DBHDD PolicyStat Index - DBHDD Applications

DBHDD PolicyStat Index http://gadbhdd.policystat.com CHAPTER #

01 02 03 04 05 06 07-12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

NOTES

TITLE OF THE CHAPTER

Behavioral Health Community Services Developmental Disability Community Services Hospital Operations Administrative Issues for Behavioral Health and Developmental Disability Community Services RESERVED Forensic Services RESERVED Accountability & Compliance RESERVED Access to Services Audits Budget and Finance Communications and Media Relations External Affairs Facilities and Property Management Procurement and Contracts Human Resources Information Management & Information Technology Legal Services Protection of Human Subjects State Automobile, Liability and Property Insurance Transportation

Click on the Chapter Titles to see the Index of the policies contained in that Chapter. Most policies are available within DBHDD PolicyStat but some are still in progress. If you need a policy that is not yet available, or have any other questions, send an email to: [email protected]

Policy #

CHAPTER-01

Behavioral Health Community Services

Updates

A. Behavioral Health Community Services

Applicable for Community Providers?

01-101 01-102 01-103

DUI Intervention Program Region of Responsibility Determination for Behavioral Health Providers Accreditation and Standards Compliance Requirements for Providers of Behavioral Health Services

Yes Yes Yes

01-104 01-105

Informed Consent for Psychotropic Medication Treatment For Child and Adolescent Population Denial and Appeals Process for Psychiatric Residential Treatment Facility (PRTF) Level of Care for Children and Adolescents with a Mental Health Diagnosis Requirements to Access DBHDD Funds for Child & Adolescent Behavioral Health Services Payment by Individuals for Community Behavioral Health Services Management of Personal Needs Spending Accounts for Consumers (BH) Priority Admission, Medication Assisted Treatment, and Interim Services for Women Seeking Substance Use Treatment Form 1013 and Form 2013 – Certificate Authorizing Transport to Emergency Receiving Facility and Report of Transportation Recruitment & Application to become a Provider of BH Services Provider Manual for Community Behavioral Health Providers Noncompliance with Performance, Staffing, and Accreditation Requirements for Community Behavioral Health Providers Assertive Community Treatment (ACT) Teams Program Operations Manual Discharge Planning for Assertive Community Treatment (ACT) Actions Necessary upon Closure or Termination of a Community Provider of Behavioral Health Services Transportation Reimbursement for Assertive Community Treatment,Community Support Team and Supported Employment Services Suicide Prevention, Screening, Brief Intervention and Monitoring Best Practices for Serving "Emerging Adults" - Transitioning from Late Adolescence to Young Adulthood Supported Housing Needs and Choice Survey Georgia Department of Behavioral Health and Developmental Disabilities’ Definition of Severe and Persistent Mental Illness Transition Planning Process for Individuals on the ADA Ready to Discharge List

Yes Yes

01-106 01-107 01-108 01-109 01-110 01-111 01-112 01-113 01-114 01-115 01-116 01-117 01-118 01-119 01-120 01-121 01-507 01-508

Follow-up for Individuals Discharged from the State Hospital Who Were on the Americans with Disabilities Act (ADA) Ready to Discharge List

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

REVISED

Yes Yes Yes Yes Yes Yes

DBHDD Policystat Index

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B. Community Provider Network 01-199 01-200

Community Behavioral Health Provider Network Structure Comprehensive Community Provider (CCP) Standards for Georgia’s Tier 1 Behavioral Health Safety Net

Yes Yes

01-201 01-202 01-203 01-204 01-205 01-207 01-209 01-210 01-212 01-213 01-216 01-218 01-219 01-225 01-230

CCP Standard 1 - Access to Services CCP Standard 2 - Crisis Management CCP Standard 3 - Transitioning of Individuals in Crisis CCP Standard 4 - Engagement in Care CCP Standard 5 - Substance Use Disorder Treatment & Supports CCP Standard 7 - Recovery Oriented Care CCP Standard 9 - Administrative & Fiscal Structure CCP Standard 10 - Required Staffing CCP Standard 12 - Accreditation, Certification & Licensing CCP Standard 13 - Administrative Services Organization and Audit Compliance CCP Standard 16 - Benefits Eligibility CCP Standard 18 - Suicide Prevention CCP Standard 19 - Housing Access Process for Reporting Compliance with Standards for Tier 1 Comprehensive Community Providers (CCPs) Community Medicaid Provider (CMP) Standards for Georgia's Tier 2 Behavioral Health Services

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

01-231 01-231a 01-232 01-233 01-234 01-236 01-238 01-238a 01-239

CMP Standard 1 - Administrative Infrastructure CMP+ Standard 1 - Administrative Infrastructure CMP Standard 2 - Accreditation, Certification and Licensing CMP Standard 3 - Access to Services CMP Standard 4 - Engagement in Care CMP Standard 6 - Substance Use Disorder Treatment & Supports CMP Standard 8 - Required Staffing CMP+ Standard 8 - Required Staffing CMP Standard 9 - Administrative Services Organization (ASO) & Audit Compliance

Yes Yes Yes Yes Yes Yes Yes Yes Yes

01-240 01-241 01-242 01-245a 01-246a 01-249

CMP Standard 10 - Recovery Oriented Care CMP Standard 11 - Transitioning of Individuals in Crisis CMP Standard 12 - Crisis Management CMP+ Standard 15 - Benefits Eligibility CMP Standard 16 - Suicide Prevention Process for Reporting Compliance with Standards for Tier 2 Community Medicaid Providers (CMPs)


