1. health and fitness
2. addiction
3. substance abuse

POLICY AND PROCEDURE MANUAL
The Council on Alcohol and Drug Abuse
Coastal Bend
Corpus Christi, Texas
Copyright 2014. All rights reserved. This manual is the proprietary property of
COADA-CB and cannot be copied, reproduced, or otherwise duplicated or
distributed to any individual, organization or entity outside the organization
without the prior consent from the Executive Director of COADA-CB.
Revised: January 2014
Introduction
This “Policy and Procedures Manual” establishes the official policies for The Council On
Alcohol and Drug Abuse – Coastal Bend on a variety of administrative, business, clinical
and operational matters, assigns responsibility for implementation of those policies and is
to be fully implemented in all programs operated by the organization. For reader
convenience, the organization is referred to simply as “COADA-CB” throughout the
manual. The manual immediately replaces all other manuals previously published by the
organization and has been reviewed and approved by the leadership of COADA-CB. In
accordance with established policy, the manual is reviewed and approved at least
annually to ensure that COADA-CB’s policies and procedures remain consistent with
those of the Department of State Health Services (DSHS), the Department of Health
Human Services (DHHS). This manual establishes the administrative and operational
“baseline” for the organization. This version of the manual is organized into five primary
sections:
Section 1: Organizational Leadership & Responsibility
Section 2: Organizational Management
Section 3: Quality Improvement
Section 4: General Program Standards
Section 5: Core Program Descriptions and Plans
COADA-CB has opted to maintain the organization of this manual in the same basic
format as previous editions. This conscious decision was made as a way to avoid
employee’s confusion and enhance the operations of the organization by continuing to
use an organizational format that is familiar to the employees.
Sections 1 through 3 of the manual contain organizational policies governing the
administrative functions of the organization including business practices, corporate
compliance, information management, fiscal accountability, human resources, outcomes
management, and health/safety/quality assurance. Section 4 contains policies pertaining
to patient care issues, i.e, patient rights, patient records, seclusion and restraint, etc.
Section 5 contains those policies that governed the way those services are delivered at
COADA-CB. All employees of COADA-CB are responsible for reading this manual and
fully complying with all policies and procedures at all times. The Executive Director is
responsible for ensuring that this manual is reviewed annually and updated as required to
reflect changes in state licensing/regulatory requirements.
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COADA-CB Policy and Procedure Manual
Table of Contents
Introduction
Who We Are, Mission Statement and Philosophy
7
Section 1: Organizational Leadership and Responsibility
Leadership
9
Policies, Procedures, Programs Descriptions and Licensure Rules
12
Community Relations
13
Media Relations
14
Personal Relationships
15
Input From Patients and Other Stakeholders
16
Cultural Competency and Diversity
18
Equal Opportunity
20
Strategic Planning
22
Corporate Compliance Program and Plan
25
Organizational Code of Ethics
31
Employee Standards of Conduct
35
Compensation Based on Indicators of Patient Revenue
37
Health Insurance Portability and Accountability Act
39
Local and State Licenses
40
Section 2: Organizational Management
Information Management
42
Organizational Communication
44
Retention and Destruction of Records
51
Management Information System/Computer Policy
53
Clinical Management Behavioral Health System (CMBHS)
58
Confidentiality and Control of Patient Records
61
Cost Allocation, Cash Control and Fiscal Management
65
Cost Allocations
73
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Banking and Bank Reconciliation
75
Cash Receipts
76
Cash Disbursements
78
Maintenance of Vendor Filing
80
Payroll
81
Billing
83
Monthly Reconciliations
86
Property and Fixed Assets
87
Procurement of Goods and Services
90
Risk Management
92
Financial Accounting and Planning
95
Employees Recruitment
99
Criminal Background Checks
102
Hiring Practices
105
Employee Records
108
Employee Files and Training Records
110
New Employee Orientation
112
Primary Source Verification of Employees Credentials
113
Employee Classification and Payment
114
Attendance, Leave and Time Off
118
Employee Benefits
130
Employee Discipline
134
Termination
138
Performance Appraisal Review
141
Employee Qualification Requirements
143
Employees Training
147
Drug Free Workplace Policy
150
Drug Testing Procedures
152
Random Employee Selection for Drug/Alcohol Testing
153
Post Accident Drug Testing or Reasonable Suspicion
155
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Employee Behavior Regarding Alcohol and Other Drug Use
157
Fitness for Work
159
Emergency Medical Information
161
Vehicle Safety Inspection and Liability Reporting
162
Health and Safety Program
163
Health and Safety Inspections
164
Disaster Relief Services
166
Emergency Plans and Procedures
168
Inclement Weather
176
Accessibility and Accessibility Plans
177
Satellite Services
180
Environment and Safety Awareness
181
First Aid, CPR and Infection Control
184
Incident Reporting
186
Weapons, Firearms and Other Contraband
190
HIV in the Workplace
192
Agency Transportation
195
Use of Students, Interns and Volunteers
197
Clinical Supervision
198
Section 3: Quality Improveme
Performance Improvement Plan
200
Outcomes Management
204
Quality Record Reviews
207
Section 4: General Program Standards
Fully Informed Consent/Refusal for Service
210
Patient and Participant Bill of Rights
212
Patient/Participant Grievances/Complaints
214
Onsite Crisis Intervention
216
Treatment Screening and Access to Services
218
COPSD Access to Services
221
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Clinical Assessments
224
Admission Determination and Placement
226
Length of Stay Guidelines
229
Waiting List and Interim Services
230
Patient/Participant Orientation
232
Individualized Treatment Plan
233
Discharge (Transition) and Recovery Support Services
235
Seclusion and Restraint
237
Patient Searches
238
Patient Records
239
Reporting Child Abuse
241
Reporting Abuse, Neglect, and Exploitation
242
Section 5: Core Program Descriptions
Overview of Program Services
245
Core Program and Specific Description of Services
248
Screening and Referral
251
Outpatient Treatment
255
Youth Prevention Universal Program (YPU)
259
Youth Prevention Selective Program (YPS)
261
Youth Prevention Indicated (YPI)
266
Post Partum Intervention (PPI)
266
www.coada-cb.org go to bottom of page, click “For Staff only”
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Who We Are
“COADA-CB is a private non-profit organization that serves a multi-county region with a
continuum of care in the prevention, intervention, and treatment of the disease of
alcoholism and other drug abuse for individuals, families and communities. We are
trained professionals and volunteers providing help, hope and healing.”
Mission Statement
To be the premier provider of substance abuse prevention, intervention and treatment
services in the state of Texas. We will treat our participants/patients with dignity and
respect in all phases of the continuum of care experience. We believe in the disease
concept of addictive illness and will strive to institute current research findings in our
delivery of services. We will also be a resource to the communities. Our employees will
keep our mission statement as the guiding principle in their work. Trained professionals
and volunteers providing help, hope and healing.
Philosophy
• The patient/participate always comes first.
• COADA-CB will demonstrate continuous performance improvement.
• COADA-CB functions as a cohesive organizational team.
• In order to fulfill this philosophy, COADA-CB will demonstrate dignity and respect to
each patient/participate, to each other and to the community as a whole.
• In order to fulfill the philosophy goals and meet the needs of patients/participates, the
employees of COADA-CB will work collaboratively with each other, other providers,
provider organizations, and the local community.
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SECTION 1
ORGANIZATIONAL LEADERSHIP AND
RESPONSIBILITY
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Leadership
PURPOSE: To establish the official policy of COADA-CB on organizational leadership,
define organizational relationships, and assign specific responsibility for implementation
of this policy.
POLICY: COADA-CB IS A PRIVATE NON-PROFIT AGENCY WHOSE Board of
Directors is a legally established governing body with documented authority to operate in
the State of Texas. This governing body shall have legal authority over and accepts
responsibility for the fiscal and programmatic management, services, and operation of all
levels of treatment provided by the agency in compliance with DHHS AND THE
Department of State Health Services (DSHS) Standard of Care, Subchapters A-H, I148.901, 148-904, 148.906-148.909 and Chapter 144, Subchapter C Contract
Administrative Requirements 144.301-144.306. It is the policy of COADA-CB that the
organization will be managed and led by a competent leadership team, including an
Executive Director whose responsibilities are detailed below. As used in this policy, the
organization’s leadership is defined as the Board of Directors, the Executive Director,
Division/Program Managers and the Finance Business Manager.
PROCEDURE: The organization’s leadership is primarily responsible for the following
requirements: (a) establishing the mission and direction of the organization; (b)
promoting the value of programs and services offered; (c) balancing the needs and
expectations of patients, employees, and other stakeholders with organizational assets and
resources; (d) insuring that the organization remains financially solvent as a way to
promote continuity of the highest quality care; (e) compliance with risk management and
insurance practices and requirements; (f) continuous quality/performance improvement as
a way to enhance quality of care; (g) development, implementation and oversight of
operational and business responsibilities; and (h) full and complete compliance with all
state and federal laws, codes, rules and regulations. The organization’s leadership is
ultimately responsible for accessibility planning that addresses the needs of patients
served by the organization, employees and other “stakeholders”. As a way to promote the
elimination of discrimination and stigma for those persons served by COADA-CB the
organizations leadership will ensure that public education – often referred to as
“outreach”, “marketing” and/or “community relations” – is routinely conducted and
documented.
Additionally, leadership is responsible for insuring compliance with all legal and
regulatory requirements including but not limited to: (a) patient rights; (b) confidentiality
requirements; (c) reporting requirements; (d) contractual requirements; (e) licensing
requirements; (f) corporate status; (g) employment practices; (h) mandatory employee
testing and (i) privacy of patients served by the organization. In addiction to these legal
and regulatory requirements, the organization’s leadership is responsible for: (a)
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recruiting employees at all levels (including the Board of Directors) that represent the
specific cultures served by the organization and (b) conducting an annual review of all
policies and procedures. The leadership of COADA-CB assumes final authority over and
responsibility for the accountability of all programs and services and is accessible and
available to all employees and patients served by the organization.
As appropriate and as allowed by policy, law or regulation, COADA-CB will respond to
information regarding patients/participants from: (a) input forms; (b) periodic surveys; (c)
complaint grievances or incident summaries; (d) information from the organization’s
quality/performance improvement system; (e) strategic planning results; and (f)
program/service development.
In carrying out its responsibilities, The Board of Directors shall designate an Executive
Director who is directly accountable to the Board and responsible for the day to day
operations of the agency. The Board shall work collaboratively with the Executive
Director for the benefit of organizational management. The Executive Director shall: (a)
collaborate with the governance authority to effectively manage the organization; (b)
demonstrate competence in financial and employee management and other areas needed
to manage the facility effectively; (c) ensure compliance with applicable laws and rules;
(d) ensure all employees are competent and trained; (e) ensure proper planning,
management, and delivery of funded services, inclusive of having working knowledge of
the programs provided and management of programmatic outcome; (f) ensure financial
management and maintenance of adequate financial records according to generally
accepted accounting principles including an annual budget, records of income and
expenditures, and a written fee policy; (g) be accessible and available to the persons
served and employees; (h) be responsible for integrating the organization’s core values
and the mission into the daily operations; (i) be responsible for gathering input needed for
key decision making from the persons served, all levels of employees and other
stakeholders; (j) ensure maintaining a focus on the persons served; (k) be responsible for
resource utilization and safety; (l) be responsible for development and accomplishment of
the strategic plan; (m) ensure the flow of pertinent information to appropriate parties; (n)
demonstrate an organized system of information management; and (o) ensure all facilities
are accessible to persons with disabilities as required by the Americans with Disabilities
Act (ADA).
The Board shall hold periodic meetings as defined by the by-laws. Notification of
meetings of the Board shall be sent to all of the Board as defined in its by-laws.
The President or any two Board members, with 24 hour notice, when deemed
appropriate, may call special called meetings of the Board of Directors. Minutes of these
meetings will be maintained and will include: (a) date and time; (b) location of the
meeting; (c) names and attendees present and absent.
The Board of Directors shall meet the following criteria as required by DSHS. The Board
shall: (a) be a distinct business entity with legal authority to operate in the State of Texas;
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and (b) not include in its membership any employee of the organization, including the
Executive Director.
The Board shall receive orientation and training as follows: (a) required training on
culture awareness and sensitivity related to COADA-CB patient population; (b) initial
orientation that includes information on the organization’s programs and services
(recommended but not required); and (c) additional training specific to the needs of
individual Board members.
In the event COADA-CB ceases business operations, the Board of Directors shall ensure
the following: (a) records relating to all contracts are securely stored; (b) the records are
accessible for at least three years; and (c) DSHS is provided with the name and address of
the responsible party.
The organization’s leadership will meet and communicate as required to review program
operations, policy and procedures, improvements and/or for problem resolution. A record
of such meetings will be maintained so as to be available for review by the state
regulatory agency and national accreditation organizations.
All of the organization’s leadership structure is responsible for conformance with this
policy.
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Policies, Procedures,
Licensure Rules
Program
Descriptions
and
PURPOSE: To establish the official policy of COADA-CB on the development and
maintenance of official policies, procedures and licensure rules and to assign specific
responsibility for implementation of the policy.
POLICY: COADA-CB shall operate with benefit of written policies and procedures that
provide operational guidance resulting in compliance with applicable state and federal
rules and regulations and more specifically, with DSHS Licensure Rules (Chapter 148)
and Contractual Requirements (Chapter 144).
PROCEDURE: Each program or service offered by COADA-CB (frequently referred to
as “core programs”) will have a written plan that guides the delivery of services and
includes (a) a description of the program or service; (b) the philosophy of the program;
(c) program goals; (d) description of the services to be provided to achieve the
program/service objectives; (e) identification or a description of special populations and
mechanisms to address their needs; and (f) assurance that adequate resources are
available to deliver the identified core programs.
The leadership of COADA-CB shall (a) develop and implement individualized
procedures from those established by the Board of Directors and in compliance with the
requirements of DSHS Licensure Rules; (b) ensure that policies and procedures are
reviewed, updated (if required) and approved annually by the Board of Directors; (c)
ensure that current copies of the policy and procedure manual and DSHS Licensure
Standards are electronically accessible to all employees at all times; (d) ensure that new
employees read and understand the policies and the procedures applicable to their
position with documentation of the review maintained on file in employee records; (e)
inform employees in a timely manner of any changes in the organization’s policy and
procedure manual that pertain to their job duties and responsibilities; (f) new policies and
procedures will be placed online for employee’s review; (g) ensure that revisions are
appropriately made to all Policy and Procedure Manuals maintained by the organization;
(h) inform all employees of changes to the organization’s policies and procedures; (i)
provide training as needed to all employees on revisions to the organization’s policies
and procedures within 60 days; and (j) maintain an organizational structure that is
documented in the form of an organizational chart and defined in job descriptions.
The Executive Director and/or designated employees are responsible for daily
conformance with this policy. The Board of Directors is responsible for the review and
approval of policies and procedures as outlined above.
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Community Relations
PURPOSE: The purpose of this policy is to establish the official position of COADA-CB
on community relations and other community-oriented activities and, to assign specific
responsibility for conformance with the policy.
POLICY: The leadership of COADA-CB recognizes the need to actively support and
participate in public relations, education campaigns and activities as a way to: (a)
increase public awareness about addictive disorders; (b) minimize the stigma and
negative perceptions that are often associated with mental health and substance abuse; (c)
serve as a community advocate for behavioral health services in those communities in
which COADA-CB operates; and (d) address and resolve community relations problems.
Therefore, it is the policy of COADA-CB that its employees be encouraged and allowed
to participate in such activities with prior consent and approval of the responsible
Division/Program Manager or Executive Director. Such activities include, but are not
limited to: (a) speaking to a local school or civic group on substance abuse and/or
substance abuse treatment; (b) participating in a “Red Ribbon” rally or event; (c) being
interviewed on local radio or television about substance abuse treatment issues; (d)
writing an article for a newspaper on substance abuse-related issues; (e) participating in
an advocate meeting or local community group; and (f) meeting with local law
enforcement to address common challenges and issues. It is emphasized that
participation/involvement by COADA-CB employees in such events/activities is: (a) at
the discretion of the Executive Director or Division/Program Manager; (b) must be
approved in advance; and (c) on a “not to interfere” basis with the employee’s primary
work responsibilities.
PROCEDURES: The following procedures – combined with the aforementioned policy –
constitute COADA-CB’s formal plan on community relations:
1. Any employee who desires to participate in a public relations activity as outlined
above will advise the responsible Division/Program Manager who will , in turn,
coordinate participation through the Executive Director and secure his/her permission to
do so. Division/ Program Managers will be responsible for ensuring that the proposed
activities are consistent with the philosophy and goals of COADA-CB and, will
document the employee’s participation in the event.
2. COADA-CB should maintain a community resource directory for use by the
employees when addressing patient rehabilitation/treatment needs. The directory should
include the names of local providers/provider organizations, resource and advocacy
groups, support groups, contact names, phone numbers and other appropriate contact
information; it should be updated at least annually and made available to all employees.
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3. The Executive Director will ensure that copies of all appropriate licenses and
accreditation held by the organization are prominently displayed.
All employees are responsible for the conformance with this policy.
Media Relations
PURPOSE: To establish the official position of COADA-CB on media relations and
contacts, and to assign formal responsibility for implementation of the policy.
POLICY: COADA-CB recognizes that its employees may be contacted by the media
(including print, electronic and broadcast media) for comment and/or opinion on
substance abuse treatment in general and more specifically, on COADA-CB’s services
approach, practices and policies. Therefore, it is the policy of COADA-CB that the
Executive Director and/or her/his designee alone may represent the company in contacts
with media employees. While COADA-CB is committees to good media relations and to
sharing accurate information with media representatives for the purpose of promoting
COADA-CB’s mission, this policy recognizes the need to “centralize” and coordinate all
statements made to the media on behalf of the organization. Inherent in this policy is the
recognition and acknowledgement that official statements regarding COADA-CB must
only be made by employees with a full and complete knowledge of all organizational
policies and ongoing initiatives.
PROCEDURE: The Executive Director and/or her/his designee have the sole
responsibility for all contacts with media employees. In the event that any employee is
approached, questioned or otherwise queried by any of any media organization, the
employee will immediately defer the query to the Executive Director via the appropriate
“chain of command”. In the event that the Division/Program Manager cannot be
immediately notified, direct and immediate contact with the Executive Director is hereby
authorized and required as a condition for conformance with this policy. More critically,
employees will refrain from making any statement to any media representative other than
“In accordance with company policy, I need to refer you to our Executive Director for a
response to your inquiry”.
All employees of COADA-CB are responsible for conformance with this policy.
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Personal Relationships
PURPOSE: To establish the official position of COADA-CB on personal relationship and
to assign formal responsibility for implementation of the policy.
POLICY: COADA- prohibits an employee from developing a personal relationship with
another employee. Personal Relationship is defined as a relationship between
individuals who have or have had a continuing relationship of a romantic or intimate
nature. In order to maintain cohesiveness within the organization, employees who
develop personal relationships as defined above will be terminated.
PROCEDURE: When a personal relationship arises between employees, the employees
will be terminated from employment. If such personal relationship develops, it is the
responsibility and obligation of any employee involved to disclose the existence of the
relationship to the Division/Program Manager or Executive Director.
All employees of COADA-CB are responsible for conformance with this policy.
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Input from Patients and Other Stakeholders
PURPOSE: To establish the official position of COADA-CB on the use of information
and feedback from persons served by the organization and other interested stakeholders,
and to assign specific responsibility for conformance of this policy.
POLICY: COADA-CB recognizes that patients and other “stakeholders” have a unique
perspective on service delivery and often provide the most accurate indicator of both the
effectiveness and efficiency of services. It is the policy of COADA-CB to actively seek,
obtain and use feedback from patients, family (as appropriate and as allowed) and other
interested stakeholders on those services offered by the organization. (While the policy
primarily pertains to patients/participants served by the organization, it also recognizes
that feedback will periodically be provided to COADA-CB by regulatory agencies such
as DSHS, and other sources.) Feedback from patients/participants and other stakeholders
will be obtained, reviewed, analyzed, appropriately supported by sound business and
clinical practice, and incorporated into the daily operations of the organization as a means
of continually improving the services offered by COADA-CB. Input From patients and
other stakeholders will be used for (a) programming planning, (b) performance
improvement, (c) strategic planning purposes, (d) organizational advocacy, (e) financial
planning and (f) resource planning and allocation. Direct feedback and input from the
organization’s stakeholders provides the best and most practical way to address their
needs and will enable COADA-CB to formulate programs and services that ultimately
serve the business needs of the organization. COADA-CB’s leadership will review and
respond as appropriate and practical within the limitations of the organization climate to
(a) input from patient forums, (b) formal surveys of patients and other stakeholders, (c)
patient/employees complaints and grievances, (d) summaries of incident reports, (e)
results of the organization’s quality assurance efforts, (f) strategic planning initiatives and
(g) program/service development.
PROCEDURE: The following describes COADA-CB’s written plan for obtaining input
from its stakeholders:
1. The Performance Improvement Committee (PIC) meets monthly to review complaints,
program self evaluations, training needs, and other performance related information. The
committee’s membership includes the Executive Director and the COADA-CB
management staff all whom provide feedback to their employees;
2. Many surveys are completed in the youth prevention program, such as parent, teacher,
and principal evaluations, including a team functioning scale of team. COADA-CB peer
evaluations are performed per cycle of training to evaluate FAST team compliance with
the program. In addition, each child and parent program participant completes a
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consumer satisfaction survey. This information is compiled by the Division/Program
Manager to be included in the outcome management systems review and analysis, which
is presented to the PIC. The outcome management review results are utilized in the
development of the PI plan and strategic plan;
3. The Community Coalition Program (CCP) is a mechanism for input from 0ther
community agencies. Complaints, suggestions or other communicated issues are brought
to the attention of the Division/Program Manager who brings these to PIC meetings. This
feedback is presented to the Executive Director within 24 hours;
4. The treatment programs include three satisfaction surveys: one within a week
following admission to the program, one midway through the program and at discharge.
If a patient drops out of the program, the patient is contacted via telephone and offered a
verbal satisfaction survey questionnaire;
5. Each Division/Program Manager meets with division employees at a monthly
minimum to communicate agency information and receive employees input;
6. The Executive Director meets weekly with Division/Program Managers to
communicate agency information and receive input;
7. The Executive Director meets at least monthly with all the employees to communicate
agency information and receive input;
8. The Executive Director maintains an open door policy which means that anyone at any
time may come to her/him directly to communicate, share thoughts, ideas, suggestions,
feedback and perceptions about organizational improvement;
9. Concurrent method for input are the employees complaints that have been reviewed by
the Executive Director who directs all programmatic complaints through the PIC for
review and are utilized each month in the programmatic self-evaluations;
10. The Executive Director acts as the PIC liaison and submits an updated agency report
to the Board of Directors at the monthly board meeting. Division/Program Managers may
attend the Board of Directors meetings for communications purposes and to ensure that
all levels of leadership are fully informed of ongoing quality improvement initiatives.
The Board has subcommittees that routinely meet with employees, e.g. the finance
subcommittee.
All employees are responsible for conformance with this policy and as described herein.
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Cultural Competency and Diversity
PRUPOSE: To establish the official policy of COADA-CB for the maintenance and
definition of cultural competency and diversity while representing the many populations
served by the organization, and to assign specific responsibility for implementation of the
policy.
POLICY: COADA-CB recognizes its moral, ethical and legal responsibility to respect the
varied cultures represented by its patients. It is the policy of COADA-CB to actively and
continuously seek to be an organization that is culturally competent and diverse, and to
recognize that the organization provides services in a variety of locations and to a diverse
population. The policy is specifically intended as a tangible demonstration of the
organization’s commitment to diversity in the following areas: (a) culture, (b) age, (c)
gender, (d) sexual orientation, (e) spiritual beliefs, (f) socioeconomic status, (g) language
and, (h) ethnicity. The organization’s commitment to cultural diversity specifically
applies to (a) all leadership positions, (b) direct service employees and (c) support service
(administrative) positions.
PROCEDURE: The procedures outlined in this section reflect COADA-CB’s specific
plan for maintaining cultural competency and diversity. COADA-CB will make every
effort to recruit employees who are representative of the persons served by the
organization. This is not to infer that COADA-CB either promotes or endorses a “quota
system” for hiring employees. COADA-CB will continue to recruit employees who
possess the professional qualifications and work experience necessary to deliver quality
prevention and treatment services. The organization will give every consideration to
those applicants who represent the majority of patients served at the program for which
they are being considered. COADA-CB will remain keenly aware of the cultures,
ethnicity, attitudes, values and predominant beliefs of the majority of patients served at
the clinics. COADA-CB has established and maintains an Internet website that includes a
listing of current job opportunities and openings. COADA-CB will continue to make
every attempt to recruit administrative employees that represents a true “cross section” of
the local community. COADA-CB’s continuing education training/professional
development program includes employees training on cultural competency and diversity
as a way to increase employee’s awareness on the subject. Division/Program Managers
are responsible for ensuring that cultural diversity training is conducted at least annually
for all employees and may such topics as: language, dress, traditions, ethnicity, notions of
modesty, eye behavior, work ethics, health values, traditions, help-seeking behavior,
spiritual and religious values, personal and cultural attitudes regarding behavioral health
treatment, personal boundaries, concepts of status, privacy, confidentiality, etc.
More specifically, COADA-CB’s commitment to cultural sensitivity is re-enforced
through: (a) the Board of Directors receive annual cultural competency training; (b) the
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organization’s employees training plan includes an orientation; (c) COADA-CB’s
strategic plan includes a critical analysis of employees composition, with an emphasis on
hiring and retaining employees who are bilingual; (d) COADA-CB continuously strives
to maintain an employee base representing the service population; (e) a culturally diverse
Community Advisory Committee; (f) individualized treatment plans specific to patient’s
cultural and /or predominant belief system; (g) all professional employees meet the
minimum requirements for maintaining licensure; (h) all counselors are required to attend
culturally related seminars offered by COADA-CB; and (i) new culturally sensitive
materials are incorporated into curriculum because of the culturally diverse population
served by COADA-CB.
