Family Support Services Site Audit Tool
Rights, Responsibilities and Ethics
1
There is a policy and procedure about member's/member family's rights, responsibilities, and ethics.
The following is part of the intake paperwork filled out and signed by each new incoming member:
Welcome to our facility.
As a participant receiving mental health services, you have certain rights, some defined by law, others by professional ethical codes, and others by the policies of this agency. You have the right to be fully informed of your rights and to have any questions answered about things you do nor understand.
YOUR RIGHTS INCLUDE:
- The right to decide on the provider you want to obtain services. It is our policy to provide services requested and to assist participant in finding another agency if they so desire.
- The right to be treated with dignity and respect.
- The right to a safe environment during behavioral health services, free from physical, sexual, or emotional abuse and from discrimination on the basis of race, gender, age, religion, national origin, or sexual orientation.
- The right to be informed about the professional qualifications of the providers involved in your treatment, and to be treated only by persons who are trained and qualified to provide treatment.
- The right to be informed about you or your child's mental health services, including potential benefits, the scientific basis for treatment recommendations, any risks that treatment might involve, and what alternatives there might be. This includes the right to be informed of the potential benefits and prospects of success of any treatment, the possible side effects of any medication and of the risks of any counseling procedure.
- The right to participate in planning and making decisions about you or your child's treatment.
- The right to refuse any particular medication or treatment technique or to withdraw from treatment at any time. If you request referral to another behavioral health worker, we will provide you with a list of qualified professionals.
- The right to be informed in writing about fees, payment methods, co-payments, and frequency and duration of sessions and treatments.
- The right to have access to your treatment plan, mental health assessment, and to be informed of your diagnosis, prognosis, and progress in treatment.
- The right to privacy and confidentiality in your treatment, including the right to know if your behavioral health worker will discuss your case with supervisors or colleagues.
- The right to have your clinical information released to any person or agency of your choice.
- The right to register a complaint if you are dissatisfied with your treatment, without fear of retaliation. You have the right to be assisted in filing a grievance if your need assistance.
Scientific research show that behavioral health services have helped many people, and that most people who engage in behavioral health services are helped by it, but success is never guaranteed. There are some risks as well as benefits. It is important that you know that, as problems are faced, they may seem to get worse before they get better. As you learn new ways of thinking and acting, you may make choices which may lead to conflict with others in your life. We will try hard to limit these risks, and to help you cope with any distress you encounter, but even positive change can be difficult and sometimes painful.
As a participant, you also have responsibilities. For behavioral health services to be successful, you must be an active participant. This means maintaining a consistent schedule with your behavioral health worker, talking openly to your therapist and/or other behavioral health worker about your concerns, and sometimes practicing new skills between sessions. It is your responsibility to call 24 hours in advance if you must cancel an appointment. It is also your responsibility to let us know of any changes in insurance companies or benefits, or of other factors that might affect your ability to pay for treatment.
2
There is a policy and procedure about family's involvement in care and services.
Member and Family Education and Involvement
Our facility will involve the member and their family when applicable and appropriate at the time of assessment in the treatment provided. This will be true of all treatment modalities provided by our facility.
The staff assigned to provide treatment will educate the member and family members about the modalities of services, benefits and risks of treatment, and provide for education about medications by appropriate professionals.
3
There is a policy and procedure about member's involvement in care.
Member and Family Education and Involvement
Our facility will involve the member and their family when applicable and appropriate at the time of assessment in the treatment provided. This will be true of all treatment modalities provided by our facility.
The staff assigned to provide treatment will educate the member and family members about the modalities of services, benefits and risks of treatment, and provide for education about medications by appropriate professionals.