01-249a

Process for Reporting Compliance with Standards for Tier 2 Community Medicaid Providers (CMP+)

Yes

C. Psychiatric Residential Treatment Facility 01-300

Guidelines for Use of Psychiatric Residential Treatment Facilities for Comprehensive Community Providers

Yes

01-301 01-302 01-303 01-304 01-305 01-306 01-307 01-308

Psychiatric Residential Treatment Facility (PRTF) Manual PRTF General Definitions PRTF Definition and Service PRTF Conditions of Participation PRTF Staffing Requirements PRTF Training PRTF Service Requirements Description of Youth and Emerging Adults Served in a Psychiatric Residential Treatment Facility (PRTF)

Yes Yes Yes Yes Yes Yes Yes Yes

01-309 01-310 01-311 01-312

PRTF Referral Processes PRTF Application Process for Providers PRTF Level of Care PRTF Level of Care - Community Based Alternatives for Youth, Money Follows the Person, or Balancing Incentive

Yes Yes Yes Yes

01-313 01-314 01-315 01-316 01-317 01-318 01-319

PRTF Requirements at Admission and Utilization of Service PRTF Documentation Requirements PRTF Incidents and Incident Reporting PRTF Discharge Planning and Discharge PRTF Billing and Benefits Monitoring PRTFs Establishing and Maintaining Separation Between Multiple Programs and Facilities PRTF Evaluation

Yes Yes Yes Yes Yes Yes Yes

01-325 01-326 01-327 01-328 01-329 01-330 01-331 01-332 01-333 01-334 01-335 01-336 01-337

Behavioral Health Certification and Operational Requirements for Certified Crisis Stabilization Units (CSUs) CSU: General Certification Requirements CSU: Application Requirements CSU: Operation Scope of Services CSU: Program Description CSU: Evaluations and Admissions CSU: Provision of Individualized Care CSU: Documentation of Care CSU: Protection and Safety of the Individual and Others CSU: Pharmacy Services and Management of Medication CSU: Laboratory Services CSU: Food Services CSU: Infection Prevention and Control

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

D. Crisis Stabilization Units

DBHDD Policystat Index 01-338 01-339 01-340 01-341 01-342 01-343 01-344 01-345 01-346 01-347 01-348 01-349

Policy #

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1/16/2018 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

CSU: Rights and Responsibilities of Individuals CSU: Confidentiality CSU: Documentation of Legal Status CSU: Performance Improvement Plan and Activities CSU: Environment of Care CSU: Fire Prevention and Fire or Disaster Safety Requirements CSU: Human Resources CSU: Transportation CSU: Complaint Reporting and Incident Investigations Procedures CSU: Enforcement CSU: Sanctions and Penalties CSU: Waivers and Variances

CHAPTER-02

Developmental Disability Community Services

A. Intake and Evaluation 02-101

Planning Lists for Developmental Disability Services for Individuals Living in the Community

Updates

Applicable for Community Providers? Yes

B. Support Coordination, Planning List Administration, and State Services Coordination 02-430

Operating Principles for Support Coordination & Intensive Support Coordination Providers

Yes

02-431 02-432 02-433 02-434 02-435 02-436

Standards of Conduct and Ethics for Support Coordinator Providers Support Coordination Caseloads, Participant Admission, and Discharge Standards Support Coordination Contact Frequency Requirements Support Coordination Documentation Outcome Evaluation: “Recognize, Refer, and Act” Model Support Coordinator Responsibility for Assessments, Evaluations, and Healthcare or Behavioral Plans


02-437 02-438 02-439 02-440 02-441 02-442

Reporting Requirements for Support Coordination The Service Planning Process and Individual Service Plan Development Intensive Support Coordination for Participants in Crisis Respite Homes Support Coordination and the Critical Incident Process Participant Selection of Support Coordination/Intensive Support Coordination Provider Support Coordination and Intensive Support Coordination Eligibility Determination and Conditions for Transfer Between Services


C. Crisis and Emergency Response D. Family Support and Respite 02-102 02-401 02-402 02-403 02-406 02-407 02-408 02-409 02-410 02-411 02-412 02-413 02-415 02-416 02-417

State Funded Respite for Individuals with Developmental Disabilities Family Support Services for Developmental Disability Services - All Procedures Family Support Services Guiding Principles Family Support Services Provider Requirements Family Support Services Participant Eligibility Family Support Services Program Application Process The Family Support Services Program: Enrollment/Disenrollment Process Family Support Services Brokered Goods and Services List and Protocols Family Support Transfer Process Family Support Respite Services Family Support Review and Grievance Process Family Support Records Requirements Process Family Support Quality Assurance Process Family Support Technical Assistance Family Support Provider Budget

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

02-601

Community Integration in Residential Service Options and Supervised Apartment Living Arrangements for Individuals with Developmental Disabilities Region of Responsibility Determination for Developmental Disability Providers

Yes

E. Delivery of Community Services

02-602

Yes

F. Provider Enrollment and Requirements 02-701

Recruitment and Application to become a Provider of Developmental Disability Services

Yes

02-702

Management/Supervision/Safeguarding of Possessions, Valuables, Personal Funds and Day-To-Day Living Expenses in Developmental Disability Residential Services

Yes

02-703

Accreditation and Standards Quality Review Requirements for Providers of Developmental Disability Services