All employees are responsible for conformance with this policy.
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Equal Opportunity
PURPOSE: To establish the official policy of COADA-CB on equal opportunity and to
assign specific responsibility for implementation of the policy.
POLICY: COADA-CB recognizes its moral, ethical and legal responsibility to comply
with all applicable laws, rules and regulations pertaining to equal opportunity. It is the
policy of COADA-CB to develop, implement and maintain policies and procedures that
clearly establish the organization as one that provides a workplace and treatment
environment that provides equal opportunity for all employees. The organization’s
commitment to equal opportunity specifically applies to all employee positions.
PROCEDURE: The procedures outlined in this section reflect COADA-CB’s
commitment to Equal Opportunity: COADA-CB will recruit, hire, train, compensate, and
promote all persons without regard to culture, race, color, gender, age, sexual preference
or orientation, national origin, religious preference, physical challenge, veteran status, or
other protected status as defined under Title VII, by the Americans with Disabilities Act
(ADA) and the Americans Disability Employment Act (ADEA). These procedures apply
to all aspects of employment at COADA-CB including (a) hiring and firing; (b)
compensation, assignment, or classification of employees; (c) committee participation;
(d) transfer, promotion, layoff, or recall; (e) job advertisements; (f) employee
recruitment; (g) pre-employment drug testing; (h) use of company facilities; (i) training
and apprenticeship programs; (j) fringe benefits; and (k) pay, retirement plans, or (l) other
terms and conditions of employment.
All aspects of recruitment and employment will be governed on the basis of merit,
competence, and qualifications related to the requirements of the position. Additionally,
the Executive Director will (a) ensure compliance with all local, state and federal laws,
rules and regulations pertaining to equal opportunity; (b) review recruitment, hiring,
compensation, and promotion procedures and actions as they relate to this policy and as
needed, make recommendations for changes as necessary; and (c) communicate the equal
employment opportunity policy to applicants and employees to ensure ongoing
compliance.
Discriminatory practices under these laws, which are expressly prohibited at COADACB, also include but are not limited to: (a) retaliation against an individual for filing a
charge of discrimination, participating in an investigation, or opposing discriminatory
practices; (b) employment decisions based on stereotypes or assumptions about
employees; (c) denying employment opportunities to a person because of marriage to, or
association with, an individual of a particular race, religion, national origin, or an
individual with a disability; or discrimination because of participation in schools or
places of worship; and (d) hiring employees based on any criteria or consideration other
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
20
than applicant qualifications and the job qualifications described in the job description for
the position being filled.
In prohibiting discrimination, the Department of Labor (DOL) and the Equal
Employment Opportunity Commission (EEOC) regulations cover such employment
practices as recruitment, rates of pay, upgrading, layoff, promotion and selection for
training, among others. Race, color, religion, sex or national origin distinctions may not
be made in recruitment or advertising efforts, employment opportunities, wages, hours,
job classifications, seniority, retirement ages or job fringe benefits such as employer
contributions to company pension or insurance plans.
COADA-CB does not support, endorse, or maintain any type of exclusionary policies that
differ between sexes.
Annually, the QMT reviews its employment practices to determine whether of the
various religious and/or ethnic groups are receiving fair consideration for job
opportunities, and the division must undertake appropriate outreach and positive
recruitment activities in order to remedy existing deficiencies.
COADA-CB accommodates the religious observances and practices of employees as long
as the accommodation can be achieved without undue hardship on agency business and
maintains adequate services for patient/participant programs.
The organization expressly prohibits any attempts to intimidate or discriminate against an
individual for filing a complaint or participating in a proceeding under the referenced
statutes. Periodically, the QMT will review any incidences that may have been or
appeared to have been an attempt at intimidation or discrimination. If any such incidences
are found, immediate action will be taken to rectify the situation and prevent future
occurrences.
COADA-CB abides by the ADEA’s broad ban against age discrimination, the Equal Pay
Act (EPA) that prohibits discrimination on the basis of sex in the payment of wages or
benefits for the same work and responsibilities and Title I of the American with
Disabilities ACT (ADA) that prohibits discrimination on the basis of disability in all
employment practices.
COADA-CB’s leadership will make every reasonable accommodation to a qualified
individual with a disability unless doing so would impose an undue hardship on the
operation of the agency.
COADA-CB will not ask job applicants about the existence, nature, or severity of a
disability, although applicants may be asked about their ability to perform job functions.
COADA-CB recognizes that employees and applicants currently engaging in the illegal
use of drugs are not protected by the ADA.
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All employees are responsible for conformance with this policy and more critically, for
actively promoting and fostering an environment characterized by equal opportunity.
Strategic Planning
PURPOSE: To establish the official position of COADA-CB on strategic planning
including the strategic planning process and to assign responsibility for implementation
of the policy.
POLICY: COADA-CB is committed to strategic planning including a formal strategic
planning process as a way to ensure continuity of services and provide the highest quality
services to its patients/participants. It is the policy of COADA-CB to engage in a formal
strategic planning process under the direction of the leadership to determine short and
long time goals and objectives, key strategies, review the organization’s mission
statement and develop an action plan for implementation. This policy calls for the
development of the organization’s Strategic Plan and the Annual Performance
Improvement.
PROCEDURE: The organization’s leadership is responsible for all aspects of strategic
planning. Strategic planning is undertaken in conjunction with the budget
planning/development process and includes a review of input from patients, participants,
employees, and other interested stakeholders.
The annual strategic planning process involves the following sequential steps:
1. The Quality Management Team (QMT) meets and initiates the annual strategic plan
review process.
2. Division/Program Managers organize employee meetings that provide an opportunity
for review, evaluation and documentation of programmatic strengths, deficiencies and
recommendations for improvements.
3. The Executive Director meets with Division/Program Managers to draft short/long
term goals and objectives for each service program. The service program goals and
objectives are drafted and presented to the QMT for review, evaluation and comment.
4. The QMT reviews the consumer and family satisfaction surveys from the previous
year.
5. The QMT reviews incident reports to determine any trends and incorporates their
findings regarding incident reports.
The annual strategic planning process also includes a review of (a) the organization’s
mission statement and values; (b) the philosophy and purpose of COADA-CB; (c) the
population served; (d) descriptions of programs and services (e) geographic service
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boundaries; (f) short and long term strategies, goals and objectives; (g) the organization’s
Policy and Procedures Manual.
The following “steps” describes the organizations procedure for developing its Mission
Statement.
1. Toward the end of the fiscal year, an individual is assigned by the Executive Director
to review the progress of the agency in implementing the previous year’s strategic plan,
aggregate and evaluate outcomes management data; review patient and family
satisfaction survey results, incident report patterns and other helpful operational and
programmatic information needed to draft the mission statement.
2. A final mission statement report is submitted by the Executive Director to the Board.
3. The Executive Director and Division/Program Managers are available to answer and/or
respond to the Board questions/comments.
The mission statement is used during the strategic planning process to develop the
organization’s Annual PI Plan and Strategic Plan for the next year. (For clarification,
COADA-CB’s Annual PI Plan represents an “action plan” to address the improvements
needed to reach or revise established performance goals. In the interests of operational
continuity and to minimize confusion for the employees, the decision was made to retain
the name. i.e. Annual PI Plan.)
Both the mission statement and the Annual PI Plan are “plain language” documents and
are written in formats that are both understandable and useful to patients/participants, all
level employees, and other interested stakeholders. Copies of both documents are made
available to COADA-CB employees, patients/participants and other stakeholders upon
request. More critically, both documents are designed, written and produced in simplified
form so that they can be used as an effective marketing and outreach tool and to
effectively advocate for additional programs and services for persons suffering from
substance abuse treatment.
As part of the strategic planning process, the organization also conducts an annual review
of its Policy and Procedures (P&P) Manual. The process specifically includes the
following steps;
1. Toward the end of the fiscal year, an individual is assigned by the Executive Director
to review the P&P Manual to ensure it continues to reflect current rules, regulations and
standards.
2. The assigned individual submits a draft policy and procedure manual to the Executive
Director for review, evaluation and modification.
3. The Executive Director and Division Managers are available to answer and/or respond
to the Board questions/comments regarding the updated policy and procedure manual.
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23
4. Employees are instructed to review the update P&P Manual.
5. Training is conducted for all employees.
6. All employees are asked to sign an acknowledgement that they have been “briefed” on
the changes to the manual.
All employees are responsible for conformance with this policy. All employees are
responsible for reading and knowing the contents of the organization’s P&P Manual and
any and all documents published and disseminated by the organization that are intended
for “public consumption”.
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Corporate Compliance Program and Plan
PURPOSE: To establish and publish the official policy of COADA-CB, regarding the
organization’s corporate compliance program/plan and to assign responsibility for
implementation of the policy.
POLICY: COADA-CB is dedicated to the delivery of behavioral health care in an
environment characterized by strict conformance with the highest standards of
accountability for administration, clinical, program, marketing and financial
management. COADA-CB’s governance and management authorities are fully
committed to the need to prevent and detect fraud, fiscal mismanagement and
misappropriation of funds and therefore, to the development of a formal corporate
compliance program to ensure ongoing monitoring and conformance with all legal and
regulatory requirements. The organization is committed to the establishment,
implementation and maintenance of a corporate compliance program that emphasizes: (a)
prevention of wrong doing – whether intentional or unintentional; (b) immediate
reporting and investigation of questionable activities and practices without consequences
to the reporting party; and (c) timely correction of any situation which puts the
organization, its leadership or employees, funding sources or patients at risk. By formal
resolution and in accordance with this policy, the organization’s leadership has delegated
overall responsibility for the Corporate Compliance Program to the Executive Director.
PROCEDURE: The following procedures/guidelines will govern the design and
implementation of the organization’s corporate compliance program:
Designation of a Corporate Compliance Officer
The Executive Director will formally designate a Corporate Compliance Officer (CCO),
monitor the organization’s corporate compliance program and ensure that the governance
authority is fully informed at all times on matters pertaining to compliance.
Responsibilities of the Corporate Compliance Officer
In the performance of his/her duties, the CCO shall: (a) serve as the organization’s
primary point of contact for all corporate compliance issues; (b) develop, implement and
monitor the organization’s corporate compliance plan, including all internal and external
monitoring, auditing, investigative and reporting processes, procedures and systems; and
(c) prepare, submit and present periodic reports on corporate compliance issues to the
Executive Director as requested and/or as may be required. In the performance of his/her
duties, the CCO shall report to the Executive Director.
Annual Corporate Compliance Report
The CCO shall submit an annual corporate compliance report to the Board of Directors
via the Executive Director. Annual reports will include at a minimum: (a) a summary of
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
25
all allegations, investigations and/or complaints processed in the preceding 12 months in
conjunction with the corporate compliance program; (b) a complete description of all
corrective action(s) taken; and (c) any recommendations for changes to the organization’s
policies and/or procedures.
Risk Management Assessment
As part of corporate compliance program, the CCO shall schedule and coordinate
periodic risk management assessments and/or audits to identify potential problem areas
and “threats” that could put the organization at risk for unusual liability, i.e., information
technology, billing and cash handling procedures, health and safety procedures,
medication management policies etc. Such assessments will augment the organization’s
annual audit of its accounting system and provide an additional, internal measure of
operational accountability in a variety of areas.
Corporate Compliance Plan Elements
The corporate compliance program for COADA-CB consists of:
1. A formal resolution on corporate compliance that has been adopted by the governance
authority as a way to document the effective date of program implementation.
2. Written designation of a CCO responsible for monitoring and reporting on matters
pertaining to corporate compliance.
3. A corporate code of ethics regarding professional conduct, personal behavior, program
practices, marketing practices, clinical practices and potential conflicts of interest.
4. A “no reprisal” system for employees to use in reporting waste, fraud, abuse or other
questionable activities and practices.
5. Written procedures contained herein for:
A. Timely investigation of allegations of waste, fraud, abuse and/or other wrongdoing.
B. Dealing with violators of the organization’s code of ethics in a fair and consistent
manner.
C. Dealing with violators of the organization’s corporate compliance program/plan in a
fair and consistent manner.
6. Policies and procedures to guide employees in responding to subpoenas, search
warrants, investigations and other legal actions.
7. Employee training.
Agency Code of Ethics
Since COADA-CB employs providers and practitioners from a variety of disciplines, it is
the expectation of the organization that every service provider will act and deliver
professional treatment services in a manner consistent with the Code of Ethics of his/her
respective discipline. In the event that a service provider is not legally, ethically or
otherwise bound by a specific Code of Ethics, COADA-CB will expect that he/she will
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
26
provide treatment services and in strict accordance with the organization’s code of ethics.
All new employees will be briefed on the organization’s expectations regarding ethical
conduct as part of new employee orientation and will be asked to sign an
acknowledgement of receipt of the written material.
In program, marketing, and human resource practices, COADA-CB employees will be
guided by the following philosophy: Honesty, integrity, respect, and fairness which
constitute the key components of all our dealings with patients, vendors/suppliers,
potential customers, employees and our communities. In all program and marketing
activities, all employees are hereby enjoined to represent the organization and its
programs and services in an honest manner and to accurately portray the capabilities of
the agency and its employees. This is an essential step if the agency is to establish
productive and meaningful professional relationships in the local community. A critical
part of the agency’s corporate compliance program is the expectation that each employee
will fully comply with all state and federal laws, statutes, rules and regulations pertaining
to program, marketing and human resources and do so at all times without exception. No
program code of ethics/conduct can cover every conceivable scenario that might arise in
the course and scope of program, marketing and human resources management and
business in general. Therefore, employees are enjoined to abide by the aforementioned,
guiding principles and to seek assistance and clarification from the Executive Director,
CCO, of Division/Program Manager in the event that any situation or scenario arises that
might challenge the application of these principles. As a related matter, situations and
circumstances occasionally arise that may represent a potential conflict of interest. As a
general principle, no employee of COADA-CB will make any decision on behalf of the
organization or obligate the organization in any way that would represent, result in or
give the appearance of personal gain or benefit, however slight. Examples of conflict of
interest situations are:
1. Accepting gifts, other than those of normal amounts, from a vendor or contractor.
2. Employing family members contrary to the policy on nepotism.
3. Providing services to other organizations for personal gain using COADA-CB or grant
resources.
4. An employee or family member providing services for reimbursement to COADA-CB
without prior review and approval by the Executive Director.
5. Promoting personal social, religious, or political programs or beliefs using COADACB resources or facilities.
6. Developing a personal relationship with patient/client.
7. Accepting a private professional fee or any gift of gratuity from a patient if the
patient’s/participant’s treatment/services are paid for by another funding source, or if the
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
27
patient/participant is receiving treatment from a facility where the counselor provides
services (unless all parties agree to the arrangement in writing).
8. Paying or receiving any commission, consideration, or benefit of any kind related to
the referral of s patient/participant for treatment.
In such cases, employees are enjoined to discuss the situation with the Executive Director
or CCO prior to making any decision or engaging in any practice that would represent a
commitment of the organization’s assets, obligate the organization in any way and/or
have the potential to give the appearance of impropriety or conflict of interest.
As part of new employee orientation process, all new employees will be fully informed as
to the organization’s expectations regarding conformance with all applicable codes of
conduct. Additionally, new employees will be asked to sign a copy of the organization’s
code of ethics as a way to demonstrate their awareness of the code. A copy of the code
will be distributed to each new employee during the new employee orientation.
No-Reprisal Reporting System
An integral part of the organization’s corporate compliance program is a non-retaliatory
system that employees can use to report suspected waste, fraud, abuse and other
questionable activities and practices. Reports can be submitted to the CCO in four ways:
(a) mail, (b) telephone, (c) fax, and (d) email. Division/Program Managers are
responsible for posting a “Corporate Compliance Notice” in each clinic as a way to
inform patients, employees and other interested stakeholders about the organization’s
Corporate Compliance program and the process including contact information for
reporting suspicious activities and/or practices.
Investigation Process and Timeframes
Upon receipt of any report of suspected wrongdoing (including an alleged violation of the
organization’s Code of Ethics), the CCO will contact the Executive Director.
Investigations of corporate compliance matters will be conducted as expeditiously ass
possible with results including recommendations for any disciplinary and/or corrective
action.
Violations Procedure
Substantiated violations of the organization’s corporate compliance program and/or code
of ethics are serious matters and have potential legal ramifications for both COADA-CB
and its employees. All allegations of violation of federal and/or state law, organizational
policy and/or applicable codes of ethics will be fully investigated by the Executive
Director. Violators are subject to and will be handled in accordance with the
organization’s disciplinary policies outlined in the employee policies.
Search Warrants, Subpoenas, Investigations and Other Legal Actions
In the event that any employee of COADA-CB receives or is notified of any search
warrants, subpoena, investigation, inquiry or other legal action involving the agency, the
Executive Director, or Division/Program Manager, and or CCO will be immediately
contacted by the most expedient means, i.e., telephone, email, cell phone, fax, etc. Copies
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28
of all legal documents served against COADA-CB and/or its employees will be
immediately copied and faxed or hand delivered to the Executive Director, or
Division/Program Manager, and or CCO. Under no circumstances will any records, files,
receipts, or other forms of documentation be released without authorization from the
Executive Director of COADA-CB. This policy recognizes that employees might find
themselves in a situation in which they could potentially be threaten or coerced into
releasing documentation without following this policy. All employees must fully
recognize and understand that: (a) “due process” includes the opportunity to follow the
established procedures of COADA-CB regarding search warrants, subpoenas,
investigations and other legal actions; and (b) these procedures include immediate
notification to the Executive Director, and/or Division/Program Manager in all cases
without delay. Only the Executive Director or her/his designee shall represent COADACB with legal actions. Thus, only the Executive Director or the designee will converse in
verbal or written form and provide COADA-CB’s response to any legal actions. The
Executive Director or her/his designee shall contact the organization’s attorney promptly
for guidance in responding to subpoenas, search warrants, investigations and other legal
actions.
Consultant Contractual Relationships
The organization will enter into contractual relationships only with consultant and entities
with similar values and who, if required, have signed Business Associate Agreements as
required by the Health Insurance Portability and Accountability Act (HIPPA) of 1996. As
a general policy, COADA-CB does not endorse the practice of entering into contractual
agreements with family, friends and/or acquaintances of the organization’s leadership,
employees and/or patients/participants. However, this policy recognizes that in some
situations, it may be expedient and/or advantageous for the organization to do so.
Therefore, all contracts must be “pre-approved” by the Executive Director. For
clarification, no employee other than the Executive Director of COADA-CB is authorized
to enter into any binding agreement, contract, or covenant on behalf of the organization
without the express consent of the Executive Director.
Corporate Citizenship and Patient Advocacy Efforts
The leadership of COADA-CB is committed to being a good organizational citizen. As a
manifestation of this commitment, COADA-CB will support and participate in
recognized community activities that advocate for services for persons suffering from the
effect of chemical dependency and/or substance abuse. Further, the organization is
committed to advocacy efforts in support of its patients/participants. Specifically, the
organization supports within the parameters defined in the organization’s community
relations policy, plan and participation on local boards and agencies, sponsorship of local
programs promoting good health and citizenship, and employee’s participation in various
service clubs or organizations in order to support the communities served.
Legal Conformance
The organization’s corporate compliance program also includes an expectation that the
organization will maintain all required licenses and, will undergo periodic inspections by
the state. The Executive Director must be immediately informed of any regulatory
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
29
inspection, or Division/Program Managers, must record any and all information provided
during regulatory audits/visits. In the event that formal correspondence is received from
any regulatory entity, copies must be immediately provided to the Executive Director.
Additionally, COADA-CB will comply with all legal and regulatory requirements
including but not limited to: (a) rights of persons served, (b) confidentiality requirements,
(c) reporting requirements, (d) contractual agreements, (e) licensing requirements, (f)
corporate status, (g) employment practices, and (i) privacy of patients.
Responsibility for Conformance
All employees are responsible for strict conformance with this policy. At least annually,
the CCO will ensure that all employees receive a “refresher orientation” on the
organization’s corporate compliance program with an emphasis on the organization’s
code of ethics. As part of new patient orientation, patients are informed of the
organization’s code of ethics as it pertains to clinical practice and treatment issues. In the
event that any patient or other interested “stakeholder” requests a copy of the
organization’s code of ethics, a copy of this policy will be immediately provided by the
responsible Division/Program Manager.
All employees are responsible for the conformance with this policy.
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
30
Organizational Code of Ethics
PURPOSE: To establish the official policy of COADA-CB on expectations regarding
ethical conduct by all employees of the organization and to assign formal responsibility
for implementation of the policy.
POLICY: It is the policy of COADA-CB that all employees will conform to an
established organizational code of ethics in the performance of their job responsibilities.
These expectations are in addition to those described in the organization’s Corporate
Compliance Policy and Plan. Inherent in this policy is the expectation that all employees
will conform to the ethical standards of their respective professional disciplines. Any
employee who is confirmed to have violated her/his code of ethics, or that of the
organization, may be subject to disciplinary action and or termination.
PROCEDURE: The following reflects the organization’s established code of ethics and
expectations for all employees:
1. Employees shall not discriminate against any person or group of people for any reason.
Employees shall ensure that no person or group of persons is restricted from receiving the
same services or the same quality of services available to others.
2. Employees shall maintain objectivity, integrity, and the highest standards in providing
services to the patient/participant.
3. Employees shall (a) report violations of Texas Occupations Code, Chapter 504 or rules
adopted under the stature; including violations of this section, to DSHS; (b) recognize the
limitations of his or her ability and shall not offer services outside the employee’s scope
of practice or use techniques that exceed his or her professional competence; and (c)
prevent the practice of chemical dependency counseling by unqualified or unauthorized
persons.
4. Employees shall not engage in the practice of chemical dependency counseling if
impaired by, intoxicated by, or under the influence of chemicals; including alcohol.
5. Employees shall uphold the law and refrain from unprofessional conduct. In doing so,
employees shall (a) comply with all applicable laws and regulations; (b) not make any
claim, directly or implied, that the counselor/education division employee(s) possess
professional qualifications or affiliations that the employee does not possess; (c) not
mislead or deceive the public or any person; and (d) refrain from any act that might tend
to discredit the profession.
6. Employees shall (a) report information fairly, professionally, and accurately to
patients/participants, other professionals, and the general public; (b) maintain appropriate
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
31
documentation of services provided; and (c) provide responsible, objective trainings,
supervision to interns/subordinates under the counselor’s supervision or that of other
employees. This includes properly documenting work experience, supervisory sessions,
while providing supervisory documentation needed for licensure.
7. In any publication, all employees shall give written credit to all persons of other
contributory works which have directly influenced the publication.
8. Employees shall respect a patient’s/participant’s dignity, and shall not engage in any
action that may injure the welfare of any patient/participant or person to whom the
employee is providing services. Toward this end, employees shall;
A. Make every effort to provide access to treatment, including advising
patients/participants about resources and services, taking into account the
financial constraints of the patient/participant.
B. Remain loyal and professionally responsible to the patient/participant at all times,
disclose the employee’s ethical code of standards, and inform the
patient/participant of the employee’s loyalties and responsibilities.
C. Not engage in any activity which could be considered a professional conflict and
shall immediately remove himself or herself from such a conflict if one occurs.
D. Terminate any professional relationship or counseling service which is not
beneficial or is in any way detrimental to the patient/participant.
E. Always act in the best interest of the patient/participant.
F. Not abuse, neglect, or exploit a patient/participant.
G. Not have sexual contact with or intentionally enter into a personal or business
relationship with a patient/participant (including any patient receiving services
from the employee’s employer) for at least two years after the patient’s date of
discharge.
H. Not request a patient/participant to divulge confidential information that is not
necessary or appropriate for the services being provided.
I. Not offer or provide chemical dependency counseling or related services in
settings or locations which are inappropriate, harmful to the patient/participant, to
others, or which would tend to discredit the profession of chemical dependency
counseling.
9. Employees shall protect the privacy of all patients/participants and shall not disclose
confidential information without express written consent; except as permitted by law. The
employee shall remain knowledgeable of and obey all state and federal laws and
regulations relating to confidentiality of chemical dependency treatment records and
shall;
A. Inform the patient, and obtain the patient’s consent, before tape-recording the
patient/participant, allowing another person to observe or monitor the
patient/participant.
B. Ensure the security of patient/participant records.
C. Not discuss or divulge information obtained in clinical or consulting relationship
except in appropriate settings and for professional purposes which clearly relate to
the case.
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D. Avoid invasion of privacy of the patient/participant.
E. Provide the patient/participant his/her rights regarding confidentiality, in writing,
as part of informing the patient in any areas likely to affect the
patient’s/participant’s confidentiality.
F. Ensure the data requested from other parties is limited to information that is
necessary and appropriate to the services being provided and is accessible only to
appropriate parties.
10. Employees shall inform the patient/participant about all relevant and important
aspects of the professional relationship between the patient/participant and the counselor
and shall;
A. In case of patients/participants who are not their own consenters, inform the
patient’s/participant’s parent(s) or legal guardians of circumstances which might
influence the professional relatio0nship.
B. Not enter into a professional relationship with any patient’s/participant’s family,
close friends or associates, or others whose welfare might be jeopardized in any
way by such a relationship.
C. Not establish a personal relationship with any patient/participant (including any
individual receiving services from the employee’s employer) for at least two years
after the patient’s date of discharge.
