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TABLE OF CONTENTS
_______________________________________________________________________________
SUBJECT: OUTPATIENT CASE MANAGEMENT EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure that case management is being conducted in the most professional manner possible
while adhering to the guidelines regulated by DMHSAS and accrediting agencies.
PROCEDURE
WHO WHAT
Case Manager 1. Reviews the record and contacts the consumer, who is
diagnosed with a severe mental illness and/or a
Co-occurring disorder, to set an appointment upon
assignment. The emphasis is on maintaining or improving
the current level of functioning, unless a deteriorating
physical or mental condition exists. Screens and assesses
for possible case management needs.
_______________________________________________________________________________
SUBJECT: COUNSELING/THERAPY EFFECTIVE DATE: 04 APR 93
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure that counseling/therapy is being conducted in the most professional manner possible
while adhering to the guidelines regulated by DMHSAS and accrediting agencies.
PROCEDURE
WHO WHAT
Licensed Clinician 1. Reviews the record and contacts the consumer, who Is
diagnosed with a severe mental illness, substance abuse,
emotional disturbance, depression, and/or a
Co-occurring disorder, to set an appointment upon
assignment.
_______________________________________________________________________________
SUBJECT: OUTPATIENT DHS/TANF EFFECTIVE DATE: 01 JAN 05
SUBSTANCE ABUSE GROUP DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
As required by ODMHSAS Contract with Department of Human Services (DHS) toward services for all
potential referrals for assessment and/or treatment for substance abuse and/or co-occurring issues.
PROCEDURE
WHO WHAT
Substance Abuse Clinician 1. Clinician will receive referral form from DHS Caseworker for
administration of a SASSI (Substance Abuse Subtle
Screening Inventory) questionnaire to identify a need for
substance abuse/ co-occurring treatment. Each potential
consumer must be seen within 10 days of referral.
_______________________________________________________________________________
SUBJECT: OUTPATIENT DHS/TANF EFFECTIVE DATE: 01 JAN 05
SUBSTANCE ABUSE GROUP DATE REVIEWED: 01 FEB 08
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WHO WHAT
Substance Abuse Supervisor 6. Supervisor will assure that there will be a 55:1 ratio of
clinician versus consumer maintained through staff
assignment upon entry into program. Supervisor will assure
that there will be a 12:1 ratio of clinician versus consumer for
group services.
OUTPATIENT PROCEDURE
PROCEDURE #: 101.2
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__2__
_______________________________________________________________________________
SUBJECT: OUTPATIENT CO-OCCURRING EFFECTIVE DATE: 01 JAN 05
PROGRAM/GROUPS DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
Establish a set procedure for clinicians to adhere to for referral process into Co-Occurring services.
PROCEDURE
WHO WHAT
Substance Abuse Supervisor 2. Supervisor will receive referral from one of three sources, the
Triage Unit, Inpatient Unit or Case Management Unit.
Supervisor will then confirm a need for Co-Occurring services
and assign consumer to a Co-Occurring Clinician at that time.
Substance Abuse Clinician 3. Clinician will contact the consumer upon receiving referral from
supervisor to establish an appointment. Each clinician will
contact assigned consumer within 2 days of referral. Each
consumer will be offered Co-Occurring services which include
group/ individual sessions, case management, family support,
vocational rehab support, and medication clinic.
_______________________________________________________________________________
SUBJECT: OUTPATIENT CO-OCCURRING EFFECTIVE DATE: 01 JAN 05
PROGRAM/GROUPS DATE REVIEWED: 01 FEB 08
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WHO WHAT
6. Upon referral for the group process, the clinician will educate
each consumer toward mental health and substance abuse
issues. Each consumer will be required to attend group
Monday, Wednesday and Thursday 9 a.m. to 12 p.m. for a
period of 8 weeks. Each participant will be required to
attend at least 3 AA/NA meetings per week, and be subject
to random drug urine screens while in the program. Upon
successful completion of this 8 week process the consumer
will have the option of attending an Aftercare group 1x per
week for 12 weeks. The Aftercare group meets 1x per week
for 1 ½ hours for a period of 12 weeks. The client will be
required to attend 3 AA/NA meetings per week and be
subject to random drug urine screens while in the program.
Substance Abuse Supervisor 7. Supervisor will ensure that there will be a 55:1 ratio of clinician
versus consumer maintained through staff assignment upon
entry into program. Supervisor will ensure that there will a 12:1
ratio of clinician versus consumer fro group services.