Yes

02-704

Process for Enrolling, Matching, and Monitoring Host Home/Life-Sharing Sites for DBHDD Developmental Disability Community Service Providers

Yes

G. Health and Safety 02-801 02-802 02-803 02-804

Prevention of Choking for Individuals with Developmental Disabilities Living in the Community Bowel Management for Individuals Diagnosed with Developmental Disabilities Living in Community Settings Health Risk Screening Tool (HRST) Exceptional Rate Submission and Review Procedures

Yes Yes Yes Yes

H. Clinical Technical Assistance and Support I. Training J. Quality Management 02-1101

Human Rights Council for Developmental Disability Services

Yes


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K. DD Administration 02-1201 02-1202

Policy #

Yes Yes

Provider Manuals for Community Developmental Disability Providers NOW and COMP Waivers for Community Developmental Disability Services

CHAPTER-03

Hospital Operations

A. Ethics, Rights and Responsibilities 03-102 03-105 03-106 03-108

Advance Directives for Health Care Detecting and Preventing Fraud, Waste and Abuse in DBHDD Operated Facilities and Services Peer Councils in DBHDD Hospitals Claims for Personal Injury, Loss or Damage of Belongings in DBHDD Hospitals

03-109 03-111 03-112 03-588 03-313

Claims for Small Property Loss or Damage in DBHDD Hospitals Satisfaction Surveys For Individuals Served by DBHDD Hospitals Staff Interactions with Individuals in Adult Mental Health and Forensic Units Guardianship Gift Giving to Individuals

B. Environment of Care 03-202 03-203 03-204 03-205 03-205-AT 03-205-CS 03-205-EC 03-205-SV 03-205-WC 03-206 03-206-AT

Nursing Staff Scheduling, Holdover, and Staff Sharing Cardio-Pulmonary Resuscitation (CPR), Automated External Defibrillator (AED) and First Aid Certification Emergency Code Designations for State Hospitals Medical Emergency Response System - All Hospitals Medical Emergency Response System for Georgia Regional Hospital - Atlanta Medical Emergency Response System for Central State Hospital Medical Emergency Response System for East Central Regional Hospital Medical Emergency Response System for Georgia Regional Hospital - Savannah Medical Emergency Response System for West Central Georgia Regional Hospital Medical Emergency Respiratory Support - All Hospitals Medical Emergency Respiratory Support for Georgia Regional Hospital - Atlanta

03-206-CS 03-206-EC 03-206-SV 03-206-WC 03-207 03-207-AT 03-207-CS 03-207-EC 03-207-SV

Medical Emergency Respiratory Support for Central State Hospital Medical Emergency Respiratory Support for East Central Regional Hospital Medical Emergency Respiratory Support for Georgia Regional Hospital - Savannah Medical Emergency Respiratory Support for West Central Georgia Regional Hospital Automated External Defibrillator Use - All Hospitals Automated External Defibrillator Use for Georgia Regional Hospital - Atlanta Automated External Defibrillator Use for Central State Hospital Automated External Defibrillator Use for East Central Regional Hospital Automated External Defibrillator Use for Georgia Regional Hospital - Savannah

03-207-WC 03-209 03-210 03-211 03-212 03-213 03-219 03-223 03-230 03-232 03-238 03-239 03-240 03-242 03-243 03-244 03-260 03-261 03-262 03-269 03-270 03-271 03-272 03-273 03-276 03-277 03-278 03-279 03-280 03-281 03-282

Automated External Defibrillator Use for West Central Georgia Regional Hospital External Transfer Information Form for Emergency Medical Services Contraband, Monitored Use and Discretionary Items in Adult Mental Health and Forensic Units Solid Waste Management and Recycling Emergency Medical Evaluations: Clinician Guidelines for When to Transport Lock and Key Management Electrical Safety Safe Use, Handling, and Storage of Flammable and Combustible Liquids Hazardous and Biohazardous Waste Lockout / Tagout Maintenance Department Warehouse Services And Inventory Control Environmental Services Equipment and Supplies Management Utility System Management Program and Plans Power Plant Maintenance Emergency Power System Inspection and Testing D.W.Ollerich Memorial Park at Clarks Hill Housekeeping Services Housekeeping Cart Management Wheelchair Cleaning Laundry Services for Hospitals that Provide Linen Services In-House Laundry Services for Hospitals that Contract for Linen Services Laundering Of Individuals' Clothing On Units Heating, Ventilation, and Air Conditioning (HVAC) Management Electrical Distribution System Managing the Failure of the Natural Gas System Management and Maintenance of East Central Regional Hospital Swimming Pool Elevator Evacuation and Emergency Management (CSH) Hazardous Chemicals, Materials, and Waste Management Program and Plans Hospital Communication Systems and Plans Medical Gas and Vacuum System Operation and Maintenance

Updates


DBHDD Policystat Index 03-283 03-285 03-286 03-287 03-288 03-289 03-290 03-291 03-292 03-293 03-294 03-295 03-296 03-297 03-298 03-299 03-805 03-910 03-930