4 There is a policy and procedure about confidentiality.
All worksite associates with access to confidential information may not use that information for personal gain. Once an associate becomes separated from our facility he or she is not allowed to divulge or use any of the our facility worksites’ confidential information or trade secrets directly, or indirectly, personally, or on behalf of any other person, business, or corporation or entity. Such confidential information includes, but is not limited to, the following examples:
Patient Information
Customer Lists
Corporate Strategies
Financial/Accounting Information
Manual of Operations
Marketing Strategies
Personnel Data
Pending Projects
Research & Development Information and Strategies
Worksite Associate Information
Inappropriate disclosure of proprietary and/or confidential information of inappropriate removal of records may result in disciplinary action up to and including termination and legal action for damages.
The following is included in our intake paperwork and is to be signed by each incoming prospective member.
Mental Health Clinic Services: HIPAA & Confidentiality (Medicaid Provider Agreement Page 1 of 3.1. Compliance):
Our facility will ensure accurate documentation regarding HIPAA Privacy Statement
Our facility will define what a participant’s right entails in their medical record
Our facility will ensure the clinic observes confidentiality practices
Our facility will ensure standard employee confidentiality agreement
Our facility will ensure that clinical medical record information is available to employees on a need-to-know basis
Our facility will ensure the definition and documentation for violations of confidentiality
Our facility will ensure accuracy in reporting HIPAA violations. This policy should include internal investigations and resolution and also show ability for anyone in the clinic, participant or employee to report to the Federal Government
Our facility will ensure the clinic’s security (e.g., double-locked clinical files)
Our facility will ensure a safe electronic exchange of Protected Health Information
Our facility will ensure a contingency plan for responding to emergency or disaster that damages systems that contain Protected Health Information.
The privacy of your treatment is protected by federal and state laws, as described in the Notice of Privacy Practices statement you have received. Because we are obligated by law and professional ethics to protect you and other members of society from harm, there are circumstances under which your right to confidentiality may be limited:
If we learn of an imminent danger to someone’s life or health (such as threat of suicide or homicide);
If we learn that a child or other vulnerable person is being abused or neglected;
If we learn that a communicable disease (such as HIV) may be transmitted and the person at risk has not been informed;
If we are ordered by a court to divulge information about you;
If a medical emergency occurs while you are at the clinic, we will share just enough information with medical personnel to ensure that you receive needed treatment.
STATEMENT OF INFORMED CONSENT
I have carefully read or had read to me the above statement of my rights and responsibilities as a participant in mental health treatment. I have also had a chance to ask questions and obtain additional information needed to make a decision about entering mental health treatment. By my signature, I certify that my options for mental health services have been explained to me including a choice of who provides these services. I freely give my informed consent to receive mental health treatment from our behavioral health facility and acknowledge that I have been given a copy of this statement.
Environment of Care
5 The agency location is easily identifiable from the street.
There is signage at our entrance.
6 There is a policy addressing safety and security.
Security: All individuals entering our facility must first check in with the administrative/office staff located in the reception area. Suspicious behaviors or concerns are to be brought to the attention of our facility's staff to assess potential risks. If a consensus of danger/risk is determined, immediate alerts will be placed to local law enforcement and our facility executive management.
7 There is a policy or written criteria addressing control of hazardous materials and wastes, including management of any spills of bodily fluids (This question applies to all agencies).
Toxic Substances: Our facility will ensure hazards or toxic substances are properly labeled and stored under lock and key.
Procedure for cleaning up blood or bodily fluids on hard surfaces:
Blood, vomit and feces may contain germs that can cause serious infections. People who clean blood and other bodily fluids should reduce the risk of infection to themselves and others by following these procedures:
Procedure for Blood Spills/Vomit/Feces
1. Wear appropriate personal protective equipment, such as disposable gloves when cleaning up a spill. If the possibility of splashing exists, protective eyewear and a gown should be worn. Eye glasses are not considered to be protective eyewear.
2. Dispose with care, any broken glass or sharps into a puncture-proof container. If available, disposal of sharps into an approved sharps container for biomedical waste is preferred.
3. Clean the spill area with paper towel to remove most of the spill. Disinfectants cannot work properly if the surface has blood or other bodily fluids on it. Cloth towels should not be used unless they are to be thrown out.