OUTPATIENT PROCEDURE
PROCEDURE #: 101.3
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__2__
_______________________________________________________________________________
SUBJECT: COMANCHE/COTTON COUNTY EFFECTIVE DATE: 01 JAN 05
DRUG COURT PROGRAM DATE REVIEWED: 01 FEB 08
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PURPOSE
As required by ODMHSAS Drug Court requirements, all clinicians will adhere to referral process and
group procedures.
PROCEDURE
WHO WHAT
Drug Court Coordinator 1. Coordinator will submit assessment referral to Drug Court
Clinician and set an appointment time.
Drug Court Clinician 2. Clinician will accept referrals for Drug Court Program only from
Drug Court Coordinator.
Drug Court Clinician 3. Clinician will perform an initial assessment to consist of the
ASAM PPC-2R, URICA (University of Rhode Island Change
Assessment), ASI (Addiction Severity Index) and drug urine
screen. Upon completion of these tools, the clinician will
determine a need for substance abuse treatment within the
drug court program. If the client is a good candidate, there will
be a referral for the program given to the Comanche/Cotton
County Drug Court Board.
Drug Court Board 4. Upon receiving the assessment results and referral from
clinician, the board will then vote to accept or deny consumer
into this process. If the board accepts the consumer into the
process, there will be an intake appointment set at that time for
consumer to begin group, individual and monitoring sessions.
_______________________________________________________________________________
SUBJECT: COMANCHE/COTTON COUNTY EFFECTIVE DATE: 01 JAN 05
DRUG COURT PROGRAM DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
WHO WHAT
Drug Court Clinician 6. Clinician will educate, monitor and document progress of each
consumer throughout this 5 Phase, 2 year process. Consumer
will initially be required to attend group 1-2x per week for 12
months, 2-4x per month for 6 months and then 1x per month 6
months. Throughout this process the consumer will be
required to attend at least 3 AA/NA meetings per week and be
subject to random drug urine screens. The consumer will also
be required to attend individual sessions initially 2x per month
for 12 months and 1x per month for 12 months.
Drug Court Clinician 7. Clinician will be responsible for monitoring and reporting back
to Drug Court Board every 2 weeks as to the progress and
participation of each consumer. If the consumer has been non-
compliant, the clinician must report immediately to the Drug
Court Coordinator for immediate sanctions process. The
sanctions process will be carried out by assigned Drug Court
Judge.
Substance Abuse Supervisor 8. Supervisor will assure that there will be a 55:1 ratio of
clinician versus client maintained through staff assignment
upon entry into program. Supervisor will assure that there
will be a 12:1 ratio of clinician versus consumer for group
services.
OUTPATIENT PROCEDURE
PROCEDURE #: 101.4
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__1__
_______________________________________________________________________________
SUBJECT: OUTPATIENT AFTERCARE EFFECTIVE DATE: 01 JAN 05
SUBSTANCE ABUSE GROUP DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
Establish procedures for referral and monitoring of Aftercare groups and processes.
PROCEDURE
WHO WHAT
Substance Abuse Clinician 1. Clinician will receive referral from 2 sources, an Outpatient
Substance Abuse Clinician or Triage clinician, and confirm
successful completion of residential or outpatient substance
abuse program.
Substance Abuse Clinician 2. Clinician will educate, monitor and document each consumer’s
progress toward relapse prevention. Each consumer will be
required to attend Aftercare group/individual sessions 1x per
week for 12 weeks, attend at least 3 AA/NA meetings per
week, and will be subject to random drug urine screens while in
the program. Clinician will continue to monitor co-occurring
and case management needs.
Substance Abuse Supervisor 3. Supervisor will assure that there will be a 12:1 ratio of clinician
versus consumer maintained through staff assignment upon
entry into Aftercare groups only.
OUTPATIENT PROCEDURE
PROCEDURE #: 102
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SERVICES PAGE__1__OF__2__
_______________________________________________________________________________
SUBJECT: OUTPATIENT MEDICATION CLINIC EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide efficient and professional operation of medication clinics for those individuals seeking
medication evaluation, medication adjustment, and/or medication maintenance..
PROCEDURE
WHO WHAT
Consumer 11. Obtains a medication clinic appointment slip for next doctor
visit from Outpatient Receptionist.
