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CONSUMER ORIENTATION MANUAL

 

CONSUMER RIGHTS AND RESPONSIBILITIES

 

POLICY: To ensure the process that a consumer will be an active, informed participant in his/her plan of care, the consumer will be empowered with certain rights and responsibilities as described in the Consumer Rights and Responsibilities. A consumer may designate someone to act as his/her consumer representative. This representative, on behalf of the consumer, may exercise any of the rights provided by the policies and procedures established by the agency.

 

All policies are available at all times to the agency personnel, consumers, and representatives, as well as other organizations and the interested public to assist with fully understanding the consumer’s rights and responsibilities.

 

PROCEDURE:

  1. Before or upon admission, the staff will provide each consumer and/or their representative with a copy of the Consumer Rights and Responsibilities.
  2. The Consumer Rights and Responsibilities will be explained and distributed to the consumer prior to the initiation of agency services and annually. This explanation will be in a language he/she can reasonably understand. Communication of these rights and responsibilities can occur through:
    1. Verbal
    2. Written
    3. For non-English speakers, all related information will be translated.

 

CONSUMER RIGHTS:

The consumer is informed at admission and annually of:

  1. Confidentiality of all personal and treatment/service related information.
  2. The right to privacy, security, and respect of property.
  3. The right for protection from abuse, neglect, retaliation, humiliation, exploitation.
  4. Considerate, respectful care under all circumstances, with recognition of personal dignity.
  5. Active participation in treatment planning and decision making in the least restrictive manner possible.
  6. Reasonable opportunity to choose a service provider and to make changes in that service provider for cause.
  7. The right to have access to, review, and obtain copies of pertinent information needed to make decisions regarding treatment/services in a timely manner.
  8. The rights to informed consent or refusal or expression of choice regarding participation in all aspects of care/services and planning of care/services to the extent permitted by law including:
    1. 1) service delivery, 2) release of Information, 3) concurrent services, 4) composition of the service team.
  9. The right to access or referral to legal entities for appropriate representation.
  10. The right to access to self-help and advocacy support services.
  11. The right to investigation and resolution of alleged infringements of rights.
  12. The right to provision of care in the least restrictive environment.
  13. The right to adequate and humane care.
  14. The right to evidence-based information about alternative treatments/services, medications, and modalities
  15. The value or purpose of any technical procedure that will be performed, including the benefits, risks, and who will perform the task/procedure.
  16. The right to protection from the behavioral disruptions of other persons served.
  17. The right to 24-hour crisis intervention.
  18. The right to equal access to treatment/services for all persons in need regardless of race, ethnicity, gender, age, sexual orientation, or sources of payment.
  19. The right to a grievance procedure that includes the rights to: be informed of appeal procedures, initiate appeals, have access to the grievance procedures posted in a conspicuous place, receive a decision in writing, and appeal to an unbiased source.
  20. The cost of services that will be billed to his/her insurance(s) and/or self (verbally and in writing). Consumer has the right to examine and receive an explanation of his/her bill. Pathways' services are not free.

    It is the Fee Policy of Pathways' Board that all consumers receiving services should contribute toward the cost of providing that service, either personally or through eligibility in private or public insurance programs, unless strictly prohibited by regulations of funding resources or government bodies.

    In certain situations, consumers cannot pay the full cost of service. Then, consumers shall be charged according to a discount fee schedule. To receive a discount, consumers must complete an application to determine the amount of discount. The discounted amount will be reviewed at least annually.

    Pathways may engage in fee collection activities in the event you fail to make any payments within 90 days from your service date.

  21. Additionally, consumers who utilize Pathways' residential facilities have the right to:
    1. Time, space, and opportunity for personal privacy.
    2. Communicate, associate, and meet privately with persons of choice.
    3. Send and receive unopened mail.
    4. Retain and use personal possessions, including clothing and grooming articles.
    5. Private, accessible use of the telephone.

 

If any restrictions are placed on a consumer’s privileges, a member of Pathways’ Leadership Team will meet with the consumer to inform him/her of any and all restrictions and regularly evaluate the restrictions placed on the persons served through consumer interviews, case notes, staffing minutes, incident reports, and any formally filed grievance reports. Only a member of Pathways’ Leadership Team is able to make medical/clinical decisions that will place limits or return the restricted privileges of the persons served.

 

CONSUMER RESPONSIBILITIES:

 

Consumer agrees to meet the following guidelines for successful completion of treatment/services.

  1. Provide financial information and payment for services at the time the service occurs as described in the Fee Policy Agreement.
  2. Be open and honest with your service provider(s) and participate in the development of and compliance with your treatment plan.
  3. Keep appointments as scheduled and/or contact the office at least 24 hours in advance to cancel appointment.
  4. Show respect and concern for other consumers and their privacy.
  5. Be informed about your rights.
  6. Abide by Pathways’ and the Commonwealth’s policies and procedures.
  7. Agree to not bring weapons of any kind on Pathways property or to a Pathways function.
  8. Be informed about services and treatment options.

 

REFERENCES:

 

 

 

 

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

If you have any questions, please contact our Privacy Officer, whose name and number is at the bottom of this notice.

 

Our Duty to Safeguard Your Protected Health Information

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information” (“PHI”). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when, and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of the use of disclosure.

 

We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, we will post a new Notice in waiting rooms, with the receptionist at the unit where you receive services.

 

How We May Use and Disclose Your Protected Health Information

We may use and disclose PHI for a variety of reasons. Most uses and disclosures of PHI – including psychotherapy notes – require your authorization. We have a limited right to use to use and/or disclose your PHI for purposes of treatment, payment, or operations. For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity, that it will extend the same degree of privacy protection to your information, as we must apply to your PHI. However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. The following offers more description and examples of our potential uses/disclosures of your PHI. Uses and disclosures of PHI that are not described in this notice will not be made without your written authorization.

 

Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations

Generally, we may use or disclose your PHI as follows:

  • For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team. Your PHI may also be shared with outside entities performing ancillary services relating to your treatment, such as lab work or for consultation purposes, or other health agencies involved in provision and/or coordination of your care.

  • To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may contact your employer and/or release portions of your PHI to the Medicaid program, the Medicare program, the local Vocational Rehabilitation office, and private insurer to get paid for services we delivered to you.

  • For health care operations: We may use/disclose your PHI in the course of operating our Behavioral Health, Addiction, Developmental and Intellectual Disabilities, and Family and Children’s programs. For example, we may take your photograph for medication identification purposes, use your PHI in evaluating the quality of services provided, or disclose your PHI to our accounting department or attorney for audit purposes. Since we are an integrated system, we may disclose your PHI to designated staff in our central office or our support services for similar purposes. Release of your PHI to the Regional Board and/or state agencies might also be necessary to determine your eligibility for publicly funded services.

 

 

Appointment Reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to your home.

 

 

Uses and Disclosures Requiring Authorization

For uses and disclosures beyond treatment, payment, and operations purposes, we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.