D. Neither engages in any type or forms of sexual behavior with a patient/participant
(including any individual receiving services from the employee’s employer) for at
least two years after the patient’s date of discharge nor accept as a
patient/participant anyone with whom they have engaged in sexual behavior.
E. Not exploit relationships with patients/participants for personal gain, including
social or business relationships.
11. Employees shall treat other professionals with respect, courtesy, and fairness and;
A. Refrain from providing or offering professional services to patient/participant
who is receiving chemical dependency treatment or other services from another
professional; except with the knowledge of the other professional and consent of
the patient/participant, or until treatment with the other professionals end.
B. Cooperate with DSHS professional peer review groups or programs, and
professional ethics committees or associates, and promptly supply all requested or
relevant information unless prohibited by law.
C. Ensure that his/her actions in no way exploit relationships with supervisees,
employees, students, research participants, or volunteers.
12. Prior to treatment/education/intervention services, the employee shall inform the
patient/participant of the counselor’s fee schedule and establish financial arrangements
with a patient/participant. The employee shall not;
A. Charge exorbitant or unreasonable fees for any treatment, educational, prevention,
intervention services.
B. Pay or receive any commission, consideration, or benefit of any kind related to
the referral of a patient/participant for treatment.
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C. Use the patient/participant relationship for the purpose of personal gain, or profit,
except for the normal, usual charge for treatment/ services provided.
D. Accept a private professional fee or any gift of gratuity from a patient if the
patient’s/participant’s treatment/services are paid for by another funding source,
or if the patient/participant is receiving treatment from a facility where the
counselor provides services (unless all parties agree to the arrangement in
writing).
13. Employees will work to ensure that facilities and services shall be accessible to
persons with disabilities as required by The Americans with Disabilities Act (ADA).
All employees are responsible for conformance with this policy.
The Council on Alcohol and Drug Abuse – Coastal Bend, COADA-CB
34
Employee Standards of Conduct
PURPOSE: To establish the formal policy of COADA-CB on accepted standards of
professional and ethical conduct for all employees, interns, volunteers and other official
representatives of the organization. (For clarification, the standards of conduct outlined in
this policy are in addition to those identified in COADA-CB’s organizational code of
ethics.)
POLICY: It is the policy of COADA-CB that all employees and any other person acting
in an official capacity on behalf of the organization will adhere to a code of professional
conduct that complies with that established by the DSHS Standard of Care.
PROCEDURES: The following represents the organization’s specific procedures in
support of this policy:
1. COADA-CB employees, including all volunteers and student workers, shall;
A. Protect the health, safety, rights, and welfare of patients/participants including,
but not limited to provision of adequate nutrition, clothing, and health care when
indicated; and provision of an environment free form abuse.
B. Provide adequate services as specified in the program description.
C. Comply with all applicable laws, regulations, policies and procedures.
D. Maintain required licenses, permits, and credentials.
E. Maintain the required number of trained employees as specified by DSHS
Standard of Care.
F. Establish and implement appropriate individualized services.
G. Comply with professional and ethical codes of conduct.
H. Report any violations of laws, rules, and professional and ethical codes of conduct
to the DSHS as defined in Policy and Procedure 204.1; including Significant
Incident Reports.
I. Ensure that no person or group of persons is restricted from having the same
services or the same quality of services available to others.
2. COADA-CB employees including volunteers and student workers shall not:
A. Provide services while under the influence of alcohol or illegal drugs.
B. Enter into a personal or business relationship with patients/participants for a
minimum of two years after the patient/participant has been discharged.
C. Accept any gifts from patients/participants and/or patient’s/participant’s family or
significant other(s). The Executive Director may be consulted for exceptions.
D. Commit an illegal, unprofessional, or unethical act (including patient abuse,
neglect, or exploitation), or assist or knowingly another to do the same.
E. Discriminate against an individual or group based on:
 Race
 Religion
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





F.
G.
Ethnicity
Country of origin
Age
Disability (including mental illness)
Sexual orientation, or
Gender
Assist or knowingly provide false or misleading information.
Falsify, alter, destroy, or omit significant information from required reports and
records or interfere with their preservation.
H. Retaliate against anyone who reports a violation or cooperates during a review,
inspection, investigation, hearing, or related activity.
I. Interfere with DSHS reviews, inspections, investigations, hearings, or related
activities including taking action to discourage or prevent someone else from
cooperating during the activity.
3. COADA-CB employees, contractors, including volunteers and student workers, shall
exhibit a high standard of personal conduct indicative of that position. Examples of gross
misconduct include, but are not limited to, the following:
A. Falsification of COADA-CB records, including, but not limited to, employment
applications, resumes, timesheets, and/or expense reports.
B. Unauthorized possession or use of COADA-CB co-worker’s property.
C. Theft of money or property from COADA-CB.
D. Fraudulent use of leave, particularly Sick Leave.
E. Threatening, intimidating, coercing, using abusive language, or interfering with
the performance of COADA-CB employees.
F. Discourteous treatment to the public or those receiving COADA-CB services.
G. Insubordination.
H. Unlawful or improper conduct, both at the worksite and during non-working
hours, or conviction of criminal offenses which adversely affect the employee’s
relationship to his/her job, Division/Program Managers, COADA-CB reputation
or goodwill in the community.
I. Willful lose of or damage to any COADA-CB owned equipment or property.
J. Willful violation of any agency rule or policy.
K. Any other act of behavior or conduct, which is detrimental to the interest of either
COADA-CB or COADA-CB employees.
Any person associated with the organization that receives an allegation or has reason to
suspect that a person associated with the facility has been, is, or will be engaged in
illegal, unethical, or unprofessional conduct shall immediately inform the Executive
Director or designee. If the allegation involves the Executive Director, it shall be reported
to the Commission and the organization’s governing body.
The organization and its personnel shall comply with TEX. HEALTH & SAFETY CODE
ANN. CH.164 (Vernon2001 & Supp. 2003) relating to Treatment Facilities Marketing
and Admission Practices.
All employees are responsible for conformance with this policy.
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Compensation Based on Indicators of Patient Revenue
PURPOSE: To established the official position of COADA-CB on the rights of persons
by the organization, to engage in freedom of choice regarding treatment programs
without unethical or undue influence by the employees and to assign formal
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that no employees will engage or be involved in
the referral of any patient in any manner that represents a violation of any portion of
DSHS Standard of Care Chapter 148. Furthermore, it is the policy of COADA-CB that
any employee who is confirmed to have violated this policy may be subject to
disciplinary action in accordance with the organization’s disciplinary policies.
PROCEDURES: The following represents the organization’s specific procedures in
support of this policy:
1. Compensation based on indicators of patient revenue is strictly prohibited. COADACB employees shall not accept, permit, or provide compensation for referrals or other
indicators of patient revenue. Compensation includes:
A. Initial or continued employment.
B. Promotion, advancement, or privileges.
C. Pay.
D. Anything of value and/or.
E. Any other form of benefit or consideration.
F. Be compensated or evaluated based on indicators of patient revenue. Indicators of
patient revenue include:
 Referrals
 Admissions
 Contacts made to solicit patients; and/or
 Determinations made regarding length of stay.
2. The engagement of false, misleading, or deceptive advertising is prohibited. COADACB employees shall not:
A. Advertise or support any level of chemical dependency treatment, unless it holds
the required license.
B. Make unsubstantiated claims, promises of cure, or guarantees of treatment results.
C. Advertise intervention and assessment services, unless they are available and
provided by qualified credentialed counselors.
D. Represent a qualified referral service, unless it complies with all standards found
in the Texas Health and Safety Code, Section 164.007, or
E. Charge for undelivered services unless:
 The facility offers a scheduled service described in the patient’s treatment
plan
 The patient does not attend or refuses to participate, and
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
The facility has documentation that patient was informed of this billing
policy in writing at time of admission.
3. Non-compliance with any statures or regulations governing solicitation and referral,
including those found in Chapter 164 of the Texas Health and Safety Code, is prohibited.
COADA-CB employees shall not:
A. Illegally or unfairly solicit or refer patients and shall not allow others to do so on
behalf.
B. Solicit referrals without proper disclosure and consent.
C. Own, operate, manage, control, or enter into a relationship with an intervention or
assessment service that makes referrals to a treatment facility for inpatient
treatment of mental illness or chemical dependency, unless the intervention and
assessment service meets all requirements as listed in Chapter 164 of the Texas
Health and Safety Code.
4. Referral processes are provided in the best interest of the patient(s). COADA-CB
employees shall provide referral information regarding other programs in the area or
around the state that can provide immediate treatment or other type of service if:
A. The individual is found ineligible for services provide through COADA-CB, or;
B. The individual cannot be served because capacity of COADA-CB service has
been reached;
C. It is perceived to be in the best interest of the patient to further enhance services
by treating co-occurring disorders; or
D. To promote a full continuum or services following discharge from COADA-CB.
All employees of COADA-CB are responsible for conformance with this policy.
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Health Insurance Portability and Accountability ACT
PURPOSE: To establish the official position of COADA-CB on compliance with the
Health Insurance Portability and Accountability Act (HIPAA) of 1996 and to assign
responsibility for implementation of the act.
PLOICY: It is the policy of COADA-CB that it will operate and conduct its program
compliance with all applicable laws, regulations and rules, including HIPAA.
PROCEDURE: The following procedures are followed in support of this policy:
1. The Executive Director shall designate a HIPAA Privacy Officer to ensure that
COADA-CB operates in accordance with HIPAA at all times. The Privacy Officer will
serve as the organization’s primary point of contact for all matters pertaining to HIPAA
and patient requests for protected health information as defined by the Act. If allegations
surface, the Privacy Officer will prepare and present an annual report to the Executive
Director on the organization’s ingoing compliance with HIPAA.
2. A copy of the organization’s “Notice of Privacy Practices” will be posted in each
facility. Additionally, a copy of the notice will be provided to each patient as part of the
new patient orientation process.
3. Employees will ensure that each patient signs an acknowledgement that they have
received a copy of the “Notice of Privacy Practices”, and
4. No protected health information will be released in response to a patient request under
this act without the consent and approval of the Privacy Officer. For clarification, patients
may request copies of their records and/or authorize the release of their information from
their records under 42CFR Part 2 by signing and executing a release form; such releases
do not have to be approved by the organization’s Privacy Officer.
All employees are responsible for conformance with HIPAA.
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Local and State Licenses
PURPOSE: To establish the official policy of COADA-CB, on local and state licenses
and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization obtains and maintains all
required licenses. For clarification, this policy requires that organization obtains various
types of programming operating licenses in addition to pharmacy, state program licensure
and federal licensure.
PROCEDURE: The Executive Director will maintain a listing of all required licenses and
shall insure that all applications for license renewal are submitted insufficient time for
renewal.
Copies of all licenses should be appropriately displayed so as to be in view of patients
and other visitors. Original licenses will be maintained on file in the Human Resources
Department.
The Executive Director is responsible for insuring for insuring that the organization has
all required licenses and operates in full conformance with those licenses.
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SECTION 2
ORGANIZATIONAL MANAGEMENT
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Information Management
PURPOSE: To establish the official position of COADA-CB on information
management, to define the ways in which the organization manages information flow,
and to assign specific responsibilities regarding implementation of the policy.
POLICY:
It is the policy of COADA-CB that information management will be a matter of the
highest priority as a way to ensure consistency and standardization of all operations. At
the root of this policy is the acknowledgement that (a) the organization’s management
authority must have valid and reliable information from a variety of sources, (b) all
employees must have a clear understanding of the organization’s mission, strategic goals,
objectives in order to work efficiently and effectively to provide the highest quality
prevention and treatment services, (c) all employees must have a clear understanding of
improving the quality of programs and services offered by the organization and
facilitating decision making by COADA-CB’s leadership. This refers to the collection of
information that addresses the needs of patients as to (a) the reason they seek services
from COADA-CB, (b) patient input regarding treatment activities, goals and objectives,
and (c) their individual choices regarding treatment options. This collective information
will ensure that all services are provided in a way that is consistent with the
organization’s core values and philosophy and mission statement. The system considers
that needs of other stakeholders as well as the program and strategic needs of the
organization itself. As part of this policy, the organization will utilize information
collected to review the implementation of the mission and core values of the
organization, improve program and service quality and facilitate organizational decisionmaking.
PROCEDURE: From a business perspective, the organization collects and analyzes-on an
ongoing basis and as part of its formal “year end” data collection effort-information from
the following sources and processes: (a) internal strategic planning efforts, (b)
financial/fiscal information compiled by the Finance Business Manager and employees,
(c) stakeholders input, (d) reviews of incident reports and patient grievances regarding
environmental issues (including health and safety concerns). To the greatest extent
possible, the organization always attempts to ensure that information gathered is reliable,
valid, complete and accurate.
The Executive Director is responsible for the communication of essential information to
the Division/Program Managers. This is accomplished through direct communications,
email, other written communication and follow-up as required or as deemed appropriate.
In turn, Division/Program Managers communicate the information with their respective
employees. Additionally, the Executive Director convenes periodic meetings with the PI
team as a way to provide updates on organizational developments, changes in operational
matters, and to solicit feedback and suggestions on ways to further improve service
delivery. Division/Program Managers conduct regular employee meetings with
employees to ensure effective communication throughout the organization. The P&P
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manual is used to standardize and to clarify communication on a variety of administrative
and clinical topics.
COADA-CB’s technology department shall evaluate the organization’s current
technology to (a) enhance the effectiveness of individualized treatment services, (b)
improve the efficiency and productivity of the employees, (c) improve communications
with patients and stakeholders, and (d) enhance the quality of services through
improvements in communications effectiveness.
All employees are responsible for conformance with this policy.
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Organizational Communication
PURPOSE: To establish the policy of COADA-CB on all forms of organizational
communication and to establish formal responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all of the organization’s leadership and
employees, including volunteers and student workers, will engage in communications
that support mission accomplishment and more critically, portrays the organization in a
positive manner.
PROCEDURE: The following guidelines apply to organizational communication:
1. General guidelines:
A. COADA-CB Board and employees will interact with each other and others with
respect, courtesy, and fairness and afford the same professional courtesy to other
professionals.
B. Adhere to all local, state, and federal laws and rules governing the delivery of care
and professional relationships with recipients of services and/or information.
C. Adhere to the professional code of ethics of their certifying body.
D. Will not include language that is demeaning or discriminatory; that is,
discriminatory on the basis of race, color, gender, sexual orientation, age, religion,
or national origin.
E. Maintain respect for the rights and opinions of others.
F. Refrain from engaging in any type of sexual, romantic communications, or
activity with a recipient of service or their family for a period of two years after
services have ceased unless a longer period is specified by the employee’s
professional code of ethics.
G. Use agency business cards to identify the employee other than official agency
business.
H. All electronic, telephonic, and other communication systems (including email,
voice mail, etc.) and all communication and information transmitted by, received
from, or stored in COADA-CB’s systems are the property of COADA-CB, and
such as, are to be used, solely, for job related purposes; unless expressly permitted
by the Executive Director.
I. Employees are strictly forbidden from using any software or business equipment
for private purposes, unless expressly permitted by the Executive Director.
J. Employees are to keep their password confidential from other employees with the
exception of their Division/Program Manager and or CIS Coordinator.
K. The Finance Business Manager, Executive Director, and CIS Coordinator shall be
the only persons at COADA-CB with CIS security access.
L. Employees go through the Division/Program Manager for all information
technology needs, inclusive of needing access to files on the server, passwords,
hardware maintenance, etc.
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M. Employees are not permitted to send a message to their Division/Program
Manager that they are going to be late or absent. If the Division/Program Manager
is unavailable then the Executive Director shall be notified.
N. Foul, inappropriate, or other offensive messages such as racial, sexual, or
religious slurs are prohibited on any form of communication (e.g. email, voice
mail, letters, etc).
2. Open Door Policy:
A. Communication through the chain of command begins with the Division/Program
Manager. Employees are encouraged to facilitate interagency communication, but
are not required.
B. Employees may approach the Executive Director, at any time, to talk without
going through the chain of command.
C. The Executive Director acknowledges individuals may not feel comfortable going
through the chain of command.
D. The Executive Director acknowledges that situations arise that require urgency
and going through the chain of command may serve as a barrier to effective and
efficient response.
3. Media Relations:
All requests for representation to the media should be channeled through the Executive
Director.
A. Only the Executive Director or designee may schedule media contacts.
B. The Executive Director or designee is COADA-CB’s primary spokesperson for
the media.
C. Other employees, as approved by the Executive Director, may be authorized to
represent the agency on a topic-by-topic basis.
D. No “off the record” comments may be made by employees to the media.
E. Incoming calls from the media should be routed to the Executive Director or
designee.
F. Written press release may be issued as approved by the Executive Director. If
legal or controversial issues are involved, an attorney for potential liability,
accuracy, legality, should review the press release before release authorization is
given.
G. Telephone calls from the media will be returned; even if COADA-CB will not be
answering the questions.
H. Employees who violate the media relation policies and procedures may be subject
to disciplinary action; including termination.
4. Mail:
COADA-CB has the legal right to open all mail addresses to any of our businesses;
regardless of whose name appears on the envelope.
A. Outgoing mail will be processed for mailing at the conclusion of each business
day.
B. Items to be mailed are to be prepared by the employee.
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C. Administrative employees will process the stamping of this mail at the end of
each business day and make mail drop arrangements.
D. No personal mail is to go out under agency postage. Periodic checks of prepared
mail may be done to facilitate this.
5. Telephone Accountability
All long distance telephone calls made either on agency telephone credit cards or on
agency telephones are strictly for agency business.
A. Any employee placing personal long distance telephone calls, at the agency’s
expense, is required to receive prior approval from the Executive Director and
reimburse the agency.
B. Local personal calls are to be kept to a minimum.
C. All phones calls are subject to review by management.
D. List of emergency contact telephone numbers are to be kept next to each phone.
6. Use of Cell Phones at Work:
COADA-CB recognizes the use of a personal cell phone while at work may present a
distraction to the user and/or co-employees. This policy is meant to ensure that cell phone
use while at work does not disrupt business operations or cause a safety hazard.
Therefore, it is the policy of COADA-CB, that;
A. Authorized personnel may only use organization issued cell phones for business
related issues.
B. “On call” counselors have been issued a set of directions specifically applicable to
them.
C. Cell phone use of any kind is strictly forbidden while driving a vehicle during
Work hours or conducting business on behalf of COADA-CB.
D. To the extent authorized, or as circumstances may warrant, personal cell phone
use should be limited to making business related telephone calls or for limited
personal calls or family emergencies. The use of personal cell phones in common
office areas and meetings is discouraged. The excessive use of personal cell
phones for any purpose may lead to disciplinary actions including termination.
In addition to telephone service, many cell phones or cellular providers offer additional
functions and/or services, including text messaging and digital photography. It is not
possible to list all of the services that are new or may become available. It is a concern
these functions may compromise the confidentiality of clients or staff. Whether
enumerated or not, employees are strictly prohibited from using any of these services at
work. Violation of this policy will subject an employee to disciplinary action up to and
including immediate termination.
7. Bulletin Board Postings:
COADA-CB bulletin board will be used for agency related business (e.g. notices of local
workshops and seminars on alcohol and drug abuse, employment opportunities, substance
abuse/dependency related educational information, etc.).
A. COADA-CB bulletin board is not for display of advertising pieces or for purposes
other than agency-related business.
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B. All notices must be cleared in advance with the Executive Director or designee.
C. English and Spanish versions of the Patient/Participant Bill of Rights shall be
posted continuously in an area accessed be patients/participants.
8. Time Activity Reporting Documentation:
COADA-CB employees shall maintain reporting documentation of all labor activities
through a time activity sheet:
A. All reporting documents by employees shall be factual, accurate and legible.
B. Employees incurred labor expense of all work related activities will be allocated
to a specific program and based on the actual time spent working within the
specified program.
C. All reporting documents and entries by employees shall be dated and
authenticated by the person responsible for the content.
9. Supporting Documentation:
COADA-CB employees shall maintain supporting documentation.
A. All reporting documents by employees shall be factual, accurate and legible.
B. All reporting documents and entries by employees shall be dated and
authenticated by the person responsible for the content.
C. Records shall contain only those abbreviations included on COADA-CB list of
approved abbreviations.
D. Authentication of paper records shall be an original signature that includes at least
the first initial, last name, and required credentials. Initials may be used if the
patient record includes a document that identifies all individuals initialing entries,
including the full printed name, signature, credentials, and initials.
E. If the document relates to past activity, the date of the activity shall also be
recorded.
F. When it is necessary to correct a patient record, incident report, or other legal
document, the error shall be marked through with a line, dated, and initialed by
the writer.
G. COADA-CB shall maintain documentation of formal agreements and contracts to
address identified deficiencies in access to program services for people with
disabilities.
10. Solicitation:
Employees and non-employees are prohibited from verbal and written communication in
COADA-CB’s office during work hours when this communication encourages,
advocates, demands or request money, time, effort, or personnel involvement in any fund,
organization, or the purchase of merchandise; unless authorized by the Executive
Director. Any unauthorized solicitation should be reported, immediately, to the
employee’s Division/Program Manager. If any employee is conducting unauthorized
solicitation, the Executive Director may take appropriate disciplinary action.
11. Internal information sharing mechanisms:
A. Employees have ongoing electronic access to the P&P manual.
B. COADA-CB web site.
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C.
D.
E.
F.
G.
H.
I.
J.
K.
Regular employee schedule meetings.
QMT meetings.
Board meetings.
Patient satisfaction surveys results.
Family satisfaction survey results.
Description of funding activities.
Strategic planning process.
Schedule training activities.
Executive Director maintains an open door policy.
12. Organizational information is shared among;
A. Organizational leadership.
B. Employees.
C. Other stakeholders as determined by the Executive Director,
D. Persons served.
13. Opportunities are available for employees to provide input regarding strategic
planning process, fund raising activities, employee meetings, etc.
14. COADA-CB is engaged in public education that promotes:
A. Its mission.
B. Its activities.
C. Accessibility to its programs.
D. The outcomes of its programs.
15. COADA-CB:
A. Responds to public requests for information relevant to its services or programs.
B. Answers specific questions about the performance of its services or programs.
C. Reports information in formats and languages that are accessible and
understandable to the primary population served.
D. Make the public aware of its procedure for responding to such requests.
E. Reports accurate information.
16. COADA-CB demonstrates communication that supports collaborations with:
A. Consumer or family groups.
B. Advocacy groups.
C. Government agencies.
D. Other service providers.
E. Businesses.
F. Professional groups.
17. As part of effective communications, the organization will prepare and maintain a
number of different records and record keeping systems:
A. Patient records:
1. COADA-CB clinical employees shall establish CMBHS documentation and
maintain a hard copy record for every patient at the time of admission.
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2. The content of patient records shall be complete, current, and well organized.
3. COADA-CB employees shall protect all patient records and other “patient
identifying” information from destruction, loss, tampering, unauthorized access,
use or disclosure.
a. All hard copy active patient records are stored in locked filing
cabinets at COADA-CB facility.
b. All inactive records are secured and fully protected from
unauthorized access.
c. Information that identifies applicants shall be protected to the same
degree as information that identifies patients.
d. Electronic patient information is protected to the same degree as
paper records with a reliable backup system.
e. COADA-CB limits the employee access to patient information and
records on a legitimate need-to-know basis.
4. COADA-CB employees shall ensure that all patient records can be located and
retrieved promptly at all times.
5. COADA-CB employees shall comply with federal and state confidentiality
laws and regulations, including 42 CFR Part 2 (the federal regulations on the
Confidentiality of Alcohol and Drug Abuse Patient Records) and Texas Health
and Safety Code, Chapter 611 (relating to Mental Health Records). The facility
shall also protect the confidentiality of HIV information as required in Texas
Health and Safety Code §81.103 (relating to Confidentiality; Criminal Penalty).
6. COADA-CB employees shall not deny patients access to the content of their
records; except as provided by the Texas Health and Safety Code, §611.0045.
7. Adult patient records shall be kept for at least six years. Records of adolescent
patients shall be kept for at least five years after the patient turns 18.
B. Contractual Records:
1. COADA-CB shall maintain all records relating to the contract for at least three
years from the date the independent financial audit is accepted (when required) or
would have been due (when not required) as stated in DSHS Rule 444.506
relating to Independent Audit Reporting Submission).
2. If COADA-CB is involved in the process of any litigation, audit, or other
action at the end of three years, the records shall be kept until the action is
resolved.
3. If COADA-CB closes business operations; it shall ensure that records relating
to the contract are securely stored and accessible for at least three years. COADACB shall provide DSHS with the name and address of the responsible party.
C. Training Records:
1. Human resources shall maintain a training file on each training session provided
to employees. Documentation includes:
a. Title of training.
b. Date of training.
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c.
d.
e.
f.
Length of training
Sign-in attendance sheet from internal training
Outline of presentation/training material.
Name of instructor.
All employees are responsible for conformance with this policy.
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Retention and Destruction of Records
PURPOSE: To establish the official position of COADA-CB on the retention and
destruction of confidential records (including both patient and confidential administrative
records) and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all records will be maintained in
accordance with applicable federal and state laws. Further, it is the policy of the
organization that the only acceptable ways to destroy records is through shredding.
PROCEDURE: The following procedures apply to the retention and destruction of
records:
Security Provision
All client records, whether active or inactive, will be filed, stored and locked in a cabinet,
vault or secure room to prevent unauthorized access and inadvertent loss or compromise.
This policy specifically authorizes the secure storage of patient records overnight in
counselor offices provided that they are afforded and adequate degree of protection as
provided elsewhere in this policy.
Off-Site Storage of Inactive/Archived Records
In the event that the organization ever lacks adequate room to store inactive (archived)
records, such records may be transferred to a secure, off-site, commercial facility. A
complete listing of records transferred to the off-site storage facility will be prepared by
designated employees and will include, at a minimum: (a) patient name (b) patient
number (c) date admitted to treatment, and (d) date last seen by a counselor.