OUTPATIENT PROCEDURE
PROCEDURE #: 102
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SERVICES PAGE__1__OF__2__
_______________________________________________________________________________
SUBJECT: OUTPATIENT MEDICATION CLINIC EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
WHO WHAT
_______________________________________________________________________________
SUBJECT: PSYCHOLOGICAL TESTING EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide guidelines for requesting Psychological Testing.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: ORAL MEDICATION REFILLS EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for medication refills.
PROCEDURE
WHO WHAT
Outpatient Receptionist 1. Medication refills are noted on prescription in the lower left hand.
2. Dates for return refills are placed on the appointment slip and
explained to the consumer.
_______________________________________________________________________________
SUBJECT: LABORATORY PROCEDURE EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines in conjunction with staff physician/psychiatrist and with contract laboratory to
ensure proper procedure is being followed.
PROCEDURE
WHO WHAT
B. MEDICARE
_______________________________________________________________________________
SUBJECT: LABORATORY PROCEDURE EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
WHO WHAT
_______________________________________________________________________________
SUBJECT: LABORATORY PROCEDURE EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
WHO WHAT
_______________________________________________________________________________
SUBJECT: LAB CORP CONTRACT EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for laboratory corp procedures.
PROCEDURE
WHO WHAT
4. Saves last carbon copy and files in a folder for own reference.
Medical Records Staff 6. Receives printed copy of reports and sends to area requesting
documents.
OUTPATIENT PROCEDURE
PROCEDURE #: 108
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__1__
_______________________________________________________________________________
SUBJECT: PHYSICAL EXAMINATION FOR EFFECTIVE DATE: 31 JUL 04
OUTPATIENT DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To create awareness regarding physical examinations.
PROCEDURE
WHO WHAT
Physician Determines the need for a physical examination by employing
the following steps:
_______________________________________________________________________________
SUBJECT: MEDICATION ERRORS EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for reporting medication error(s).
Any medication error or incident shall be reported to the Unit Physician immediately on discovery.
PROCEDURE
WHO WHAT
Responsible Staff 5. Completes the medication incident report form. In the event the
staff responsible for the error is not available any staff
discovering the error shall complete the medication incident
report form. It shall be signed by the person who is responsible
for the error as soon as possible and documented in the
consumer’s clinical record.
Director of Nursing Services 6. Reviews all medication errors/incidents. Identifies any patterns
of medication error/incident. Recommends corrective action to
Incident Review Committee.
_______________________________________________________________________________
SUBJECT: MEDICAL EMERGENCIES EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for handling medical emergencies.
PROCEDURE
WHO WHAT
Director of Program Evaluations 9. Routes CIR to Risk Manager for review and sends to Executive
Director for review.
10. Follows up with staff to review the incident and debrief staff as
needed.
_______________________________________________________________________________
SUBJECT: OBSERVING AND REPORTING EFFECTIVE DATE: 31 JUL 04
CONVULSIVE SEIZURES DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for observing and reporting convulsive seizures.
PROCEDURE
WHO WHAT
Nurse/Mental Health Aide 1. Checks for breathing; if consumer is not breathing, tilts head
back to open airway.
Registered Nurse 9. Notifies physician, reports, and follows doctor’s orders, and
notes.
_______________________________________________________________________________
SUBJECT: OBSERVING AND REPORTING EFFECTIVE DATE: 31 JUL 04
CONVULSIVE SEIZURES DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: PRESCRIBING AND DISPENSING EFFECTIVE DATE: 31 JUL 04
OF MEDICATIONS TO INMATES OF THE COUNTY/CITY JAIL DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for prescribing and dispensing of medications to inmates of
the county or city jail.
PROCEDURE
WHO WHAT
City/County Jail Nurse 1. Notifies JTCMHC staff of need for evaluation for medication or
treatment.
_______________________________________________________________________________
SUBJECT: PROTECTION OF CONSUMER’S RIGHTS EFFECTIVE DATE: 31 JUL 04
DURING VISITATION DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure protection of consumer rights.
PROCEDURE
WHO WHAT
Director of Outpatient Services 1. Arranges for group visitations for educational or professional
purposes only. Schedules these visits so they are the least
disruptive.
_______________________________________________________________________________
SUBJECT: CRISIS INTERVENTION EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide the most efficient and appropriate treatment for a consumer in crisis.
PROCEDURE
WHO WHAT
Consumer and/or Significant 1. Calls the Center or comes to the Center requesting help with
the problem.
