Bluebonnet Trails Community MHMR
Center
Policies and Operating
Procedures
(Last Revision to
the Index 8/13/2007)
Lines in
blue are active links. Black lines are for
reference purposes only.
I.
ADMINISTRATIVE FUNCTIONS AND OPERATIONS
A. Administrative Functions
1. (Policy) Travel Policy
a.
(Procedure) Travel Procedure
2.
(Policy) Board Travel Policy
3.
(Policy) Board Attendance Policy
4.
(Policy) Travel Policy Reimbursement
B.
Operations
1.
Vacant
2.
Vacant
3.
(Policy) Property Inventory
a)
(Procedure) Property Inventory
II.
CLIENT RIGHTS
A.
Human Rights
Committee
1.
Review of
Organizational Practices
2.
Review of Rights
Restrictions
(1)
Attachment A: You
have the rightΧ
3.
Review of
Intrusive/Restrictive Behavior Therapy Programs
a)
(Policy) Behavior
Management (Substance Abuse Services)
B.
Client Abuse,
Neglect, and Exploitation
C.
Client Abuse,
Neglect, and Exploitation Review Authority
1.
Vacant
2.
Other
Investigations
III.
CLIENT SERVICES
A.
List of Services
1.
(Procedure) Client Services-ECI
B.
Admission/Discharge
1.
Intake
a)
(Procedure) Screening and Intake (MR) deleted
2/8/02
b)
(Procedure) Admission/Discharge: Intake/Screening
(ECI)
c)
(Procedure) Screening & Intake (MR)
d)
(Procedure) Mental
Health Procedure for Admission to Services
e)
(Procedure) Waiting List Procedure for MH Services
(1) Attachment C- Waiting List Letter
f)
(Procedure) Mental Health Discharge Determination
g)
(Procedure) Admission/Discharge: Assessment and
Eligibility Process (ECI)
2.
MR Appeals
a)
(Procedure) Termination
of Services
(1) Attachment A Letter - MR Termination of Services
(2) Attachment A1 Letter - MR Termination of Services
(Span)
(3) Attachment B
Letter - MR Termination of Medicaid Services
(4) Attachment B1
Letter - MR Termination of Medicaid Services (Span)
(5) Attachment C
Letter - MR Notice of Appeal Decision (Termination)
b)
(Procedure) MR
Denial of Services Procedure
(1) Attachment A Letter - MR Denial of Services)
(2) Attachment A1 Letter - MR Denial of Services (Span)
(3) Attachment B Letter - MR Denial of Medicaid Serv Coord
(4) Attachment B1 Letter - MR Denial of Medicaid Serv
Coord (Span)
(5) Attachment C: Letter - MR Denial Appeal Decision
3.
MH Apeals
a)
(Procedure) Mental
Health Appeals for Denial of Services
(1) Attachment A Letter Medicaid Fair
Hearing
(2) Attachment B Letter Referral Letter
(3) Attachment B.1 Letter Referral Letter (Spanish)
(4) Attachment C Letter Waiting List Letter
(5) Attachment D Letter Crisis Denial Letter
(6) Flow Chart Crisis
(7) Flow Chart Denials of Admission
b)
(Procedure) Mental Health Appeals for Reduction of
Services
(1) Attachment A Letter Right to Appeal Reduction Letter
(2) Attachment B Letter Medicaid Fair Hearing Letter
(3) Flow Chart Non-Medicaid
(4) Flow Chart Medicaid
c)
(Procedure) Mental Health Appeals for Termination of
Services
(1) Attachment A Letter - Notice of Termination of
Services
(2) Attachment B Letter - Medicaid Fair Hearing
(3) Flow Chart Non-Medicaid
(4) Flow Chart Medicaid
d)
(Procedure) Appeals
to the MH Authority from a Provider
4.
Screening and Emergency
Services
a)
(Procedure) Screening and Crisis (MH)
b)
(Procedure) Admissions/Discharge: Emergency
Services (ECI)
5.
MR Waiting List Management
6.
Authorization for
Services
a)
(Procedure) Determination of Mental Retardation
(1)
Attachment: DMR
Report
b)
(Procedure) Admission/Discharge: Authorization
for Services (ECI)
C.