 

Uses and Disclosures of PHI from Behavioral Health Records Not Requiring Consent or Authorization

The law provides that we may use/disclose your PHI from behavioral health records without consent or authorization in the following circumstances:

 

  • When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect, or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.

  • For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.

  • For health oversight activities: We may disclose PHI to our central office, the Protection and Advocacy agency, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents.

  • Relating to decedents: We may disclose PHI relating to an individual’s death to coroners upon request.

  • For research purposes: In certain circumstances, and under supervision of a privacy board, we may disclose PHI to our central office research staff and their designees in order to assist medical/psychiatric research.

  • To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

  • For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.

 

Uses and Disclosures of PHI from Alcohol and Other Drug Records Not Requiring Consent or Authorization

The law provides that we may use/disclose your PHI from alcohol and other drug records without consent or authorization in the following circumstances:

 

  • When required by law: We may disclose PHI when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the program premises or against program personnel, or in response to a court order.

  • Relating to decedents: We may disclose PHI relating to an individual’s death if state or federal law requires the information for collection of vital statistics or inquiry into cause of death.

  • For research, audit, or evaluation purposes: In certain circumstances, we may disclose PHI for research, audit, or evaluation purposes.

  • To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI to law enforcement when a threat is made to commit a crime on the program premises or against program personnel.

 

Uses and Disclosures Requiring You to have an Opportunity to Object

 

In the following situations, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law. However, if there is an emergency situation and you cannot be given your opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interest. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

 

Your Rights Regarding Your Protected Health Information

You have the following rights relating to your protected health information:

 

  • To request limits on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it, except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.
  • To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.
  • To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have the right to see your protected health information upon your written request. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have the right to choose what portions of your information you want copied and to have prior information on the cost of copying.
  • To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (i) correct and complete, (ii) not created by us and/or not part of our records, or (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the changes in the PHI.
  • To find out what disclosures have been made: You have the right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for treatment, payment, and operations; to you, your family; or pursuant to your written authorization. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or before April, 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.
  • To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by e-mail upon request.
  • To receive notice of a breach: We will notify you if your PHI has been breached.
  • To request restriction of PHI to your health plan: If you pay cash in full for a specific service, you can request information relating to that service not be disclosed to your health plan.

 

HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

 

If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at:

 

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

 

We will take no retaliatory action against you if you make such complaint.

 

Contact Person for Information, or to Submit a Complaint

If you have questions about this Notice or any complaints about our privacy practices, please contact:

 

Marie Sublett, Privacy Officer Pathways, Inc.

1212 Bath Avenue, 8th Floor

P.O. Box 790

Ashland, KY 41105-0790

606-329-8588 Ext. 4075

 

Toll Free in Kentucky - 800-562-8909

 

Marie.Sublett@pathways-ky.org

 

CONSUMER COMPLAINT/GRIEVANCE POLICY

 

POLICY: Pathways’ Complaint/Grievance System is to ensure and improve customer service. All Pathways’ employees should make every effort to attempt to informally resolve issues locally prior to using the formal Compliant/Grievance System. If a formal grievance/complaint is made but not resolved to the satisfaction of the complainant then the action will be elevated to the level of a complaint/grievance. The consumer will have the right to have an advocate present at complaint/grievance hearings. At any time during the process, the consumer has the right to contact the state ombudsman.

 

PROCEDURES:

  1. Upon admission to Pathways’ services, the consumer or consumer’s representative shall be given a copy of the “Consumer Orientation Manual.” The consumer’s rights and Pathways’ grievance/complaint procedure will be explained to the consumer and their representative.
  2. Grievance/Compliant forms will be available in every Pathways’ facility. When a complaint is not resolved informally by local supervisors, the complainant should immediately be given a form to complete. Envelopes will be available in order to seal the form and send directly to the Chief Compliance Officer in order to ensure confidentiality. The consumer should be given a stamped envelope addressed to Compliance Department, Pathways, Inc., P.O. Box 790, Ashland, KY 41105.
  3. The office manager or other designated staff will send any complaint forms by U.S. mail to the Chief Compliance Officer. The office manager/designated staff will ensure that the envelope with the form will remain sealed.
  4. Upon receipt, the Chief Compliance Officer or designee will:
    1. Call the consumer, if a phone number is provided, informing them that their concern has been received and is being acted upon.
    2. Assign the staff person who should address the complaint and call them, alerting them that a complaint form is being sent to them.
      1. After the complaint has been assigned, a member of the Compliance Department will fax the form and cover memo to the person assigned to address it.
      2. A copy of the form will be sent to the program director, indicating if they need to take an action.
    3. The Chief Compliance Officer will evaluate the complaint, and will have several options:
      1. Determine that immediate action is needed. Immediate action is defined as a complaint that carries a significant chance of a serious adverse outcome that could result in serious physical or psychological injury, or the risk thereof, or death.
        1. Upon determining that immediate action is needed, the Chief Compliance Officer will report the information to the program director responsible, who will inform the executive director, as needed, and inform the involved site supervisor, who will immediately investigate and provide feedback within two (2) days to the Chief Compliance Officer regarding action and outcomes. If requested, the Chief Compliance Officer will provide feedback regarding the outcome to the complainant and will enter the resolution of the complaint into the data bank.
      2. Determine that immediate action is not needed.
      3. The Chief Compliance Officer will determine whether or not standard operating policy and procedures were first attempted with regard to the nature of the complaint. If not, the complaint will be returned to the originator, urging company policy and procedure first be followed before utilizing the Grievance/Complaint System. If standard policy and procedures do not resolve the situation, then the complaint should be resubmitted.
      4. If the Chief Compliance Officer determines that standard policy and procedures were initially followed, the form will be forwarded to the site supervisor with a copy to the program director. The site supervisor will have five (5) working days to study the situation, and report any actions and outcomes to the Chief Compliance Officer.
      5. If the Grievance/Complaint form is not received back in the Compliance Department within the specified time, the Compliance Department secretary will call the person assigned as a reminder.
        1. The Chief Compliance Officer will also be responsible for determining whether or not to grant an extended study time and the length of said extension. If extended time for study is required, the person assigned to the complaint may request a time extension from the Chief Compliance Officer. The new date for completion should be noted on the Grievance/Complaint form.
      6. Upon receiving the form, the Chief Compliance Officer or designee will enter information into the data bank, and provide feedback to complainant, if requested.
  5. When a complaint involves more than one major program or department, a copy of the form will be sent to the directors or department heads involved. The program director/department head has the final authority to determine the acceptability of an outcome of a complaint, and will inform the Chief Compliance Officer of such.
  6. If the complainant requests to be informed of the resolution, the Chief Compliance Officer will contact the individual to explain the decision.
  7. If the complainant is not satisfied with the resolution of the complaint and the complaint is related to a rights violation, then the complaint will be escalated to the status of a grievance. The Chief Compliance Officer shall then contact the Pathways’ ombudsman, providing all necessary information regarding the grievance and actions that have taken place to this point. The Chief Compliance Officer will also inform the appropriate program director/department head that this is now a grievance.
    1. The meeting must be held within five (5) working days of the receipt of the grievance.
    2. This meeting shall result in a written plan of resolution. The plan will be written by the program director or their designee.
    3. The plan will be mailed to the aggrieving person. If asked, the program director or designee will meet with the consumer to explain the resolution plan.
    4. If the consumer rejects the Pathways’ ombudsman’s decision, he/she will be asked to put their reasons in writing for rejecting the Pathways’ ombudsman’s proposed resolution and will be referred to the Board of Directors.
    5. The entire record of the grievance will be sent to the executive committee of the Board of Directors.
      1. At the next monthly meeting of the Board of Directors, the executive committee will review and decide in favor of the aggrieved person or in favor of the plan developed by those involved in the grievance process.
      2. The Board decision will be mailed to the consumer within five (5) working days of the Board’s decision.
      3. If the decision by the Board of Directors is not satisfactory, the consumer will be assisted by the Pathways’ ombudsman to appeal to the applicable department within the Cabinet for Health Services:

        State Ombudsman
        275 East Main Street
        Mail Stop 1ED
        Frankfort, KY 4062
        Phone: 502-564-549
        Toll Free: 800-372-2973

  8. The Chief Compliance Officer will be responsible for compiling data regarding the nature and resolution of the compliant/grievance. Reports will be made on a quarterly basis to the Executive Team.

 

CONSUMER INPUT ON QUALITY OF CARE

 

 

Quality of care, achievement towards goals, and consumer satisfaction are all essential aspects of effective and efficient treatment/services. Our team is required to formally address these issues, verbally or in writing, at the time of assessment and at the end of each 90-day period. The primary therapist uses this input to complete the reports and make adjustments to the treatment/service plan to assure that the goals stated on the treatment/service plan are the goals of the person served.

 

 

 

 

Consumers are encouraged to meet directly with the primary therapist at any time they feel there is an issue related to quality of care, achievement toward goals, or satisfaction of services. We will also offer the consumers the opportunity to complete a Consumer Satisfaction Survey every three (3) months during their time in treatment/service.

 

SATISFACTION OF PERSON SERVED

 

 

 

 

Pathways, Inc. desires the input of all persons served on the quality of services that are being provided. Pathways, Inc. provides a Consumer Satisfaction Survey to each consumer on a quarterly basis to provide a means of measuring the quality of services being delivered and any suggestions for improvement of services.

 

 

 

 

CONFIDENTIALITY/PRIVACY OF CONSUMER INFORMATION

 

 

 

 

POLICY: All information, written and verbal, regarding consumer care or services is to be treated as confidential information in accordance with local, state, and federal guidelines. Pathways, Inc. will adhere to all HIPAA requirements and 42 CFR part 2 regulations regarding confidentiality of consumer information. It must be understood, however, that all such information is to be discussed only with those individuals participating in the consumer’s care and only as necessary to meet an identified need. All Pathways, Inc. employees and contracted staff must at all times be aware of the responsibilities in maintaining consumer confidentiality. Pathways, Inc. will not release any information, written or otherwise, without a properly executed release of information form.

 

 

 

 

PROCEDURE:

1. Staff is ultimately responsible for ensuring the privacy and respect due each consumer in each unique situation.

 

2. The information in the consumer case record and billing records is only accessed by authorized staff of Pathways, Inc. and any contracted organizations or individuals.

 

3. Records or copies of the record will be made available for review by licensing, regulatory and/or accrediting bodies authorized by Pathways, Inc. agency administrator as well as for Quality Assurance reviews.

 

 

Confidentiality can and will be broken, by law, if an individual discloses information that expresses intent to harm him/herself or others, or discloses information regarding abuse or neglect towards him/herself or others.

 

Informed consent about treatment, its expectations and limitations, including privacy, confidentiality, and prohibition on re-disclosure of information as referred to in Federal confidentiality rules (42 CFR, part 2) and HIPAA Regulations. Pathways' consumer records are protected by Federal law and regulations. Disclosure of information is prohibited unless:

1) The consumer consents in writing.

 

2) The disclosure is allowed by a court order.

 

3) The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.

 

4) There is evidence of possible physical harm to the consumers or others.

 

 

 

 

 

REFERENCES:

 

INFORMED CONSENT

 

 

 

 

POLICY: Pathways, Inc. follows all local, state, and federal guidelines related to providing services. Pathways, Inc. reviews with the consumer the facts and risks concerning all treatment/service procedures, including the use of medications. Consumers are informed that participation in this program is strictly on a voluntary basis.

 

 

 

 

PROCEDURE:

 

 

 

1. Pathways, Inc. performs an initial intake on each individual seeking services from the agency. Detailed information is gathered to determine the consumers’ needs and the level of care required to address their individual issues.

 

 

 

 

2. All consumers are made aware that they have the right to express choice or refuse to participate in the areas of service delivery, release of information, concurrent services, and the composition of the service delivery team.

 

 

 

 

3. All individuals are informed that the overall goal of therapy is improved quality of life.

 

 

 

 

4. All consumers must have completed a General Consent to Care and Treatment and Acknowledgement form (which includes informed consent), signed prior to the beginning of any treatment/services

 

 

 

 

5. Individual consultation with the consumer is completed at a minimum of 30, 90, or 180 days depending on the requirements of the program or as needed to effectively address current clinical need. At these meetings, the provider and the consumer will discuss present level of functioning, course of treatment/services, and future goals.

 

 

 

 

 

REFERENCES:

 

 

 

 

AGENCY EXPECTATIONS OF CONSUMERS

 

 

 

 

Pathways, Inc. expects that all consumers will provide the agency and staff with clear, complete, and honest information at all times so the agency can provide the most effective and efficient services possible. Pathways, Inc. demonstrates a commitment to our consumers’ care and expects that the recipient will work and participate in treatment/services with an equal amount of dedication.

 

Pathways, Inc. clearly states the agency and program requirements for proper participation to all consumers and their families and expects that each individual will honor their responsibilities to the therapeutic process.

 

DISCHARGE POLICY

 

 

 

 

POLICY: Pathways, Inc. will discharge any and all consumers for the following reasons:

 

Discharge Criteria

1. Consumer Drivena. Upon the death of the consumer.

 

b. Voluntary withdrawal or relocation, or consumer is unavailable for services (e.g., long-term hospitalization).

 

c. Repeated no-shows or consumer/family refusal of services.

 

d. Pattern of non-compliance with program rules.

 

e. Individual behaves in a manner deemed likely to cause physical harm to others or serious harm to self, interferes with the treatment/services of others in the program, and all other available resources have been used to minimize the behavior without success.

 

f. Non-emergency services may be terminated due to consumer’s unwillingness (not inability) to pay for service.

 

 

2. Treatment/Service Drivena. Treatment/habilitation goals have been accomplished, or treatment/service is ended by mutual consent. Evaluation and/or screening had been completed.

 

b. Improvement of consumer’s condition to a degree as to warrant a service of less intensity, or discontinuation of services.

 

c. The consumer’s condition has deteriorated to the extent that a service of greater intensity is necessary in order to protect the individual’s safety and security.