Switchboard or Outpatient 2. Makes an attempt to see what the immediate problem(s) is/are
Receptionist and directs the consumer to hi or her case manager or
outpatient counselor. If primary clinician is unavailable,
contacts the crisis case manager or Triage staff to see the
client.
Crisis Case Manager or 3. Interviews the consumer to determine immediate need(s) of the
Triage Staff consumer and initiates appropriate treatment.
_______________________________________________________________________________
SUBJECT: CODE FOR AGITATED CONSUMERS EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written guidelines for the safety of consumers, staff, and visitors.
The code word for seeking help with agitated consumers or medical emergencies will be
“Mr. Magoo” plus the location of the emergency, which can be called from any location.
PROCEDURE
WHO WHAT
Designated Auxiliary Staff 4. Provides assistance for staff called to respond. Removes
(Trained in Basic CAPE) debris in area if damage has occurred. Clears area of
consumers, if necessary, and explains necessity for action
taken. Ensures availability of help.
_______________________________________________________________________________
SUBJECT: OBSERVING AND REPORTING EFFECTIVE DATE: 31 JUL 04
CONVULSIVE SEIZURES DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
The Jim Taliaferro Community Mental Health Center shall have a process for resolving consumer/family
grievances and complaints and shall adhere to the ODMHSAS guidelines governing the protection of
consumer rights. Consumer/family grievances and complaints shall be reported to the Supervisor and
resolved at the lowest level possible.
PROCEDURE
WHO WHAT
JTCMHC Consumer Advocate 1. Assures the name and telephone number of the ODMHSAS
Consumer Advocate, assigned by the Advocate General’s
Office, as well as the JTCMHC Consumer Advocate’s name
and number, shall be posted in all treatment areas.
_______________________________________________________________________________
SUBJECT: OBSERVING AND REPORTING EFFECTIVE DATE: 31 JUL 04
CONVULSIVE SEIZURES DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: ADMISSION CRITERIA EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide a written reference of the criteria required for admission into Outpatient Services.
PROCEDURE
WHO WHAT
Outpatient Admission Staff 1. Any individuals or families may be seen by outpatient for any
mental, emotional, substance abuse, or Co-Occurring
problems that meets DSM IV Diagnostic criteria with a resulting
Axis I or II diagnosis.
_______________________________________________________________________________
SUBJECT: APPOINTMENT PROCEDURES EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure that appointments made in Outpatient Services are done efficiently and consistently.
PROCEDURE
WHO WHAT
B. Appointments with the physician are made through the Outpatient Receptionist.
_______________________________________________________________________________
SUBJECT: DOCUMENTATION PROCEDURES EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
REFERENCES: ODMHSAS Standards and Criteria #401.11
JCAHO Consolidated Standards PE.2.3, TP.1.3.2.1.4
****************************************************************************************************************
PURPOSE
To provide written guidelines to ensure documentation follows the criteria of ODMHSAS and JCAHO
standards.
PROCEDURE
It is the policy of JTCMHC that all outpatient medical records will contain the following information:
1. Consumer’s name and chart number.
2. Signatures by staff completing the forms. The signature should consist of their full name or
first initial and last name along with their highest degree and licensure, if applicable. All forms
and entries should be dates with the time, month, day, and year of completion.
WHO WHAT
_______________________________________________________________________________
SUBJECT: DOCUMENTATION PROCEDURES EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
REFERENCES: ODMHSAS Standards and Criteria #401.11
JCAHO Consolidated Standards PE.2.3, TP.1.3.2.1.4
****************************************************************************************************************
PURPOSE
WHO WHAT
_______________________________________________________________________________
SUBJECT: DISCLOSURE OF CONFIDENITAL INFORMATION EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure that privacy of each consumer is maintained.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: REFERRALS TO PSYCHOSOCIAL EFFECTIVE DATE: 02 AUG 04
REHABILITATIVE SERVICES DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
PROCEDURE
WHO WHAT
Referring Clinical Staff 1. Completes referral form and forwards to physician for signature
and approval.
Psychosocial Staff 4. Reviews the clinical chart and interviews the consumer to make
a determination for acceptance into the program.