Charges for
Services
1.
(Procedure) Charges
for Services (MR & MH)
a)
Attachment A: Fee Scale for 2006
b)
Attachment B Financial Form and Attachment
c)
Attachment C: Consumer Brochures
(1)
English
(2)
Spanish
d)
Attachment D: Standard Charges, fee schedule MH
e)
Attachment E: Standard Charges, fee schedule MR
f)
Attachment F: Non
General Revenue Financial Form
2.
(Policy) Payment for Services
3.
(Procedure) Charges for Services (ECI)
4.
(Procedure) Consumer Benefits Unit
5.
(Policy) Bed
Hold Policy for ICFMR Programs
D.
Individualized
Treatment/Service Plans
1.
(Procedure) Individualized Treatment/Service Plans:
IFSP- ECI
2.
Person Directed and Family Directed Planning
E.
Continuity of
Services/Service Coordination
1.
(Procedure) Continuity of Services (MH)
2.
(Procedure) Continuity of Care: MR Authority
Functions for HCS (MR)
3.
(Procedure) MR Service Coordination (MR)
4.
(Procedure) Continuity of Services (ECI)
5.
(Procedure) Service Coordination Eligibility-MH
F.
Availability/Accessibility
of Services
1.
(Procedure) Access to Services Mental Health
a)
Attachment A: New
Applicants Letter Requiring Medicaid/Chip Application
2.
(Procedure) Availability/Accessibility to Services
(ECI)
G.
Transportation of
Consumers
H.
Death/Burial
1.
(Procedure) Burial Policy (MR)
I.
HCS
1.
HCS Enrollment
2.
HCS Transfer Process
J.
Billing Protocols
K.
Respite
L.
Vacant
N.
Chain of Command
(MR)
O. General Procedures for Day
Activity/Habilitation
P.
MRLA
1.
MRLA Waiting List Management
2.
MRLA Enrollment Procedure
3.
Communication With Providers
4.
MRLA Transfer Procedure
5.
MRLA UR Procedure
6.
MRLA Appeals Procedure
Q.
(Procedure) MH
Residential Services Contracted Assisted Living Group Homes
R. (Procedure) Texas Correctional Office on Offenders (TCOOMMI)
S.
OSAR Statement of Work
T. Seven Day Follow-Up
Procedure for State Facility Discharges
IV.
CLIENT RECORDS
ADMINISTRATION
A.
Clinical Records
B.
Clinical Records
Committee
1.
(Procedure) Clinical Records Committee
C.
Vacant
D.
Vacant
E.
Release and
Confidentiality of Clinical Information
1.
(Procedure) Confidentiality, Security and Access of Client Records and
Client-Identifying Information
2. (Procedure) Access to Clinical Records
F.
Record
Duplication Fees
1.
(Procedure) Clinical Record Duplication Fees
V. COMMUNITY RELATIONS
VI.
CONTRACT
MANAGEMENT
A.
Vacant
D.
Initiating and
Referral to Network Provider
F.
Vacant
G.
Contractor/Provider
Responsibilities
1.
(Procedure) External Counseling
H.
Vacant
I.
Vacant
K.
(Procedure) Initiating and Referral to Network
Provider Services Counseling
VII. FISCAL MANAGEMENT
A. Investment
Policy
B. (Procedure) Cash Receipts
VIII.
FIXED ASSETS
A. (Procedure) Procurement Credit Cards
IX.
HUMAN
RESOURCES
A.
(Policy) Leave Policies
1.
(Procedure) Leave Procedure
2.
(Procedure) FMLA
3.
(Procedure) Inclement Weather Procedure
4.
(Procedure) Injury/Illness on the Job
B.
1.
(Policy) Donation of Paid Leave Time for Illness
Policy
2.
(Procedure) Donation
of Paid Leave Time for Illness Procedure
C. (Procedure) Workers
Compensation
D.
(Procedure) Time and Attendance
E.
(Procedure) Return to Work
1.
Attachment
A: Bona Fide Job Offer Example
2.
Attachment B: Responsibilities of Host Department
3.
Attachment C:
Termination of RTW Duty by Employee
4.
