Care Policy Outpatient Treatment Center Policies and Procedures Owner’s Manual

Care Policy Outpatient Treatment Center Policies and Procedures

Product Information

Specifications

• Product Name: Policy and Procedure Manual
• Version: 1.0
• Confidentiality: Classified as Confidential
• Agency Name: [AGENCY NAME]

Introduction
The Policy and Procedure Manual serves as a guide for staff, clients, and stakeholders of [AGENCY NAME]. It ensures the delivery of safe, ethical, and effective mental health services in accordance with the regulations and guidelines set forth by the State of Ohio and other relevant bodies. The manual aims to continuously improve the quality and accessibility of services provided.

Vision and Mission Statements
[AGENCY NAME] is committed to providing high-quality, evidence-based, and culturally responsive outpatient mental health services to individuals and families in the State of Ohio. The mission is to promote the recovery, resilience, and wellness of clients and support their integration into the community.

Values
The values of [AGENCY NAME] guide actions and decision-making processes, playing an integral role in achieving the mission of providing high-quality mental health services to the community.

Document Control
The Policy and Procedure Manual undergoes periodic revisions. Document revisions are recorded in a table that includes version number, revision page number, description of amendment, and approval details. Document review and approvals are also recorded in a separate table. All policies and procedures are reviewed at least annually, with recommended changes submitted for approval by the governing body as necessary.

Statement of Policy
[AGENCY NAME] is committed to providing high-quality, evidence-based, and culturally responsive outpatient mental health services. The services aim to promote recovery, resilience, and wellness of clients and support their integration into the community. The policy statement is grounded in principles of recovery-oriented practice, trauma-informed care, and person-centeredness. Mental health conditions are recognized as treatable, and recovery is viewed as a collaborative and holistic journey.

The key principles of the policy statement are:

1. Client-Centered Care: Prioritizing the needs and preferences of clients, involving them in all aspects of their treatment planning and delivery, respecting their autonomy, diversity, and cultural backgrounds, and providing a welcoming, non-judgmental, and empowering environment.
2. Evidence-Based Practice: Utilizing up-to-date research and best practices in interventions and services, ensuring staff is trained and competent in the latest techniques and approaches in the field of mental health.
3. Safety and Quality: Prioritizing the safety and well-being of clients, staff, and the community, adhering to high standards of quality assurance, risk management, and ethical conduct. Policies and procedures are in place to prevent and respond to emergencies, incidents, and complaints.

Product Usage Instructions

Section 1: Client-Centered Care
Client-centered care is a fundamental principle of [AGENCY NAME]. The following instructions outline how to prioritize client needs and preferences:

1. Involve clients in all aspects of their treatment planning and delivery.
2. Respect client autonomy, diversity, and cultural backgrounds.
3. Create a welcoming, non-judgmental, and empowering environment for clients.

Section 2: Evidence-Based Practice
Ensuring evidence-based practice is essential to providing high-quality mental health services. Follow these instructions:

1. Stay updated with the latest research and best practices in the field of mental health.
2. Ensure staff receives training to stay competent in the latest techniques and approaches.

Section 3: Safety and Quality
Prioritizing safety and quality is crucial for [AGENCY NAME]. Use the following instructions:

1. Adhere to high standards of quality assurance, risk management, and ethical conduct.
2. Implement policies and procedures to prevent and respond to emergencies, incidents, and complaints.

Frequently Asked Questions (FAQ)

• Q: How often is the Policy and Procedure Manual reviewed?
  A: The Policy and Procedure Manual is reviewed at least annually, with recommended changes submitted for approval by the governing body as necessary.

• Q: What is the purpose of the Document Control section?
  A: The Document Control section records document revisions and approvals, ensuring transparency and accountability in maintaining the manual’s accuracy and compliance with regulations.

Copyright [Year] © [Agency Name]
Disclaimer: All rights reserved. No part of this publication may be utilized, reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, recording or otherwise, without the prior written consent of the publisher.