 

d. The consumer ages out of service.

 

e. The consumer no longer meets eligibility criteria and/or the program in which the consumer is admitted is no longer the most appropriate, least restrictive service.

 

f. Services appropriate to consumer needs are unavailable.

 

 

 

 

 

 

PROCEDURE: At the time of discharge, the primary therapist will:

1. Planned Discharge

A consumer’s record may be terminated from active status as a planned discharge (i.e., at the mutual agreement of the consumer and therapist).

 

The following procedures should be taken:

A. If the consumer has been seen three times or fewer, the record may be terminated with a Discharge/Transition form.

1. The therapist will make sure that the Diagnostic Screening Assessment is in ‘final’ status.

 

2. The therapist will take the case to Interdisciplinary Case Consultation (ICC) to officially terminate the case.

 

3. The therapist will then turn in the ICC sheet to the clerical staff, who will close the record in the computer.

 

 

B. If the consumer has been seen in excess of three times, the therapist will complete the electronic Discharge/Transition form. The Discharge/Transition will be used to restate significant findings and events pertaining to the consumer’s treatment, including final evaluation regarding the consumer’s progress toward goals and objectives set forth in the treatment plan, final diagnosis and diagnostic impression, disposition, and recommendations.

1. The therapist will make sure that the Diagnostic Screening Assessment and Bio- Psychosocial are in ‘final’ status.

 

2. The therapist will need to make sure that the Electronic Treatment Plan dates and status are complete.

 

3. The therapist will take the case to Interdisciplinary Case Consultation (ICC) to officially terminate the case.

 

4. The therapist will then turn in the ICC sheet to the clerical staff, who will close the record in the computer.

 

 

 

2. Unplanned Discharge

If a consumer has not been seen by any practitioner in excess of ninety (90) days, the record should be considered for unplanned discharge/termination.

 

The following procedures should be taken:

A. The attending practitioner will attempt to contact the consumer for follow up.

1. The practitioner will contact the consumer by phone and document the attempt in the electronic record, indicating the decision whether or not the consumer is going to continue in services.

 

2. If unable to reach by phone, the practitioner will send the consumer a follow-up letter informing them that in order for their case to remain active in Pathways, Inc., they will need to be seen, giving them a two-week period to contact the office to set up an appointment. If after that two-week period there has been no contact, the case will be considered for termination.

 

3. If the consumer is opened to a 316 program and he/she has requested that he/she finish his/her DUI requirement with a different provider outside of Pathways, Inc., his/her case will remain opened for the duration of time that it takes to complete their DUI requirement. By state regulation, the Addictions staff remains the consumer’s case manager until the consumer has completed his/her assigned care. Once he/she has completed his/her assigned care, the case would then be terminated as stated below in section C or D.

 

 

B. If the consumer is severely mentally ill, the attending practitioner will consult with the case manager to attempt contact through a home visit. If this effort is not successful, the attending practitioner will take the case to Interdisciplinary Case Consultation (ICC) to consult with the team to determine whether or not the record will be terminated. The team’s decision will be documented in the ICC note.

 

C. If the team’s decision is that termination is appropriate and the consumer has been seen three times or less, the record may be terminated with a Discharge/Transition form.

1. The therapist will make sure that the Diagnostic Screening Assessment was in ‘final’ status.

 

2. The therapist will take the case to Interdisciplinary Case Consultation (ICC) to officially terminate the case.

 

3. The therapist will then turn in the ICC sheet to the clerical staff, who will close the record in the computer.

 

 

D. If the team’s decision is that termination is appropriate and the consumer has been seen in excess of three times, the therapist will complete the electronic Discharge/Transition form. The Discharge/Transition will be used to restate significant findings and events pertaining to the consumer’s treatment, including final evaluation regarding the consumer’s progress toward goals and objectives set forth in the treatment plan, final diagnosis and diagnostic impression, disposition, and recommendations.

1. The therapist will make sure that the Diagnostic Screening Assessment and Bio- Psychosocial are in ‘final’ status.

 

2. The therapist will need to make sure that the Electronic Treatment Plan dates and status are complete.

 

3. The therapist will take the case to Interdisciplinary Case Consultation (ICC) to officially terminate the case.

 

4. The therapist will then turn in the ICC sheet to the clerical staff, who will close the record in the computer.

 

5. Post Discharge:A. The organization will follow up with the discharged consumers as soon as possible for unplanned discharges and within 30-days for planned discharges.

 

 

 

 

 

 

 

 

REFERENCES:

 

 

 

 

TRANSITION PLANNING POLICY

 

POLICY: Pathways, Inc. approach to transition planning is to discuss and develop the expected steps that will lead to a successful completion of services and proper transition to alternative levels of care, discharge, and after care. Proper transition planning allows input from the consumer, family members, significant others, referral sources, and staff. The plan that is developed is formally written upon the consumer’s exit from their current level of care or the agency. All individuals that participate in the transition planning are offered copies of the written transition plan. All consumers that transition or discharge from agency services will be contacted after departure from the agency to determine the status, needs, or to confirm contact with the referrals offered.

 

PROCEDURE: At the time of transition:

1. The primary therapist will discuss the need or purpose for the consumer’s transition with their supervisor and/or treatment/service team.

 

2. The primary therapist will discuss and seek input from the consumer, family members, significant others, referral resources, and staff to determine the most effective and proper transitional needs and services.

 

3. A written Discharge and Transition Planning Summary and other required documentation will be completed. This summary must include the designation of alternative services determined to meet the consumer’s needs.

 

4. All information will be documented on the Discharge and Transition Planning Summary Form and filed in the consumer’s record.

 

5. The organization will follow up with the transitioned consumers after the transition date.

 

 

 

 

 

Unplanned Transitions:

 

When a consumer is involved in an unplanned transition, the primary therapist will:

1. Provide notification to the consumer, family members, and significant others regarding the transition to a different level of care, to another facility, or to after care as soon as possible after leaving services.

 

2. Discuss with the consumer any need for further services or assistance.

 

3. Provide the consumer with the services or assistance requested.

 

4. Document all information on the Discharge and Transition Planning Summary Form and file in the consumer’s record.

 

 

Transition due to aggressive behavior:

 

When a consumer is transitioned out of services due to aggressive or assaultive behavior, follow-up will be provided by Pathways, Inc. to:

1. Ensure that linkage has occurred to provide appropriate care.

 

2. Ensure that the follow-up has occurred as soon as possible after exit from the program.

 

3. Document all information on the Discharge and Transition Planning Summary Form and filed in the consumer’s record.

 

 

 

 

 

REFERENCES:

 

 

 

 

ABUSE AND NEGLECT

 

 

 

 

POLICY: Adults are provided protection from abuse and neglect under Kentucky Revised Statutes, Chapter 209.

 

 

 

 

Under KRS 209.020(7), abuse and neglect is defined as "the infliction of physical pain, injury, or mental injury, or the deprivation of services by a caretaker which are necessary to maintain the health and welfare of an adult, or a situation in which an adult, living alone, is unable to provide or obtain for him/herself the services which are necessary to maintain his/her health or welfare."