Destruction of Records (448.508)
Division/Program Managers or their designees will document those records destroyed
through the shredding process. Destruction documentation will be maintained on file in
accordance with regulatory requirements for compliance purposes and will be afforded
the same degree and extent of confidentiality protection as patient records. Prior to the
destruction of any patient records, employees will contact the Division/Program Manager
who will approve or disapprove the proposed destruction.
Stopping Destruction If a Legal Process is Initiated
In the event that the employees are involved in the destruction of records an a legal
process is initiated against the organization, all such destruction will be terminated
immediately upon discovery of the legal process. For the purpose of this policy, “legal
process” is defined as the presentation of an appropriately signed and sworn subpoena,
warrant or search warrant by a duly sworn of a local, state or federal law enforcement
agency. Upon discovery that a legal process is pending, the employee who is initially
notified or contacted or, who is first alerted to or discovers the existence of the process,
will immediately notify the Executive Director. The Executive Director will be
responsible for ensuring that all employees are appropriately notified so that any
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destruction of records, if ongoing, can be immediately terminated, if required, as a
condition of the legal process.
All employees are responsible for implementation of this policy and will ensure that all
retention policies and procedures are consistent with those mandated by law and/or
regulatory agency policy.
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Management Information System/Computer Policy
PURPOSE: To establish the official position of COADA-CB on the management and
utilization of COADA-CB’s technology systems. This includes but is not limited to the
organization’s computing resources, information technologies, networks, computers,
computing employees, hardware, software, computing laboratories, databases, files,
information, software licenses, computing-related contracts, network bandwidth,
usernames, passwords, documentation, disks, CD-ROMs, DVDs, magnetic tapes,
electronic mail and to establish formal responsibility of the policy.
POLICY: It is the policy of COADA-CB that the organization’s technology systems will
be managed and used in a manner that represents an “optimal usage” philosophy while
recognizing the significant cost of such systems and the investment that the organization
has made in such technologies. This policy specifically includes procedures pertaining to
freedom of expression, internet access and usage, use of COADA-CB’s resources for
research and public service activities, and requires all users and stewards of the
organization’s technology systems to comply with all applicable local, state and federal
laws.
PROCEDURE: The following represents the organization’s specific procedures in
support of this policy:
In support of academic instruction, research, public service, and administrative functions,
COADA-CB encourages the use of, and provides access to, information technologies and
network resources.
In keeping with its role and values, COADA-CB supports the use of electronic
communication for the conduct of official COADA-CB business and for individual
professional purposes related to official COADA-CB purposes.
Users of COADA-CB’s computing resources, information technologies, and networks are
responsible for using those resources in accordance with the law and with COADA-CB
policy.
Use of COADA-CB’s computing, information technologies and networking resources is
a privilege that is dependent upon appropriate use of those resources.
Individuals who violate the law or COADA-CB’s policy regarding the use of computing
resources, information technologies, and networks are subject to the loss of resource
access in addition to being subject to agency disciplinary system.
APPLICABILITY:
This policy applies to all employees, students, contractors, and volunteers who use
computing resources, information technologies, and networks owned or managed by
COADA-CB.
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1. All such individuals, by virtue of their use of COADA-CB’s computer resources,
information technologies, and networks accept the responsibility for using these
resources only for appropriate COADA-CB activities.
2. Computer network users are responsible for reading, understanding, and behaving in a
manner consistent with this policy.
APPROPIATE USE:
COADA-CB’s computer resources, information technologies, and networks may be used
for legitimate COADA-CB purposes only. Appropriate use of COADA-CB’s computer
resources, information technologies, and networks includes:
1. Employees, all appropriate use by employees and administrators shall be directly
related to instruction, research, and scholarly, professional and administrative endeavors
on behalf of COADA-CB or within the scope of COADA-CB employment.
2. Practicum students, while working in COADA-CB employment/affiliation capacities,
will be governed by policies for employees.
3. Volunteers, while working in their COADA-CB employment/affiliation capacities, will
be governed by policies for employees.
INAPPROPIATE USE:
COADA-CB computer resources, information technologies and networks shall not be
used for:
1. Supporting, establishing, or conducting any private business operation or commercial
activity.
2. Conducting personal activities unrelated to any COADA-CB or student educational
purposes, unless, otherwise, allowed by this policy.
3. Attempting to gain unauthorized access to any portion of the system or using COADACB’s computer resources, information technologies, and networks as a staging area to
attempt to gain unauthorized access to any other system or account.
4. Violating COADA-CB’s policy of discrimination against individuals on the bases of
race, sex (including sexual harassment), religion, age ,color, creed, gender, national or
ethnic origin, physical, mental, or sensory disability, marital status and sexual orientation.
5. Intentionally disseminate, access, or provide a hyperlink to obscenity, as that term is
defined by law.
6. Sending unsolicited e-mail (e.g. “spam”) in violation of law or in quantities that
interfere with COADA-CB’s server and/or server of another organization or entity.
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7. Engaging in political activities that violate state law (state law prohibits the use of state
facilities or public resources for the purpose of assisting in an election campaign or for
the promotion or opposition to a ballot proposition.
8. Destroying, altering, compromising the integrity or security, or making inaccessible
COADA-CB computer resources, information technologies, and networks when such
uses are not authorized.
9. Utilizing COADA-CB resources with the purpose of intentionally interfering with
others’ use of computing resources, information technologies, or network resources or
conduct of COADA-CB’s business.
10. Compromising the privacy of users of the resources, information technologies, and
networks.
11. Violating copyright law (thus, information technology and network users who do not
hold the copyright on a work must have permission to publish information, graphics,
cartoons, other material, photographs, or the publication must be, otherwise, permitted
under copyright law).
12. Violating trademark law.
13. Violating any local, state or federal law.
14. Copying of software in violation of a license or when copying is not authorized.
ADDITIONAL POLICIES APPLYING TO COADA-CB EMPLOYEES
1. Computer resources, use of information technologies, and networks by COADA-CB
employees is governed by Texas Law, while working in an employment capacity for
COADA-CB, are also governed by the Texas Ethics Law. COADA-CB’s employees
must comply with the Ethics Law and with any rules adopted by the Executive Director.
Computer resources, use of information technologies, and networks used by COADACB’s employees are subject to the Executive Directors direction.
2. Employees shall use COADA-CB’s information technologies and networks primarily
for the purpose of conducting COADA-CB business. Employees may use COADA-CB’s
information technologies and networks to conduct other business within the scope of their
employment, such as, communicating with other professional organizations about their
areas of expertise or visiting Web pages of such professional organizations.
ADDITIONAL PROCEDURES FOR WEB/ELECTRONIC PUBLICATIONS
The quality of information published and communicated by COADA-CB plays an
important role in maintaining the strong reputation and image of COADA-CB. Because
all internet users may view electronic publications, the quality of electronic publications
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reflects upon all of COADA-CB community. In general, electronic publications are
subject to the same COADA-CB policies and standards as print publications.
1. Unit Web Pages and Other Electronic Publications: Unit Web pages and other
electronic publications are the equivalent or printed publications or official
communication. They are official COADA-CB publications.
2. COADA-CB Web graphic identity guidelines are available upon request and all
academic and administrative units are encouraged to use them.
3. Each unit Web page, cluster of linked pages, or other electronically published
information will contain:
A. The unit name;
B. An electronic mail address with the unit’s Web page creator or administrator;
C. The page’s expiration date when appropriate;
D. A link to COADA-CB’s Copyright, Disclaimer, and Freedom of Expression
Policies;
E. A link to COADA-CB’s main or home page.
PRIVACY
1. All computer access is subject to routinely inspection or for monitor use of computing
and networking resources.
2. COADA-CB does not guarantee the security and privacy of any user’s electronic mail
and/or electronic files.
3. E-mail can easily be misdirected or forwarded to others. For these reasons, it is not
advisable to send information in electronic mail that you would not want to be distributed
to others.
4. COADA-CB may access such electronic mail or files in a number of situations:
A. Retention of electronic mail. Electronic mail is backed up and retained in
accordance with record retention, requirements of state laws and COADA-CB’s
policy. Additionally, users are advised that electronic messages and other files are
not removed from their hard drive when erased by the individual. Material that
continues to exist on a hard drive, or on another’s computer, also may be subject to
disclosure.
B. Access during routine system maintenance. Responsible system maintenance may
require that files are backed up, data cached, activity logs kept, and overall system
activity monitored. In the process of these activities, COADA-CB’s employees may
see an individual’s user’s electronic mail and files.
C. User’s responsibility for maintaining privacy. System users are responsible for
maintaining appropriate access restrictions for their files as well as protecting their
passwords. An employee or student who knowingly allows another person to use his
or her username or password may be found responsible for any inappropriate use on
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the part of that person.
SANCTIONS
1. Evidence of illegal activities or policy violations will be turned over to the appropriate
authorities as soon as possible after detection. COADA-CB imposed sanctions for
inappropriate use of COADA-CB computer resources, information technologies, and
networks will depend upon the nature of the abuse in question.
2. Inappropriate use includes failure by Division/Program Managers and employees to
adhere to provisions governing access to others’ electronic files in this policy. Such
sanctions may include restrictions on access, suspension of the individual’s user account,
or revocation of the individual’s user account.
COADA-CB imposed sanctions may also include disciplinary measures and/or
termination of employment. Imposed sanctions for inappropriate use of electronic
resources are also included in this policy. Any such disciplinary action will be taken in
accordance with the appropriate provisions of the Employees Manual, the student code or
employee policy, including any collective bargaining agreement.
All employees are responsible for conformance with this policy.
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Clinical Management for Behavioral Health Services
(CMBHS)
PURPOSE: To establish the official position of COADA-CB on the organization’s use of
the DSHS Clinical Management for Behavioral Health Services (CMBHS), to describe
the use of the system within the organization, and to assign formal responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization will fully implement and
utilize the DSHS CMBHS as a way to support a comprehensive service delivery system
while meeting state and federal requirements for capturing and reporting required patient
and billing data.
PROCEDURE: The following procedures identify the organization’s specific processes
and responsibilities in support of this policy:
1. CMBHS (Clinical Management for Behavioral Health Services)
A. COADA-CB utilizes the CMBHS system, a nationally recognized internet-based
computer system for behavioral health providers that support a comprehensive
service delivery system. CMBHS offers tools for clinicians to ensure provision of
consistent, quality services. Using CMBH, COADA-CB employees can easily meet
state and federal requirements for reporting, including capturing required patient
and billing data, including HIPAA requirements.
B. CMBHS provides research, trend analysis and management information for
decision making that requires significantly more data to be collected from a greater
number of sources within an organization.
C. Many of the business processes designed in CMBHS are modeled on input from
provider focus groups as well as the Target Cities model. The solution combines
case management and reporting capabilities of previous
DSHS software and
adds additional tools making CMBHS a comprehensive information management
network to facilitate cooperation and coordination among service providers.
D. The purpose of CMBHS is to provide a management information system that offers
cost efficient support of provider’s networks, web-based computerization of record
keeping, data sharing within a service network, and support of state and federal
reporting requirements.
E. CMBHS improves the system for a service provider to perform clinical business.
This includes;
1. Patient Screening: The ability to collect initial patient engagement information.
2. Patient Assessment: The ability to capture demographic, service and clinical
data.
3. Problem List The ability to generate a problem list based on the responses to
specific questions on a completed assessment.
4. Treatment Plan: The ability to complete a treatment plan from the problem list
on line.
5. Patient Admission: The ability to record patient admission disposition and other
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documentation required at admission.
6. Referral: The ability to track and refer selected patient documentation to a
provider as authorized by the patient.
7. Service Delivery: The ability to record services rendered in support of the
patients recovery process.
8. Capacity Management: The ability to track and managed bed/slot availability.
9. Patient Discharge: The ability to record patient discharge disposition, ending
diagnosis, plans, summaries and other documentation required at discharge.
10. Follow Up: The ability to capture and track a patient’s recovery process after
discharge.
11. Prevention/Intervention: The ability to track prevention/intervention activities
at the event detail level.
F. CMBHS extends COADA-CB’s capabilities to include DSHS billing and patient
demographic data.
G. CMBHS extends COADA-CB’s statistical analysis and reporting capabilities.
H. CHIPS and private insurance patient billing is submitted manually.
I. CMBHS requires strong, secure communication between DSHS server and the
user’s web browser to ensure data privacy and integrity. Users are required to use a
unique login ID and password to gain access. These IDs and passwords will be
maintained and updated by the user through secure processes. Beyond basic login
security, there are three primary security concerns on the Internet:
1. Eavesdropping: Information remains intact, but is privacy compromised. For
example, someone could view the classified treatment information for the
patient.
2. Modification: Original information is changed or replaced and sent to the
recipient, who is unaware of the modifications. For example, someone could
alter information when a patient is referred to another provider.
3. Impersonation: Information passes to a person who poses as the intended
recipient.
J. Privacy on the Internet is accomplished through data encryption. The industry
standard for data encryption is Secure Sockets Layer (SSL). DSHS uses SSL
technology by VeriSign, the same as that used by more than 575,000 web sites
worldwide including major e-commerce and banking sites. SSL provides the
following security benefits:
1. Privacy: Data is encrypted to and from the browser, so privacy is ensured
during transactions.
2. Message Validation: An encoded message digest accompanies data to detect
any massage tampering.
3. Server Authentication: A server certificate accompanies messages to ensure the
browser that the server identity is authentic.
K. CMBHS also implements role-based security that allows individuals access to
specific data. For example, assessors will have access to only data that they author
or have been allowed to access through the consent of the patient. Data is secure to
the screen level for each document based on that individual’s role with the patient
and the organization.
L. CMBHS allows for real time collection of all the data entered into the system.
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Familiar outcome and process measures have been formatted in different reports
for easy access and download. COADA-CB also has the ability to download data
into excel or access to create other specific reports that offer analysis of
administrative and programmatic services. All this data is utilized in the decision
making processes at COADA-CB, including the development and revision of the
PI and strategic plan, policies and procedures, management summary, etc.
M. COADA-CB will work with DSHS to continue ongoing assessment of the
technology need of CMBHS through input from a variety of sources including
service providers, service agencies, network systems, consumer and provider
advocacy groups, and state and federal sources. The assessment includes
applicability to enhance individual services, evaluate outcomes of the
organization, the programs and the persons served, improve efficiency and
productivity of employees, communication with stakeholders, improvement of
services to isolated populations.
All employees are responsible for conformance with this policy.
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Confidentiality and Control of Patient Records
PURPOSE: To establish the official position of COADA-CB on the confidentiality and
control of patient related data and information and to assign specific responsibility for the
implementation of the policy.
POLICY: COADA-CB is committed to the protection of all patient related information
and data and recognizes its legal and ethical responsibility to comply with the Health
Insurance Portability and Accountability Act (HIPAA) OF 1996, 42 CFR Part2,
Communicable Disease Prevention and Control Act, Section 9.03, as amended by SB 959
and Texas Health and Safety Code, Chapter 611. The facility shall, protect the
confidentiality of HIV information as required in Texas Health and Safety Code §81.103,
Chapter 35, Section 35.03 of Texas Family Code, Texas Civil Statute Article 447(I)
V.T.C.S.
This policy specifically recognizes that patients are afforded confidentiality protection
from the time they initially seek services and into perpetuity. COADA-CB recognizes
that the protection of patient confidentiality represents a moral and ethical obligation for
the organization and all its employees. Therefore, it is the policy of COADA-CB that
patient confidentiality and protection will be of paramount concern and, that the
organization will make every attempt through both policy development and service
delivery to afford the highest degree of protection to all records and files that contain any
patient related data.
PROCEDURES: The following describes the organization’s general procedures relative
to the confidentiality and protection of patient or employee records:
PHYSICAL SAFEGAURDS TO PROTECT PATIENT RECORDS, FILES AND
CHARTS
This policy recognizes that the physical safeguards COADA-CB takes to protect
confidentiality are the cornerstone for protecting patient information and data. Each
Division/Program Manager will ensure that a system is in place to provide for the
“positive control” of all patient records. Implied in the term “positive control” is the
requirement for (1) the organization of the records is a systematic fashion so that the
employees will always know the location and be able to ascertain the location of records;
(2) the designation of an individual in the organization with specific responsibility for
controlling the records and implementing the policies and procedures pertaining to all
organizational records; (3) procedures to limit access to clinical and administrative
records (including and electronically generated records such as email, fax, etc.) to those
authorized employees with a legitimate “need to know”; (4) procedures for securing all
records in a way that provides maximum protection of patient confidentiality at all times
and reasonable protection against fire, water damage and other hazards; (5) procedures
for the routine backup of data files in all computer/electronic systems; and (6) a separate
policy on the retention and destruction of records that is clearly implemented and (a)
identifies the procedures for paper and/or electronic record keeping, (b) specifies the
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provisions for stopping the destruction of records in the event that a legal process is
initiated against the organization, and (c) complies with all applicable state and federal
laws. It should be noted that COADA-CB has a separate policy on “Retention and
Destruction of Records”. That policy provides specific guidelines regarding retention and
destruction of records and includes the required provisions for stopping destruction in the
event that the agency is served with legal notice of any kind.
Under no circumstances will records be left unsecured at the end of the working day or
after normal working hours. An employee must be physically present in the office so that
he/she has personal custody and control of the records. Alternatively, the door to the
office must be locked during those times that the employees may need to leave the office
for even short periods of time. (Not to exceed 15 minutes).
Release of Patient-related Data and Protected health Information
The release of patient-related data/information is specifically prohibited without the
express, written consent/permission of the patient, or unless specifically allowed by
applicable legal guidelines. For emphasis, the other “exemptions” from the general
prohibition against the release of patient-related information include: (a)internal program
communications; (b) communications that do not disclose the identity of the patient; (c)
communications during medical emergencies; (d) court ordered disclosures; (e)
communications with law enforcement officials regarding crimes committed by patients
on clinic premises or against COADA-CB’s employees; (f) communications in
conjunction with research, audit or evaluation and that do not disclose the patient’s
identity; (g) reporting of child abuse and neglect; and (h) communications as part of a
qualified service organization agreement. The following guidelines will be enforced
when preparing signature release forms for the patient:
1. Patients will be asked to sign a consent form only when there is a legitimate need to
communicate with/release information to another individual, entity or organization.
UNDER NO CIRCUMSTANCE WILL A PATIENT BE ASKED TO SIGN A BLANK
RELEASE FORM. For emphasis, consent forms must be prepared and signed in response
to a specific need and not simply as a matter of convenience or expediency for the
employees.
2. All consent forms must include the following:
A. Patient name;
B. Name of the organization (COADA-CB);
C. Name of the organization and/or person to which information will be released;
D. A complete description of the specific information released;
E. The intended purpose for which information will be released;
F. The specific date, event or condition upon which the patient’s consent will expire.
UNDER NO CIRCUMSTANCE WILL THE EXPIRATION DATE BE LONGER
THAN ONE YEAR FROM THE DATE THE PATIENT SIGNS THE CONSENT
FORM.
G. Information to describe the circumstances, events or incidents under which the
authorization can be revoked; consent may only be withdrawn in writing;
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H. The date the release is signed by the patient; and
I. The signature of the patient or the signature of the patient’s legal guardian or
authorized representative, as applicable.
In all cases in which the organization releases confidential patient information, a
statement will be included to specifically advise/warn the recipient that the information
cannot be released or re-disclosed to a third party.
The originals of all consent forms will be maintained in the patient’s chart/record; a copy
will be forwarded to the receiving entity along with the requested information.
In the event that a patient desires to review his/her record or any part thereof, the request
should be submitted in writing to the counselor or Division/Program Manager. The
counselor or Division/Program Manager will schedule an appointment with the patient as
soon as possible. Additional information relative to a patient’s right to review his/her
record is contained in the organizations “Notice of Privacy Practices’ under HIPAA and
under the organization’s policy on HIPAA conformance.
In all cases, access to and the release of patient related information will be accomplished
in sufficient time for the patient to make fully informed decisions about his/her treatment.
In some cases, the organization will receive requests for patient records and/or patientrelated information from attorneys involved in lawsuits and/or legal action against
COADA-CB. In such cases, no records will be released without (a) a properly executed
consent form signed by the involved patient and (b) prior approval from the Executive
Director. It is reasonable that the organization would want to review any patient record
that might ultimately be used in legal action against the organization and therefore,
approval by the Executive Director must be obtained as a condition for release.
On occasion, COADA-CB may be presented with court orders, search warrants and
other legal demands for documents or for the arrest of patients receiving services at
COADA-CB. In such cases, law enforcement officers should be afforded every courtesy
and consideration and given free and unencumbered access to the facility. However,
federal confidentiality laws prohibit the employees from assisting in the actual
identification of any patient enrolled at the clinic. For clarification, this also includes any
act or statement that would confirm that a patient is actually receiving services and/or is
enrolled in treatment. In the event that a search warrant is presented, a copy of the
warrant should be made and retained by the Division/Program Manager; the original
should be forwarded to the Executive Director immediately. Additional guidelines for
responding to subpoenas, search warrants, investigations, inquiries and other legal actions
are contained in the organizations policy on corporate compliance. The Division/Program
Manager should contact the Executive Director prior to releasing any information as a
way to ensure that COADA-CB complies with all legal requirements and demands.
Additionally, the following specific procedures apply to the organization’s efforts to
protect patient and employee confidentiality:
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1. Violation of patient or employee confidentiality subjects the employee to COADACB’s disciplinary procedures, up to and including termination.
2. The confidentiality of employee files will be maintained and access restricted to the
Executive Director, Human Resource Coordinator, Finance Business Manager, and the
Division/Program Manager, on a “need to know” basis.
3. The disclosure of privilege information by COADA-CB employees is prohibited.
4. Any violations of confidentiality of COADA-CB’s patients, employees, or privileged
information will be reported to the Executive Director for investigation upon discovery.
Based on the investigation, appropriate disciplinary action will be taken; up to and
including termination.
5. COADA-CB has developed specific written procedures, forms, and training to protect
patient confidentiality to authorize the release of information in compliance with the state
and federal laws. Employees are expected to use these procedures and forms at all times.
6. If an employee of COADA-CB receives a subpoena requiring records or testimony
regarding official matters or facts possessed by an employee in his/her official capacity,
the employee will notify the Executive Director immediately. An employee is prohibited
from giving out any official records or any copies to private persons or to local or state
officials without prior written approval.
All employees are responsible for conformance with this policy.
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Cost Allocation, Cash Control and Fiscal Management
PURPOSE: To establish the official position of COADA-CB on fiscal control policies
and procedures and to assign specific responsibility for implementation of the policy.
POLICY: The leadership of COADA-CB is fully committed to business conduct and
practices that are consistent with sound fiscal management and reflect the organization’s
commitment to protect all of its assets and resources from fraud, waste and/or abuse.
Inherent in this policy is the recognition that sound fiscal management is the foundation
for services offered by the organization and vital to continuity of operations. It is the
policy of COADA-CB that the organization will consistently operate in accordance with
the established procedures outlined herein.
PROCEDURES: The following specific policies and procedures apply:
1. All program accounting is done to allocate and charge each program for the costs
associated with providing the program/service. COADA-CB does not allocate indirect
costs.
2. Accounting System:
A. Uses a computerized system for all accounting practices.
B. COADA-CB has established a chart of accounts, which allows for each program to
be directly charged for revenues and expenditures.
C. Business Finance Manager will allocate employees reported labor expense of all
work related activities to specific programs as reported on the time activity report
and as dated and authenticated by the employee signature.
D. Source documents are maintained by the accounting requisition division.
Documentation retained also includes all award documents such as Coastal Bend
United Way, Aransas United Way, DHHS, and DSHS forms, reports and
Correspondence relative to each program funded.
E. Internal controls have been established to safeguard all assets of COADA-CB. In
setting these internal controls, the following concepts were utilized:
• Segregation of duties
• Proper authorization
• Proper recording of transactions
• Limiting access to assets
• Evaluation of progress toward objectives
F. The agency uses the accrual basis of accounting.
G. Financial statements are prepared each month and include the Balance Sheet and the
Statement of Revenues and Expenditures.
H.The Board of Directors is provided the financial statements as part of the Financial
Report at monthly Board of Directors meetings.
I. The Board of Directors has a financial subcommittee that reviews COADA-CB
budget in depth on a monthly basis.
J. The Division/Program Managers also review COADA-CB budget in depth on a
monthly basis.
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3. Reporting Requirements:
A. Reports are submitted to DSHS through the CMBHS for prevention.
B. The CMBHS automatically calculates the treatment reimbursement amount
based on the type of service documented by the counselor in the web-based
system.
C. CMBHS has a functionality that allows for direct submission of billing to DSHS
use of CMBHS.
D. CMBHS has a functionality that allows easy retrieval of data for reporting
requirements.
E. CMBHS has a functionality that calculates treatment services for non-DSHS
patients.
F. All program income is recorded separately and identified as to the program
generating the income.
G. Medicaid patient billing information is submitted through a separate program.
H. CHIPS and private insurance patient billing is submitted manually using the
HCFA 1500 and the WB92 forms.
4. Control of Income and Reimbursements:
A. When applicable, program income is used to offset allowable costs of the
program and/or cash match requirement of the program.
B. If applicable, program income will be used to expand or increase program
activities or to expand objectives.
C. Approval for program expansion will be obtained before any expansion is made.
D. Reimbursement of Federal/State funded programs will only be credited to the
program approved in the original funding grant.