• [Agency Name]
• [Agency Address]
• [Contact Number]
• [Email Address]
• [Website]

Introduction

• Welcome to the Policy and Procedure Manual of [AGENCY NAME]. We are an outpatient treatment center located in the State of Ohio, dedicated to providing high-quality mental health services to individuals in need. This manual serves as a comprehensive guide for our employees, outlining our policies and procedures that are designed to ensure the safety and well-being of our clients, while also providing a supportive and therapeutic environment for their treatment.
• Our goal is to provide a holistic approach to mental health treatment that addresses the unique needs and concerns of each client, through evidence-based practices and a client-centered approach. We believe in the importance of promoting the dignity, respect, and self-worth of each individual, and strive to create a culture of inclusivity and diversity in our organization.
• The policies and procedures outlined in this manual are designed to comply with the regulations and guidelines set forth by the State of Ohio, and are subject to change as new regulations and best practices are identified. It is the responsibility of all employees to read, understand, and adhere to these policies and procedures in their daily work activities.
• We are committed to providing a safe and therapeutic environment for our clients, and to supporting our employees in their professional growth and development. We believe that through collaboration and communication, we can provide the highest quality care to our clients and promote positive outcomes in their mental health journey.

Vision and Mission Statements

• Vision Statement:
  [AGENCY NAME] strives to be the leading provider of mental health services in the State of Ohio by providing the highest quality of care and support to our clients.

• Mission Statement:
  [AGENCY NAME] is dedicated to providing accessible, evidence-based, and client-centered mental health services to individuals and families in our community. Our mission is to empower individuals to achieve their full potential and improve their overall well-being by promoting mental health and offering comprehensive treatment and support services. We are committed to fostering a safe and inclusive environment that promotes healing, recovery, and growth for our clients.

Values
The values of [AGENCY NAME], an Outpatient Treatment Center in the state of Ohio, are:

1. Compassion: We are committed to providing compassionate care to all of our clients and their families.
2. Respect: We believe in treating every individual with dignity and respect, regardless of their background or circumstances.
3. Excellence: We strive for excellence in everything we do, from the quality of our services to the professionalism of our staff.
4. Integrity: We are dedicated to maintaining the highest standards of ethical behavior, honesty, and transparency in all of our operations.
5. Empowerment: We believe in empowering our clients to take control of their mental health by providing them with the resources and support they need to succeed.
6. Collaboration: We value collaboration and teamwork, and work closely with our clients, their families, and other healthcare providers to ensure the best possible outcomes.

These values guide our actions and decision-making processes, and are integral to achieving our mission of providing high-quality mental health services to the community.

Document Control
Document revisions shall be recorded in the table below;

Document review and approvals shall be recorded in the table below;

Note: All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary.

Statement of Policy

[AGENCY NAME] is committed to providing high-quality, evidence-based, and culturally responsive outpatient mental health services to individuals and families in the State of Ohio. Our services are designed to promote the recovery, resilience, and wellness of our clients and to support their integration into the community.
We believe that every individual has the right to access compassionate, respectful, and personalized care that is grounded in the principles of recovery-oriented practice, trauma-informed care, and person-centeredness. We recognize that mental health conditions are treatable and that recovery is a journey that requires a collaborative and holistic approach.
Our Policy and Procedure Manual serves as a guide for our staff, clients, and stakeholders to ensure that our services are delivered in a safe, ethical, and effective manner. We adhere to the regulations and guidelines set forth by the State of Ohio and other relevant bodies, and we strive to continuously improve the quality and accessibility of our services.

Our policy statement encompasses the following key principles:

1. Client-Centered Care: We prioritize the needs and preferences of our clients and involve them in all aspects of their treatment planning and delivery. We respect their autonomy, diversity, and cultural backgrounds and provide them with a welcoming, non-judgmental, and empowering environment.
2. Evidence-Based Practice: We utilize the most up-to-date research and best practices in our interventions and services. We ensure that our staff is trained and competent in the latest techniques and approaches in the field of mental health.
3. Safety and Quality: We prioritize the safety and well-being of our clients, staff, and community. We adhere to the highest standards of quality assurance, risk management, and ethical conduct. We have policies and procedures in place to prevent and respond to emergencies, incidents, and complaints.
4. Continuous Improvement: We are committed to ongoing learning, evaluation, and innovation. We regularly collect and analyze data, feedback, and outcomes to inform our decision-making and improve the effectiveness and efficiency of our services.