4. Discard the paper towel soaked with the blood, vomit, feces or fluid in a plastic-lined garbage bin.
5. Care must be taken to avoid splashing or spraying during the clean up process.
6. Clean the affected area with soap and water then disinfect with a 1:10 bleach solution for 10 minutes or an appropriate disinfectant with proven effectiveness against non-enveloped viruses (eg. Poliovirus, Norovirus, Rotavirus, Feline Calicivirus). Refer to the manufacturer’s label to ensure the disinfectant is left on the contaminated surface for the correct contact time. With bleach, this would mean the surface stays wet for at least 10 minutes.
7. Ventilate the room well when using a bleach solution. Make sure it is not mixed with other cleaning agents.
8. Wipe the treated area with paper towels soaked in tap water. Allow the area to dry.
9. Discard contaminated paper towels, gloves and other disposable equipment in a plastic lined garbage bin. Immediately tie and place with regular trash. Take care not to contaminate other surfaces during this process. Change gloves if needed.
10. Practice hand hygiene, either with soap and water or an alcohol-based hand rub of at least 60% concentration, for 15 seconds after gloves are removed. If the hands are visibly soiled, then soap and water should be used over a hand rub.
11. If an injury occurs during the cleaning process, such as a skin puncture with a blood-contaminated sharp object, seek medical attention immediately. Any occurrence that takes place in a workplace should be reported to the occupational health and safety representative.
Mixing a 1:10 Bleach Solution
(1 cup of bleach: 9 cups of water).
Contact time on surface is 10 minutes
HIV and HIPAA
Idaho law does not provide increased protection of records of HIV test results.
Idaho law does not prohibit the individual testing of a person without their informed consent.
It permits adolescents to be tested for HIV without the consent of a parent.
Exception: Anonymous testing sites are exempt from the requirement that the informed consent be in writing.
The diagnosis of AIDS is PHI that can be disclosed (or must be protected) using the same standards for disclosure of all other PHI.
A signed consent is not required when HIV test results are disclosed to the following:
To the patient
To the healthcare provider designated by the patient
To a person or persons to whom the test subject has authorized disclosure in a writing
Anonymous testing sites
Court ordered disclosure
According to HIPAA, “it is not necessary to separate contents related toHIV matters in the patients medical records.
All information, e.g. test results, treatment records for AIDS, patient concerns related to HIV, psychiatric conditions related to or resulting from AIDS, may be integrated into the body of the chart.”
Remember: If a patient has not signed an authorization to disclose HIV test information contained in their medical records, it is the responsibility of the provider to remove that information before responding to a request for medical records.
8 There is a disaster plan.
In the event of an unexpected closure of our behavioral health facility that would require members to seek other services, our facility administrative staff will be required to call all members.
If members cannot be reached by phone, a letter from the CEO will be mailed to the participant’s last known address advising them on options available.
9 There is a fire safety plan.
Fire Extinguishers: Our facility will ensure the presence of fire extinguishers installed throughout the facility. Each fire extinguisher will be inspected to ensure the charge is current, have the number, type and location correct as directed by fire authority.
Fire Inspection: Our facility will ensure clinic facilities meet all local and state codes concerning fire and life safety. The facility will be inspected by local fire authority and pass inspection. In absence of local fire authority inspections must be obtained by Idaho State Fire Marshall’s Office. A copy of the inspection must be made available upon request and must include documentation of any necessary corrective action taken on violations cited.
Fire Drills:Our facility will ensure all employees engage in periodic fire drills. At least one of these fire drills must include evacuation of the building.
Summary of Fire Drills: Our facility will ensure the accurate documentation of a brief summary of the fire drill and the response of the employees and participants. This must be written and maintained on file. The summary must indicate the date and time the drill occurred, problems encountered and corrective action taken.
Electrical Installations: Our facility will ensure all applicable local or state electrical requirements on installations. Extensions cords and multiple electrical outlet adapters must not be utilized unless U.L. approved and the numbers, locations, and use of them are approved, in writing, by the local fire or building authority.