E. The Board of Directors, the Executive Director, Finance Business Manager, give
attention to long-term financial solvency and to continuity of services. The
Executive Finance Committee reserves the discretionary right to collect and retain
6 months in excess cash reserves or non-directed funds in a secured banking
institution. Should a specific program(s) expense exceed program income, the
money reserves may be used at the discretion of the Executive Finance Committee
to compensate for the loss of program funding.
5. Program Budgets:
A. An annual budget is developed and submitted to the Board of Directors for
approval.
B. All program budgets are submitted to DSHS in a timely fashion so as to assure
the continuation of program/services.
C. Additions or changes to program budgets will be requested for the following:
• Change in service
• Change in facility/site
• Change in target population
• Change in goals or scope of service
• Change in key employee
• Change in costs, which require DSHS approval prior to expenditure.
D. Budget revisions may be requested by completing the Budget Program Adjustment
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form by a member of management or by the Executive Director. The Budget
Program Adjustment form is subject to final approval by the Executive Director
E. Budget revisions will be approved or rejected by DSHS within 30 days of
submission.
F. All approved budget revisions will be retained and filed as part of the permanent
program file.
6. Employees are trained as needed in regards to reporting, billing and coding procedures
as needed. CMBHS has a coding and billing system built within so training for billing
using CMBHS is quite minimal. New employees are provided CMBHS training.
7. An annual review is completed by an independent certified public accountant. The
Board of Directors determines if the recommended action from the independent review
will occur. One or more of the members on the board are CPAs.
8. There is an internal system used for inventory and monitoring of capital equipment.
Employee Allocation Costs
1. Employee costs include wages for employees directly associated with services
provided to patients/participants.
2. All agency employees will complete a time and activity report on a daily basis
regardless of whether the employee is part of a funded program. This report will detail,
by day, the hours spent by each employee providing services for the various programs
provided by COADA-CB. The time and activity report will be a direct accounting of the
employee’s calendar.
3. On a semi-monthly basis, these hours are used to determine the percentage of time
each employee spends in each program provided by COADA-CB.
4. These percentages are the applied to the employee’s salary to determine the actual cost
of providing each program/service.
5. This same percentage is also applied to all fringe benefit accounts including payroll
taxes, vacations, health benefits, sick leave, and SEP contributions.
Consultant Professional Services/Direct Services
1. Contracts for consultant professional services are obtained upon the qualifications of
the provider.. Every effort will be made to bid professional services with the final
selection based upon consultant qualifications, similar experience, references, ability to
provide the service within the specified time frame and total cost of the service provided.
Contract consultant awards will be made upon the lowest or fairest bid.
2. When COADA-CB contracts for a consultant or professional services, it is determined
at the time of service whether it is a direct cost of a program/service. If it is a direct cost
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then the appropriate expenditure code cost center is used to identify the program being
charged.
3. Consultant and professional services are allocated to programs based upon the cost
allocation plan.
Supplies
1. Supplies are directly charged to the particular program that will used them. (E.G.,
Videotapes for a specific program, craft supplies for a youth program, etc.).
2. Supplies, which cannot be directly charged to a program, are allocated based on Cost
Allocation Plan.
Travel Conferences and Meetings
1. Reimbursement for travel is made according to the travel policy and procedures
guidelines:
A. All travel expenses are to be reasonable and necessary.
B. All travel is to be pre-approved by the Division/Program Manager and/or the
Executive Director.
C. Mileage, meals, incidentals and lodging charged to Federal Programs are limited
to rates published in the Federal Travel Regulations.
D. Air fare is limited to coach and car rental to mid-size or smaller.
E. Travel costs will be reimbursed based on travel vouchers, expenditure reports or
other documentation listing each cost individually along with original receipts.
2. Examples of travel expenses and the proper documentation include original receipts
for:
A. Airline tickets limited to coach.
B. Lodging and meals (no gratuities).
C. Parking.
D. Ground transportation (as it relates to car rentals: economy or mid-size or mileage).
3. Mileage and other Travel Expenses:
A. All locations to which a COADA-CB employee must travel to perform business and
which require the use of the employee’s personal transportation will be reimbursed
at a rate per mile to be determined by the Executive Director.
B. If a team of employees are conducting business at the same location with the same
amount of expected time, the Division/Program Manager has the right to ask them
to carpool in the same vehicle to save on mileage re-imbursement.
C. Employees must record odometer reading documentation of miles traveled on
behalf of the agency.
D. Parking will be reimbursed at actual cost (subject to approval by the Executive
Director).
E. Employees shall not be paid when traveling from home to work and back.
F. Non travel business meals that have been approved will be reimbursed based on
actual receipts submitted not to exceed the established per diem rate and which
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does not include service tips paid by the employee.
G. Out-of-town: Approval is required by the Executive Director in selection made
between use of personal transportation or airline, plus ground travel to point of
destination and return.
H. An employee will receive a per diem as a payment to cover meals and incidentals
while traveling for business purposes followed by a signed requisition form. The
per diem rate will be based upon the cost of living within the traveling state and
according to the established guidelines. The State of Texas currently allows a per
diem of $35.00 per day. For travel outside the State of Texas, per diem rates
established by U.S. General Services Administration will serve as a guideline.
I. Mileage reimbursements attributable to a specific program are charged to the
program cost center. Grant reimbursable expenses are incurred when an employee
is involved in training or employee development activities necessary to the grant
or contract supported program.
4. Other employee travel is allocated based upon the percentages determined in the
employee cost allocation.
5. Local travel should indicate the following and be submitted on a travel reimbursement
form:
A. Name and signature of the employee receiving travel funds.
B. Signature of employee’s Division/Program Manager.
C. Grant program name.
D. Dates of travel.
E. Destination of travel (to and from).
F. Number of miles incurred.
G. Total miles for the trip.
H. Total amount of reimbursement.
All Other Expenditures
1. Any expenditure, which is directly attributable to a program, is charged to the cost
center.
2. Any expenditure, which is not directly attributable to a program, is reviewed to
determine if it can be allocated to a program based upon the costs allocation plan
methods.
3. Any cost not allocated or directly associated with a program is charged to COADACB.
Billing
1. Miscellaneous Billings:
A. All billings should be recorded accurately and on a timely basis.
B. Accounting prepares billing for pre-approved amount.
C. Billing is entered into the accounting system as a general journey entry to accounts
receivable.
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2. Grant Billings:
A. Only charges attributed to program operation will be billed to DSHS.
B. Request for Reimbursement (RFR) from DSHS are made on a monthly basis:
• By the 20th of each month, an RFR form is completed for each prevention and
intervention program funded by the DSHS for the prior month’s expenses.
• These forms are submitted to DSHS by means of the CMBHS System.
• Direct deposit payment vouchers are received by the Finance Business Manager
from DSHS or DHHS.
3. Contract Billings:
A. Services provided under individual and group counseling contracts will be
submitted.
by the Billing Coordinator every Monday following delivery of services.
• Individual counselors will maintain documentation of services provided in the
patient clinical records and in CMBHS.
• Billing Coordinator copies billing from CMBHS system.
B. Billing Coordinator submits billing through CMBHS to DSHS.
C. Billing Coordinator divides billing to be entered in spreadsheets for clinic totals.
• Billing Coordinator files billing in monthly file system.
• Direct Deposit payment vouchers are received by Finance Business Manager.
• Billing Coordinator uses labeling and coding procedure for patients to ensure
That only a single appropriate source is billed and that no double billing occurs.
4. Third Party Billing
A. Medicaid
• Individual counselors will maintain documentation of services provided in patient
clinical records.
• Counselors provide the Billing Coordinator with Counseling Record forms for
billing.
• Billing Coordinator files the billing paperwork in a monthly file system.
• Billing Coordinator enters Patient billing paperwork in a monthly file system.
• Direct deposit payment report is received by the Finance Business Manager.
• A Remittance & Status Report is received by the Finance Business Manager.
B. Billing Coordinator uses labeling and coding procedure for patients to ensure that
only a single appropriate source is billed and that no double billing occurs
C. CHIPS and Insurance
• Individual counselors will maintain documentation of services provided in the
patient clinical records.
• Counselors provide the Billing Coordinator with Counseling Record forms for
billing purposes.
• Billing Coordinator enters Patient Billing information on the HCFA 1500 Form
and WB92 mails to CHIPS and Insurance Companies.
• Billing Coordinator files billing in a monthly file system.
• An explanation of benefits w/check is received by Billing Coordinator.
• Billing Coordinator uses labeling and coding procedures for patients to ensure
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that only a single appropriate source is billed and that no double billing occurs.
5. Aged Receivables
A. The Billing Coordinator is to keep all charges current for every patient so as to
keep an accurate balance of what is owed to the organization.
B. The Billing Coordinator is to provide cumulative monthly statements to the
Finance Business Manager of the outstanding billings owed no later than the first
week following the month of billings.
C. The Billing Coordinator is to notify the Business Finance Manager of any disputes
or refusals to pay in a timely manner.
6. Financial Eligibility and Payment
A. COADA-CB shall complete a standardized financial assessment and obtain signed
service consent prior to providing treatment services.
B. The potential patient will be required to provide potential funding sources for
substance abuse services, family income and expenditures to determine method
of service reimbursement.
C. DSHS will be billed if potential patient income is less than 200% FPIL and
individual has no other insurance.
D. COADA-CB will use a sliding scale to seek reimbursement for services if the
potential patient income is greater than 200% FPIL and individual has no other
insurance. The sliding scale allows payment to be split between DSHS and the
patient.
E. COADA-CB shall make a reasonable effort to collect fees generated from patients
paying according to a sliding fee scale, but may waive collection if the
administrative cost of collection will exceed the fee to be collected. DSHS shall\
not be billed for any uncollected patient fees.
F. DSHS will not be billed for services if the individual has access to another public
or private funding source that pays for substance abuse services addressing the
individual’s diagnosis or condition.
G. DSHS will not be billed for any part of any unit of service that has been billed to
another entity or that is eligible for reimbursement by another entity.
H. DSHS will be billed for the unit or service if the patient income is justified and
When the funding source (HMO/BHO, PPO, other private insurance, etc.) denies
payment and all appeals have been exhausted.
• Prior to receiving services, an HMO/BHO service authorization will be obtained if
the potential patient is covered under CHIP (Children’s Health Insurance Plan) or
private insurance.
• No prior authorization for DSHS and Medicaid reimbursement is required.
• If a potential patient is under 19 years of age and family income is between
100% and 200% FPIL, DSHS will be billed while a substantial effort is made to
get patient enrolled in CHIP. Once the patient is enrolled in CHIP, the CHIP
HMO/BHO will be contacted for authorization for continued treatment.
• If the potential patient is under 18 years of age and family income is less than
100% FPIL, DSHS will be billed while a substantial effort is made to get patient
enrolled into Medicaid. Medicaid will be billed once the patient is enrolled into
Medicaid.
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• Once patient is enrolled into Medicaid, Medicaid will be billed for up to the
previous 3 months of service prior to the enrollment date. Any previous
Medicaid funds collected will be returned to DSHS.
I. For adolescents, the ability to pay is determined by family income unless:
• The adolescent applies for treatment without parental knowledge; and
• The adolescent refuses to consent to parental notification.
All employees are responsible for conformance with this policy.
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Cost Allocations
PURPOSE: To establish the official position of COADA-CB on cost allocation
processes and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that it will operate under a standardized cost
allocation system that includes generally accepted allocation processes for fiscal
management and control.
PROCEDURE: The following procedures apply to the organization’s cost allocation
processes:
Personnel Costs
1. Employee costs include wages for employees directly associated with the services
provided to patients/participants.
2. All agency employees will complete a time activity report on a daily basis regardless
of whether the employee is part of a funded program. This report will detail, by day, the
hours spent by each employee providing services for the various programs provided by
COADA-CB. The time activity report will be a direct accounting of the employee’s
calendar.
3. On a semi-monthly basis, these hours are used to determine the percentage of time
each employee spends in each program provided by COADA-CB.
4. These percentages are then applied to the employees’ salary to determine the actual
cost of providing each program/service.
5. This same percentage is also applied to all fringe benefit accounts including payroll
taxes, vacations, health benefits, sick leave, and SEP contributions.
Consultant and Professional Services/Direct Services
1. Contracts for consultant professional services are obtained upon the qualifications of
the provider. Every effort will be made to bid professional services with the final
selection based upon consultant qualifications, similar experience, references, ability to
provide the service within the specified time frame and total cost of the service provided.
Contract consultant awards will be made based upon the lowest or fairest bid.
2. When COADA-CB contracts for a consultant or professional services, it is determined
at the time of the service whether it is a direct cost of a program/service. If it is a direct
cost then the appropriate expenditure code cost center is used to identify the program
being charged.
3. Consultant and professional services are allocated to programs based upon the cost
allocation plan.
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Supplies
1. Supplies are directly charged to the particular program that will use in them.
2. Supplies, which cannot be directly charged to a program, are allocated based on Cost
Allocation Plan.
Travel Conferences and Meetings
1. Travel for mileage reimbursement is made according to the Travel Policy and
Procedures guidelines.
2. Mileage reimbursements attributable to a specific program are charged to the program
cost center. Grant reimbursable expenses are incurred when an employee is involved in
training or employees development activities necessary to the grant or contract supported
program.
3. Examples of travel expenses and the proper documentation include:
A. Airline tickets
B. Lodging and Meals
C. Parking
D. Ground Transportation (as it relates to airline tickets or mileage)
4. Other employee travel is allocated based upon the percentages determined in the
employee cost allocation.
5. Local travel should indicate the following and be submitted on a travel reimbursement
form:
A. Name and signature of the employee receiving travel funds.
B. Signature of employees Division/Program Manager
C. Grant Program name
D. Dates of travel
E. Destination of travel (to and from)
F. Number of miles incurred
G. Total miles for the trip
H. Total amount of reimbursement
All Other Expenditures
1. Any expenditure, which is directly attributable to a program, is charged to the
appropriate cost center.
2. Any expenditure, which is not directly attributable to a program, is reviewed to
determine if it can be allocated to a program based upon the cost allocation plan methods.
3. Any cost not allocated or directly associated with a program is charged to COADACB.
All employees are responsible for conformance with this policy.
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Banking and Bank Reconciliation
PURPOSE: To establish the official position of the organization on those procedures to
be followed for bank reconciliation of the organization’s fiscal assets and to assign
formal responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that it will strictly follow accepted procedures
for the reconciliation of all bank accounts.
PROCEDURES: The following procedures outline the organization’s approved processes
for bank reconciliation.
Computerized Bank Reconciliation:
1. Finance Business Manager receives monthly bank statements from the bank.
2. Reconcile checks from bank statement to general ledger and make journal entries as
necessary for interest and bank charges.
3. Reconcile deposits and debits in computer accounting system from bank statement.
4. Make sure there is not an “un-reconciled” difference.
5. If so, research and make adjusting entries.
6. Outstanding checks remaining after six months should be researched and voided if
necessary.
A. Journal entries will be made to record returned checks and miscellaneous bank
charges, interest income, compensated absences accrued and depreciated expense.
B. All valid journal entries, and only those entries, should be accurately recorded in
the general ledger.
C. All journal entries must be originated by Finance Business Manager.
D. Record journal entry including account number, account name, amount and
explanation.
E. Attach documentation to support entry if applicable.
F. Enter in the accounting system in general journal and post to General Ledger.
Banking of Cash Assets:
1. Cash assets will be deposited in banking institutions insured by the FDIC.
2. Deposited assets will be maintained in separate banking institutions to ensure that the
total deposit does not exceed the FDIC maximum insured amount[$250,000 until
12/31/2013].
All employees involved in the organization’s financial management system are
responsible for conformance with this policy.
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Cash Receipts
PURPOSE: To establish the official position of the organization on those procedures to
be followed for maintaining cash receipts for purchases made by the organization,
establish positive control over all cash and checks received, ensure prompt deposits of all
checks and cash received by the organization and to assign formal responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that it will follow strict check and cash handling
procedures, including the requirement for cash receipts, as a way to maintain
accountability for fiscal assets.
PROCEDURE: The following procedures detail the organization’s specific processes in
support of this policy:
1. Receipt books are issued to employees who receive cash and checks and a log kept on
individuals making payments which documents name, date and amount paid.
2. Opening Mail Receipts, Receptionist delivers accounting mail to Finance Business
Manager mailbox.
A. COADA-CB program facilitator receives cash payment and prepares a triplicate
receipt. One copy is given to the client.
B. A duplicate monetary receipt log is prepared including the program name, date of
transaction, client name, and the amount paid.
C. The duplicate monetary receipt log, the cash payment, and yellow cash receipt
are placed in a sealed envelope and hand delivered to the Finance Business Manager
who then logs all receipts and payments by program and date.
3. General Fund Receipts by Finance Business Manager:
A. Receives sealed envelopes from intake coordinator.
B. Runs total of cash payment and verifies total against monetary receipt log.
C. The Finance Business Manager signs monetary receipt log.
D. Intake coordinator receives a copy of receipt log and one copy of receipt.
E. The payment is placed in a secured lock box in preparation of a bank deposit
transaction.
F. A cover sheet is prepared including program and amount of receipt. One copy
of receipt and one copy of monetary receipt log are attached. A deposit slip is
prepared for the bank deposit with the monetary receipt log number on it.
G. Cover sheet is coded for entry into the cash receipt journal in Peachtree Accounting
System and verified for correct data entry.
H. DSHS Payment vouchers are coded and entered as received.
I. The Finance Business Manager will make one or more cash deposits per week. One
copy of bank deposit slip is attached to cover sheet, with monetary receipt log, and
filed by month.
J. At month end, cash account reconciliation is printed and filed with a copy of the
bank statement.
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K. Program income is recorded separately from DSHS income in each program.
All employees involved in the handling and/or processing of cash receipts are responsible
for conformance with this policy.
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Cash Disbursement
PURPOSE: To establish the official position of COADA-CB on cash disbursements for
the purchase of goods and/or services on behalf of the organization and to assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that it will follow strict procedures for the
disbursement of the organization’s funds.
PROCEDURE: The following processes identify the organization’s procedures pertaining
to cash disbursements:
1. Requisition vouchers are required for all purchases.
2. Employee purchase request:
A. Call vendor for price estimate or consult catalogs for comparative pricing.
B. Indicate on requisition voucher the program/grant to be charged.
C. Division/Program Managers, and or the Executive Director must pre-approve
requisition.
D. The appropriate division places order after the purchase has been approved.
E. Division receives goods and indicates receipts on the packing slip and the date
received, the receiving division delivers packing slip to accounting division.
F. The accounting division matches packing slip to requisition voucher.
G. Upon receipt of invoice in accounting division the requisition voucher is matched
with the invoice.
H. Accounting verifies all items on the requisition voucher have been received before
processing payment.
3. Standard Invoices:
A. Receptionist receives invoices through daily mail and places in Finance Business
Manager’s mailbox.
B. The accounting division codes all payments and Finance Business Manager initials
voucher indicating approval.
C. All invoices are entered into the accounts payable system.
D. Checks are processed on the 15th and last day of the month.
E. The check and one copy are attached to the invoice and requisition vouchers. The
second copy is filed in numerical order.
F. The Executive Director reviews all checks and forwards for second signature.
G. The check requires two (2) signatures. A COADA-CB employee will be assigned as
second signature designee for checks written under $1,000.00. The Executive
Director and one executive board member may sign all checks.
H. In addition to the Executive Director or Chief of Staff signature, a Board signature
must also accompany any check made $1,000.00 and above.
4. Disbursement of petty cash funds should only be made for valid purchases.
A. The authority to disburse petty cash funds is assigned to the Finance Business
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Manager or the Executive Director. Access by other personnel is strictly forbidden.
No employees will be allowed to accept funds without proper documentation and
authority.
B. All petty cash funds will be kept in a secure box in the Finance Business Managers
office. All transactions will be recorded in a notebook journal with attached receipts.
The use of petty cash:
• Is intended to alleviate the need for emergency checks;
• Is to save time and money expended on small items, which are unusual in nature
and small in cost.
• Is not to be used to bypass the requisition system.
• Document all cash purchases so that a proper audit trail can be developed and
maintained.
C. It is the intent of the accounting division to maintain petty cash funds wherever
necessary throughout the organization. The rules and regulations governing these
funds will, however, be rigidly applied and will require time and effort on the part
of the individual maintaining the funds. Periodic spot audits of the funds shall be
conducted.
• A full audit of all items purchased.
• All documentation received in support of the purchase.
• At all times the amount of the receipts and available cash should balance to the
total amount in the fund.
• No employees will be allowed to withdraw funds without proper documentation
and authority.
• Petty cash is not to be used to cash personnel checks or to make advances to
agency employees.
• When the available cash in the fund has been reduced to where requirements
cannot be met, then the accounting division shall prepare a check for cash in the
amount necessary to replenish the fund up tp a maximum of $550.00.
5. Petty Cash Reimbursements:
A. Receipt should show date purchased, total amounts paid, name and location of store
and items purchased.
B. Finance Business Manager or the Executive Director disburses cash per
documentation.
6. Petty Cash Replenishment:
A. Petty cash fund is limited to a maximum of $550.00.
B. Finance Business Manager reconciles and replenishes the fund monthly or as
deemed necessary if higher than average number of disbursements is anticipated.
C. Finance Business Manager prepares check for cash in the amount necessary to
replenish fund to a maximum of $550.00.
All employees involved in the financial management of the organization are responsible
for conformance with this policy.
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Maintenance of Vendor Filing
PURPOSE: To establish the official position of COADA-CB on the maintenance of
financial documentation related to commercial vendors and to assign specific
responsibility for implementation of this policy.
POLICY: It is the policy of COADA-CB that it will adhere to specific procedures for the
filing and retrieval of financial records related to vendors.
PROCRDURE: The following procedures pertain to the maintenance of files of financial
records pertaining to vendors with which the organization conducts business:
1. Files are to be kept alphabetically by vendor.
2. Maintenance of Vendor Filing:
A. Each invoice/requisition voucher should have a copy of a check attached.
B. Each invoice/requisition voucher should be coded to a particular program.
C. When setting up a new vendor on the accounts payable system, the following
information should be required:
• Exact name
• Mailing address
• Tax identification number or social security number for an individual contractor.
All employees involved in the financial management of the organization are responsible
for conformance with this policy.
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Payroll
PURPOSE: To establish the official position of COADA-CB on the processing and
handling of the organization’s employee payroll as a way to provide accountability for
the organization’s fiscal assets and to assign specific responsibility for implementation of
the policy.
POLICY: It is the policy of COADA-CB that payroll will be processed in accordance to
strict procedures as a way to ensure the accountability of the organization’s fiscal assets
and to ensure that payment for wages will be made at authorized rates.
PROCEDURE: The following procedures pertain to the preparation of the organization’s
payroll:
1. Agency employees are paid on the 15th and the last day of the month.
2. Payroll Processing:
A. Accounting division calls for timesheets 3 working days before payday.
B. Any change to regular amounts must be approved by the Executive Director and
noted on the employee’s time activity sheet in the employee pay period and fringe
benefit spreadsheets maintained by the Finance Business Manager.
C. All employees must submit a properly approved timesheet signed by Division/
Program Manager and Executive Director.
3. Preparing Payroll Spreadsheet:
A. Executive Director and Business Finance division reviews timesheets for accuracy.
B. Each employee’s actual time per program is used to calculate time spent in each
program into a percent.
C. The employee’s salary is entered in that percent is then calculated into dollars to
allocate to each program.
D. Spreadsheet is delivered to the outsourced payroll service for the processing of
the checks.
4. Processing Payroll Checks:
A. Utilizing the payroll system, dollars are entered to each program and checks are
printed. The checks are saved in the payroll system.
B. A copy of the employee checks are kept on file in numerical sequence.
C. The check requires two (2) signatures. Approved COADA-CB management
employees will be a signature designee for checks written under $1,000.00.
The Executive Director and one Executive Board may sign all checks.
D. An Executive Board must be a signature designee for any check written for
$1,000.00 and above, in addition to the Executive Director with the following
Exceptions:
• Routine Payroll Checks
• Rent Checks
• Utility Checks
• Monthly insurance premium Checks
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E. Payroll deposits are prepared and called into the EFTPS system by the Finance
Business Manager.
F. 403B SEP contributions are manually entered into employee elected individual
accounts and reconciled through an electronic transfer of funds.
5. Quarterly Payroll Activity:
A. The contracted payroll service will prepare the quarterly 941 and all other tax
Requirements and provides copies of the report for filing by the Finance Business
Manager.
B. The contracted payroll service will prepare the Texas Workforce Commission
Quarterly report and provide copies of the report for filing by the Finance
Business Manager.
6. Annual Payroll Activity:
A. The contracted payroll service will prepare the required W-2 forms and mail to
the last known address of the employees.
B. The contracted payroll service will provide copies of the individual W-2’s for
filing by the Finance Business Manager.
All employees involved in the financial management of the organization are responsible
for conformance with this policy.
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Billing
PURPOSE: To establish the official position of COADA-CB on those procedures to be
followed to establish and maintain consistent and appropriate billing processes and, to
assign specific responsibility for implementation of the policy.
PLOICY: It is the policy of COADA-CB that it will strictly adhere to a set of clearly
defined procedures for all billing procedures.
PROCEDURE: The following procedures will be followed in support of this
organization’s billing process:
1. Miscellaneous Billings:
A. All billings should be recorded accurately and on a timely basis.
B. Accounting prepares billing for pre-approved amount.
C. Billing is entered into the accounting as a general journal entry to accounts
receivable.
2. Grant Billings:
A. Only charges attributed to program operation will be billed to DSHS or DHHS.
B. Request for reimbursement from DSHS/DHHS is made on a monthly basis for all
fees.
C. By the 20th of each month, a request for reimbursement form is completed for each
Prevention program funded by DSHS/DHHS for the prior month’s expenses.