Attachment D:
Temporary RTW Respons. Of Employee
F. (Policy) Employee
Evaluations
G.
(Policy) Equal Employment Opportunity
1.
(Procedure) Productivity Pay
2.
Attachment A: Productivity Pay MH Services
3.
Attachment B: Productivity Pay MR Services
H.
Separations,
Suspensions, and Demotions
1.
a)
(Policy) Disciplinary Action Policy
b)
(Procedure) Disciplinary Action Procedures
2.
a)
(Policy) Corrective Action Policy
b)
(Procedure) Corrective Action Procedures
3.
a)
(Policy) Privacy
Violation Policy
b)
(Procedure) Privacy Violation
I.
Overtime Procedure
K.
(Policy/Procedure) Grievance Procedures
L. (Procedure) Temporary
Modified Duty
O. (Procedure) Staff
Turnover
P.
Policy) Vehicle Operator Standards
Q.
(Procedure) Probation Period
R. (Procedure) Selection
of Personnel
X.
HUMAN RESOURCE DEVELOPMENT
A.
Vacant
B.
Vacant
C.
Competency-Based
Training
1.
(Procedure) Human Resource Development
2.
(Policy) Human Resource Development (Deleted)
D.
(Policy) Educational Leave Policy
E. (Procedure) Educational
Leave Procedure
F.
Vacant
G.
(Procedure) Service Coordination
Training
XI.
INFORMATION
SERVICES
A.
(Policy) Internet Policy (revised 10/03/01)
XII.
MEDICAL SERVICES
A.
Vacant
B.
Ongoing Medical
Assessment and Treatment
1.
(Procedure) Nursing Procedures for Mental
.Retardation
a)
Attachment A:
ICF-MR Standards of Participation Summary
b)
Attachment B:
American Cancer Society Screening Recommendations for Early Detection for Men
c)
Attachment C: American
Cancer Society Screening Recommendations for Early Detection for Women
d)
Attachment D: AMA
General Guidelines for Good Health for Men
e)
Attachment E: AMA
General Guidelines for Good Health for Women
f)
Attachment F: AMA
Pediatric Guidelines-Children
2.
(Procedure) Treatment
Services and General Medical Care
b)
Attachment B:
Medical Incident Form
C.
Medication
Acquisition, Storage and Distribution
1.
(Procedure) Standards of Care-Medication Services
a)
Attachment A: Drug
Program
b)
Attachment B: Drug
Application
c)
Attachment C:
Pharmacy Overview
d)
Attachment D: MH
Centers
D.
Infection Control
a)
Appendix A
Hepatitis B Vaccine Declination Statement
b)
Appendix B
Assessment Tool
E.
Vacant
F.
(Procedure) Credentialing and Competency-Nursing Peer Review (Deleted)
G.
(Procedure) Advanced Directives
1.
Exhibit A:
Directive to Physicians and Family or Surrogates
2.
Exhibit B:
Disclosure Statement for Medical Power of Attorney
3.
Exhibit C:
Procedure When Person Has Not Executed or Issued a Directive and is Incompetent
or Incapable of Communication
4.
Exhibit D:
Out-Of-Hospital Do Not Resuscitate Order
5.
Exhibit E Consent
to Medical Treatment
H. (Procedure) Expired
or Discontinued Medications/MH
1.
Appendix A Log of
Expired or Discontinued Medications
I.
(Procedure) Special
Medical Needs
J.
(Procedure) Medication
Errors
K. (Procedure) LVN On-Call Protocol
XIII. PURCHASING AND
SUPPLY
XIV. RISK MANAGEMENT
A.
General Safety
and Safe Workplace
C.
(Procedure) Maintenance
1.
(Procedure) Minimum Facility
Standards Environment for a Community Residence
a)
Attachment A:
Fire/Evacuation Drill Revised 6/03)
a)
Attachment A:
Monthly Drivers Inspection
b)
Attachment B:
Emergency and Vehicle Accident Information
c)
Attachment C:
Claims Notice
d)
Vehicle Use
Report
3.
(Procedure) Service Site Safety, Sanitation and Maintenance
D.
(Procedure) BTCMHMRC Safety Committee
E.
(Procedure) Vehicle Use
F.
Vacant
G.