Portable Heating Devices: Our facility will ensure portable heating devices are prohibited except units that have heating elements that are limited to not more than two hundred twelve (212°) degrees Fahrenheit. The use of unvented, fuel-fire heating devices of any kind is prohibited. All portable space heaters must be U.L. approved as well as approved by the local fire or building authority.
Exits: Our facility will ensure all furnishings, decorations, or other objects do not obstruct exits or access to exits.
Evacuation Plans: Our facility will ensure evacuation plans are posted in every occupied room. The plans must include the point of orientation, location of fire extinguishers, location of fire exits and designated meeting area outside of building.
In the event an evacuation is necessary, employees performing services with a participant shall be responsible for safely evacuating that individual according to the evacuation plan.
The Administration Team Leader/ designee is charged with ensuring all individuals working and/or participating in services at the time of an emergency evacuation are present and accounted for at the designated staging area.
10 There is evidence of compliance with fire safety procedures/regulations, including inspection by the fire department/marshal.
Fire Inspection: Our facility will ensure clinic facilities meet all local and state codes concerning fire and life safety. The facility will be inspected at least annually by local fire authority and pass inspection. In absence of local fire authority inspections must be obtained by Idaho State Fire Marshall’s Office. A copy of the inspection must be made available upon request and must include documentation of any necessary corrective action taken on violations cited.
11 There are fire extinguishers in the facility or there is a fire suppression system.
Fire Extinguishers: Our facility will ensure the presence of fire extinguishers installed throughout the facility. Each fire extinguisher will be inspected to ensure the charge is current, have the number, type and location correct as directed by fire authority.
12 The exits are well marked and free of obstruction.
Exits: Our facility will ensure all furnishings, decorations, or other objects do not obstruct exits or access to exits.
Evacuation Plans: Our facility will ensure evacuation plans are posted in every occupied room. The plans must include the point of orientation, location of fire extinguishers, location of fire exits and designated meeting area outside of building.
13 The agency appearance is reasonably neat and clean.
Our facility is cleaned daily and deep cleaned each weekend.
14 The waiting room and member areas are of adequate size and reasonably comfortable.
We have a patient waiting area that is sizable and we utilize waiting area music to help ensure audible privacy in rooms during sessions.
15 The furnishings and décor are appropriate.
Our furnishings are up-to-date and professional, we clean the furnishings on a weekly basis.
16 There are no culturally insensitive or offensive materials posted.
We are very mindful of diversity and do our best to ensure our patrons feel safe and respected.
Continuum of Care
17 There is a policy/written criteria about expectations and limitations for services being provided.
Treatment Modality Criteria (Transitions & Exclusions)
A. Initial intake completed
B. Client has problems/issues that they need/want help in dealing with
Client assigned clinical therapy.
a. Client has a mental health diagnosis and a GAF score that indicates a need for therapy, Comprehensive Diagnostic Assessment completed
For Family Support Services:
a. Client scores on the CAFAS or PECFAS when applicable indicate they will need multiple levels of care; and
b. Client has mental illness that pervades three or more functional areas of their lives; and
c. Problems include those that are beyond the scope and limitations of the expectations of clinical therapy alone.
d. Parent/guardian requests these services after being explained the risks/benefits of this modality
e. Documentation on assessment outlines the current treatment modalities, the expectation of each and the differentiation between services to ensure there is not an overlap of services
f. Client meets eligibility requirements for this modality of treatment based on appropriate IDAPA regulations IDAPA 16.03.10 as well as Optum Guidelines established in the Provider Manual
g. Clinical therapist may recommend family support services for the member and parent/guardian or member accepts this recommendation after therapy has begun due to need.
h. Comprehensive Diagnostic Assessment states or is amended to state that these services are necessary for the member's current needs.
I. Client may meet the goals of this service modality. Discharge summary completed with appropriate referrals outlining the continuing care needs of the member.