D. Required DSHS forms are submitted by means of CMBHS System.
E. Required DHHS forms are submitted by means of electronic transmission.
F. Direct deposit payment vouchers are received by the Finance Business Manager
from DSHS/DHHS.
3. Contract Billings:
A. Services provided under individual and group counseling cost contracts will be
submitted by the Billing Coordinator every Monday following delivery of services.
B. Individual counselors will maintain documentation of services provided in the
patient clinical records and in CMBHS.
C. Billing Coordinator copies billing from CMBHS system.
D. Billing Coordinator submits billing thru CMBHS to DSHS.
E. Billing Coordinator divides billing to be entered in spreadsheets for clinic totals.
F. Billing Coordinator files billing in a monthly file system.
G. Direct Deposit payment vouchers are received by the Finance Business Manager.
H. Billing Coordinator uses labeling and coding procedure for patients to ensure that
only an appropriate source is billed and that no double billing occurs.
4. Third Party Billing:
Medicaid
A. Individual counselors will maintain documentation of services provided in the
patient clinical records.
B. Counselors provide the Billing Coordinator with counseling record forms for
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billing purposes.
C. Billing Coordinator enters patient billing information in the Compass21 system and
transmit to Medicaid.
D. Billing Coordinator files billing in a monthly file system.
E. A Remittance & Status Report w/check are received by Finance Business Manager.
F. Billing Coordinator uses labeling and coding procedure for patients to ensure that
only a single appropriate source is billed and that no double billing occurs.
5. CHIPS & Insurance
A. Individual counselors will maintain documentation of services provided in the
patient clinical records.
B. Counselors provide the Billing Coordinator with Counseling record forms for
billing.
C. Billing Coordinator enters patient billing information on the HCFA 1500 form and
mails to CHIPS & Insurance companies.
D. Billing Coordinator files billing in a monthly file system.
E. An explanation of benefits w/check is received by Billing Coordinator.
F. Billing Coordinator uses labeling and coding procedure for patients to ensure that
only a single source is billed and that no double billing occurs.
6. Aged Receivables
A. The billing coordinator is to keep all charges current for every patient so as to keep
an accurate balance of what is owed to the organization.
B. The billing coordinator is to post all payments received into the system to keep the
patient balances accurate.
C. The billing coordinator is to provide statements to the Finance Business Manager
monthly of the cumulative billings owed to the organization no later than the first
week following the month of billings.
D. The Billing Coordinator is to notify the Finance Business Manager of any disputes
or refusals to pay in a timely manner.
7. Financial Eligibility and Payment:
A. COADA-CB shall complete a standardized financial assessment and obtained
signed service consent prior to providing treatment services.
• The potential patient will be required to provide potential funding sources for
substance abuse services, family income and expenditures to determine method
of service reimbursement.
• DSHS will be billed if potential patient income is <200% FPIL and individual has
other insurance.
• COADA-CB will use a sliding scale to seek reimbursement for services if the
potential patient income is >200% FPIL and individual has no other insurance.
The sliding scale allows payment to be split between DSHS and the patient.
• COADA-CB shall make a reasonable effort to collect fees generated from patients
paying according to a sliding fee scale, but may waive collection if the
administrative cost of collection will exceed the fee to be collected. DSHS shall
not be billed for any uncollected patient fees.
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• DSHS will not be billed for services if the individual has access to another public
or private funding source that pays for substance abuse services addressing the
individuals diagnosis or condition.
• DSHS will not be billed for any part of any unit of service that has been billed to
another entity or that is eligible for reimbursement by another entity.
• DSHS will be billed for the unit of service if the patient income is justified and
When the funding source (HMO/BHO, PPO, other private insurance etc.) denies
Payment and all appeals have been exhausted.
B. Prior to receiving services, an HMO/BHO service authorization will be obtained if
the potential patient is covered under CHIP (Children’s Health Insurance Plan) or
private insurance
C. No prior authorization for DSHS and Medicaid reimbursement is required.
D. If a patient is under 19 years of age and family income is between 100% - 200%
FPIL, DSHS will be billed while a substantial effort is made to get the patient
enrolled into CHIP. Once the patient is enrolled into CHIP, the CHIP HMO/BHO
will be contracted for authorization for continued treatment.
E. If a potential patient is under 18 years of age and family income is <100% FPIL,
DSHS will be billed while a substantial effort is made to get patient enrolled into
Medicaid. Medicaid will be billed once the patient is enrolled into Medicaid.
F. Once patient is enrolled into Medicaid, Medicaid will be billed for up to the
previous 3 months of service prior to the enrollment date. Any previous Medicaid
funds collected will be returned to DSHS.
8. For adolescents, the ability to pay shall be determined by parental or family income
unless:
A. The adolescent applies for treatment without parental knowledge; and
B. The adolescent refuses to consent ot parental notification.
All employees in the billing process are responsible for conformance with this policy.
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Monthly Reconciliations
PURPOSE: To establish the official position of COADA-CB on monthly reconciliations
to be performed on all significant general ledger accounts and to assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that strict procedures will be established and
followed to guide employees in conducting reconciliations on general ledger accounts.
PROCEDURE: The following procedures provide guidance regarding the processes to be
followed in conducting monthly reconciliations.
1. Reconciliation is to be performed on a monthly basis for all significant general ledger
accounts.
2. Accounts Receivable:
A. A copy of all outstanding receivables is kept by the Finance Business Manager.
B. Run a total of all copies at the end of the month.
C. Compare tape to general ledger balance.
D. Reconcile any differences and make appropriate journal entries.
3. Accounts Payable:
A. The Finance Business Manager keeps a copy of all outstanding payables.
B. Run a total of all invoices.
C. Compare tape to general ledger balance.
4. Cash:
A. All cash accounts are reconciled as a part of the bank reconciliation procedure.
5. Reimbursements or refunds of billing errors are to be completed before the following
monthly reconciliation.
All employees who are involved in monthly reconciliations are responsible for
conformance with this policy.
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Property and Fixed Assets
PURPOSE: To establish the official position of COADA-CB on those procedures to be
followed in maintaining and monitoring the organization’s property and fixed assets and
to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that it will adhere to generally accepted
accounting principles to record the value of property and fixed assets at historical or
estimated historical costs.
PROCEDURE: The following identifies the organization’s specific procedures for
maintaining and monitoring the organization’s property and fixed assets:
1. Generally Accepted Accounting Principles require governments to record the value
of property and fixed assets at historical or estimated historical cost.
2. Historical cost is the actual cost of property and assets to the present owners.
3. All costs that are associated with the procurement of the property/assets and will be
capitalized as part of the asset value.
4. If expenditures on currently owned property or assets are for other than routine
maintenance, they extend the useful life of the asset beyond its current life, and the
amounts expended are in excess of the capitalization limit, they also should be
capitalized as part of the asset value.
5. Donated property and fixed assets should be capitalized at their current market value, if
such value is above the capitalization limit and/or has a useful life greater than five
years.
6. COADA-CB will not record salvage values on any of its property.
A. Salvage values represent a value estimate of a property/asset at the end of its
useful life.
B. Salvage values are normally used in the calculation of gains and losses when a
property/asset is retired and in the calculation of a property/asset’s depreciable
basis.
C. Salvage values are not maintained because the record information maintenance
costs exceeds the benefit derived, and because salvage values are usually
immaterial.
7. Additions to Fixed Asset:
A. Additions to fixed assets are recorded for expenditures of tangible property,
which have an expected useful life greater than one year and/or cost greater
than $1,000. These costs include the price of the base equipment, shipping
and handling charges, and modifications made to the site to prepare it to
receive the equipment.
B. All items charged to an asset account should be added to the fixed asset listing
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Including the following information:
• Asset description
• Acquisition date
• Purchase cost
• Estimated life
• Condition of the item
• Tag number
• Funding source
• Location
C. Items should be tagged upon delivery.
D. The above procedure should be repeated to process the addition of a donated asset.
E. The Finance Business Manager should obtain the same information as if the asset
had been purchased.
F. If the donor does not provide the current value, every effort should be made to
obtain comparing pricing. The value assigned should be reasonable.
G. In accordance with IRS regulations, the donor should be provided with a statement
or letter acknowledging the donation and stating the value of the donation. The
statement should be prepared by the Finance Business Manager signed by the
Executive Director
8. Disposal of fixed assets is to be communicated to the accounting employees at the time
an asset is retired for proper recording on the accounting system. Disposal can occur if:
A. An asset is sold;
B. The asset was determined to be obsolete;
C. The asset has been lost or stolen; or
D. The asset was entered in error.
9. The accounting division should be provided with a written description of the items
being disposed of including:
A. Asset description
B. Asset serial number
C. Division owner
D. Disposal date
E. Reason for disposal
F. Division or Division/Program signature
10. The fixed register will be updated to include the date of disposal.
A. Depreciation of Fixed Assets should be calculated for all capital purchases.
B. Depreciation is calculated annually.
11. Office equipment inventory process is maintained by the Finance Business Manager
and supervised by the Executive Director.
A. An office equipment inventory file shall be developed and maintained for each
office at every location of over $500 and for all new additions or subtractions.
B. All new office equipment purchases greater than $500 are added to the inventory
list of items and its corresponding value recorded.
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C. Items on the inventory list that break and are not repairable will be removed from
the list and its corresponding value will be subtracted out by the Finance Business
Manager.
12. A physical inventory will be conducted annually by the Finance Business Manager
And the results reported to the Executive Director and the Board Finance Committee.
13. All property of COADA-CB will be secured to prevent loss or theft. All major
locations have monitored alarm systems licensed by the local police department.
inventory is stored in locked closets or secure offsite storage facilities. Access to the
facilities is controlled by a reception desk during working hours; employees must log
entry and exit times.
All employees involved in monitoring and/or accountability for the organization’s fixed
assets are responsible for conformance with this policy.
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Procurement of Goods and Services
PURPOSE: To establish the official position of COADA-CB regarding the procurement
procedures to be followed for the awarding of contracts and/or the purchasing of goods
and services for the organization and to assign specific responsibility for implementation
of the policy.
POLICY: It is the policy of COADA-CB that it will follow specific procedures in all
procurement matters and will do so as a way to protect the organization’s fiscal assets.
PROCEDURES: The following processes will be followed in all procurement activities
conducted on behalf of the organization:
1. Requisition vouchers are required for all purchases.
2. Employee Purchase Request:
A. Complete a requisition voucher and report the program/grant to be charged.
B. Division/Program Managers or Business Finance Manager may approve
requisitions up to $300. The Executive Director must pre-approve requisitions
in excess of $300.
C. The appropriate division places order after the purchase has been approved.
D. Division receives goods and indicates receipt on the packing slip and the date
received, the receiving division delivers packing slip to accounting division.
E. Upon receipt of invoice in the accounting division the requisition voucher is
matched with the invoice.
F. Accounting verifies all items on the Requisition Voucher have been received
before processing payment.
Consideration will be given to the contractor/company integrity, compliance with public
policy, record of past performance and financial and technical resources in the awarding
of all purchases.
1. All purchases will be reviewed to avoid purchases of unnecessary or duplicated items.
2. An analysis of lease verses purchase alternatives will be made to determine the most
economical and practical procurement.
3. Solicitations will be made for goods and services whenever possible.
4. Solicitations will include a clear and accurate description of the technical requirements
for the material, product or service to be procured.
5. Purchases under $5,000 do not require price or rate quotations.
6. Purchases between $5,000 and $10,000 require three verbal or written price or rate
quotations. Telephone or other verbal quotations must be documented and available
for inspection.
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7. Purchases over $10,000 require three written price or rate quotations. When a written
price or rate quotations cannot be obtained due to contractor business practices, verbal
quotations may be accepted if documented in writing by the Executive Director. A
combination of Facsimiles or bulleted printed copies of electronic transmissions are
acceptable.
8. This policy does not apply to obtaining the services of a professional as defined in
Texas Government Code, Chapter 2254.
9. The cost and price analysis associated with the purchase will be documented in
the procurement files.
Professional Services/Direct Services
Contracts for professional services are obtained upon the qualifications of the provider.
Every effort will be made to bid professional services with the final selection based upon
qualifications, similar experience, references, ability to provide the service within the
specified time frame and total cost of the service provided. Awards will be base dupon
the lowest or fairest bid.
Conflict of interest
Under no circumstances will COADA-CB enter into a vender relationship with any
current patient/participant or who have received services within the preceding two years.
As a general policy, COADA-CB does not endorse the practice of entering into
transactions with family, and friends of the organization’s leadership, employees and/or
patients/participants. However, this policy recognizes that in some situations, it may be
expedient and/or advantageous for the organization to do so. In a situation similar to to
the described above, only the Executive Director may approve a transaction similar to the
transaction stated above. For clarification, no employee other than the Executive Director
of COADA-CB is authorized to accept a business transaction or enter into any binding
agreement, contract, or covenant on behalf of the organization without the express
consent of the Executive Director.
The following guideline from the U.S. Government Accounting Office provides a basis
for the organization’s policy and procedures on procurement: “The plan of organization
and methods and procedures adopted by management to ensure that resource use is
consistent with laws, regulations, and policies; that resources are safeguarded against
waste, loss, and misuse; and that reliable data are obtained, maintained, and fairly
disclosed in reports.”
All employees involved in procurement activities are responsible for strict conformance
with this policy.
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Risk Management
PURCHASE: To establish the official policy of COADA-CB on risk management and to
assign responsibility for operational implementation of the policy.
POLICY: COADA-CB is committed to long range planning to ensure service continuity
and therefore, to a formal and periodic risk management process as a way to: (1) identify
any loss exposure; (2) analyze and evaluate any loss exposures; (3) identify a strategy
that includes techniques and/or actions to be taken to mitigate/rectify any identified
exposures; (4) implement the most effective strategic actions to reduce the potential risk;
(5) provide ongoing management/governance oversight/monitoring of the efficacy of
decisions made regarding risk management/loss prevention activities to reduce risk; (6)
implement any necessary changes as may be dictated by a changing service and/or
business environment; (7) report the results of action taken to reduce risks; and (8)
include risk reduction activities in the organization’s quality assurance/performance
improvement plan as a means of continuous quality improvement. The results of the
RMA process will be incorporated into the organization’s strategic planning and budget
development process, used in the development of the annual performance improvement
plan completed, presented to and approved by the governance authority.
PROCEDURE: At least annually, the Executive Director will ensure that a formal RMA
is conducted and, that the findings of the assessment are reported to the organization’s
governance authority. At a minimum, the annual RMA process will address/answer the
following questions:
1. Does the organization anticipate significant changes in the types of patients the
organization currently serves? If “yes”, describe the impact of these anticipated
needs in terms of fiscal and human resources and the projected impact on service
delivery.
2. Does it appear that the organization’s inventory and accountability system for office
equipment , computers and other “high value” items is sufficient to protect against
loss, theft, or inappropriate use? If “no” identify a course of corrective action.
3. Does the organization’s physical plant at all clinics provide reasonable security for
patients and employees? If “no” identify improvements and/or changes needed to
rectify the problem.
4. Does the organization’s health and safety program appear effective in identifying
possible risks and hazards? If “no” list all problem areas and a plan of corrective
action.
5. Does the organization have an adequate oversight system in place to minimize the
risk of misappropriation of funds? If “no” what will the organization do to address
that situation?
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6. Does the organization’s corporate compliance program appear to be effective in
preventing fraud, waste and abuse? If “no” what changes need to be made?
7. Does it appear the organization will face increased business competition in the next
18 months? If “yes” provide an estimate as to how that competition could effect
the organization’s revenue generation efforts and patient base.
8. Does it appear that the organization has sufficient insurance coverage to protect the
organization’s assets in the event of an emergency situation?
9. Describe the organization’s most significant challenge in the next 18 months; include
an assessment of how that challenge will impact the organization and more critically,
how the organization will meet the challenge.
10. Describe any immediate action that needs to be taken to ensure the viability of the
organization.
In addition to the “global” RMA described above, the Financial Committee of the Board
of Directors meets monthly to oversee the financial status of COADA-CB. Financial
Committee includes 3 board members (1 is a CPAs by profession), COADA-CB’S
Executive Director and the Finance Business Manager. The Financial Committee the
Monday prior to month Tuesday monthly board meetings and tracks and monitors the
effects of any actions previously taken.
Other actions taken as part of the organization’s Risk Management process includes:
1. Financial Committee reviews COADA-CB budget, identifies loss exposures, analyze/
evaluate loss exposure and implements actions to be taken to minimize loss and/or
increase income.
2. The Executive Director and Finance Business Manager meet monthly to review
COADA-CB’s budgetary status;
3. Reviewing expenditures verses income;
4. Reviewing ledger accounts verses bank statements;
5. Implementing strategies and/or actions to correct actual or potential loss;
6. Finance Business Manager prepares a monthly budget; Division/Program Manager
reviews their specific monthly budget.
7. All checks written for an amount over $1,000 require two signatures (Executive
Director and an executive board member).
8. Receipts and available cash are to balance to the total amount in the fund;
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9. No one is ever to be allowed to withdraw funds without proper documentation and
authority;
10. Comprehensive periodic spot audits of the funds are conducted;
11. Annually, the Finance Business Manager and Executive Director review COADA-CB
insurance coverage requirements, ensure adequate coverage of all assets: equipment,
inventory, and buildings.
12. Each employee shall be bonded;
13. Insurance protects and defends individuals against reasonable claims due to adverse
events for which the organization is liable;
14. The organization has insurance to cover worker’s compensation;
15. The organization has vehicle liability coverage in vehicles used to transport patients/
participants;
16. The organization maintains professional liability coverage;
17. The organization’s insurance policy includes coverage for D & O omissions;
18. Coverage is provided for personal injury protection with liability coverage for each
occurrence is up to $3 million; and
19. Annually, COADA-CB Board of Directors is presented with an overview of the
insurance package for review and comment.
The Executive Director is authorized to use all available employees’ resources to conduct
the RMA and will ensure that appropriate documentation of RMA results are maintained
for future reference during accreditation surveys and meetings. The Executive Director
will ensure that discussions and decisions made by the organization’s leadership and
related to risk management activities will be documented in the meeting minutes of the
Board of Directors will be dictated by the Executive Director.
All employees involved in risk management activities are responsible for conformance
with this policy.
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Financial Accounting and Planning
PURPOSE: To establish the formal position of COADA-CB on financial planning, the
maintenance of an accounting system that will protect the organization’s assets, ensure
the fiscal integrity of all programs and services, and to assign formal responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that it will establish and maintain an accounting
system that utilizes generally accepted standards of accounting practice. Further, the
organization will engage in continuous financial planning and monitoring as a way to
insure that the organization has adequate resources to support the delivery of the highest
quality programs and services. More critically, it is the policy of COADA-CB to have a
viable financial planning process as a way to generate the revenue required to ensure the
continuity of services in the event of an unexpected budget “shortfall” or significant
change in the organizations funding streams.
PROCEDURE: The following procedures guide the organization’s efforts pertaining to
accounting and financial planning; COADA-CB will maintain a financial plan that
supports fiscal stability and includes (1) written annual budgets with creditable
projections of revenues, (2) an annual examination of the organization’s financial
statements by a certified public accountant or accounting firm not affiliated with
COADA-CB, (3) policies and procedures provisions for generating necessary revenue to
produce the desired outcomes, (4) attention to long-term financial solvency by the
organization’s leadership, (5) attention to continuity of services and (6) the identification
of action(s) to be taken if a deficit or significant financial variance occurs.
Financial budgets will be prepared annually and will reflect strategic planning needs and
resources to meet the established outcomes for persons served and the organizations
performance and goal objectives.
As part of the financial budget planning process, COADA-CB will identify and review
direct and indirect costs, revenues and expenses, internal and external reviews of
financial trends, challenges, opportunities and program trends and will do so with a goal
of insuring financial solvency of the organization. In the event that the review identifies
the potential for financial insolvency, the organization’s leadership will develop
remediation plans for review and approval by the organization’s Board of Directors.
Financial budgets will be shared with appropriate of the leadership employees and those
“line employees” who have a legitimate need to know. Similarly, actual financial results
will be reported to appropriate employees and will include a comparison of actual results
to budget expectations.
The following specific procedures guide the organization in support of this policy:
1. All program accounting is done to allocate and charge each program for the costs
associated with providing the program/services. COADA-CB does not allocate indirect
costs.
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2. Accounting System:
A. Uses a computerized system for all accounting practices. All transactions for
COADA-CB are recorded on the accounting system.
B. COADA-CB has established a chart of accounts, which allows for each program to
be directly charged for revenues and expenditures.
C. Source documents are maintained by the accounting division. Documentation
retained also includes all award documents, forms, reports and correspondence
relative to each program funded by DSHS.
D. Internal controls have been established to safeguard all assets of COADA-CB.
In setting these internal controls, the following concepts were utilized:
• Segregation of duties
• Proper authorization
• Proper recording of transactions
• Limiting access to assets
• Evaluation of progress toward objectives
E. The organization uses the accrual basis of accounting.
F. Financial statements are prepared each month and include the Balance Sheet and
the Statement of Revenues and Expenditures.
G. The Board of Directors is provided the financial statements as part of the Financial
Report at monthly Board of Directors meetings.
H. The Board of Directors has a financial subcommittee that reviews COADA-CB
budget in depth on a monthly basis.
I. The Division/Program Managers also review their division budget monthly.
3. Reporting Requirements:
A. Reports are submitted to DSHS electronically for prevention of false accounting.
B. The CMBHS automatically calculates the treatment reimbursement amount based
on the type of service documented by the counselor in the web based system.
C. CMBHS has a functionality that allows for direct submission of billing to DSHS
through use of CMBHS.
D. CMBHS has a functionality that allows for easy retrieval of data for reporting
requirements.
E. CMBHS has a functionality that calculates treatment services for non-DSHS
patients.
F. All program income is identified and recorded separately as to program generating
the income.
G. Medicaid patient billing information is submitted through the billing program
system.
H. CHIPS and private insurance patient billing information is submitted manually
using the HCFA 1500 and WB92 forms.
4. Control of Income AND Reimbursements:
A. When applicable, program income is used to offset allowable costs of the
program and/or the cash match requirement of the program.
B. If applicable, program income will be used to expand or increase program activities
or to expand objectives.
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C. Approval for program expansion will be obtained before any expansion is made.
D. Reimbursements of Federal/State funded programs will only be credited to the
program approved in the original funding grant.
E. The Board of Directors, the Executive Director, and Finance Business Manager give
attention to long-term financial solvency and to continuity of services. The
Executive Finance Committee reserves the discretionary right to collect and retain 6
months in excess cash reserves of non-dedicated funds in a secured banking
institution. Should a specific program(s) expenses exceed program income, the
money reserves may be used at the discretion of the Executive Finance Committee
to compensate for the loss of program funding.
5. Program Budgets
A. An annual budget is developed and submitted to the Board of Directors for
approval.
B. All program budgets are submitted to DSHS in a timely fashion so as to assure the
continuation of program/services.
C. Additions or changes to program budgets will be requested for the following:
• Change in service
• Change in facility/site
• Change in target population
• Change in goals or scope of service
• Change in key employee
• Change is costs, which require DSHS approval prior to expenditure.
D. Budget revisions may be requested by completing the Budget Program Adjustment
Form by a member of management or by the Executive Director. The Budget
Program Adjustment form is subject to final approval by the Executive Director.
E. Budget revisions will be approve or rejected by DSHS within 30 days of
submission.
F. All approved budget revisions will be retained and filed as part of the permanent
program file.
6. The Board of Directors, the Executive Director, and Finance Business Manager give
attention to long term financial solvency and to continuity of services.
7. Employees are trained as needed in regards to reporting, billing and coding procedures
as needed. CMBHS has a coding and billing system built within so training for billing
using CMBHS is quite minimal. Relevant new employees are provided CMBHS training.
8. The CMBHS is an automated medical record system that generates reports and billing
information directly from intervention and progress notes that are entered by counselors.
The data in CMBHS is validated and does not require a quarterly review of a
representative sample of records of the persons served to ensure that the documented
dates of service coincide with billed episodes of care and those COADA-CB bills
accurately for services
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9. An annual review is completed by an independent certified public accountant. The
Board of Directors determines if the recommended action from the independent review
will occur. One or more on the Board are CPAs so the organization benefits from
exceptional expertise in terms of financial leadership.
10. There is an internal system used for inventory and monitoring of capital equipment.
All employees involved in financial planning and accounting are responsible for
conformance with this policy.
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Employee Recruitment
PURPOSE: To establish the official position of COADA-CB on employee recruitment
and provide other relevant information and to assign specific responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that it will establish clearly articulated
guidelines for the recruitment of employee. Inherent in the policy is the expectation that
all recruiting, hiring and employment practices will consistently comply with all
applicable federal, state and local laws, rules and regulations.
PROCEDURE: The following procedures guide the organization in all aspects of
employee hiring:
1. Recruitment and Selection:
A. When an employee’s vacancy occurs (other than the Executive Director), the
Division/Program Manager or Executive Director will conduct recruitment and
selection process to identify the most qualified individual for the position. Full
consideration will be given to current employees of COADA-CB who meet the
minimum bona fide qualifications;
B. The Board of Directors, led by the President, is responsible for recruitment and
selection of the Executive Director;
C. The hiring process includes:
• Division/Program Manager will notify the Executive Director when an opening
occurs or is anticipated, and will obtain approval from the Executive Director to
proceed with the recruitment.
• Human Resources will publicly post a current job description. Available positions
will be publicly posted for a minimum of one (1) day or longer.
• Division/Program Manager conducts relevant interviews and recommends the
selection of a final candidate to the Executive Director; unless otherwise directed
by the Executive Director.
• The Executive Director shall make final hiring and salary decision for all positions
with the exception of the Executive Director in which case, the Board of Directors
will finalize this decision.