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Management of Flooding Due to Plumbing Failure Preventive Maintenance of Boiler and Steam Systems Equipment Management Emergency Management Program and Emergency Operations Plans Managing the Water Distribution System Management of East Central Regional Hospital Public Water System Environmental Surveillance Rounds Tool Control on Treatment Units Interim Life Safety Measures (ILSM) Working with Law Enforcement to Prepare for an Active Shooter in DBHDD Hospitals Code Silver (Active Shooter Alert) for DBHDD Hospitals: Steps for Staff Actions to be Taken After an Active Shooter Incident Medical Equipment Management Program and Plans Security Management Program and Plans Management of Pregnant Women During an Emergency or Disaster Safety Program and Safety Management Plans in DBHDD Hospitals Rehabilitation Therapy Competency Plan Management of Secured and Monitored Use Items in SNF and ICF/IID Units DBHDD Skilled Nursing Facilities Quality Assurance Performance Improvement Plan

C. Leadership 03-300 03-301 03-302 03-303 03-304 03-305 03-307 03-308 03-309 03-310 03-311 03-324 03-325 03-326 03-327 03-314

Governing Bodies of DBHDD Hospitals Hospital Census Management Plan Chain of Authority and Organizational Structure Medical Staff Initial Credentialing and Privileging Medical Staff Reappointment and Reprivileging Medical Staff Bylaws Volunteer Program Management Space Allocation and Management Psychology Services and Competency Plan Administrative and Clinical Staff On Duty Public Access to Hospitals and State-Operated Services The Joint Commission Survey Management Team Committees Intra-Hospital Communication Employee Support after a Serious Adverse Event

D. Management of Human Resources 03-402 03-403 03-404

Safety-Care Training and Certification Professional Licensing or Certification Requirements and the Reporting of Practice Act Violations Supervision of Medical Students, interns, Residents, Nurse Practitioner Students and Physician Assistant Students

03-432 03-433

High Risk, Hazardous, Look-Alike and Sound-Alike Medications Management of Expired, Discontinued, or Recalled Medications

E. Provision of Care, Treatment, and Services 03-113 03-202 03-256 03-284 03-312 03-401 03-425

End of Life Care Nursing Staff Scheduling, Holdover, and Staff Sharing Ordering, Administering, and Dispensing Controlled Substances Ice Machine Cleaning and Ice Dispensing Managing Clothing and Other Donated Items Pharmacy Services DBHDD State Hospitals' Continuation of Community-Based Treatment Regimens for Opioid Dependency

03-427 03-428 03-429 03-431 03-432 03-433 03-501 03-502 03-503 03-504 03-505 03-509 03-510 03-514 03-515 03-516 03-517

Medication Purchasing, Receiving, and Storage Pharmaceutical Representatives and Drug Samples Management of Standard Unit Inventory Clozapine (Clozaril) Testing and Monitoring High Risk, Hazardous, Look-Alike and Sound-Alike Medications Management of Expired, Discontinued, or Recalled Medications Levels of Observation for Individuals in DBHDD Hospitals Criteria for Mental Health Admissions of Adults to DBHDD Hospitals Unit Safety Scans Suicide, Violence and Victimization Risk Assessment Medication Variance Reporting and Analysis Do Not Resuscitate (DNR) Orders Seclusion or Restraint Seizure Management Incident Management in Adult Mental Health and Forensic Units Medical Immobilization, Medical Protective Devices and Adaptive Supportive Devices Infection Prevention and Control

REVISED


Page 6 of 12

03-518 03-519 03-520 03-521 03-522 03-524

Pain Management Psychosocial Rehabilitation Mall Medical Evaluation Guidelines and Exclusion Criteria for Admission to State Hospitals and Crisis Stabilization Units Sentinel Events Physical and Nutritional Supports Adverse Drug Reaction Reporting and Intensive Review of Serious or Lethal Adverse Drug Reaction

03-525 03-526 03-527 03-528 03-529 03-530 03-531 03-532 03-533 03-534 03-536 03-537 03-538 03-539 03-540 03-542 03-543 03-544 03-546

Mortality Review Process for DBHDD Hospitals Treatment Standards for Patients Admitted to DBHDD Facilities Telemedicine Usage By DBHDD Hospitals Actions Necessary Upon Death of an Individual while in a DBHDD Hospital or Following Discharge from a DBHDD Medication Reconciliation at Admission and Transfer Management of Medication Brought to a State Hospital Discharge Medications and Prescriptions Supplied by DBHDD Hospitals DBHDD Medication Formulary and Non-Formulary Drugs Elopement Informed Consent and Involuntary Administration of Psychotropic Medication in DBHDD Hospitals Peer Review in DBHDD Hospitals Behavior Services in DBHDD Hospitals Individualized Recovery Plans (IRP) for Individuals in DBHDD Hospitals Consultation Report Form for Non-Emergency Medical Services Nursing Note Documentation Nursing Care of Individuals with Diabetes and Management of Diabetic Emergencies Abnormal Involuntary Movement Scale (AIMS) Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Procedures for Individuals with Developmental Disabilities Who are Referred to or Who Arrive at a DBHDD Hospital