Our facility will adhere to all IDAPA rules as well as Optum guidelines pertaining to the requirements and exclusionary criteria for these service modalities. All clients or designated caregivers will be notified of their eligibility for these services as well as an reasons or regulations that may exclude them from obtaining these services.
Members will be notified of their eligibility for these services as well as the expectations of these services.
Members may stop services at any time for any reason and may attempt to start these services once again at any time. Our staff will assist members in accessing the services required to meet the needs of the individual and family (when applicable). Services rendered or recommended will be the least restrictive to meet the needs of the member and also may be deemed medically necessary for the member.
18
The program description is recovery and resiliency focused.
Members may be excluded for these services due to not meeting the requirements established for these services. These exclusions may be due to not meeting medical necessity, possible duplication of services, or not being the least restrictive level of care required.
19 There is a policy/written criteria outlining any exclusionary criteria for the program.
Members may be excluded for these services due to not meeting the requirements established for these services. These exclusions may be due to not meeting medical necessity, possible duplication of services, or not being the least restrictive level of care required.
20
There is a policy/written criteria that includes continuation of service needs of the member/member family at the time of their transition from the program.
Our facility will review member progress as required by IDAPTA rules and any and all requirements of member insurance carrier. At any time, member may terminate services or no longer meet requirements by these services. At this time the assigned worker will complete a transition of care summary for the member to include any outpatient or additional services member may continue to need. Staff will ensure continuing care needs are addressed through the completion of the transition of care summary .
Discharge Planning
When services begin, the Peer Support Specialist and the member develop an initial discharge plan and estimate the length of services.
During the initiation of services, the Peer Support Specialist and the member update the initial discharge plan based on the member’s response to services ensuring that:
An appropriate discharge plan is in place prior to discharge;
The member agrees with the discharge plan;
The discharge plan includes:
The date services will end;
Recommended self-help and community support services;
Information about what the member should do to in the event of a crisis.
How the discharge plan will be communicated to the member’s providers.
Ongoing discussion should occur between the Peer Support Specialist and the member regarding the member’s continued need for services.
The Peer Support Specialist shares the discharge plan with the Care Advocate to ensure that necessary prior authorizations or notifications are completed prior to discharge and to trigger outreach and assistance to the member.
If the member has requested discontinuation of Peer Support Services, a discussion as to the reasons why should occur.
The Peer Support Specialist should provide the member with information as to how to reactivate or access Peer Support Services in the future if the need arises.
If it has been determined that the member has achieved established goals, the Peer Support Specialist and member should work to determine if:
The member feels comfortable using recovery tools, community resources, and support groups and that the member is comfortable and confident using accessing and utilizing these resources.
The member is using their Personal Wellness Plan or another recovery management tool and if the member understands when an Advanced Directive should be implemented.
The member, Peer Support Specialist and other clinicians providing
care to the member should develop a plan as to how post-discharge services will be coordinated.
Initiation
21
The policy/written criteria for initiation procedures includes an inventory of the member's/member family's strengths and resiliency factors.
The member is under 18 years of age and resides in the state of Idaho.
AND
The member has a DSM diagnosis other than a standalone substance- related disorder or developmental disability diagnosis, although a substance-related disorder or developmental disability disorder may coexist with other DSM diagnoses.
AND
The member is not in imminent or current risk of harm to self, others, and/or property.
AND
The “why now” factors that precipitated access to this service (e.g., changes in the member’s signs and symptoms, psychosocial and environmental factors, or level of functioning) indicate that the member’s family and member require assistance with accessing treatment and/or community resources. Examples include:
The member’s family requires information about the member’s behavioral health condition, evidence-based treatment, approaches to self-care, or community resources.
The member’s family could benefit from learning skills related to problem-solving, communication, managing crises or stress, supporting and engaging the child’s activation and self-care, or promoting recovery and resiliency.
The member’s family requires assistance navigating the system of care.
AND
The member is receiving behavioral health therapeutic services, or is likely to engage in therapeutic treatment with the provision of Family Support Services.