• The Executive Director may participate in the interview process as deemed
necessary.
• The Executive Director shall participate in the interview process for senior
management positions.
• Human Resources , unless otherwise directed by the Executive Director, will
review all applications/resumes to identify candidates who meet the minimum
qualifications and schedule pre-employment response questions for the
employment interview process.
• Human Resources , unless otherwise directed by the Executive Director, shall
conduct reference checks, criminal background checks, and schedule preemployment drug screens. Human Resources conducts the reference checks and
verification of any and all degrees and/or licensure.
• The Division/Program Manager will notify Human Resources regarding applicant
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job acceptance of new employment. Human Resources will complete the Status
Change Form for appropriate signatures and seek signature approval from the
Executive Director.
• Human Resources shall assemble and prepare the employee file.
2. Equal Employment Opportunity
A. COADA-CB will recruit, hire, train, compensate, and promote all persons without
Regard to race, color, gender, age, national origin, sexual orientation, religion,
handicap, veteran status, or other protected status. All aspects of recruitment and
employment will be governed on the basis of merit, competence, and qualifications
related to the requirements of the position.
B. The Executive Director of COADA-CB will:
• Ensure compliance with the equal employment opportunity policy. The Executive
Director will review recruitment, hiring, compensation, and promotion procedures
and actions as they relate to this policy.
• Communicate the equal employment opportunity policy to applicants and
employees to ensure compliance.
C. All employees, regardless of status or length of service, are required to meet and
maintain COADA-CB’s standards for job performance.
3. Employee Probationary Period:
A. New employees will serve a probationary period of 90 calendar days from the date
of hire. This period is used to determine whether the employment relationship
should continue. If the new employee is dissatisfied with COADA-CB, the
employee may leave with neither advance notice nor cause. If COADA-CB is
dissatisfied with a probationary employee, it may either extend or terminate the
relationship without explanation during the probationary period.
B. If an individual accepts employment and enters the probationary period their
employment status is contingent upon the successful passing of both the preemployment drug testing and or reference check. The Executive Director shall
determine if the results of a criminal background check interfere with position
placement.
C. The Division/Program Manager is responsible for program training and evaluation
during the probationary period.
D. The Division/Program Manager will complete a probationary status change prior to
ending of the 90-day period.
E. Upon satisfactory completion of the probationary period, new employees may move
to regular status and are subject to the annual performance evaluation process of the
agency, unless the Division/Program Manager or Executive Director direct
otherwise (e.g. extension of probationary period).
4. Immigration and Employment:
A. COADA-CB shall comply with the Immigration Reform and Control Act of 1986.
B. COADA-CB will employ only individuals entitled to work in the United States. In
complying with the Immigration Reform and Control Act of 1986, it is against
COADA-CB’s policy to discriminate because of an individual’s national origin,
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citizenship, or intent to become U.S. citizen.
C. All prospective new hires must comply by accurately completing an I-9 form. The
following procedures are applicable:
• Offers of employment to an applicant must be contingent upon the applicant’s
producing the proper documentation prior to the first day of employment.
• Human Resources is responsible for examining the new hire’s documents to
ensure they are genuine. Human Resources will complete the employer section of
the I-9 form in ink.
• If a prospective employee cannot provide adequate documentation within 48 hours
to comply with the law, the individual will not be hired.
5.Human Resources Records and Privacy:
A. The information contained in human resources records shall be managed to achieve
accuracy, privacy, and legal compliance.
B. Human Resources employee files of COADA-CB are the sole property of COADACB and will be restricted to access by the Executive Director, the Human Resources
staff, the employee’s Division/Program Manager, on a “need-to-know” basis. The
employee may access his/her own file during regular business hours with written
explanation and pre-approval. The records cannot be removed from the Human
Resources files and/or offices for purposes other than copying documents within
those files.
C. Outside requests for information from COADA-CB’s human resources files,
including requests for references for current or former employees will be directed to
Human Resources. Information requests for references will be limited to the dates
of employment and job title. In addition, salary information can be verified through
requisitioned information No other information will be given without a written
release signed by the employee.
D. Employees or former employees can authorize, in writing, the release of salary, job
chronology, and performance information.
• COADA-CB, the Executive Director, will cooperate with federal, state, or local
agencies performing investigatory or monitoring functions. COADA-CB will
cooperate with personal investigators to the extent which they are entitled by law.
• Human resources records will be maintained in human resources files and kept
locked. These records will be kept accurate and current.
6. Nepotism:
A. Only one of a related family or extended family (by blood, marriage, or adoption)
system may be eligible for employment at COADA-CB unless special authorization
has been obtained in advance from the Executive Director.
B. Under no circumstances can two related or extended of family work for each other
or report to the same Division/Program Manager.
7. Political Activities:
A. Employees of non-profit organizations are restricted from certain political activities
by Federal and State laws.
B. COADA-CB will abide by regulations governing specific activities of non-profit
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organizations.
C. Each employee is to check with his/her Division/Program Manager before engaging
in any political activity.
D. These laws do not affect an employee’s:
• Right to vote;
• Right as a private citizen to express personal opinions on all political subjects or
candidates; or
• Right to participate in campaigning for a candidate; if the employee so desires,
providing it does not interfere with the job and that campaign buttons, T-shirts,
posters, etc., are not displayed at work.
E. An employee may not:
• Use the official capacity of his/her position or influence for the purpose of
interfering with or affecting the result of an election or nomination for office.
• Directly or indirectly coerce, attempt to coerce, command, or advise a Board
member, officer, or employee to pay, lend, or contribute anything of value to a
party committee, organization, agency, or person for political purpose.
All employees involved in the recruitment, hiring and/or employment of employees are
responsible for conformance with this policy.
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Criminal Background Checks
PURPOSE: To establish the official position of COADA-CB on criminal background
checks and to assign formal responsibility for implementation of the policy.
POLICY: COADA- CB will conduct pre-employment and annual background checks on
all employees, practicum students, interns and sub-contractors. Background checks will
be conducted on volunteers in accordance with federal and state law and the requirements
of DSHS contracts.
PROCEDURE: When a person is processed for employment or internship with COADACB a criminal background check will be conducted by human resources through Texas
Department of Public Safety and the Federal Bureau of Investigation. Human Resources
is responsible for the scheduling of criminal background checks. A person who
volunteers to provides services with COADA-CB shall submit to a criminal background
check in accordance with federal and state laws and the requirements of the DSHS
contract in which the person volunteers services for.
1. Pre-employment Criminal Background Checks:
A. A criminal background check will be conducted on all COADA-CB employees
regardless of the position in which they are being hired for.
B. New employees may not provide services to patients/participants until the results of
the criminal background checks have been reviewed by the Executive Director and
Human Resources.
C. The Executive Director and Human Resources will determine if the results of the
criminal background check contain criminal history that would prohibit the
employee from providing services to patients/participants in accordance with
applicable federal and state laws and DSHS contracts.
D. Individuals who are on parole or probation are prohibited from providing services to
patients/participants and their families.
E. Results of criminal background checks will be stored in a separate file from the
employee’s personnel file and may be reviewed by authorized personnel only.
F. Documentation that the criminal background check was reviewed and that the
employee is not prohibited from providing services to patients/participants will be
placed in the personnel file of the employee.
2. Annual Criminal Background Checks:
A. Annual criminal background checks will be conducted on all COADA-CB
employees regardless of their position in which they are employed.
B. The criminal background check will be reviewed by the Executive Director and
Human Resources to determine if any changes have occurred.
C. Documentation that the criminal background check was reviewed and that the
individual is not prohibited from providing services to patients/participants will be
placed in the personnel file of the individual.
3. Practicum Students, Interns, Volunteers and Sub Contractors:
A. Practicum Students and Interns who provide services at COADA-CB will adhere to
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the same requirement regarding criminal background checks as employees of
COADA-CB.
B. Individuals who volunteer to provide services to COADA-CB will have criminal
background checks conducted as required by federal and state laws and the
requirements of the DSHS contract for the program they are providing volunteer
services for.
C. Individuals who are contracted by COADA-CB to provide services that have access
to patients/participants and/or their families will adhere to the same criminal
background check requirements as employees of COADA-CB.
D. The Executive Director and Human Resources will determine if the results of the
Criminal background check contain criminal history that would prohibit the
employee from providing services to patients/participants in accordance with
applicable federal and state laws and DSHS contracts.
E. Individuals who are on parole or probation are prohibited from providing services to
patients/participants and their families.
F. Results of criminal background checks will be stored in a separate file from the
individual’s personnel file and may be reviewed by authorized personnel only.
G. Documentation that the criminal background check was reviewed and that the
individual is not prohibited from providing services to patients/participants will be
placed in the personnel file of the individual.
4. Requirement to notify COADA-CB of law violations and/or criminal investigations:
A. All employees, practicum students, interns, volunteers and sub contractors of
COADA-CB are required to immediately notify their immediate supervisor of any
law violations and/or criminal investigations. The Executive Director shall
immediately notify the Board of Directors of any law violations and/or criminal
investigations in which the Executive Director is involved in.
B. The Executive Director and Human Resources shall determine in accordance with
federal and state laws and the requirements of DSHS contracts if the individual
shall be prohibited from providing services to patients/participants and their
families.
C. Documents of law violations and/or criminal investigations will be kept on file and
May be reviewed by authorized personnel.
5. On parole, probation or under criminal investigation:
A. Any employee, practicum student, intern or sub contractor of COADA-CB who is
placed on probation or is a subject of a criminal investigation will be prohibited
from providing services to patients/participants and/or their families.
B. Any employee, practicum student, intern or sub contractor of COADA-CB who is
placed on probation or is a subject of a criminal investigation may be assigned to
administrative duties, placed on administrative leave with or without pay or
terminated.
C. Documents of probation and/or criminal investigations will be kept on file and may
be reviewed by authorized personnel.
All employees, practicum students, interns, sub contractors and volunteers of COADACB are responsible for conformance with this policy.
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Hiring Practices
PURPOSE: To establish the official position of COADA-CB on the hiring of employees
and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization will adhere to generally
accepted standards of human resource policy and all applicable law, rule or regulation in
the hiring of new employees.
PROCEDURE: The following guidelines represent the organization’s procedures as they
pertain to the hiring of new employees:
1. In regards to organizational structure and employee’s responsibilities, COADA-CB
shall:
A. Maintain a current organizational chart;
B. Have a written job description for each employee, volunteer, and student worker
position, which describes in specific terms;
C. Identify job expectations (duties and responsibilities);
D. Conform with Fail Labor Standards Act(FLSA) (exempt/nonexempt);
E. List positions supervised;
F. Define job qualifications(minimum), including:
• Level of education;
• Training, and;
• Related work experience.
G. Complete routine dated reviews; and
H. Ensure that individual employees are provided a copy of job description,
information regarding insurance coverage, information about personal risks and
liabilities with the position, and have access to a copy of COADA-CB’s policy
and procedure manual.
2. COADA-CB will maintain standard definitions of employment status and will classify
employees for the purpose of human resources administration and related payroll
transactions in accordance with the following definitions:
A. Employee: A person who receives wages or salaries from COADA-CB.
B. Regular Employee: Employee who has satisfactory completed his/her probationary
period and is employed for an indefinite period. Regular employees will accrue
vacation and sick time starting on their first day of hire and be offered a fiscal
annual performance evaluation by their Division/Program Manager.
C. Probationary Employee: New employee (with less than 90 days of employment
COADA-CB) who has not yet completed his/her probationary period.
D. Temporary Employee: Employee who is assigned with a specific duration. The
employee may be full or part time. Temporary employees are not entitled to
benefits or to the grievance process.
E. Regular Full-Time Employee: Employee routinely scheduled to work 40 hours per
week.
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F. Regular Part-Time Employee: Employee routinely scheduled to work more than 20
hours, but less than 40 hours per week. A regular part time employee who works an
average of 32 hours or more per week is eligible to receive and participate in health,
dental, vision, disability and life insurance benefits.
G. Limited Part-Time Employee: Employee who is routinely scheduled to work 20
hours or less per week. A limited part time employee is not entitled to benefits.
H. Non-Exempt Employee: Employee whose position is not exempt from the FLSA.
employee is subject to overtime payments for hours worked over 40 hours in a
week.
I. Exempt Employee: Employee whose position is exempt from the FLSA. Employee
is not subject to overtime payments for hours worked over 40hours in a week.
Pre-approved flex time may be offered under special circumstances and approved
by the Executive Director.
J. Standard work week: Shall be defined as 40 hours within a seven day period
(Sunday through Saturday).
K. Probationary Period: The first 90 days of employment with COADA-CB; during
which time the employee’s job performance will be evaluated. Borderline job
performance may result in an extended probationary period for the employee or
termination.
L. Contractor: Independent contractor status.
3. COADA-CB shall have written agreements with outside agencies and individuals who
provide chemical dependency treatment services on a regular basis.
A. Outside agencies and individuals include:
• Consultants;
• Contract providers; and
• Other entities providing services required by the DSHS License Rules.
B. Written agreements shall contain:
• Job descriptions; including duties and responsibilities; and
• Minimum qualifications required including education , training, and related work
experience.
4. In regards to hiring practices for employees, COADA-CB:
A. Hire applicants who meet no less than the minimum qualifications listed in the
job description and that is in compliance with DSHS Chapters 444, 448, and 450.
B. Obtain and maintain applications and/or resumes that document required education,
training, and related work experience.
C. Verify the current status of all required credentials with the credentialing authority
by phone or letter with documentation being placed in employee file.
D. Develop/Implement an employment screening procedure for all employees which
shall:
• Be appropriate for each person’s level of access;
• Document the background and suitability of any employee with access to
patients/participants of funds including job reference; and
• Adequately protect the patients/participants and financial resources.
E. Comply with all applicable laws; including The Texas Civil Practice and Remedies
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Code, 81.003; specific with employment reference checks.
F. Provide a timely orientation of all new employees.
5. Perform periodic assessment of the training needs of all employees and develop
activities/resources based on the needs identified.
6. Provide competency-based training to direct service employees that reflects the
specific needs or persons served; clinical skills appropriate to the position, individual
plan development, and interviewing skills approaches.
7. Volunteers and student workers having contact with patients/participants:
A. Are supervised;
B. Are provided with a written lists of the qualifications required for their job
specifications pr assignments;
C. Meet the qualifications comparable to employees if they are providing professional
Services;
D. Are provided with information regarding insurance coverage or lack of insurance
coverage;
E. Are informed about any personal risks and liabilities;
F. Receive the same orientation and pre-employment screen/checklist as employees of
COADA-CB.
8. Employees hired by COADA-CB, in accordance with COADA-CB Policies and
Procedures Manual, and shall be:
A. Subject to COADA-CB initial probationary period, disciplinary action, and
procedures for employment, promotion, and termination.
B. Evaluated at the end of the probationary period, and annually, thereafter, as to
Job performance; with documentation of such being in their employee file.
C. Provided opportunities for approved education, training, and workshops as well
as travel and general expenses.
All employees involved in the hiring of new employees are responsible for conforming to
this policy.
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Employee Records
PURPOSE: The purpose of this policy is to establish the official position of COADA-CB
on employee records and content, and to assign specific responsibility for implementation
of the policy.
POLICY: COADA-CB recognizes that employee records are an important part of
employee administration and management and, that current records are needed with
regard to pay, deductions, benefits, and other employee matters. Therefore, it is the
policy of COADA-CB that an employee record will be established immediately for every
new employee hired by the organization. For clarification, this policy applies to all
regular employees of COADA-CB as well as all contract employees such as physicians,
pharmacists, security employees, etc. Further, all employee records will be maintained in
accordance with the procedures outlined in his policy.
PROCEDURES: The following procedures pertain to the establishment and maintenance
of employee records:
Required Contents of Employee Files at a minimum, all Employee files will contain:
1. Employment application and resume;
2. Verification of credentials, including certification and/or licensure as applicable;
3. Evidence of orientation;
4. Performance evaluations/appraisals;
5. Criminal background checks, when applicable;
6. Documentation of pre-employment drug test results;
7. Other items/documents required by Texas law.
Changes in Employee Information/Data
All employees are responsible for ensuring that their employee record is updated when
changes occur:
1. Legal Name;
2. Home Address;
3. Home telephone number;
4. Person to call in case of emergency;
5. Number of dependents;
6. Marital Status;
7. Exemptions on W-4 tax form;
8. Training certificates (new certificates awarded/earned); and
9. Professional credentials (licenses and/or certifications).
Employee original records will be centrally maintained for all employees. At all times,
employee records will be afforded the maximum degree of protection from inadvertent
loss, compromise and disclosure. This includes a specific prohibition on the release of
any information contained in the record to any person – by telephone or any other means
– without the express written consent of the employee. Therefore, access to employee
files will be on a strict “need to know” basis.
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Under the supervision of the Executive Director, the Human Resource Division is
responsible for the overall administration of this policy. Division/Program Managers are
responsible for day-to-day conformance with this policy. All employees are responsible
for ensuring that their employee records are current and up to date at all times.
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Employee Files and Training Records
PURPOSE: To establish the official position of COADA-CB on the establishment and
maintenance of employee files and training records on employees and to assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization will maintain a current
employee file on each employee, volunteer, and student worker which includes
documentation verifying that employees are qualified, trained, and supervised as needed
to perform assigned duties.
PROCEDURES: The following procedures will guide the development and maintenance
of employee files and training records for employees:
An employee file for each employees and student worker shall be current and include the
following:
1. Current job description are signed by employee;
2. Application and/or resume with documentation of required qualifications;
3. Documentation that required credentials were verified;
A. Documentation of criminal background check by the Department of Public Safety;
B. Documentation of pre-employment drug test results; and
C. Verification of prior employment.
4. Documentation of initial and other required training as specified by COADA-CB and
in compliance with DSHS standard;
5. Status change documentation after 90 days to indicate:
A. Cessation of an employee’s probationary period;
B. A need to extend an employee’s probationary period;
C. A need to reassign duties or position of employee; or
D. A need to terminate employee.
6. Performance evaluations and letters of recognition;
7. Documentation of any disciplinary action;
8. Documentation of training to include:
A. Date;
B. Number of hours;
C. Title;
D. Instructor’s name and qualification/credentials;
E. Signature of instructor (or equivalent verification); and
F. Name of the person who received the training;
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9. Employee data that includes:
A. Date hired;
B. Personal data such as address, phone, date of birth;
C. Rate of pay;
D. Documentation of all pay increases and bonuses.
E. Date of termination, including voluntary or involuntary termination;
F. Payroll records such as W-4 tax form, direct deposit authorization, an so forth; and
G. Employee agreements.
All clinical documentation or information involving health status condition provided by
a employees, volunteer, or student worker shall be treated as confidential and private
information as required by law.
1. Health information shall be kept in a secure file separate from personnel records.
2. Disclosure or re-disclosure of this information without the employees knowledge and
consent, except as provided by law in the Communicable Disease Prevention and
Control Act, shall be prohibited.
3. Inactive employee files must be maintained as follows:
A. A list of COADA-CB previous employees will be kept on file for at least 5 years
and will include: name, age, social security number, position held, and dates of
employment.
B. Employee files are kept for at least two years after the employee stops working for
COADA-CB. Documentation of patient/ participant/patient abuse, neglect, and
exploitation, including unethical and illegal behavior is maintained for at least five
years.
All employees are responsible for conformance with this policy.
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New Employee Orientation
PURPOSE: To establish the official position of COADA-CB on new employee
orientation and to assign specific responsibility for implementation of the policy.
POLICY: COADA-CB recognizes that new employee orientation is a critical step in
helping employees adjusts to the demands of working in a new and different
environment. Further, the orientation process provides an opportunity to acquaint new
employees with co-workers, facilities, and critical policies and procedures. Therefore, it
is the policy of COADA-CB that all new employees will participate in the new employee
orientation process. Within 30 days of beginning employment or in accordance with
Texas state regulations, all employees of COADA-CB will familiarize themselves with
the organization’s policies and procedures; and, sign a statement acknowledging that they
have read and agree to abide by all organizational policies and procedures.
PROCEDURES: New employee orientation will include, at a minimum:
1. An introduction to co-workers;
2. A tour of COADA-CB’s facilities;
3. An overview of COADA-CB “chain of command” and management and
Division/Program Manager relationships;
4. A discussion of the organization’s insurance coverage and any personal risks and
liabilities associated with the job;
5. An overview of the organization’s health and safety program;
6. An introduction to the organization’s corporate compliance program;
7. An overview of specific job duties and responsibilities and hours of work;
8. The availability of a copy of the organization’s Policy and Procedures Manual;
9. An overview of requirements as related to HIPAA and 42 CFR Part 2; and
10. An opportunity to have questions answered by the Division Manager.
In the event that the state licensing/regulatory authority dictates that additional topics be
covered as part of new employee orientation, COADA-CB will defer to such authority
and include any additional items so mandated in the initial orientation.
The new employee orientation process may also include, at the discretion of management
employees, a requirement to view selected video recordings or to complete assigned
readings on topics pertaining to the treatment of addictive disorders.
All management employees are responsible for conformance with this policy.
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Primary Source Verification of Employees Credentials
PURPOSE: To establish the official position of COADA-CB on verification of
credentials of professional employees and to assign formal responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that all professional employees will be
appropriately credentialed, i.e., licensed or certified by a recognized credentialing
organization. For purposes of this policy, “professional employees” are those employees
who provide direct services to patients/participants and who are required by federal, state
or local law to have either a license or certification as a condition for providing such
services or may provide such services by virtue of holding an academic degree
recognized by the state in which they work. Further, it is the policy of COADA-CB that
all employees’ credentials will be verified through a primary source verification process
as a way to protect patients/participants, provide the highest quality treatment services
and minimizes the organization’s potential for legal liability.
PROCEDURE: Primary source verification requires that COADA-CB verify the status
of employees credentials through direct communication with the primary source of such
credentials or degree, i.e., the licensure and/or certification body responsible for issuing
the credential or the issuing educational institution. Such verification is conducted to
ensure that: (1) all licenses/certifications held by professional employees are current; and
(2) that no administrative actions – including licensure/certification revocation – have
been initiated and/or are pending against the employee and that academic degrees are
legitimate.
Each professional employee will submit to formal verification of his/her degree and/or
licensure/certification as a condition of employment. At the time of initial employment –
or when credentials are first earned – Human Resources will initiate the primary source
verification process. Primary source verification may include any of the following three
actions: (1) mailing/forwarding of a completed Primary Source Verification Form to the
responsible credentialing organization; (2) a telephone call to the credentialing
organization; or (3) Internet search. Regardless of the method used to verify the
employee credentials, all documentation is placed in the personnel records. It is
emphasized that primary source verification needs to be conducted at the time of initial
hiring. For subsequent verification, i.e., when licenses or certifications are renewed
and/or during annual employee evaluations, Human Resources is authorized to obtain
photocopies of employee’s licenses and certifications directly from the employee and
without verifying the credentials with the responsible credentialing organization. Such
copies must also be maintained on file in employee records.
In the event that verification process reveals negative information about an employee,
Human Resources is responsible for discussing the information with the Executive
Director so that a plan of action – consistent with the organization’s employee policies –
can be developed and implemented.
All Division/Program Managers are responsible for conformance with this policy.
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Employee Classification and Payment
PURPOSE: To establish the official position of COADA-CB on the organization’s
employee classification and payment system and to assign specific responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that it will maintain an employee classification
and payment system that is consistent with state, local and federal laws and all applicable
rules and regulations.
PROCEDURE: The following guidelines apply to the organization’s employee
classification and payment system:
Exempt/Non-Exempt Classification; COADA-CB will classify its positions according to
the definitions of exempt and non-exempt employees to comply with the provisions of
the Fair Labor Standards Act (FLSA).
1. Exempt: Management, supervisory, professional, and administrative employees whose
positions meet specific tests established by the FLSA and are exempt from overtime pay
requirements.
2. Non-Exempt: Employees whose positions do not meet the exemption tests and who are
paid time-and-one-half for hours worked in excess of 40 hours in one work week.
Employment Positions:
1. Job descriptions and other appropriate information will be maintained for each
COADA-CB position. These positions and descriptions will be updated periodically by
the Human Resource Department, reviewed for accuracy by the Division/Program
Managers and approved by the Executive Director.
2. Each position at COADA-CB has been placed in a category with a salary range to
group level of responsibilities and to establish the value of the positions in relation to
other positions in the organization. Salary ranges for position levels will be reviewed
periodically by the Executive Committee of the Board of Directors.
3. Salary decisions for new hires will be based on qualifications and experience as
approved by the Executive Director.
4. Reclassification includes promotions and demotions. The Executive Director must
authorize all reclassifications.
A. Promotion: Involves a distinct increase in job responsibilities and a change in job
duties. Promotions are generally accompanied by an increase in salary; based on
the acceptance of greater responsibility.
B. Demotion: Involves a reduction in job responsibilities, position, and/or salary and
occurs when the employee would otherwise be laid off because a position has been
abolished, reclassified, loses funding, or when an employee cannot perform in
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his/her current position, but could perform satisfactorily in a different position.
C. Reclassification: There may be times that positions will be reclassified due to
service needs, agency needs, and job responsibilities. If the person filling the
original job position is qualified to assume responsibilities of the reclassified
position, they may be offered the chance to apply. If an employee is able to meet
the new qualifications in predetermined time, consideration for position will be
given. If the salary has been reduced or increased, the reclassified individual would
receive the new salary. The Executive Director shall approve all reclassifications.
Should the individual not fit the new reclassified position, he/she would be able to
apply for any other openings available within the organization. If no appropriate
position is available, the individual’s position may be phased out with employment
status being terminated.
Paydays:
1. COADA-CB shall have pay periods and paydays in order to administer the payment
of wages, salaries, and overtime.