 

 

 

 

KRS 209.030(2) states, "Any person, including, but not limited to, physician, law enforcement officer, nurse, social worker ... having reasonable cause to suspect that an adult has suffered abuse/neglect, shall report or cause reports to be made ... Death of the adult does not relieve one of the responsibility for reporting the circumstances surrounding the death."

 

 

 

 

KRS 209.990(1) states, "Anyone knowingly and willfully violating the provisions of KRS 209.030(2) shall be guilty of a Class B misdemeanor."

 

Children, as per KRS Chapter 620, are given similar protection as adults are under KRS 209.000.

 

KRS 620.010 states, "Children have certain fundamental rights which must be protected and preserved, including but not limited to, the rights to adequate food, clothing and shelter; the right to be free from physical, sexual or emotional injury or exploitation; the right to develop physically, mentally, and emotionally to their potential; and the right to educational instruction and the right to a secure, stable, family."

 

PROCEDURE:

1. Pathways wishes to emphasize that the agency will not tolerate abuse/neglect of our consumers by anyone. If a staff person has any reason to suspect abuse/neglect; they are required by law and by Pathways' policy to make an immediate oral or written report to the Department of Community-Based Services (DCBS). A report of this nature is not an accusation; it is a request for an investigation. Anyone acting upon reasonable cause in the making of a report or acting in good faith shall have immunity from any civil or criminal liability.

 

2. As per KRS 209.030(3), "Any person making such a report shall provide the following information, if known: The name and address of the adult, or of any other person responsible for his/her care; the age of the adult; the nature and extent of the abuse/neglect, including any evidence of previous abuse/neglect; the identity of the perpetrator, if known; the identity of the complainant, if possible; and any other information that the person believes might be helpful in establishing the cause of abuse/neglect.”

 

3. Staff is expected to immediately inform their supervisor when they become aware of possible abuse/neglect of a consumer. However, informing your supervisor of your suspicions does not relieve you of your legal and ethical obligations. Your obligations are fulfilled only after you have made your report to DCBS and then cooperated with them fully.

 

 

 

 

4. It is the responsibility of DCBS to then investigate and make a final determination of the incident. It is not Pathways’ role to do this.

 

 

 

 

 

5. DCBS and their Family Service workers are to be viewed and treated as professionals discharging their legal obligations and helping us to provide better care and welfare to our consumers. All staff will be expected to cooperate fully. All consumer records and our facilities are open to any representative of the Department actively involved in the conduct of an abuse/neglect investigation, without the need for any signed release of information forms as per KRS 209.030(5). EXCEPTION: However, where federal regulations for drug and alcohol consumers prohibit such disclosures, these regulations supersede state law.

 

 

 

6. Staff is expected to immediately inform their supervisor when they become aware of a consumer abuse/neglect investigation conducted by DCBS or any other agency.

 

 

 

 

7. Remember it is your legal and ethical duty to report suspected abuse/neglect to the Department of Community-Based Services (DCBS). Your report will be treated confidentially by DCBS.

 

 

For details, please refer to American with Disabilities Act Manual, July 1992.

 

REPORTING:

1. REPORTING PROCEDURE OF ABUSE OR NEGLECT WHERE ABUSER IS BELIEVED TO BE AN EMPLOYEE:a. Reporting of abuse or neglect where the abuser is believed to be an employee of Pathways, Inc. shall be immediately reported to the administration and the proper authorities for investigation.

 

b. Individuals under investigation are not permitted to be a part of the investigation team.

 

c. Individuals under investigation are prohibited from working with or having contact with the recipient who made the allegation.

 

d. Findings will be reviewed and forwarded to the governing body. All substantiated cases of abuse and neglect will be forwarded to the appropriate law enforcement and state agencies, and the employee will be terminated.

 

e. Any employee or consultant who witnesses, has knowledge of, or otherwise suspects that abuse or neglect of a recipient has occurred must report such incident to the primary therapist of that case or the Chief Compliance Officer. They must also cooperate fully with the investigation. This includes incidents that occur in the office, in the community, or in the recipient’s home.

 

f. The administration and staff are responsible for reporting abuse and neglect to the appropriate state agencies such as Child Protection, Adult Protective Services, and the local law enforcement agencies.

 

g. Reporting of abuse or neglect where the abuser is believed to be an employee of Pathways, Inc. shall be immediately reported to a local or state law enforcement agency.

 

h. The report, verbal or written, shall contain the information (if known) found on the Critical Incident Report.

 

i. The report shall name the employee or employees thought to have caused or contributed to the consumer’s condition, and the report shall contain the name of such person if the consumer names him/her.

 

j. If the initial report was in oral form by a mandatory reporter, there shall be a written report made within three (3) business days to the local law enforcement agency.

 

 

 

 

 

2. REPORTING PROCEDURE OF ABUSE OR NEGLECT WHERE ABUSER IS BELIEVED TO BE A PARENT, FAMILY MEMBER, OR CARETAKER:a. Reporting of abuse or neglect where the abuser is believed to be a parent, family member, or caretaker, shall be immediately reported to the local Child Protection agency, Adult Protection, or local law enforcement agency.

 

 

 

 

b. The report, verbal or written, shall contain the information (if known) found on the Critical Incident Report.

 

 

 

 

c. The report shall name the person or persons thought to have caused or contributed to the consumer’s condition if known, and the report shall contain the name of such person if the consumer names him/her.

 

d. If the initial report was in oral form by a mandatory reporter, there shall be a written report made within three (3) business days to the local Child Protection agency, Adult Protection agency or, if necessary, to the local law enforcement agency.

 

 

 

 

e. All reports received by local or state law enforcement agencies involving abuse or neglect where the parent or caretaker is believed responsible shall be referred to the local Child Protection agency.

 

 

 

 

REFERENCES:

 

 

 

 

CRISIS NUMBER

 

 

 

 

Pathways, Inc. has an after hour’s crisis number that is monitored by qualified staff. The number is 800-562-8909.

 

 

 

 

Pathways, Inc. will have a staff member on the premises at all times to accept referrals and accept consumers during regular business hours.

 

 

 

 

CODE OF ETHICS

 

 

 

 

Consumer Welfare

 

Primary Responsibility. The primary responsibility of Pathways, Inc. is to respect the dignity and to promote the welfare of consumers.

 

Positive Growth and Development. Pathways, Inc. encourages consumer growth and development in ways that foster the consumers' interest and welfare; Pathways, Inc. avoids fostering dependent consumer relationships.

 

Treatment/Service Plans. Pathways, Inc. staff and its consumers work jointly in devising integrated, individual treatment/service plans that offer reasonable promise of success and are consistent with abilities and circumstances of consumers. Pathways, Inc. staff and consumers regularly review treatment/service plans to ensure their continued viability and effectiveness, respecting consumers' freedom of choice.

 

Family Involvement. Pathways, Inc. recognizes that families are usually important in consumers' lives and strives to enlist family understanding and involvement as a positive resource, when appropriate.