03-547 03-548 03-549 03-550 03-551 03-552

Integrated Psychosocial Assessment (IPA) in DBHDD Hospitals Nursing Head Trauma Protocol Therapeutic Incentive Program (TIP) Admission Related Documentation for DBHDD Hospitals Psychiatric Assessments and Physician Progress Note Documentation in DBHDD Hospitals Assessment of Individuals with Both Developmental Disabilities and Mental Health Diagnoses (Dually Diagnosed Individuals) Medication Administration in DBHDD Hospitals Polypharmacy Data Review Process for DBHDD Hospitals Assessment of Individuals Regarding Substance Abuse Bowel Elimination and Management in DBHDD Hospitals Administrative Assessments at Admission to DBHDD Hospitals Change of Medical Status Social Work Repeat Admissions Review Process Social Work Documentation and Monitoring Social Work Service Plan and Competency Plan Annual Nursing Assessment or Comprehensive Review Discharge Packet for Adult Mental Health and Forensic Services Temporary Leave for Adult Mental Health and Forensic Units Discharge Planning Shift-Report Communication Between Healthcare Staff Nursing Facility Referral Temporary Leave for Individuals with Developmental Disabilities Monitoring Weight Change And Calorie Intake Daily Unit Census Procedures Community Meetings Rehabilitation Therapies – Occupational, Physical, Speech, and other Therapies Activity Therapy Services, 03-591 Nursing Standards and Approach to Care Individual Identification Protocol Prior to Treatment Management of Medications when Pharmacy is Closed Risk Management Prophylactic Antibiotics Adult Education Services, GED and Special Education Provision of Individual and Family Education Supporting the Religious and Spiritual Needs of Individuals Receiving Hospital Services Food Services Infection Control Incident Management in DBHDD Skilled Nursing Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities Parasitic Infestation - Bed Bugs, Lice, and Scabies Infection Control Practices During Construction Projects Dental Safety and Infection Control

03-553 03-554 03-555 03-556 03-557 03-558 03-560 03-561 03-562 03-563 03-564 03-565 03-566 03-567 03-568 03-570 03-584 03-586 03-587 03-590 03-591 03-592 03-593 03-596 03-601 03-602 03-605 03-606 03-607 03-611 03-615 03-617 03-618 03-619

1/16/2018

Yes Yes


Page 7 of 12

03-620 03-622 03-632 03-633 03-634 03-635 03-636 03-637 03-638 03-639 03-640 03-641 03-642 03-643 03-644 03-645 03-646 03-647 03-648 03-649 03-650 03-651 03-652 03-653 03-654 03-655 03-656 03-657 03-658 03-659 03-660 03-661 03-662 03-663 03-666 03-670 03-671 03-672 03-673 03-674 03-675 03-676 03-677 03-678 03-679 03-804 03-806 03-807 03-808 03-809 03-810 03-900 03-902 03-903 03-904

Inpatient Dental Services Dental Sedation Food Satisfaction Survey Management of Refrigerators Outside of Food Service Areas Food Temperature Management Food Safety and Sanitation Food Services Individual Food Choices and Menus Diet Orders and Special Diet Management Snacks, Supplements, and Juices Dental Post-Treatment Care Unit Schedule: Structured Time and Outdoor Breaks Diet and Nutrition Diet Roster and Tray Identification Timeout Prior to Dental Surgery Dental Instruments, Supplies, and Equipment Management Management of Personal Care Items Food Purchasing, Receiving, Production, and Preparation Dishwashing Procedures Pharmacy Quality Assurance and Performance Improvement Psychosocial-Related Assessment for SNF and ICF/IID Units Supervised Self-Medication Program for Individuals in Adult Mental Health Units and Forensic Units Food Services Special Functions Food and Nutrition Policies Hazardous Dental Materials Management and Handling Dental Desensitization Women's Health Daily Schedule for Meal Delivery GRHA Skilled Nursing Facility (SNF) Community Outings Adult Mental Health and Forensic Programs Community Outings Fire Safety Program and Fire Safety Management Plans Dental Services Policies and Procedures Consent for Dental Procedures Hospital Barber and Beautician Services Therapeutic Work Program Laboratory Policy Index ECRH Internal Laboratory Clinical Safety and Infection Control ECRH Internal Laboratory Services ECRH Internal Laboratory Specimen Collection ECRH Internal Laboratory Quality Assurance Laboratory Waived Testing and Blood Glucose Testing Use of Reference Laboratories Reference Laboratory Requests and Specimen Collection Laboratory Competency Assessments for ECRH Competency Assessments for Hospitals using Reference Laboratories Competencies for DBHDD Hospital Clinical Staff Nursing Staff Competencies Hospital New Staff Orientation and Ongoing Training Hospital Unit and Department Orientation and Training Activity Therapy Competencies Non‐Clinical Staff Human Resources‐Related Requirements Intermediate Care Facility for Individuals with Intellectual Disabilities - All Procedures Nail Care Procedure Provision of Individuals’ Personal Care Body Temperature Management for Individuals with Diagnosis of Hypothermia

03-905 03-906 03-907 03-911 03-913 03-914 03-915 03-916

Individual Appointments Unlocked Doors In Living Areas Individuals’ Mealtime Experience Lifting & Transferring Individuals Administrative Duty Officer: Campus Supervision Schedules for Sleep and Wake-Up Hours in ECRH SNF and ICF Approval for Alternate Programming Transportation of Individuals Served in Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF) at East Central Regional Hospital Body Checks Admission, Transfer, and Discharge in Skilled Nursing Facilities or Nursing Facility Units

03-917 03-918

1/16/2018


DBHDD Policystat Index 03-920 03-921 03-922 03-923 03-926

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Self-Medication Evaluation and Program for Individuals Served in Skilled Nursing Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities Care of the Individual with Enteral Feeding and Medication Minimum Staff Ratio Monitoring Vital Signs & Output Monitoring and Companion Sitters for Individuals Admitted to Local Medical Facilities

