5. Laundry: Laundry contaminated with potentially infectious materials will be handled as little as possible using gloves. Items will immediately be washed in hot water on the regular wash cycle and dried on the hot cycle. If the contaminated laundry is wet, it is to be placed in a plastic bag to prevent possible soak-through and/or leakage of fluids to the exterior. Gloves will be used to handle contaminated laundry and handling will be kept to a minimum. No one will leave the area with potentially contaminated items or clothing.
107
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP 1035 FINANCIAL POLICIES AND PROCEDURES POLICY MONARCH is committed to having sound fiscal practices in place to enable the organization to achieve its mission, goals and objectives. All fiscal practices will adhere to established accounting principles and ethical business practices. Annual Budgeting Process An annual operating budget will be prepared in the spring of each year to coincide with the organizations fiscal year end of June 30th. The Executive Director and CPA will review historical revenues and expenses of the previous and current fiscal year and determine the overall budget guidelines for the management team. The management team will work with individuals throughout the organization to determine spending needs in the upcoming year and submit these estimates to the Executive Director for review. Upon approval by the Executive Director, the CPA will prepare an initial draft of the budget. After the budget draft is reviewed by the Management Team and Executive Director, it will be presented to the Board of Directors for final approval at the June or July board meeting. Upon final approval from the Board, the budget will be distributed to the Management Team to ensure an organization wide awareness of the financial plan for the fiscal year. One of the Executive Directors duties is to operate the organization within the confines of the operating budget to ensure its continued viability. Since the organizations primary funding source is through the Oklahoma Department of Mental Health and Substance Abuse Services, it is possible annual revenue amounts may change from the initial contract if the state faces its own budget deficits. If funding projections change, the Executive Director will notify the Board and determine if an amended operating budget is necessary. Working Capital and Contingency Funds The annual operations of the organization should be formulated in a manner to ensure adequate working capital and minimal reliance on lines of credit. The organization has access to a line of credit in the amount of $400,000, which is available on demand to assist with cash flow, as needed. The line of credit is available to ensure services are provided without interruption. Every effort should be made to operate the organization in a manner that does not encourage use of the line of credit. During review of the monthly financials, the Executive Director and CPA will review cash flow projections and determine cash balances are adequate to maintain
108
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES operations. If cash balances are inadequate, the CPA will notify the Executive Director that funds are needed from the line of credit. Annual Audit To comply with the contract requirement of the Oklahoma Department of Mental Health and Substance Abuse Services, MONARCH is required to obtain an annual audit by an independent accounting firm and submit this report by December 31 st each year. The CPA will work with the accounting firm to facilitate the onsite review and organization of records to ensure a successful audit. Upon completion of the audit, the report and findings will be presented to the Board of Directors. The Executive Director is responsible for ensuring audit findings are resolved in a timely manner. Cash Control and Investment Strategy The CPA is responsible for maintaining an effective internal control structure around the cash receipt and disbursement process. MONARCHs largest cash receipts are set up to be direct deposited into the organizations bank account. Checks are prepared by the CPA for signature by the Executive Director. Any expenditure exceeding $5,000 requires two authorized signers to sign the check. Bank accounts are reconciled monthly by the CPA and reviewed by the Executive Director. The CPA is responsible for determining the presence of excess monies in the organizations general checking account and promptly transferring them into the interest bearing money market account. If possible, excess money market funds should be invested in a certificate of deposit as to enhance interest earnings.
109
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES MAP: 1036 - RISK MANAGEMENT POLICY It is the policy of MONARCH to assign responsibility for operational implementation of risk management, and to assess for potential and actual risks to persons served, to the public, to employees, and to the overall working and service delivery environment and facilities. Assessments will result in preventive measures and interventions that will serve to reduce risk and loss within the organization. MONARCH is committed to long-range planning to ensure service continuity and, therefore, to a formal and periodic risk management process as a method to identify loss exposures, analyze and evaluate loss exposures, identify a strategy to be taken to counter any potential loss, implement the most effective strategy, provide ongoing management/governance oversight of the efficacy of decisions made regarding risk