In summary, [AGENCY NAME] is dedicated to providing exceptional outpatient mental health services that promote recovery, resilience, and wellness. Our Policy and Procedure Manual reflects our commitment to client-centered care, evidence-based practice, safety and quality, and continuous improvement.

Clinical readiness

Introduction

[AGENCY NAME] is an outpatient treatment center in Ohio, offering mental health and addiction treatment services to individuals. As per Ohio state guidelines, this document outlines the policies and procedures for the clinical readiness of the agency. This includes the clinical readiness documentation that all providers must upload, which includes a diagnostic assessment, treatment plan, progress note, and discharge summary. For SUD providers, ASAM rational/Certification procedure for non-deemed status must also be uploaded.
Certification Procedure for Non-Deemed Status:
Any provider subject to or seeking certification under this rule shall apply to the Department of Mental Health and Addiction Services by filing an application. A provider that is not requesting deemed status by the department according to rule 5122-25-02 of the Administrative Code shall file an application that includes the following:

• Identifying information including:
  1. Legal name as filed with the Ohio secretary of state, including any fictitious name (“doing business as”) if applicable;
  2. Addresses and telephone numbers at which the applicant operates and address for legal notice and correspondence. Each provider shall have at least one physical location that is certified. A location which would be considered the client’s natural environment (e.g. school, home, job and family services agency) is not considered a site and need not be certified;
  3. Governing structure and the names and contact information of the governing body, board of directors, LLC members, or similar body;
  4. Provider budget;
  5. Table of organization;
  6. Name and e-mail address of executive director, chief executive officer, or president;
  7. Name and e-mail address of designated provider contact person who shall be the primary contact on behalf of the provider;
  8. Current and previous history of state agency licensure and certification;
  9. Whether the provider is requesting certification to provide mental health services, addiction treatment services, or services to both populations;
  10. Policies and procedures, plans, and other documentation required by Chapters 5122-26 to 5122-29 of the Administrative Code;
  11. List of qualified providers and supervisor according to Chapter 5122-29 of the Administrative Code and the services they provide and/or supervise, and license number;
  12. List of services according to Chapter 5122-29 of the Administrative Code to be provided during the term of certification;
  13. Number of beds for each residential and withdrawal management substance use disorder services location; and,
  14. Other information or material if requested by the department to determine the applicant’s services meet certification standards.
• Upon request of the department, the following corporate information:
  1. A copy of the applicant’s articles of incorporation and all amendments;
  2. Identification of the statutory corporate agent for service; and,
  3. If an out-of-state corporation, a copy of the certificate from the Ohio secretary of state of registration to do business in Ohio. Before requesting this information, the department shall first attempt to obtain the information from the Ohio secretary of state website.
• Copies of approved physical inspections, either initial or renewal, for each building owned or leased, including:
  1. A building inspection by a local certified building inspector or a certificate of occupancy issued by the department of industrial relations, to be re-inspected whenever there are major alterations or modifications to the building or facility. An additional building inspection shall be required for any major change in the use of space that would make the facility subject to review under different building code standards;
  2. Approved fire inspection conducted within the previous twelve months, which shall be free of deficiencies and was conducted by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce;
  3. Water supply and sewage disposal inspection, conducted by the appropriate local or state agency, to ensure that the facility is in compliance with all applicable regulations and that the water supply is safe and free from contaminants.
• Copies of all licenses and permits required by federal, state, or local laws or regulations for the operation of the business, including but not limited to:
  1. A business license issued by the city, county, or state where the business is located;
  2. A seller’s permit issued by the state board of equalization;
  3. A hazardous materials storage permit, if applicable;
  4. A health permit, if applicable.
• Proof of insurance coverage, including but not limited to:
  1. General liability insurance;
  2. Property insurance;
  3. Workers’ compensation insurance;
  4. Business interruption insurance.
• Copies of all contracts and agreements related to the operation of the business, including but not limited to:
  1. Leases or rental agreements for the business premises and any other leased or rented equipment or facilities;
  2. Service contracts for utilities, maintenance, security, and other services;
  3. Sales contracts with customers and suppliers;
  4. Employment contracts and agreements with key personnel.
• Financial statements for the past three years, including but not limited to:
  1. Balance sheets;
  2. Income statements;
  3. Cash flow statements;
  4. Tax returns.
• Marketing and advertising materials, including but not limited to:
  1. Brochures, flyers, and other promotional materials;
  2. Advertising copy for print, radio, television, and online media;
  3. Websites and social media pages.
• Documentation of compliance with applicable laws and regulations, including but not limited to:
  1. Environmental regulations, including hazardous waste disposal and air and water quality standards;
  2. Occupational safety and health regulations;
  3. Labor laws, including minimum wage, overtime, and anti-discrimination laws;
  4. Tax laws, including federal, state, and local taxes.
• Any other documentation or information deemed necessary by the licensing authority for the proper evaluation of the application. This may include information related to the qualifications of the proposed