_______________________________________________________________________________
SUBJECT: REFERRAL FOR VOCATIONAL SERVICES EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To establish guidelines for proper referral to vocational service.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: CONTACT FORM EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To establish guidelines for proper referral to vocational service.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: MEDICATIONS REVIEW AND MEDICAL EFFECTIVE DATE: 02 AUG 04
HISTORY/PAIN ASSESSMENT DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
It is the policy of Jim Taliaferro Community Mental Health Center that a Medication(s) Review and
Medical History will be completed on all admissions to Community Programs.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: MEDICATIONS ADMINISTRATION DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
It is the policy of Jim Taliaferro Community Mental Health Center that a Medication Administration
procedure will be adhered to on all admissions to Community Programs for those consumers diagnosed
with a mental illness, substance abuse, and/or Co-Occurring disorder.
PROCEDURE
WHO WHAT
Registered Nurse 3. Identifies consumer by verifying name, birth date, and photo
within consumer clinical record.
_______________________________________________________________________________
SUBJECT: MEDICATIONS REVIEW AND MEDICAL EFFECTIVE DATE: 02 AUG 04
HISTORY/PAIN ASSESSMENT DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines for transcribing and filling prescriptions.
The Jim Taliaferro Community Mental Health Center Pharmacy will give the consumer prescriptions for
non-formulary medications to be filled outside of the Center at their own expense. Should the consumer
fail to keep his or her appointment with the physician, the Registered Nurse consults the physician as to
course of action. If the consumer misses a second physician appointment, no medication will be given
until evaluated by the physician.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: GENERAL CONSULTATIONS EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written guidelines for obtaining consultations.
Consultation with another psychiatrist may be requested only by the consumer’s attending physician or
psychiatrist. A clinician can request a consultation with a physician or with any other discipline through
appropriate channels.
PROCEDURE
WHO WHAT
Attending Physician, or the 1. Request for consultation must be with reason for request.
Primary Clinician (See attached form)
OUTPATIENT PROCEDURE
PROCEDURE #: 310
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__1__
_______________________________________________________________________________
SUBJECT: SUICIDE LETHALITY CHECKLIST EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide guidelines when a clinician suspects a consumer may be suicidal.
PROCEDURE
WHO WHAT
3. Notifies Supervisor.
OUTPATIENT PROCEDURE
PROCEDURE #: 311
_______________________________________________________________________________O
RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__1__
_______________________________________________________________________________
SUBJECT: HOMICIDE LETHALITY CHECKLIST EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
WHO WHAT
3. Notifies Supervisor.
_______________________________________________________________________________
SUBJECT: MEDICATIONS REVIEW AND MEDICAL EFFECTIVE DATE: 02 AUG 04
HISTORY/PAIN ASSESSMENT DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
Treatment planning is a mechanism by which professional staff members of the multidisciplinary team
decide, with the consumer, what goals are to be reached and which therapeutic methods are appropriate
to reach said goals.
A comprehensive treatment plan is to be developed at the time of admission when a diagnostic evaluation
is completed. A comprehensive treatment plan is then completed at least once a year thereafter (see
attached OP/Satellite Procedures for this). Treatment plans should always be updated when the
following circumstances exist:
1. Change of service focus. Example: referral from case management to A&D services.
2. When consumer goes from Outpatient to Inpatient or vice versa.
3. Change in treatment plan problems.
4. Significant medication changes. Example: no longer on psychotropic medication or switch to
an injection medication.
PROCEDURE
WHO WHAT
Case Manager /Consumer 3. Reviews the comprehensive treatment plan with the consumer
and obtains signature of consumer if agreed to.
_______________________________________________________________________________
SUBJECT: MEDICATIONS REVIEW AND MEDICAL EFFECTIVE DATE: 02 AUG 04
HISTORY/PAIN ASSESSMENT DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PROCEDURE
WHO WHAT
Each Team Member 1. Reviews consumer’s contacts for the period and assesses
consumer’s progress in meeting objectives.
_______________________________________________________________________________
SUBJECT: PROGRESS NOTES EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure that documentation follows guidelines of DMHSAS and accrediting agencies.
Progress notes should be specific statements related to the consumer’s progress on the treatment plan
goals. Assessment information and other consumer related information, as well as treatment provided, is
to be included in the progress notes. All progress notes are to be dated and contain time (beginning and
ending), discipline, and worker’s full name or first initial, last name with their highest degree and licensure,
if applicable.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: DISCHARGE PLANNING EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
Provides a written reference of criteria required to complete a discharge.
The discharge planning process begins with admission and the setting of goals. As goals are met,
discharge or the need for additional goals is discussed.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: DISCHARGE OF INACTIVE OUTPAITENT EFFECTIVE DATE: 02 AUG 04
CONSUMERS DATE REVIEWED: 01 FEB 08
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PURPOSE
ODMHSAS Standards and Criteria VI B.3
It is the policy of Jim Taliaferro Community Mental Health Center that consumers who have not received
any services within 90 days shall be discharged after it is determined that services are no longer needed
or desired.