NEW

F. Information Management 03-701 03-702 03-703 03-704

Recording and Monitoring Via Electronic Media Use of Wireless Communication Devices in DBHDD Hospitals Creation, Structure and Content of Medical Records Preservation, Alteration, Falsification, Removal and Destruction of Medical Records

03-705 03-706 03-707 03-708

Avatar User ID and Password Sharing DBHDD Clinical Documentation Scanning Hospital Clinical Systems Downtime Plan Maintaining Unit Records

Policy #

CHAPTER-04

Administrative Issues for BH & DD Community Services

Updates

A. Administrative Issues Related to BH & DD Service Delivery


04-100 04-101

Access to DBHDD Policies for Community Providers Professional Licensing or Certification Requirements and the Reporting of Practice Act Violations

Yes Yes

04-102 04-104 04-106 04-107 04-108 04-109 04-110 04-112 04-117 04-120

Disaster Preparedness, Response, and Disaster Recovery Requirements for Community Providers Criminal History Records Checks for Contractors Reporting and Investigating Deaths and Critical Incidents in Community Services Requests for Waivers of the Standards for DBHDD Services Community Mortality Review Committee Guiding Principles Regarding Co-Occurring Mental Health and Addictive Diseases Disorders Guiding Principles Regarding Serving Those with Co-Occurring Behavioral Health Disorders and Developmental DBHDD Abbreviations and Acronyms Maintenance of Records for Closed Providers Transition Process for Individuals with Intellectual and/or Developmental Disabilities Moving from State Hospitals to Their Family Home or Community Residences

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Policy #

CHAPTER-06

Forensic Services

Updates


Updates


A. Forensic Services 06-101 06-102 06-103 06-104 06-105 06-106 06-107

Pretrial Evaluation of Criminal Defendants Evaluation and Treatment of Defendants Adjudicated Incompetent to Stand Trial (IST) The STEP System - Forensic STepwise Environmental Progression Risk Assessment on Forensic Inpatient Units Forensic Review Committees Victim Notification NGRI: Evaluation, Treatment and Release of Defendants Acquitted as Not Guilty by Reason of Insanity

06-108 06-109 06-110 06-111 06-113 06-114 06-115 06-116 06-117 06-118 06-513

Forensic Evaluator Certification Use of Telephones by Individuals Served in Forensic Units Initial Placement and Transfer of Individuals on Secure and Maximum Secure Units Key Control for the Cook Forensic Facility Discharge Planning on Forensic Units Key Control For Forensic Units at Regional Hospitals Control Room and Electromagnetic Locks in Cook Facility Use of Electronic Media Devices by Individuals Served in Forensic Units Development and Maintenance of the Forensic File Visitation to Forensic Units Use of a Security Device While Transporting an Individual Under the Jurisdiction of the Criminal Justice System

Policy #

CHAPTER-13

Accountability & Compliance

13-101 13-102 13-103

Internal and External Reviews and Corrective Action Plans Compliance Outcomes for DBHDD Behavioral Health Community Providers Internal and External Reviews: Accountability and Enforcement Actions,13-103

13-200 13-201 13-202 13-203 13-205 13-208 13-900 13-901

Community Service Board Oversight Community Service Board Oversight: Authority and General Responsibilities Community Service Board Oversight: Fiscal Standards and Practices Community Service Board Oversight: Financial Audits Practice Community Service Board Oversight: Approval of Executive Director Selection and Compensation Community Service Board Risk Assessment, Mitigation and Intervention Federal Grant and Award Management System Policies and Procedures PATH Program Federal Award Internal Controls (CFDA 93.150)

Yes Yes Yes Yes Yes Yes Yes Yes Yes


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13-902 13-903

Generation Rx Program Federal Award Internal Controls (CFDA 93.243) Georgia Home Recovery Program Federal Award Internal Controls (CFDA 93.243)

13-904 13-905 13-906 13-907 13-908 13-909 13-910 13-911 13-912

Georgia Suicide Safer Communities for Youth Project Program Federal Award Internal Controls (CFDA 93.243) Tapestry Program Federal Award Internal Controls (CFDA 93.243) Treatment Courts Program Federal Award Internal Controls (CFDA 93.243) Temporary Assistance for Needy Families (TANF) Program Federal Award Internal Controls (CFDA 93.558) Medicaid, (CFDA 93.778) MHBG Child and Adolescent Program Federal Award Internal Controls (CFDA 93.958) MHBG Care Management Entity (CBAY) Program Federal Award Internal Controls (CFDA 93.958) Georgia Mental Health Consumer Network Federal Award Internal Controls (CFDA 93.958) Light Early Treatment Program Federal Award Internal Controls (CFDA 93.958)

13-913 13-914 13-915

Georgia Mental Health Club Program Federal Award Internal Controls (CFDA 93.958) PEER Program Federal Award Internal Controls (CFDA 93.958) Supported Employment Program Federal Award Internal Controls (CFDA 93.958)

13-916 13-917 13-918

SABG Adult Program Federal Award Internal Controls (CFDA 93.959) SABG Child and Adolescent Program Federal Award Internal Controls (CFDA 93.959) National Suicide Prevention Lifeline Program Federal Award Internal Controls (CFDA 93.959)

CHAPTER-15

Policy #

Updates


Audits

Updates


Budget and Finance

Updates


Updates


Access to Services

A. Limited English Proficiency and Sensory Impairment 15-100

Nondiscrimination and Accessibility for Individuals with Disabilities and Individuals with Limited English Proficiency