administrator, information about the facility’s staffing, information about the types of services that will be provided, and any other information that the licensing authority determines is necessary to evaluate the application.
It’s important to note that the specific documentation and information required for licensure may vary depending on the type of facility being licensed and the state or local regulations governing licensure in that jurisdiction. Applicants should consult with their licensing authority to determine the exact requirements for their application.

Governance policy
Policy and Procedures for [AGENCY NAME] – Outpatient Treatment Center in Ohio

Introduction
[AGENCY NAME] is committed to providing quality mental health and addiction services to the community. The purpose of this policy and procedure manual is to provide guidance and direction to staff and management to ensure compliance with Ohio state regulations, including Rule 5122-26-03 governing body and governance. The policies and procedures contained herein have been developed to support the provider’s mission, vision, and goals.

Leadership Structure

• Governance – The governing body of [AGENCY NAME] shall guide, plan, and support the achievement of the provider’s mission, vision, and goals.
• Provider Administration – The provider administration shall be responsible for planning, management, and operational activities.
• Provision of Services – The provision of services shall be the responsibility of the service providers.

Governing Body
The governing body of [AGENCY NAME] shall be a non-profit corporation and shall develop written by-laws, a code of regulation, or policies for the following:

1. Selection of members of the governing body. The composition of the governing body shall reflect the demographics of the community it serves.
2. Provisions for orienting new members of the board of directors.
3. The number of members of the governing body needed for a quorum.
4. Terms of office for the members of the governing body.
5. Provisions guarding against the development of, and prohibiting the existence of, a conflict of interest between a governing body member and the provider. B. The governing body shall:
6. Provide for orientation of its new members, including providing information about governing structure, duties, responsibilities, and operations of the organization.
7. Provide financial oversight and approve the annual budget and plan for services.
8. Conduct meetings of the governing body at least quarterly, which shall include: a. Review an annual summary of quality assurance and risk management activities and document governing body actions taken as a result of this review. b. Approve the quality assurance plan. c. Review an annual summary of client rights activities and document governing body actions taken as a result of this review.
9. Maintain minutes of meetings of the governing body including, but not limited to: a. Date, time and place of the meeting. b. Names of members who attended. c. Topics discussed and actions taken.
10. Establish procedures for selecting the chief executive officer, executive director, or equivalent.
11. Establish duties and responsibilities of the executive director.
12. Select the executive director.
13. Conduct an annual review and evaluation of the executive director.
14. Identify responsibility for leadership in the absence of the executive director.
15. Establish, review and update as necessary the provider’s policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the provider’s national accrediting body, if applicable, or a minimum of every five years.
16. Ensure adequate malpractice and liability insurance protection for its corporate membership, governing body, advisory board if applicable, provider, and provider staff, and review such protection annually.
17. Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of certified services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other provider bodies, to: a. Persons who are receiving or have received certified services, and their family members. b. Persons who collectively represent a wide range of community interests and demographic characteristics of the service district in categories such as race, ethnicity, primary spoken language, gender, and socio-economic status.
18. Ensure that the hours of operation forfor services and activities accommodate the needs of persons served, their families, and significant others.
19. Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations.
20. Conduct an annual self-assessment of its governance structure and operations to identify areas for improvement and ensure compliance with state regulations.
21. Report any significant changes in its governance structure or operations to the appropriate state regulatory agency in a timely manner.