PROCEDURE
WHO WHAT
Clinician/Case Manger 1. Initiates follow-up with all consumers who have not received
services within 90 days, by telephone, visit, or letter, and
documents in the record. Makes appointments if desired.
_______________________________________________________________________________
SUBJECT: JTCMHC ACTING AS REPRESENTAIVE PAYEE EFFECTIVE DATE: 31 JUL 04
FOR THE SOCIAL SECURITY INCOME DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To act as payee for the Outpatient consumers who have been deemed unsuitable to receive their Social
Security Income directly, and have no friends or family members able or willing to take on the
responsibility. Upon determination, by a Case Manager, that a consumer meets the above policy criteria,
he or she will begin the process of opening a payee account with the Accounting Department and prepare
the appropriate request for the Social Security Administration.
PROCEDURE
Opening a Payee Account with Accounting
WHO WHAT
_______________________________________________________________________________
SUBJECT: JTCMHC ACTING AS REPRESENTAIVE PAYEE EFFECTIVE DATE: 31 JUL 04
FOR THE SOCIAL SECURITY INCOME DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
WHO WHAT
_______________________________________________________________________________
SUBJECT: JTCMHC ACTING AS REPRESENTAIVE PAYEE EFFECTIVE DATE: 31 JUL 04
FOR THE SOCIAL SECURITY INCOME DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
WHO WHAT
_______________________________________________________________________________
SUBJECT: FLEXIBLE FUNDS REQUEST EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To ensure that JTCMHC consumers have access to funds that may be used for emergency purchases,
usually on time, and goods and services critical to maintain consumers within the community.
ACCEPTABLE EXPENDITURES
1. Emergency food.
2. Consumer transportation to needed services.
3. Temporary/emergency housing.
4. Emergency medication other than psychotropics and/or needed medical supplies.
5. Needed medical services for which there is no other sources of payment.
6. On an emergency basis, first month’s rent, rental deposits and/or monthly rent payments to
prevent out of community placement.
PROCEDURE
WHO WHAT
Case Manager/Therapist 1. Completes JT-530, Flexible Fund Request form, detailing the
justification for the flex fund.
Program Coordinator/ 3. Reviews the Flexible Fund Request and approves or denies.
Director of Program Evaluation
4. If denied, request is sent back to Case Manager for more
documentation/justification.
_______________________________________________________________________________
SUBJECT: LEAVE WHEN SERVICES ARE TEMPORARILY EFFECTIVE DATE: 02 AUG 04
REDUCED DUE TO HAZARDOUS WEATHER CONDITIONS DATE REVIEWED: 01 FEB 08
(AUTOMATICALLY ALLOWED AUTHORIZED ABSENCES)
****************************************************************************************************************
PURPOSE
It is the policy of JTCMHC that the Center remain sufficiently staffed so that essential services are
provided at all times and that the potential danger to public property, consumers, and others is reduced to
a minimum in the event of hazardous weather. All Center employees are to at their scheduled work
stations unless the Executive Director/Designee declares non-essential personnel be released or
excused from reporting to work due to hazardous weather conditions. Essential personnel are those
individuals who occupy critical positions that are required to maintain essential services. Announcements
of general reductions of service apply to all departments including Satellite Clinics of JTCMHC.
PROCEDURE
WHO WHAT
_______________________________________________________________________________
SUBJECT: LEAVE WHEN SERVICES ARE TEMPORARILY EFFECTIVE DATE: 02 AUG 04
REDUCED DUE TO HAZARDOUS WEATHER CONDITIONS DATE REVIEWED: 01 FEB 08
(AUTOMATICALLY ALLOWED AUTHORIZED ABSENCES)
****************************************************************************************************************
WHO WHAT
Department Heads 11. Maintain a current list of all staff members and telephone
numbers designating responsibility for notification of hazardous
weather and reduction of operations.
Satellite Coordinators 12. May contact the Department Head/Executive Director to confirm
the need to reduce operations when dangerous/hazardous is
present in their area.
_______________________________________________________________________________
SUBJECT: BOMB THREAT EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
It is the policy of Jim Taliaferro Community Mental Health Center to assume any bomb threat received as
real. Satellite Staff will adopt this policy as it relates to the Satellite Office. Appropriate consumer/staff
safety and security measures must be followed immediately. Consumer security is the prime
consideration, followed next by staff safety, building, and equipment.