15-101 15-111

DBHDD Hospital Access Coordinators Provider Procedures for Referral and Reporting of Individuals with Hearing Loss

CHAPTER-16

Policy #

Yes

A. Audits 16-101 16-102 16-103 16-104 16-105

External Entities and Audit Standards Internal DBHDD Audits and Audit Standards Financially Weak and High Risk Contractors and Grantees Audits and Other Examinations Performed by Outside Agencies Audit Exceptions, Fund Deferrals and Disallowance

CHAPTER-17

Policy # A. Budget 17-101

Federal Grant Earmarking Requirements Verification Calculations

B. Grants and Funds Management 17-201 17-202 17-203

Grant Application and Award Processing Federal Fund Source and Parent Project Code Assignments Federal Financial Report Preparation, Reconciliation and Submission

C. General Accounting 17-301 17-302

Journal Voucher and Journal Entry Processing Cash Donations and Other Non-Appropriated Funds Management

D. Payroll E. Accounts Payable 17-501 17-502 17-503

Travel Reimbursement for DBHDD Employees Managing and Reporting Open Purchase Orders and Encumbrance Balances for State Funds Reimbursement to Employees for Damaged Clothing and Related Items Caused by Individuals Receiving Services

CHAPTER-18

Policy #

Communications and Media Relations

A. Communications 18-100 18-101 18-103 18-104 18-105 18-106 18-107

Purpose, Scope, Roles, and Responsibilities of DBHDD's Office of Public Affairs Branding, Style, and Logo Use Handling of Mail and Packages Across the DBHDD Enterprise Communication of DBHDD Information via Social Media Requests from Media Sources to DBHDD Staff for Comments or Information DBHDD Written Communications to Elected Officials and Their Staff Requests for Letters of Support

CHAPTER-19

Policy # A. Complaints 19-101

Complaints and Grievances Regarding Community Services

Yes

Yes

External Affairs

Updates



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CHAPTER-20

Policy #

Facilities and Property Management

Updates


Updates


A. Support Services 20-101

Preparing for Active Shooter at DBHDD State Office (2 Peachtree) and Regional Field Offices

B. Space Management and Leasing 20-201

Tobacco-Free and Smoke-Free Environment in DBHDD Facilities

C. Personal Property Management 20-300 20-301 20-302 20-303 20-305

Personal Property Management and Building & Capital Improvements Personal Property Acquisition & Accountability Missing or Stolen Property Disposition of Personal Property Release of Personal Property

D. Real Property 20-102 20-103 20-402 20-403 20-404 20-406

Tornado Planning at DBHDD State Office (Two Peachtree Building) Continuity of Operations Planning (COOP) at DBHDD State Office (Two Peachtree Street) Processing of Real Property Transactions Naming or Renaming of a Building, Facility, Structure or Cemetery, etc, Use of DBHDD Facilities by Outside Groups Preparation and Processing of DBHDD Board Resolutions

CHAPTER-21

Policy #

Procurement and Contracts

A. Procurement 21-101 21-102 21-103

Yes

Financial and Reporting Requirements for Community Providers Purchasing Card (P-Card) Process and Procedures Delegation of Authority to Execute Contracts

B. Contracts 21-201

Accounts Payable Contract Forms

CHAPTER-22

Policy # A. General Policies 22-101 22-102 22-104 22-105 22-106 22-107 22-108 22-109 22-110 22-111 22-112

Equal Employment Opportunity & Unlawful Discrimination Sexual Harassment Access to Human Resources Policies Delegation of Authority Assignment of Duties Third Party Involvement Administrative Closing of Offices Notices Required to be Posted Preventing Workplace Violence Teleworking Retirement Celebrations

B. Job Analysis 22-201

Position Level Reduction

C. Unclassified Service 22-302

Movement from Classified to Unclassified Employment

D. Recruitment and Selection 22-401 22-402 22-403

Recruitment Selection Medical and Physical Examination Program (MAPEP)

E. Appointments 22-501 22-502 22-503 22-504 22-505

Employee Orientation Working Test and Permanent Status for Classified Employees Verifying Identity and Employment Eligibility Criminal History Record Checks for DBHDD Employees Criminal History Record Checks for Nursing Home Units

F. Records and References 22-601 22-603

Employment Information Official Personnel Files

G. Performance Evaluations 22-701

Performance Management Program (PMP)

H. Salary Compensation/Payroll 22-801 22-802 22-803 22-804 22-807

Calculation of Salary Payments Salary Adjustments Incentive Pay and Meritorious Awards Advanced Salary Hiring Recovery of Overpayments

Human Resources

Updates



Page 11 of 12

1/16/2018

I. Benefits 22-901 22-902 22-903 22-904

Eligibility for Benefits Flexible Benefits Health Insurance Employee Behavioral Health Services

J. Leave/Holidays/Working Hours 22-1001 22-1002 22-1003 22-1004 22-1005 22-1006 22-1007 22-1008 22-1009 22-1010 22-1011 22-1012 22-1013 22-1014

Fair Labor Standards Act Official Hours and Work Schedules Administration of Employee Leave Program Observance of Holidays Family and Medical Leave Annual, Sick and Personal Leave Leave of Absence Without Pay Court Leave Military Leave Leave Donation Short Term/Other Leave Without Pay State Compensatory Time Miscellaneous Leave/Time Hourly Employment