management/loss prevention activities, and implement any necessary changes as may be indicated by a changing service and/or business environment. PROCEDURES The Executive Director will coordinate activities designed to result in reduction of risk and loss and continuously improve the quality of care. The Executive Director is charged to identify and assess risk, develop a plan with interventions, actions, and systems to control risk, conduct periodic evaluations to assess results of actions and reformulation of planning, and ensure that financial support is available to meet the goals of the risk management plan. The Executive Director will assess the organizations exposure to loss in the following causation areas: 1. People: This area is defined as acts or behaviors that may expose the organization to loss and liability. Appropriate areas for assessment would include, but not be limited to, incident reports, code of conduct standards and violations, safety standards, reports, consumer rights and grievance complaints, and purchasing/fiscal practices. 2. Organization: This area is defined as the policies, procedures, and legal guidelines that the organization is legally responsible to follow. Appropriate areas for assessment would include, but not be limited to, a review of the organizations policies and procedures compared to actual practices, a review of federal and state safety, fiscal, third party, and clinical guidelines compared to actual practices, and a review of current industry standards of care compared to actual practices. 3. Hardware: This area is defined as the conditions that exist within the organization. Appropriate areas for assessment would include, but not be limited to, the physical structures in which services are provided, equipment used throughout the organization, health and safety reports, incident reports,
110
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES maintenance reports, and the organizations tools for maintaining and transmitting information. 4. Insurance: This area is defined as the overall insurance program that the organization has in place to protect all assets and protects persons served, employees, the designated authority members, and others associated with the organization, against reasonable claims due to adverse events for which the organization is liable. Appropriate areas for assessment would include, but not be limited to, appropriate insurance coverage for buildings, equipment and inventory, workers compensation, bonding of personnel, and vehicles. In addition, assessment also includes the areas of professional liability, products and services, and designated authorities errors and omissions. The Executive Director will facilitate and encourage employees involvement in assessing risk and loss through staff meetings that provides basic education regarding risk management and directs the employees to provide opinion and feedback regarding their perception of risk within their work environment. The Executive Director will review the organizations historical losses, or potential for loss in all areas assessed, and will utilize this information to establish a standing Risk Management Plan. The plan will be directed towards investigation, continued assessment, and/or coping with a specific issue, solving a particular problem, or reaching a clearly identified objective. Each goal will contain specific objectives, time lines, persons responsible, review dates, and target dates for completion. When developing, managing, monitoring, and revaluating the Risk Management Plan, the Executive Director will address issues through a continuous review of the following: Can the problem or potential problem be eliminated? If a problem cannot be eliminated, can action be taken to maintain an acceptable level of risk? If a loss occurs, can the severity of the loss be reduced? What are the various causes that can lead to the problem? What are the possible event frequencies and consequences related to the various causes? What alternatives can be established to deal with potential problems? Would a combination of technical and organizational measures increase the level of prevention? What are the results of selected control measures? Periodic evaluation of control measures. Corrections of control measures if they are not carried out properly. Evaluation of risk financing options. Evaluation of overall goal results. Ongoing reformulation of the plan.
111
MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES The Executive Director will provide an annual summary of its activities, and results of planning and interventions to the Board of Directors to provide information for decision making and planning, and inclusion in the organizations reports to persons served, employees, third parties, referral sources, regulatory agencies, and other stakeholders.
112

MM-CAT-1 - Administrative Policy and Procedures Approved 10-2012

Încărcat de

Informații document

Descriere originală:

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

MM-CAT-1 - Administrative Policy and Procedures Approved 10-2012

Încărcat de

Drepturi de autor:

Formate disponibile

MONARCH, INC.

ADMINISTRATIVE POLICIES AND PROCEDURES TABLE OF CONTENTS POLICY # TITLE PAGE 3 4

MISSION, VISION, AND CORE VALUES. PHILOSOPHY AND PURPOSE..

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

MONARCH, INC. ADMINISTRATIVE POLICIES AND PROCEDURES

CORE VALUES Commitment Service Relationships

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

Approved: 9-19-12 Effective: July 1, 2012 June 30, 2013

S-ar putea să vă placă și