PROCEDURE
WHO WHAT
Evacuation of Building
Satellite Coordinator 7. Designates specific area of satellite to search first, then uses an
assembly area for the temporary safety of consumers if
evacuation is impractical until all can be evacuated or returned
to their places of normal activity.
OUTPATIENT PROCEDURE
PROCEDURE #: 601
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SUBJECT: LEAVE WHEN SERVICES ARE TEMPORARILY EFFECTIVE DATE: 02 AUG 04
REDUCED DUE TO HAZARDOUS WEATHER CONDITIONS DATE REVIEWED: 01 FEB 08
(AUTOMATICALLY ALLOWED AUTHORIZED ABSENCES)
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WHO WHAT
Designated Search Team 8. Searches designated area covering each entire satellite.
Staff Searchers 9. Work in two pairs to make a clockwise sweep of entire satellite.
Handling Suspected Explosives 10. Refrains from handling or removing suspected explosives;
Staff Searchers clearing all areas of personnel, if not evacuated, and blocks off
adjacent areas to prevent accidental disturbances of item(s).
Local Police Department 11. Checks suspicious item(s), and if appropriate, contacts the
Explosive Ordinance Disposal (EOD) at Fort Sill.
Explosive Ordinance 12. Issues instructions which will be followed carefully to assure
safety of all consumers/staff.
Designated Staff 13. Renders assistance to EOD, Police Department in traffic control,
communications, tools and equipment, etc., as long as deemed
necessary.
Satellite Coordinator 14. Notifies main Center of all clear and announces all clear when
search is completed and/or dangerous item(s) has been
removed/defused and rendered harmless.
OUTPATIENT PROCEDURE
PROCEDURE #: 602
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SUBJECT: FIRE PLAN EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written guidelines in the event of a fire.
In the event of a fire, or fire drill, all persons will be evacuated from the building. All employees involved
with clients will assist those members in evacuating the building.
PROCEDURE
WHO WHAT
Satellite Coordinator/Director 1. Ensures that evacuation plans and exit routes are posted in
each area. Conducts fire drills quarterly. Ensures that
new/former staff receive orientation regarding location and use
of fire extinguisher, evacuation policy, duties, and exit routes.
.
Any Employee Observing 2. Extinguishes fire when appropriate, such as a trash can fire.
Fire/Smoke
Satellite Coordinator/Director 5. Ensures all consumers and staff are accounted for.
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SUBJECT: SEVERE STORM WARNING/ EFFECTIVE DATE: 02 AUG 04
TORNADO WARNING DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written guidelines in the event of severe weather.
In the event a severe storm warning is sounded and tornado is eminent, consumers will be taken to a
designated Storm Shelter. Otherwise, staff will congregate with consumers in a central room containing
no outside walls, if possible.
PROCEDURE
WHO WHAT
Satellite Coordinator/Director 3. Makes certain designated storm shelters and addresses are
posted and familiar to staff/consumers.
OUTPATIENT PROCEDURE
PROCEDURE #: 700
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SUBJECT: TRAVEL EXPENSES EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written for obtaining reimbursement for travel expenses.
Staff is reimbursed for use of their own private automobiles when a state vehicle is not available and pre-
approval has been given.
PROCEDURE
WHO WHAT
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SUBJECT: WORKSHOP ATTENDANCE EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
Clinicians are encouraged to attend workshops for training that will enhance their skills in working with
those diagnosed with a mental illness, substance abuse, or Co-Occurring disorder.
PROCEDURE
WHO WHAT
Clinician will receive the form back with the workshop/trip approved/disapproved. Upon return, the
clinician will follow procedure below.
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SUBJECT: GUIDLEINES FOR UNIVERSAL PRECAUTIONS EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To ensure protection of consumers and staff.
Since medical history of and examination cannot reliably identify all consumers infected with HIV or other
blood-borne pathogens, blood and body fluid precautions should be consistently used for all consumers.
This approach, referred to as “Universal Precautions”, will be used in the care of all consumers.
PROCEDURE
WHO WHAT
All Nursing Staff 1. Wears gloves for touching blood, body fluids, and for
performing venipuncture. Gloves should be changed after
contact with each consumer. Gloves will reduce the incidence
of blood contamination of hands during venipuncture, but they
cannot prevent injuries caused by needles or other sharp
instruments.