K. Promotions/Demotions/Transfers 22-1101 22-1102 22-1103

Promotions Demotions Transfer of Employees

L. Standards of Employment 22-1201 22-1202 22-1203 22-1204 22-1205 22-1209

Standards of Conduct and Ethics in Government Political Activity Other Employment Employment Status of Relatives Use of State Property Staff Appearance and Dress

M. Drug Testing 22-1301 22-1302

Drug-Free Workplace Alcohol and Drug Testing Programs

N. Reserved for Future Use O. Dispute Resolution Procedures 22-1501 22-1502 22-1503 22-1504 22-1505

Grievance Procedure for Classified Employees Grievance Procedure for Unclassified Employees Unlawful Discrimination Complaint Procedure Process for Review of Written Reprimands Mediation Procedure

P. Disciplinary Actions/Separations 22-1601 22-1602 22-1603

Disciplinary/Dismissal Actions - Classified Employees Disciplinary/Separation Actions - Unclassified Employees Personnel Actions in Cases of Abuse, Neglect and/or Exploitation of Individuals Served by DBHDD

22-1701 22-1702 22-1704

Workers' Compensation and Special Injury Return-to-Work Program Leave and Payment for Workers' Compensation and Special Injury Claims Americans with Disabilities Act

Q. Employee Injuries/Disabilities

R. Other Employee Programs 22-1801 22-1802 22-1803

Charitable Contributions Program Employees' Suggestion Program Education and Training for DBHDD Employees

S. Separations/Reductions-in-Force 22-1901 22-1902 22-1903 22-1904 22-1905

Separations From Employment Retirement Unemployment Compensation Involuntary Separation - Retirement Benefits Staff Reduction

T. Licensure/Certification 22-2001 22-2002

Policy #

Professional Licensing of DBHDD Employees Teacher Certification and Compensation

CHAPTER-23

Information Management & Information Technology

A. HIPAA Privacy and Security 23-000 23-100 23-101 23-102

HIPAA and Confidentiality - All Policies Confidentiality and HIPAA Notice of Privacy Practices Reporting and Notification of Breaches of Confidentiality

Updates

Applicable for Community Providers? Yes Yes Yes Yes

DBHDD Policystat Index 23-103 23-104 23-105 23-106 23-107 23-108 23-109 23-110

Page 12 of 12

1/16/2018 Yes Yes Yes Yes Yes Yes Yes Yes

Confidentiality and HIPAA Privacy Complaints Sanctions Related to Confidentiality and HIPAA Rights of Individuals regarding their Confidential and Protected Health Information Disclosures of Confidential and Protected Health Information Confidentiality and HIPAA Practice Involving Business Associates Faxing Protected Health Information (PHI) Georgia Health Information Network (GaHIN) Authorization for Release of Information (ROI) Forms

B. Information Security Standards 23-200 23-201 23-205

Information Security Policies Wireless Devices for DBHDD Staff Physical and Environmental Security to Prevent Unauthorized Disclosure of Information

23-206 23-207 23-208 23-209 23-210 23-211 23-212 23-213 23-214 23-215 23-216 23-217 23-218 23-219 23-221 23-222 23-223 23-225 23-227 23-228 23-229 23-230 23-231

General Information Security Administration of Security Role-Based Access to Information Technology Communications and Operations Management to Ensure Information Security Systems Development and Maintenance to Ensure Information Security Information Security Compliance Standards Email Use and Security Secure Disposal and Re-Use of Information Assets Use of Removal Storage Devices to Store Protected Health Information (PHI) Use, Access, Dissemination, Storage, Protection, and Destruction of Criminal History Record Information Expectation of Privacy When Using DBHDD Technology Devices Information Security Awareness Training Password Structure Appropriate Use of Information Technology (IT) Resources Remote Access Review of Information Security Policies, Standards and Guidelines Security Incident Discovery and Reporting Waivers to DBHDD Security Policies, Standards and Guidelines Cloud Computing Data and Asset Categorization and Impact Levels Individual Use Agreement Information Asset Incident Response Plan User Provisioning and Deprovisioning

C. IT Governance 23-301 23-302

Process for Requesting Changes to Existing IT Applications Data Governance

D. Technology Service Standards E. Records Management 23-501

Yes

Records Management

CHAPTER-24

Policy #

Legal Services

Updates

A. Legal Services 24-101 24-102 24-103 24-105 24-106 24-107 24-109

Policy #

Access to Public Records Pursuant to the Georgia Open Records Act Open and Public Meetings Patients' Rights and Clients' Rights Responding to Legal Documents and Responding to Outside Attorneys Legal Status for DBHDD Hospitals Legal Status for Intellectually Disabled Individuals in DBHDD Hospitals Verification of Lawful Presence in United States for Individuals Seeking Services and Related Discharge Procedures

CHAPTER-25

Protection of Human Subjects

Yes

Yes Yes

Updates

A. Protection of Human Subjects 25-101

Research, Protection of Human Subjects, and Institutional Review Board (IRB)

25-102

Submission, Approval, and Oversight of Research Projects using DBHDD Datasets

Policy # 26-101

CHAPTER-26

CHAPTER-27 Transportation

A. Coordinated Transportation System 27-101

Updates


Updates


State Automobile, Liability and Property Insurance Services

Policy #

Transportation and Management of DBHDD Vehicles


State Automobile, Liability and Property Insurance


DBHDD PolicyStat Index - DBHDD Applications

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