 

Career and Employment Needs. Pathways, Inc. works with its consumers in considering employment in jobs and circumstances that are consistent with the consumers' overall abilities, vocational limitations, physical restrictions, general temperament, interest and aptitude patterns, social skills, education, general qualifications, and other relevant characteristics and needs. Pathways, Inc. neither places nor participates in placing consumers in positions that will result in damaging the interest and the welfare of consumers, employers, or the public.

 

Respecting Diversity

 

Nondiscrimination. Pathways, Inc. does not condone or engage in discrimination based on age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

 

Respecting Differences. Pathways, Inc. staff will actively attempt to understand the diverse cultural backgrounds of the consumers with whom they work. This includes, but is not limited to, learning how the agency’s own cultural/ethnic/racial identity impacts the values and beliefs about the therapeutic process.

 

 

 

 

Consumer Rights

 

Disclosure to Consumers. When treatment/service is initiated, and throughout the treatment/service process as necessary, Pathways, Inc. staff informs consumers of the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services to be performed, and other pertinent information. Pathways, Inc. staff takes steps to ensure that consumers understand the implications of diagnosis, the intended use of tests and reports, fees, and billing arrangements. Consumers have the right to expect confidentiality and to be provided with an explanation of its limitations, including supervision and/or treatment/service team professionals; to obtain clear information about their case records; to participate in the ongoing treatment/service plans; and to refuse any recommended services and be advised of the consequences of such refusal.

 

 

 

 

Freedom of Choice. Pathways, Inc. staff offers consumers the freedom to choose whether to enter into a therapeutic relationship and to determine which professional(s) will provide services. Restrictions that limit choices of consumers are fully explained.

 

Inability to Give Consent. When treating minors or persons unable to give voluntary informed consent, Pathways, Inc. staff acts in these consumers' best interests.

 

 

 

 

Consumers Served by Others

 

If a consumer is receiving services from another health care professional, Pathways, Inc. staff, with consumer consent, informs the professional persons already involved and develops clear agreements to avoid confusion and conflict for the consumer.

 

 

 

 

Personal Needs and Values

 

Personal Needs. In the therapeutic relationship, Pathways, Inc. staff is aware of the intimacy and responsibilities inherent in the therapeutic relationship, maintains respect for consumers, and avoids actions that seek to meet their personal needs at the expense of consumers.

 

Personal Values. Pathways, Inc. staff is aware of their own values, attitudes, beliefs, and behaviors, and how these apply in a diverse society, and avoid imposing their values on consumers.

 

 

 

 

Dual Relationships

 

Avoid When Possible. Pathways, Inc. staff is aware of their influential positions with respect to consumers, and they avoid exploiting the trust and dependency of consumers. Pathways, Inc. makes every effort to avoid dual relationships with consumers that could impair professional judgment or increase the risk of harm to consumers. (Examples of such relationships include, but are not limited to,

 

familial, social, financial, business, or close personal relationships with consumers.) When a dual relationship cannot be avoided, Pathways, Inc. takes appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.

 

Superior/Subordinate Relationships. Pathways, Inc. staff does not associate as consumer’s superiors or subordinates with whom they have administrative, supervisory, or evaluative relationships.

 

 

 

 

Sexual Intimacies with Consumers

 

Current Consumers. Pathways, Inc. staff does not have any type of sexual intimacies with consumers and do not counsel persons with whom they have had a sexual relationship.

 

Former Consumers. Pathways, Inc. employees do not engage in sexual intimacies with former consumers within a minimum of two (2) years after terminating the therapeutic relationship. Pathways, Inc. employees who engage in such relationship after two (2) years following termination have the responsibility to examine and document thoroughly that such relations did not have an exploitative nature, based on factors such as duration of treatment/service, amount of time since treatment/services, termination circumstances, consumer's personal history and mental status, adverse impact on the consumer, and actions by the employee suggesting a plan to initiate a sexual relationship with the consumer after termination.

 

 

 

 

Multiple Consumers

 

When Pathways, Inc. staff agrees to provide therapeutic services to two or more persons who have a relationship (such as husband and wife, or parents and children), Pathways, Inc. staff clarify at the outset, which person or persons are consumers and the nature of the relationships they will have with each involved person. If it becomes apparent that Pathways, Inc. staff may be called upon to perform potentially conflicting roles, they clarify, adjust, or withdraw from roles appropriately.

 

 

 

 

Group Work

 

Screening. Pathways, Inc. staff screens prospective group counseling/therapy participants. To the extent possible, Pathways, Inc. staff selects members whose needs and goals are compatible with goals of the group, who will not impede the group process, and whose well being will not be jeopardized by the group experience.

 

Protecting Consumers. In a group setting, Pathways, Inc. staff takes reasonable precautions to protect consumers from physical or psychological trauma.

 

 

 

 

Fees and Bartering

 

Advance Understanding. Pathways, Inc. staff clearly explains to consumers, prior to entering the therapeutic relationship, all financial arrangements related to professional services.

 

Bartering Discouraged. Pathways, Inc. staff refrains from accepting goods or services from consumers in return for therapeutic services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship.

 

Termination and Referral

 

Abandonment Prohibited. Pathways, Inc. staff does not abandon or neglect consumers in treatment/service. Pathways, Inc. staff assists in making appropriate arrangements for the continuation of treatment/services, when necessary, during interruptions such as vacations, and following termination.

 

Inability to Assist Consumers. If Pathways, Inc. staff determines an inability to be of professional assistance to consumers, they avoid entering or immediately terminate a therapeutic relationship. Pathways, Inc. staff is knowledgeable about referral resources and suggests appropriate alternatives. If consumers decline the suggested referral, Pathways, Inc. staff should discontinue the relationship.

 

Appropriate Termination. Pathways, Inc. terminates a therapeutic relationship, securing consumer agreement when possible, when it is reasonably clear that the consumer is no longer benefiting, when services are no longer required, when treatment/services no longer serve the consumer's needs or interests, or when agency or institution limits do not allow provision of further therapeutic services.

 

 

 

 

PROCEDURE:

 

If there is a claim that an employee or contractor has violated the Code of Ethics, the following steps will be followed:

1. A verbal report will be made to the immediate supervisor.

 

2. The verbal report will be summarized in writing on a Critical Incident Report form and sent to the Chief Compliance Officer for investigation.

 

3. After completion of all required investigations and a clear understanding of the violation, the Chief Compliance Officer will meet with and address the violation with the party(ies) involved.

 

4. A decision will be rendered as to the sanctions, if any, for the violation, and this will be written and placed into the individual’s personnel chart, if applicable.

 

 

 

 

 

 

 

REFERENCES: http://www.counseling.org/resources/ACA_Ethics.pdf

 

 

 

 

FINANCIAL OBLIGATIONS OF CONSUMERS

 

 

 

 

When a consumer has been determined to be eligible for services in the program, the organization will discuss all financial obligations with the recipient.