AND
The member and member’s family do not demonstrate at least one of the following:
Knowledge of wellness tools and their use;
The presence of a support system;
A sense of purpose;
A sense of empowerment;
Hope about recovery;
The ability of the family to self-advocate;
Progressing toward independent living;
Engagement with community, school and positive recreational activities.
22
The policy/written criteria for initiation procedures includes a review of the member's/member family's support network.
The CFSP is working toward the following outcomes with the family:
The ability to identify and use wellness tools;
Progress towards age-appropriate, adaptive skills for independent living;
2. ContinuedServiceCriteria
Re-engaging with support systems that may have been lost;
A sense of purpose;
Increased empowerment;
Ability for family self-advocacy
Increased engagement with supportive services for community, school, and positive recreational activities.
23
The policy/written criteria for initiation procedures includes a review of whether the member and/or family has an individualized recovery plan or family-centered service plan that includes a description of the member's/member family's goals, timeframes for meeting these goals, and the interventions that will assist in meeting the goals.
The CFSP, in conjunction with the member’s family, develops a service plan within 15 days of the evaluation that addresses the following:
The member’s recovery and resiliency goals;
The member and family’s strengths;
The member and family’s educational needs;
The member and family’s self-care needs and resources;
Problems;
Specific and measurable goals for each problem;
Interventions that will support the member’s family and member in meeting the goals.
24
There is a policy/written criteria for obtaining appropriate consents to contact the member's behavioral health clinician, medical physician, family/social supports, and or agencies and other programs that is involved in the member's care.
Release of information and consent forms will be filled out and signed by the member at the onset of services insuring that communication with all the other programs and providers will be done in accordance with HIPPA and state law.
25
There is a policy/written criteria for the development of a individualized family-centered service plan that is developed with the member/member family.
Service plans are designed to help staff have better idea of how Family Support services will help the member progress in the recovery. The member/member family is involved with the development of the plan and agrees to the implementation of the plan as demonstrated by their signature.
26
There is a policy/written criteria for the review and update of the individualized family-centered service plan at a minimum of 120 days (per IDAPA 16.07.37, section 407).
Service plans will be reviewed and updated at least every 120 days. Documentation will be on a Recovery Plan Review tool that becomes part of the member file
Performance Improvement
27 There is a Performance Improvement Program.
A. Supervising therapists and Director meet weekly
Ensure quality services are provided based on weekly supervision of staff
Identify problems with staff and/or clients in treatment.
a. provide solutions to these problems
b. Redirect staff as needed to ensure quality services
c. Contact clients/parent or guardian to review changes to services
d. Risk management for clients with issues that are potentially dangerous to self and/or others as well as develop appropriate plan of intervention for each as they occur.
Assign clients to staff based on client needs and staff strengths
Review Adverse problems situations that have occurred throughout the week.
B. Supervising Therapist reviews all Incident reports weekly to ensure staff follows through with protocols put forth by our facility.
C. All therapists meet weekly to discuss problems and successes and provide feedback to each other on their cases.
D. Family support staff attend staff meetings with clinical supervisor and director to ensure treatment plans, policies and procedures and rules and regulations are followed.
E. Director meets with client/parent or guardian annually.
For review purposes to determine if services are still wanted, needed and appropriate.
To receive feedback on the satisfaction with services
To make any changes needed on service plans and update assessments
Review progress (or lack thereof) with the client/parent or guardianship
Discharge planning
F. Owners review all grievances as they are submitted and determine any action needed to take.
Management of Information
28
The program has a process in place to ensure the availability of service records to the CFSP.
Records from the Simply Clinical EMR can be saved as a .pdf and faxed to an outside prescriber/clinician if correct releases are in place. Any in house provider has access to their clients file via a secure and unique login.
29
The program has a policy for making the service record available to the family/member upon request in a reasonable amount of time.