The implementation of “Universal Precautions” eliminates the need for isolating consumers for “blood and
body fluid precautions,” and prevents consumers from being inadvertently “labeled.”
OUTPATIENT PROCEDURE
PROCEDURE #: 801
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SUBJECT: INFECTION CONTROL – HAND WASHING EFFECTIVE DATE: 02 AUG 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To prevent the spread of infectious diseases.
Policies and procedures are not a replacement for common sense. Hand washing is the single, most
important procedure for preventing the spread of infectious diseases by removing transient microbial
contaminants acquired through recent contact with infected consumers, co-workers, and/or environmental
sources.
PROCEDURE
1. Wet hands under warm, running water, keeping hands lower than elbows. Apply soap (bar, liquid,
granules) or antiseptic soap (Hibiclens).
2. Use friction to clean between fingers, palms, back of hands, wrists, forearms, and clean under
fingernails. Routine hand washing should be vigorously performed for at least ten seconds.
WHO WHAT
All Employees 1. Wash hands after contact with a source that is likely
contaminated, such as blowing nose, personal toileting, etc.
Food Service Workers 2. Wash hands with soap and water prior to handling and/or
preparing food, drink, and utensils.
Medical/ Nursing Staff 3. Wash hands with soap before preparing or serving food/drink,
before and after any aseptic nursing procedure(s), such as
wounds care, lab work, suture removal, etc. Wash hands with
antiseptic soap before and after contact with wounds, after
contact with potentially infected persons/objects, and after any
contact with blood and body fluid(s). Always wear gloves where
indicated.
OUTPATIENT PROCEDURE
PROCEDURE #: 802
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SUBJECT: INFECTION CONTROL – EMPLOYEE RISK EFFECTIVE DATE: 02 AUG 04
EXPOSURE DATE REVIEWED: 01 FEB 08
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PURPOSE
To identify the procedure to be followed in the event of a risk to exposure to blood-borne pathogens.
I. Beginning January 1, 1989, the “Rules and Regulations Governing Risk Exposure” took effect.
This regulatory change was authorized by the Oklahoma State Board of Health under the statutory
authority of Title 630.S.S 1988 Section 1-502.1 (B).
These rules were developed to establish a system of notification for emergency responders,
funeral workers, and heath care workers who, while performing their jobs, sustain risk exposures
which are epidemiologically demonstrated to have the potential for transmitting a communicable
disease.
II. Definitions:
A. Body Fluid: blood or blood product(s), semen, pleural or spinal fluid, or any fluid visibly
contaminated in blood.
C. Risk Exposure: an exposure which has been epidemiologically demonstrated to pose a risk
for transmission of a communicable disease. Such an exposure would include parenteral
(needle stick or cut), permucosal (mouth-to-mouth resuscitation, splash to eye or mouth),
exposure to blood, or prolonged contact with blood to skin which is chapped, abraded, or
afflicted with dermatitis, or exposure to respiratory secretions.
PROCEDURE
WHO WHAT
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SUBJECT: INFECTION CONTROL – EMPLOYEE RISK EFFECTIVE DATE: 02 AUG 04
EXPOSURE DATE REVIEWED: 01 FEB 08
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WHO WHAT
All reasonable cost(s) associated with follow-up and testing of the exposed employee shall be applied to
Workers’ Compensation.
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SUBJECT: INFECTION CONTROL – CLEANING AND EFFECTIVE DATE: 02 AUG 04
DISINFECTION OF CONSUMER CARE DATE REVIEWED: 01 FEB 08
EQUIPMENT
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PURPOSE
To prevent spread of infection from one consumer to another.
All reusable consumer equipment is to be cleaned and disinfected after each consumer contact. Items
which are intended to be disposable need not be cleaned and should always be discarded after each
single consumer use.
PROCEDURE
WHO WHAT
Exam Table
1. Removes and discards used table paper and places into trash
container.
2. Washes top table surface with approved disinfectant.
3. Covers surface with clean table paper.
EKG Machine
1. Removes suction cups, bulbs, wrist and ankle bands, and
metal contacts. Washes these parts with soap and water,
rinses with clean tap water.
2. Utilizing a toothpick or other clean, straight object, clears any
remaining gel from suction cup/bulb.
3. Allows parts to air dry prior to reassembly.
Stethoscope
1. Earpieces are to be wiped clean with alcohol prep before and
after each use.