 

 

 

 

PHYSICAL RESTRAINT/EMERGENCY INTERVENTION POLICY

 

 

 

 

POLICY: Pathways, Inc. does utilize restraint, emergency interventions or therapeutic holds when absolutely necessary to protect or control inappropriate behaviors from child, adolescent or adult consumers. Local law enforcement will be contacted if a child, adolescent or adult consumer becomes aggressive or violent. Standing orders are not issued to authorize the use of restraint/emergency intervention. Restraint/emergency intervention is authorized by a qualified behavioral health practitioner and the practitioner will evaluate the consumer within one hour of the use of

 

restraint/emergency intervention. Restraint/emergency intervention will only take place in an environment that can safely and humanely accommodate the practice of restraint/emergency intervention. Staff is to examine contributing environmental factors and consider contraindications prior to the use of restraint that may promote maladaptive behaviors and take actions to minimize these factors. These contraindications will be noted on the assessment.

 

 

 

 

DEFINITIONS

 

Therapeutic holds: A less intrusive physical intervention designed to redirect inappropriate behaviors without disrupting the therapeutic process.

 

Physical escort: Touching or holding a consumer without the use of force for the purpose of directing the consumer.

 

Physical restraint/emergency intervention: The use of bodily force to limit a consumer’s freedom of movement when the consumer becomes aggressive or violent.

 

Extended restraint: A physical restraint the duration of which is more than twenty (20) minutes. Extended restraints increase the risk of injury and, therefore, require additional staff assistance.

 

 

 

 

PROCEDURE:

 

DETERMINING WHEN PHYSICAL RESTRAINT MAY BE USED

1. Physical restraint may be used only when:a. Documentation demonstrates that less restrictive emergency intervention techniques were used prior to the use of restraint.

 

b. The type of restraint will be determined in accordance with the consumer’s characteristics. Adults, children and adolescents, and consumers with special needs will be restrained as appropriate for their circumstances.

 

c. A review of the medical history is made to determine whether restraint can be administered without risk to health and safety

 

d. The consumer’s behavior poses a threat of imminent, serious, physical harm to self and/or others.

 

 

2. Limitations of restraint:

 

Physical restraint will be limited to the use of reasonable force as is necessary to protect a consumer or other consumers and staff members from assault or imminent serious physical harm.

 

 

 

3. Instances when restraint is not to be used:a. Physical restraint is not to be used as a means of punishment.

 

b. Physical restraint should not be used as an intervention, if the consumer has known physical, sexual, and emotional abuse, neglect, trauma, and exposure to violence, which would knowingly exacerbate their condition.

 

c. Restraint is not used as coercion, discipline, convenience, or retaliation by personnel in lieu of adequate programming.

 

 

4. Nothing in this document prohibits:a. The right of an individual to report to appropriate authorities a crime committed by a consumer or another individual.

 

b. Law enforcement or judicial authorities from exercising their responsibilities, including the physical detainment of a consumer or other persons alleged to have committed a crime or posing a security risk.

 

c. The exercise of an individual’s responsibilities as a mandated reporter of abuse/neglect to the appropriate state agency.

 

d. Any employee from using reasonable force to protect consumers, other persons, or themselves from assault or imminent, serious physical harm.

 

 

 

PROPER ADMINISTRATION OF PHYSICAL RESTRAINT

1. Trained personnel:

Only staff that has been trained in de-escalation and physical restraint procedures shall administer it to consumers. To the greatest degree possible, another employee who does not participate in the restraint should witness administration of a restraint. However, this policy shall not preclude an employee from using reasonable force to protect consumers, other persons, or themselves from assault or imminent, serious physical harm.

 

2. Use of force:

Any individual(s) administering physical restraint shall use only the amount of force necessary to protect the consumer or others from physical injury or harm.

 

 

 

 

3. Safety requirements:a. The physical plant can safely and humanely accommodate the practice of restraint.

 

b. Restraint will be administered in a manner so as to prevent or minimize physical harm to the consumer. Restraint will not last over 45 minutes and will be terminated when proper law enforcement officials arrive.

 

c. A restraint will not be administered in a manner that prevents the consumer from speaking or breathing.

 

d. During a restraint, a staff member shall continuously monitor the physical status of the consumer including skin color and respiration.

 

e. If at any time during the restraint the consumer displays significant physical distress, the restraint will immediately terminate and medical assistance will be sought.

 

f. Staff will review and take into consideration any known medical or psychological limitations and/or behavioral intervention plans regarding physical restraint on an individual consumer.

 

g. During a restraint, staff will continuously talk to and engage the consumer in an attempt to de- escalate behavior and to end the restraint as soon as possible. Staff will communicate with the consumer explaining that restraints are being performed to keep them and others safe. Staff will review for continued need for the physical hold every 15 minutes.

 

h. Staff administering physical restraint will use the safest method available that is appropriate to the situation.

 

i. Floor or prone restraints will only be used when conventional holds are ineffective. This type of

 

restraint may be necessary in order to provide for the safety of the consumer as well as others present. In such a situation, the primary staff member administering the restraint will communicate with the consumer for safety purposes in an attempt to de-escalate and end the restraint as soon as possible.

 

j. Restraint will immediately terminate when the staff member determines that the consumer is no longer at risk of causing imminent physical harm to themselves or others.

 

k. After release of a consumer from restraint, the incident, when applicable, will be reviewed with the consumer and the behavior that led up to the restraint will be addressed.

 

l. The administrator in charge will review the incident with the staff member who administered the restraint to ensure that proper procedures were followed and to consider if any follow-up is appropriate for consumers who may have been present during the restraint.

 

m. Immediate medical attention is made available for any injury resulting from seclusion or restraint.

 

 

 

 

 

 

REPORTING REQUIREMENTS

1. When restraint must be reported:a. Any staff member, who administers a restraint which lasts longer than twenty (20) minutes or results in any injury to a consumer or staff member, shall verbally inform the Administrator or Clinical Supervisor as soon as possible and by written report no later than the next working day. However, if the Administrator or Clinical Supervisor has administered the restraint, then he/she shall submit the report to an Administrator who was not involved in the restraint. The agency administration shall maintain an ongoing record of all reported instances of physical restraint, which shall be made available for review.

 

An assessment of any environmental stimuli that contributed to any incidents of restraint will be assessed and proper adjustments will be made. Administration will review with staff member the incident report to assess the need for revision of treatment/service plan or program model for the person served.

 

b. For any consumer that does not de-escalate while in restraints or continues to pose a threat to self or others, local law enforcement will be called immediately by staff personnel to assist with the situation. If law enforcement has to be contacted, the staff will also immediately call the consumer’s parents or family members, as applicable, to come to the office and assist with the consumer.

 

 

2. Informing legal representative/caregiver/parents, as applicable,a. The Administrator or the Clinical Supervisor shall verbally inform the consumer’s legal representative/caregiver/parents, as applicable, of the restraint as soon as possible, not to exceed eight hours after restraint has been utilized.