Records from the Simply Clinical EMR can be saved as a .pdf and faxed to an outside prescriber/clinician if correct releases are in place. Any in house provider has access to their clients file via a secure and unique login.
30
The program has an organized system of filing information in the service records.
Simply Clinical EMR organizes the member record in a filing system similar to but much more complete than a paper file.
31
The program must have an established procedure to maintain the confidentiality of service records in accordance with any applicable statutes and regulations.
Mental Health Clinic Services: HIPAA & Confidentiality:
Our facility will ensure accurate documentation regarding HIPAA Privacy Statement
Our facility will define what a participant’s right entails in their medical record
Our facility will ensure the clinic observes confidentiality practices
Our facility will ensure standard employee confidentiality agreement
Our facility will ensure that clinical medical record information is available to employees on a need-to-know basis
Our facility will ensure the definition and documentation for violations of confidentiality
Our facility will ensure accuracy in reporting HIPAA violations. This policy should include internal investigations and resolution and also show ability for anyone in the clinic, participant or employee to report to the Federal Government
Our facility will ensure the clinic’s security (e.g., double-locked clinical files)
Our facility will ensure a safe electronic exchange of Protected Health Information
Our facility will ensure a contingency plan for responding to emergency or disaster that damages systems that contain Protected Health Information.
32
If service records need to be transported to another service location, there is a protocol in place to maintain confidentiality of records throughout the transportation process.
All patient records and documents containing patient protected health information (“PHI”) must be adequately secured to help ensure our patients’ information is not exposed to unauthorized individuals.
All staff and associates should follow these standards when transporting medical records, documents and portable media devices (such as laptops or flash drives) containing PHI:
Transporting Client Files
Ensure the necessary authorizations given and/or obtained for sharing PHI.
Only transport PHI off-site after obtaining your supervisor’s approval.
Transport the minimum amount of PHI necessary. Never leave PHI (including portable media devices) unattended, including in your vehicle.
Transport PHI information in a SEALED folder available at the front desk.
Human Resources
33
There is evidence of on-going assessment of CFSP staff competency through verification of certification status, ongoing supervision, performance evaluations and training.
FSS maintains a working knowledge of current trends and developments in the fields of mental health, substance use disorders, brain research as it relates to behavioral health, wellness and recovery, ethical practices and family support services by reading current journals, books, etc., attending webinars, workshops and conferences as they relate to these fields, and sharing with other FSSs.
34
Personnel files include: resume, background checks, job description, appropriate license or certification for CFSP staff, and annual evaluations.
This is all included
35
There is a specific policy/written criteria addressing initial and ongoing training of CFSP staff.
FSS maintains a working knowledge of current trends and developments in the fields of mental health, substance use disorders, brain research as it relates to behavioral health, wellness and recovery, ethical practices and peer support services by reading current journals, books, etc., attending webinars, workshops and conferences as they relate to these fields, and sharing with other FSSs.
Add governing body to get qualifications
36 There is evidence that staff have received training related to agency policies and procedures.
Staff is required to review facility's policies and procedures for each modality prior to their providing services.
37
There is a specific policy/written criteria addressing staff supervision of CFSP staff.
FSS candidate completes 20 supervision hours with a designated Idaho FSS supervisor within a year from completing the training.
Supervising Practitioner is required to have regular one-to-one (1:1) supervision with the Non-credentialed
Group Based Provider to review treatment provided to Members on an ongoing basis. The frequency of the 1:1 supervision is guided by the Group Based Provider’s needs and experience and should occur at least once a month.
Group supervision may be used in addition to 1:1 supervision. The group should not include more than six (6) Noncredentialed
Group Based Providers. Supervision is clinical and consultative in nature and focuses on specific cases the Non-credentialed Group Based Provider is assigned to. Supervision is to be documented and kept on file.
38
There is documentation of on-going supervision of CFSP staff.
The Supervision meeting will be documented each week with Attendee, Clinician’s signature, Date and brief summaries of each member staffed – Question from staff and answers from clinician. All of this information can be found on the Supervision note located in each staff file on the Simply Clinical EHR.