Procedure for Governance

1. The governing body of [AGENCY NAME] shall meet at least quarterly to oversee the organization’s operations and ensure compliance with state regulations.
2. The governing body shall develop and maintain written by-laws, a code of regulations, or policies that outline the selection, orientation, and terms of office for governing body members.
3. The governing body shall ensure that the composition of its membership reflects the demographics of the community it serves.
4. The governing body shall provide orientation to new members to ensure that they are familiar with the organization’s governance structure, duties, responsibilities, and operations.
5. The governing body shall provide financial oversight and approve the annual budget and plan for services.
6. The governing body shall review an annual summary of quality assurance and risk management activities and document its actions taken as a result of this review.
7. The governing body shall approve the quality assurance plan and review an annual summary of client rights activities.
8. The governing body shall establish procedures for selecting the chief executive officer, executive director, or equivalent and identify their duties and responsibilities.
9. The governing body shall conduct an annual review and evaluation of the executive director and establish who is responsible for leadership in their absence.
10. The governing body shall establish, review, and update the organization’s policies as necessary, and document that this review has occurred.
11. The governing body shall ensure adequate malpractice and liability insurance protection for its corporate membership, governing body, advisory board if applicable, provider, and provider staff and review such protection annually.
12. The governing body shall ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of mental health and addiction services.
13. The governing body shall ensure that the hours of operation for services and activities accommodate the needs of persons served, their families, and significant others.
14. The governing body shall ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations.

Procedure for Orientation of New Governing Body Members

1. The executive director or equivalent shall provide orientation to new governing body members, including information about the organization’s governance structure, duties, responsibilities, and operations.
2. The orientation shall include an overview of the organization’s mission, vision, and goals.
3. The executive director or equivalent shall provide new governing body members with a copy of the organization’s by-laws, code of regulations, or policies.
4. The orientation shall provide new governing body members with an understanding of their roles and responsibilities, including their fiduciary responsibilities.
5. The executive director or equivalent shall provide new governing body members with an overview of the organization’s finances, including its budget and sources of revenue.
6. The orientation shall provide new governing body members with an understanding of the organization’s quality assurance and risk management programs.
7. The executive director or equivalent shall provide new governing body members with an overview of the organization’s client rights policies and procedures.
8. New governing body members shall have the opportunity to meet with key staff members and receive an overview of the organization’s services and operations.

Procedure for Financial Oversight:

1. Create a budget: A budget should be created for the organization and should be reviewed and approved by the board. The budget should include all income and expenses, as well as anticipated funding sources.
2. Regular Financial Reports: The board should receive regular financial reports, at least quarterly, to monitor the organization’s financial health. These reports should include a statement of income and expenses, a balance sheet, and a cash flow statement.
3. Financial Policies: The board should establish financial policies to guide the organization’s financial management. These policies should include guidelines for managing the organization’s cash flow, investment practices, and procedures for handling financial emergencies.
4. Audit: The board should engage an independent auditor to conduct an annual audit of the organization’s financial statements. The auditor’s report should be shared with the board and made available to the public.
5. Reserve Fund: The board should establish a reserve fund to provide financial stability in times of economic downturn or financial emergencies. The reserve fund should be invested in low-risk, liquid investments and should be regularly reviewed and adjusted as needed.
6. Donor Stewardship: The board should ensure that donors’ contributions are used for their intended purposes and that donors are regularly informed about the organization’s financial health and activities.
7. Risk Management: The board should assess the organization’s financial risks and implement strategies to mitigate those risks. This includes identifying and addressing potential fraud or embezzlement, as well as protecting the organization’s assets through appropriate insurance coverage.

By following these financial oversight procedures, the board can ensure that the organization remains financially stable, accountable, and able to fulfill its mission.

*This is only a preview of the Original Document
Document Classification: Confidential_ [AGENCY NAME]

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