 

 

 

 

 

 

DEBRIEFING:

 

The agency will conduct a debriefing within 24 hours after the incident and there will be documentation of the following:

1. A review with the consumer regarding their perspective on what they experienced, review of the situation that caused the restraint to be conducted, and a reminder to the consumer that they are in control of the need for future restraints.

 

2. Documentation of the staff members involved.

 

3. Names of others that observed the incident.

 

4. Names of others (family/guardian/significant others) that were present at the debriefing.

 

5. A documented discussion that addresses:

a. The incident

 

b. Its antecedents

 

c. An assessment of contributing factors on an individual, programmatic, and organizational basis.

 

d. The reasons for the use of restraint.

 

e. The person’s reaction to the intervention.

 

f. Actions that could make future use of seclusion or restraint unnecessary.

 

g. Modification made to the treatment plan to address issues or behaviors that impact the need to use seclusion or restraint.

 

 

 

 

REFERENCES:

 

 

 

 

SECLUSION POLICY

 

 

 

 

POLICY: In the event of a behavioral emergency Pathways, Inc. staff is not authorized to use any form of seclusion to stop or divert a consumer’s behavior. Pathways, Inc. staff may attempt to defuse potentially violent situations using verbal preventive intervention techniques and strategies but if these strategies are unsuccessful, Pathways, Inc. staff is expected to call 911 to contain the behavioral emergency.

 

 

 

 

TOBACCO/SMOKING

 

 

 

 

POLICY: In keeping with Pathways, Inc. intent to provide a safe and healthful work environment, vaping, smoking, or tobacco use in the workplace is prohibited except in those locations that have been specifically designated as smoking/tobacco areas. Vaping, smoking or tobacco use in any vehicle occupied by a consumer is strictly prohibited. In situations where the preferences of tobacco users and non-tobacco user are in direct conflict, the preferences of non-tobacco users will prevail. This policy applies equally to all employees, customers, and visitors. The use of tobacco and tobacco products by minors is strictly prohibited.

 

 

 

 

HANDLING OF WEAPONS AND DRUGS

 

 

 

 

POLICY: Pathways, Inc. will assure the safety and well-being of consumers and staff personnel in regards to dangerous weapons, legal, illegal, and prescription drugs. Pathways, Inc. has the right and responsibility to remove, if possible and confiscate any items deemed to be dangerous or illegal.

 

PROCEDURE: Pathways, Inc. will adhere to the following procedure if legal, illegal, prescription drugs, or weapons are discovered on the agency premises.

 

Legal Drugs: (Over the Counter, Vitamins, Herbs, and Alcohol)

1. If legal drugs are present on the person of a consumer or personnel, the consumer or personnel is required to keep all legal drugs concealed and not freely visible.

 

2. Consumers and personnel are not allowed to dispense any legal drugs to any other consumer or personnel while on the organization’s premises.

 

3. The consumption or distribution of alcohol on the organization’s premises is strictly prohibited. Use or distribution of alcohol while on the premises of the organization will result in the consumer or personnel being asked to leave the premises immediately. If the consumer is underage, the parents or the appropriate authorities will be contacted immediately.

 

 

 

 

Illegal Drugs:

1. If illegal drugs are discovered on any consumer or personnel, Pathways, Inc. staff members will attempt to isolate the consumer or personnel from the other consumers and staff members.

 

Staff will immediately notify the Supervisor/Administration for further instructions.

 

2. If the illegal drugs are discovered on a consumer, Pathways, Inc. personnel will require the consumer to turn over the illegal substance to staff, who will then ensure that it is properly disposed of. If consumer refuses, he/she will be asked to leave Pathways.

 

3. If the illegal drugs are discovered on a staff member, this must be reported immediately to the Human Resources Director who will take appropriate action.

 

4. A Critical Incident Report should be completed within twenty-four (24) hours of the incident.

 

 

Prescription Drugs:

 

1. Prescription drugs are allowed for consumers and personnel when the medication is in a prescription bottle with the consumer’s or personnel’s name on the bottle.

 

Weapons:

1. If any weapon is discovered on any consumer or personnel, Pathways, Inc. staff members will attempt to isolate the consumer or personnel. Staff will remove all other consumers and personnel from the agency and immediately call the local authorities. Staff will focus on assuring the safety of the consumers and other staff members. Staff will avoid attempting to secure the weapon and will wait for proper authorities to arrive.

 

2. Pathways, Inc. staff will immediately notify the Supervisor/Administration to receive any additional instructions on how to handle the current situation.

 

3. Pathways, Inc. will immediately notify the consumer’s legal representative, if applicable, regarding the situation.

 

4. Pathways, Inc. may press charges with the local authorities and participate fully in their investigation.

 

5. Pathways, Inc. will meet with consumer and/or legal representative within 48 hours (if possible) of the incident to discuss the consumer’s status in the program.

 

6. A Critical Incident Report should be completed within (24) hours after the incident.

 

 

 

 

 

REFERENCES:

 

PRIMARY THERAPIST

 

A primary therapist for each consumer will be assigned at the beginning of services. This individual will be the person that is responsible for identifying issues and designing a treatment/service plan that will meet the needs of each recipient individually. All questions that arise regarding goals and objectives should be brought to the attention of the assigned staff member.

 

 

 

 

RESTRICTION OF SERVICES

 

 

 

 

Pathways, Inc. reserves the right to restrict services in the event that the person served demonstrates behaviors or attitudes that are detrimental to the therapeutic process for themselves or others seeking services. Aggressive or extreme defiance, refusal to participate in treatment/services, denial of access to the person served, or hostile or threatening gestures to Pathways, Inc. personnel or consumers will result in the removal of the person served from some or all of the therapeutic services available.

 

 

 

 

Pathways, Inc. will attempt to continue delivering services to the person served in an environment that is more restrictive. When the Supervisor/Administrator determines that the behaviors or attitudes that cause restrictions have been resolved, the person served will be allowed to return to the previous level of services. If the behaviors or attitudes continue or worsen, the Primary Therapist will determine if the person served is in need of discharge or transition.

 

 

 

 

FIRE AND SAFETY NOTIFICATION

 

 

 

 

All consumers accepted into the program are oriented to all emergency exits, fire suppressant equipment locations, and how to access first aid supplies prior to beginning services.

 

 

 

 

ASSESSMENT PURPOSE AND PROCEDURE

 

 

 

 

The purpose of the assessment is to gather all needed data through interviews with the consumer, family members, essential others, and other stakeholders. The primary therapist will design a treatment/service plan that will address the identified issues and develop therapeutic strategies to resolve each issue. This assessment is the original information that guides treatment/services. There is a constant effort to assess the needs and desires of the person served throughout the individual’s time in treatment/services.

 

 

 

 

DEVELOPMENT OF INDIVIDUAL PLAN OF CARE

 

 

 

 

Pathways, Inc. develops an individualized plan of care for each person served. Staff uses the historical data collected at the time of evaluation and the current information gathered during assessment to identify therapeutic issues and develop strategies to address these needs. The person served has input into this process from the beginning of treatment/services. The person served has the right to change or refuse any of the goals that are developed over the course of treatment/services.