39
The CFSP job description lists essential knowledge and skills consistent with the State of Idaho's Behavioral Health Standards Manual for CFSP services.
Ability to maintain and respect confidentiality.
Ability to self-direct the work.
Effective stress coping skills
Should be patient with member and circumstances.
Should respect cultural, social and racial differences.
40
The agency has a protocol to notify the certifying entity/program of any violations of certification standards in accordance with the State of Idaho's Behavioral Health Standards Manual for CFSP services.
Facility will track the certification of employees designated as Certified Family Support Specialists (CFS).
Facility will assist the CFS in obtaining the necessary service hours and hours of supervision needed to maintain current certification. Facility will assist the CFS in applying for their certification annually.
Facility will notify the certifying body, including the Department of Health and Welfare of any violations of these certification standards.
41
Verification of appropriate certification for CFSP staff is completed. There is evidence certification is obtained in accordance with the State of Idaho's Behavioral Health Standards Manual for CFSP services. (During initial credentialing, this verification is completed by the network manager).
CFSP passes the Appalachian Group/DBSA certification exam with a score of 80% or higher.
CFSP understands and lives by Idaho’s Certified Family Support Code of Ethics.
Credentialing of Practitioners
42
A sample of the CFSP's employee files were reviewed and the files contained documentation of hiring consistent with program policy.
Check
Infection Control
43 There is a policy and procedure regarding infection control at the agency which includes written protocols for communication with local public health authorities.
In the event that staff is exposed to infectious material they will notify District 7 Health Department (208) 522-0310 and follow their guidelines and recommendations
44
There are written protocols for the treatment of family's/members with infectious diseases.
Infectious Diseases
Member is identified in the Assessment process to have an infectious disease
Pertinent Staff informed of the disease based on HIPPA guidelines for disclosure and treatment
In the event that staff is exposed to infectious material they will notify District 7 Health Department (208) 522-0310 and follow their guidelines and recommendations
Staff will notify supervisor of the incident.
Staff will complete an incident report
Handicap Accessibility
45 The agency has parking for handicapped vehicles.
Yes
46 The agency has a ramp allowing entrance into the building.
Yes
47 The agency has wide doorways for wheelchair access.
Yes
48 The agency has handicap accessible restroom(s).
Yes
49 If the agency is not handicap accessible, does the program staff screen for handicap needs prior to initiation of services?
N/A
Member Complaints
50 There is a protocol for dealing with complaints.
Any member can submit a complaint either verbally or in writing to any of the clinical therapists, managers or owners of the agency. If a complaint comes to an employee they will share the complaint with ownership. Ownership will then investigate the complaint and the necessary or proper action will be taken based on the complaint. The complaint will be addressed by ownership with the member within 48 hours of receipt. Any action needed will take place within an appropriate time allotment, based on the complaint. Notes from that meeting will be signed by the owner and member and entered into their file.
51 The agency documents that members/families are informed of methods of resolving complaints.
(As taken from the intake paperwork, signed by member or parent/guardian)
The right to register a complaint if you are dissatisfied with your treatment, without fear of retaliation. You have the right to be assisted in filing a grievance if you need assistance.
Recovery and Resiliency
52
The mission statement of the agency is recovery oriented. (For example, SAMHSA has established a working definition that defines recovery as a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. Recovery is built on access to evidence-based clinical treatment and recovery support services for all populations.)
We believe that healthy and functional families strengthen individuals and communities. Our mission is to inspire healthy, positive change in our clients through teaching, mentoring and skill building. We strive to remove barriers to treatment by allowing individuals and families timely and responsive care. We focus on teaching our clients, and those identified as their support the skills to achieve their mental wellness goals by developing a meaningful sense of belonging and positive sense of identity. Clients will be encouraged to improve their life despite or within the limitations imposed by their condition. We offer a safe place to learn and practice effective and efficient skills helping our clients to progress in their own recovery efforts.