2. Employees of COADA-CB will be paid on a semi-monthly basis:
A. Employees are paid on the 15th and the last day of each month. When the 15th or the
last day of the month falls on a Saturday, Sunday, or a Legal Holiday, the payday
will be the last regular workday before the above mentioned date.
B. Each employee is responsible for reporting changes in payroll status by 10:00 a.m.
three (3) prior to the payroll dates. Accounting will not process any payroll changes
unless the required paperwork is accurate and complete. Failure to turn in
timesheets and other required paperwork may result in delay of paychecks.
C. All timesheets are due on predetermined dates preceding the payday with correct
signatures, hours worked, grant allocations, semi-monthly activity reports, and
leave requests signed and approved with appropriate signatures.
D. It is the responsibility of the Finance Business Manager to communicate with the
payroll service center the earnings reported by each employee for each pay period.
E. It is the responsibility of each employee to accurately report cost allocations on each
time activity sheet and to ensure all supporting forms are attached as necessary.
The Division/Program Manager will approve the time activity sheet with a signature
after careful review of accurate reporting by the employee. The Executive Director
signature will then be obtained and turned into the Finance Business Manager for
processing.
F. Leave without pay is discouraged and will only be approved by Executive Director
for medical or critical incidents. Actual or anticipated leave without pay or other
salary changes must be pre approved by the Division/Program Manager three (3)
days prior to payday. Each Division/Program Manager is responsible for reporting
any actual or anticipated leave without pay or any salary changes of an employee to
the Finance Business Manager and the Executive Director. Untimely notification of
leave without pay or salary changes will necessitate a change of amount on
employee’s check at a later date.
G Failure to turn accurate timesheets will result in progressive written discipline
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leading up to and including termination.
Overtime:
1. Non-Exempt Employees:
A. Overtime pay will be paid only to employees who meet the non-exempt status as
established by the FLSA. Non-exempt employees will be paid time-and-one-half
for hours worked in excess of 40 hours per workweek. To receive overtime pay,
prior authorization must be obtained from the Division/Program Manager or the
Executive Director for the overtime.
B. Normally, overtime will only be approved:
• When necessary to cope with emergencies, such as those resulting from accident,
natural disasters, breakdowns of equipment, or occasional operational bottlenecks
of a sporadic nature;
• When employees are performing indirect functions such as administration,
maintenance or accounting;
• In the performance of tests, trainings or other similar operations which are
continuous in nature and cannot be reasonably interrupted or otherwise
completed;
• When a lower overall cost to the funding agency will result.
2. Exempt Employees:
A. Exempt employees are not entitled to overtime pay. Exempt employees are
expected to work the hours required to complete their tasks without additional
compensation. The recognized workweek begins at 12:00 am on Sunday morning
and ends at 11:59 pm on Saturday night. All hours worked must be recorded on the
employee time and activity report and approved by the Division/Program Manager
and/or Executive Director.
B. Flextime approval: Employees are required to obtain approval from their
Division/Program Manager prior to the award of flextime. Employees who
anticipate the need to work beyond their scheduled hours must notify the
Division/Program Manager in advance and obtain written approval prior to working
the hours that extend beyond their normal schedule.
C. Employees who fail to obtain approval prior to working hours that extend beyond
their normal 40 hour workweek and then later request the flex time approved time
off will be subject to disciplinary action. Repeated offenses may result in
termination.
Honoraria for Professional Services:
1. Employees shall not be paid any additional fees by outside sources for services
rendered while representing the agency and performing duties in connection with their
job or carrying out the mission of COADA-CB. In the event that honoraria or fees for
service are paid, they shall be remitted to COADA-CB with recognition of the providing
agency. Employees should exercise extreme care and caution to indicate when they are
and when they are not representing the agency in both counseling and carrying out
professional obligations at all times. Extreme care and caution should be made to let
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people know in which context they are expressing an opinion or offering professional
advice or otherwise.
2. Honoraria for professional services fees may be paid to local individuals who, from
time to time, provide COADA-CB with a specialized service or training. All speakers,
presenters, trainers, whether paid a fee or not, are to be cleared in advance with the
Executive Director.
3. COADA-CB will allow assistance from organizations to provide a variety of activities
for the community. If financial assistance is given by an outside organization for one of
these activities, credit will only be given to the supporting organization in the form of a
letter stating the financial assistance that was paid.
The Executive Director may or may not approve the reimbursement of State Of Texas
Certification/Recertification/Licensing/Relicensing Fee at any time.
All employees are responsible for conformance with this policy.
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ATTENDANCE, LEAVE AND TIME OFF
PURPOSE: To establish the official position of COADA-CB on employee attendance,
leave and time off, and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization will establish and adhere
to an employee system that provides specific guidelines pertaining to employee
attendance leave and time off. The guidelines will be in full compliance with all
applicable laws, codes, rules and regulations pertaining to such matters.
PROCEDURE: The following specific guidelines govern the organization’s practices
regarding attendance, leave and time off:
Attendance and Time Off:
1. COADA-CB agency will be open for normal work hours from 8:00 a.m. to 8:00 p.m.
Monday through Thursday and 8:00 am through 5:00 pm on Friday except on authorized
holidays. The workweek is defined as Sunday through Saturday.
2. Employees receive a one-hour lunch period each day, which should be scheduled
between 11:00 a.m. and 2:00 p.m. Employees scheduled to work 11:30 a.m. until 8:30
p.m. will receive their lunch period between 2:30 and 5:30 p.m. An employee may not
work through lunch and leave early, unless the Division Manager gives prior approval for
a specific day.
3. Each employee will arrange an individual work schedule with his or her
Division/Program Manager, which must be approved by the Division/Program Manager.
When arranging individual work hours, the Division/Program Manager will take into
consideration the needs of the division. It may not always be possible to accommodate
each employee. Changes in regular work schedules must be approved in memo form by
the Division/Program Manager for prior approval.
4. For an occupationally incurred injury or illness, time spent by an employee waiting for
and receiving emergency medical attention during the employee’s normal working hours
constitutes hours “excused” and will be paid for a normal workday.
5. All employees are required to record their daily attendance on timesheets and
document their absence by the type of leave. The timesheets are to be given to the
Division Manager for approval three days prior to payday. Division/Program Managers
are required to submit employee timesheets to the Finance Business Manager no later
than 10:00 a.m. three days prior to payday.
6. With Division/Program Manager approval, the employee’s routine work hours may be
changed if his/her responsibilities involve a structured, routine variance from regular
work hours. For example, if an employee teaches a structured counseling class one night
every week, his/her Division/Program Manager may decide to amend the work schedule
for that employee on the designated day.
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7. Flex time is only allowed with prior written approval. Prior to working extra hours
that may influence flex time; a written prior approval for flextime must be obtained from
the employee’s Division/Program Manager or Executive Director. The employee will not
be allowed flextime if they work extra hours and then seek written approval for flex time.
Prior flextime authorization documentation is to be filed with the employee’s time
activity report.
Absenteeism and Tardiness:
1. Every employee has the responsibility to maintain a good attendance record and to be
on time. Employees are expected to be conscientious in the performance of their job
responsibilities.
2. Division/Program Managers exercise the primary management-level responsibility for
control of employee attendance. Employee absence and/or tardiness are undesirable
performance factors and will be managed by Division/Program Managers in accordance
with the procedures listed below.
3. The employee may be terminated or considered to have resigned after three
consecutive workday absences without notice to COADA-CB. Reinstatement may occur
only if exceptional circumstances explain why the employee could not notify COADACB of the reason for absence.
4. Definitions:
A. Absence: An absence from work during scheduled working hours (including
scheduled work activities outside the basic work hours), excluding approved
absence for vacation, Personal/Floater Leave, Sick Leave, and bereavement leave.
B. Tardiness: Being late for work, including scheduled work activities outside the
basic work hours. Regular or frequent tardiness is not an acceptable level of
attendance and is subject to disciplinary action and or termination.
C. Leaving Early: Leaving early during scheduled work hours, including a scheduled
work activity outside basic working hours, or ending work prior to the end of the
work period.
5. Employees will request pre-approval from their Division/Program Manager, when
possible, of an absence through submission of an Employee Leave Request form for the
Division/Program Manager’s signature. As much notice as possible is requested from the
employee.
6. If advance notice is not possible, the employee should notify his/her Division/Program
Manager directly, by phone. If the immediate Division/Program Manager is not
available, the employee should then speak, directly, with the Executive Director.
7. Notification calls should be made as early as possible to enable the employee’s
Division/Program Manager time to find coverage for the employee’s job responsibilities.
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At the latest, notification calls may be made within one hour following the start of the
employee’s assigned work period.
8. Employees are required to maintain contact for any period of absence beyond one day,
unless the employee has provided a doctor’s certification covering a specified period.
Frequency of contact between the employee and the Division/Program Manager will be a
minimum of once a day.
9. Division/Program Managers are responsible for regularly reviewing their employees’
daily attendance records and identifying chronic attendance and tardiness problems.
10. Division/Program Managers should address problems with absence, tardiness, or
leaving early with the employees as occasions occur. Division/Program Managers will
also review attendance records as part of the performance appraisal process.
11. Chronic absenteeism, tardiness, or other unusual infractions of the attendance
standards will be handled in accordance with employee discipline.
Vacation:
1. Employees accrue vacation time beginning on the first day of employment and ending
the last day on employment. Regular full-time employees of COADA-CB are entitled to
accrue vacation based on the employment anniversary date.
A. Accrued vacation is the amount of vacation an employee has earned at the end of
each month of employment.
B. Expected vacation is the amount of vacation an employee will earn by the end of the
fiscal year. Employees may proportion his/her vacation time in four hour
increments throughout the year but is subject to the approval of the
Division/Program Manager and or the Executive Director.
C. Exceptions to vacation earned are:
• Employee is not eligible to take vacation time during their 90 day probation
period. This may not apply to employees rehired with less than a six month break
in service if approved by the Executive Director or a designate.
• If an employee does not complete the 90 day probationary period to the
satisfaction of the Division/Program Manager or Executive Director, all vacation
time is lost.
• If the 90 day probationary period is extended and the employee does not
complete
the extended probationary period to the satisfaction of the Division/Program
Manager or Executive Director, all vacation time is lost.
• If an employee resigns or is terminated from employment during the initial 90day probationary period, all vacation time is lost.
• If an employee resigns or is terminated from employment during the extended
probationary period beyond the 90 days, all vacation time is lost.
2. Vacation leave is accrued, on a monthly basis, as follows:
A. Less than three years of completed employment: Full-time employees will accrue
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12 full vacation days per year at the rate of 8 hours per month.
B. More than three years of completed employment: Vacation will increase to 15 days
per year once the full-time employee has completed three years of employment and
will accrue at a rate of 10 hours per month.
C. Six years of completed employment: Vacation will increase to 20 days per year
once the full-time employee has completed six years of employment and will accrue
at a rate of 13.34 hours per month.
D. The Executive Director is entitled to 160 hours or 20 days of vacation days per year.
3. Accrued vacation time may be taken upon prior written notice and approval by the
employee’s Division/Program Manager. Vacation time must accommodate COADACB’s program needs and the Executive Director makes final approval or rejection. The
Executive Director reserves the right to change vacation schedules as needed with as
much prior notice to the employee as possible.
4. Holidays that occur during an employee’s vacation time will not count as part of
vacation time taken.
5. Unless approved by the Executive Director in writing, unused vacation time carried
over from fiscal year to fiscal year may not exceed 40 hours.
6. COADA-CB will not reimburse for lost vacation time due to carry over limitations. In
rare or unusual situations, COADA-CB may purchase the vacation time from the
employee if both the Executive Director and the employee have a written mutual
agreement.
7. An employee who resigns, is dismissed, or separated from COADA-CB’s employment
shall be entitled to be paid for all unused, accrued vacation as long as the separation does
not involve theft or gross misconduct from the agency. Payment is calculated on the
basis of the employee’s salary at the time of separation. If an employee uses vacation
that he/she has not yet accrued and his/her employment is terminated with the agency for
any reason, the employee must pay the agency for any vacation taken but not actually
accrued. The agency may deduct this amount from the employee’s final paycheck.
8. If any employee dies while employed by COADA-CB, a lump sum payment of all
unused, accrued vacation leave will be made to the employee’s estate. Payment will be
calculated on the basis of the employee’s salary at the time of death.
9. Vacation must be taken in a minimum of four-hour increments.
10. The scheduling of vacation leave is not automatic and must be approved by the
employee’s Division/Program Manager. The Executive Director must approve leave
time for over one week (five days) period. The needs of the agency during the requested
vacation period will be the primary consideration in approving or disapproving a vacation
request. Vacation requests will be submitted on an Employee Leave Request form. The
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immediate Division/Program Manager must make arrangements for coverage of duties
during employee’s absence.
11. Requests, particularly for more than one day, should be submitted at least two weeks
in advance. In extenuating circumstances and when substitutes for the employee’s work
responsibilities can be scheduled, the Division/Program Manager or Executive Director
may approve vacation leave time without the two week required notice.
12. The Finance Business Manager will be responsible for recording vacation leave
eligibility used in COADA-CB’s payroll records. The Billing Coordinator will be
responsible for recording vacation time accrued, spent vacation time, as well as changing
vacation eligibility in the agency financial records.
13. Pay for scheduled vacation leave will be in accordance with the regular pay schedule.
14. In the case of a break in service due to termination or lay off of not more than six (6)
months, employees shall go back to the original date of hire for determining the extent of
the vacation accrual. Under no circumstances will vacation accrue during a break in
service. With approval of the Executive Director or a designate, the employee may not
need to complete the 90 day probation period in order to use accrued vacation.
15. An employee rehired by COADA-CB with after a break of six (6) months or longer
will be rehired as a new employee with a new employee hire date.
Holidays
1. All full-time employees of COADA-CB are eligible for thirteen (13) holidays plus two
personal days per year. Regular part-time employees are eligible for holidays with pay if
their regularly scheduled working hours and days include the holiday. Regular part-time
employees will receive pay for the normal number of hours they would routinely be
scheduled to work on the holiday.
2. The following 13 days are observed as holidays by COADA-CB:
New Year’s Day
Martin Luther King, Jr. Day
Columbus Day
Presidents’ Day
Good Friday
Memorial Day
Independence Day
Labor Day
Veterans Day
Thanksgiving Day
Day after Thanksgiving Day
Christmas Eve Day
Christmas Day
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3. If a holiday you observe is not on this list, special arrangements can be made to
exchange a personal/floater day.
4. If a holiday falls on Saturday, the preceding Friday will be taken in observance of a
holiday. If an observed holiday falls on a Sunday, the Monday after the holiday will be
taken in observance of the holiday.
5. Full-time employees are eligible to receive holiday pay provided they are on the job
the entire workday before and after the holiday. Exceptions to this policy will be made
only when an employee’s absence on the day before or after a holiday is due to:
A. A scheduled Vacation or Personal/Floater Day (must be scheduled prior to the
holiday);
B. Personal illness or illness of an immediate family which is confirmed by a
physicians statement;
C. Bereavement Leave; or
D. Jury Duty.
6. If you are on an approved leave of absence with or without pay, when a designated
holiday occurs, you will not receive holiday pay.
Personal/Floater Days:
1. Regular full time employees get two personal/floater days per fiscal year (September 1
– August 31). Accrual rate is 1.33 hours per month. Personal/floater day may not be
taken until the hours are actually accrued.
2. To schedule personal/floater days for an unobserved holiday, the employee must
submit an Employee Leave Request Form for approval to his/her immediate
Division/Program Manager. Personal/Floater Leave may be taken in a minimum of four
hour increments.
3. Unused Personal/Floater Leave will not be paid upon separation from COADA-CB.
4. Personal/Floater Leave cannot be carried over beyond the end of any fiscal year
(August 31).
5. Personal/Floater Leave must be approved, in advance, by the employee’s immediate
Division/Program Manager and requested on an Employee Leave Request form, with a
minimum of one week’s notice. In extenuating circumstances and when substitutes for
the employee’s work responsibilities can be scheduled, a Division/Program Manager may
approve Personal/Floater Leave time without the one week required notice.
6. The Billing Coordinator will be responsible for recording Personal/Floater Leave
eligibility and Personal/Floater Leave used in COADA-CB’s payroll records.
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7. With approval of the Executive Director or a designate, employees rehired with a break
in service of less than six months may not need to complete the 90 day probation period
in order to use accrued floating holidays.
Sick Leave:
1. Employees earn sick leave beginning on the first day of employment and ending on the
last day of employment. Full-time employees earn sick leave at a rate of eight hours per
month.
2. Full-time employees will have accrued twelve (12) full sick days at the completion of
each year of employment. Sick Leave may only be taken after is has been accrued.
3. Paid sick leave may be taken when disability prevents an employee’s performance of
duty. Paid sick leave may also be taken if the employee’s immediate family (father,
mother, spouse, children, brother, sister, or an individual who took the place of a parent
in the employee’s childhood) is ill and is dependent on the employee for personal care or
service during the illness. These individuals may or may not be living in the employee’s
household.
4. An employee who must be absent from work because of illness shall notify the
Division/Program Manager of the fact at the earliest time possible. Immediately upon
returning to work, the employee must complete an employee leave request form and
submit it to his/her Division/Program Manager. Sick time should be documented on
employee leave request forms in a minimum of thirty – minute increments. An employee
must keep the Division/Program Manager informed as to the length of the illness. If an
employee takes sick leave for more than three consecutive working days the agency
reserves the right to request a physician’s statement and release to return to work.
5. A pregnant woman, without regard to marital status, is entitled to the same rights given
to other employees absent from work for a disability. Pregnancies or the adoption of a
child less than three years of age shall be treated as any other temporary disability. Since
pregnancy is treated as medical disability, a request for extended leave without pay due to
a pregnancy-related disability will be reviewed based on the merits of the particular case.
6. An employee who used sick leave for purposes not listed above will be subject to
corrective actions up to and including termination.
7. Upon discretionary terms and upon request, the Division/Program Manager or
Executive Director may require the employee to submit a physician note for return to
work regarding excessive health issues, patterns of absenteeism, or other related
concerns.
8. Unused sick leave may be carried over from year to year, but is not to exceed 975
hours. Unused sick leave in excess of 975 hours will be forfeited. An employee who
resigns, is dismissed, or separated from COADA-CB’s employment will not be
compensated for any unused sick leave.
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9. Employees will request approval from their Division/Program Manager in advance, for
an absence due to a medical or dental appointment. This leave should be approved a
minimum of 3-days in advance unless medical reasons do not make such notice feasible.
An employee leave request form must be submitted and approved by the employee’s
Division/Program Manager.
10. Employees will request approval from their Division/Program Manager in advance, if
possible, for an absence. If not possible, notification by telephone should be given by the
employee directly to the Division/Program Manager. If the Division/Program Manager is
not available, the employee should speak directly to the Executive Director.
11. Notification calls should be made directly to the Division/Program Manager as early
as possible to enable the Division/Program Manager time to find coverage for employee’s
job responsibilities. At the latest, notification calls for illness or accident should be made
within one hour following the start of the employee’s assigned work period.
12. Employees on sick leave are required to maintain contact for any sick leave beyond
one day, unless the employee has provided a written doctor’s certification covering a
specific time period.
Frequency of contact between the employee and the
Division/Program Manager will be set by mutual agreement. If the employee is absent 4
or more days the Division/Program Manager will notify Human Resources of the absence
for the purpose of determining eligibility for Short Term Disability. If the employee is
absent beyond 15 days, Human Resources will provide Short Term Disability forms to
the employee. It is the employee’s responsibility to submit completed forms to Human
Resources to be filed with the insurance company for Short Term Disability benefits.
Sick leave benefits are contingent upon maintenance of contact as established.
13. Depending on the length and circumstances of the employee’s disability, the
Division/Program Manager may require physician’s written notice for certification of the
illness or release for the employee to return to work.
14. The Division/Program Manager is responsible for regularly reviewing the use of sick
leave by their employees and identifying abuse or chronic use of sick leave.
Division/Program Manager should address problems with absences for sick leave with
the employee as occasions occur or if a pattern of absences occurs. Division/Program
Manager will also review absences as part of the overall performance appraisal.
15. Abuse or misuse of sick leave will be handled in accordance with COADA-CB’s
disciplinary procedures.
Life-Threatening Illnesses: COADA-CB offers the following guidelines when dealing
with ill employees; Division/Program Manager should:
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1. Realize an employee’s medical condition is confidential and reasonable precautions are
to be taken to ensure information regarding the employee’s health is provided only to
those persons who need to know.
2. Contact the Executive Director if they believe they or other employees need
information about an illness or if they need further assistance.
3. Contact the Executive Director if they have any concerns about the possible contagious
nature of an employee’s illness.
4. Contact the Executive Director to determine if a statement should be obtained from the
employee’s attending physician stating that continued presence at work will pose no
threat to the employee, coworkers, or patients. COADA-CB reserves the right to require
an examination by a medical doctor chosen by COADA-CB.
5. Make reasonable accommodations, if necessary, for employees with illnesses
consistent with the business needs of COADA-CB.
6. Be sensitive and responsible to coworkers’ concerns and emphasize employee
education.
7. Give no special consideration beyond normal transfer requests for employees who feel
threatened by a coworker’s illness.
8. Encourage employees to seek assistance from community groups for medical treatment
and counseling services.
Sick leave donation:
1. To be considered eligible for the sick leave donation, the employee must be currently
employed by COADA-CB;
2. An employee is ineligible for sick leave donation if on a probationary status;
3. Sick leave donation eligibility and amount will be determined by the Executive
Director on an individual case basis, and may request medical information to assist in
determination of the eligibility to use from sick leave donation;
4. The Billing Coordinator is responsible for tracking and managing the sick leave
donation;
5. Current COADA-CB employees may donate sick time to the sick leave donation
recipient;
6. Current employees donating sick time may specify the recipient upon approval by the
Executive Director.
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Leave Of Absence Without Pay:
1. A leave of absence for medical reasons without pay may be granted when medical
circumstances require a prolonged absence for a qualified employee. Qualified
employees are those regular employees who have worked for COADA-CB for at least
2,080 hours for COADA-CB during the 12 months prior to the request for a leave of
absence for medical reasons without pay. Family Medical Leave Act is not applicable to
organizations with 49 or fewer employees.
2. Accrued, paid leave days must be used prior to commencement of the unpaid leave for
medical reasons. Therefore, a medical leave of absence without pay will begin at the
expiration of the period for which any benefits are granted under COADA-CB’s sick
leave, vacation, or personal/floater leave policy.
3. A physician’s statement will be required to support an employee’s request for leave of
absence for medical reasons. A second medical opinion may be required at COADACB’s expense. COADA-CB may require an employee to report periodically with a
physician’s statement on the employee’s status and intent to return to work.
4. No benefit credit will accrue during unpaid medical leave of absence toward vacation,
sick, or personal/floater leave. Any holidays occurring during an unpaid medical leave of
absence will not be paid.
5. A leave of absence for any purpose (other than medical reasons) without pay may be
granted when circumstances require a prolonged absence for a qualified employee.
Qualified employees are those regular employees who have worked for COADA-CB for
at least 2,080 hours for COADA-CB during the 12 months prior to the request for a leave
of absence for without pay. Family Medical Leave Act is not applicable to organizations
with 49 or fewer employees.
6. An employee must provide a physician’s release to return to work prior to
reinstatement. Upon return from medical leave, an employee will be restored to his/her
original job or an equivalent job with equivalent pay, benefits, and other employment
terms and conditions. If an employee fails to report to work after three working days
following the expiration date of the medical leave of absence, the employee will be
considered to have voluntarily resigned. The termination date will be the last day
worked.
7. Written request for a medical leave of absence without pay will be submitted to the
employee’s Division/Program Manager. This request should be submitted in conjunction
with a request for paid sick leave, if any is available. A letter of explanation must be
attached to the employee leave request form.
8. The immediate Division/Program Manager will meet with the Executive Director and
agree upon the approval/disapproval of all requests made for leave of absence. The
Division/Program Manager will, then, communicate the decision to the employee.
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9. Written request must be submitted at least thirty working days prior to the
commencement of the leave, except when medical conditions make such a requirement
impossible.
10. An employee on unpaid personal leave or unpaid medical leave of absence will be
responsible for paying his/her entire monthly premium for health care benefits normally
paid by both COADA-CB and the employee. COBRA arrangements will be made with
the Finance Business Manager.
COADA-CB employees to secure limited time off when such time is needed for
important personal or civic reasons as described below:
Bereavement Leave:
1. Absence due to death in the employee’s immediate family (father, mother,
spouse/mate, children, brother, sister, grandparents, or an individual who took the place
of a parent in the employee’s childhood) may be approved and paid for up to a maximum
of three working days.
2. Absence to attend a funeral of any other person may be approved as personal/floater
leave or vacation time.
3. Absence of up to one day to attend a funeral of a brother-in-law, sister-in-law, motherin-law, or father-in-law may be approved and paid.
4. The Division/Program Manager and or the Executive Director may approve the
granting of leave to attend a funeral.
Jury Duty:
1. COADA-CB employees who are summoned for jury selection or summoned to serve
on a jury will receive their regular pay and benefits while serving on the jury duty. The
employee may keep the jury pay to offset the cost of jury duty such as meals and parking.
2. A copy of the jury summons and appropriate documentation as to the length of service
may be requested to document this leave.
3. The employee must notify his/her Division/Program Manager as soon as a jury
summons is received.
4. If selected for the jury, the employee must contact his/her Division/Program Manager
on a daily basis to communicate the status of the trial and the expected date of return to
work.
5. If the jury is released early (prior to 3:30 p.m.) or is asked to report late (after 10:00
a.m.), the employee should report to work.
Military Leave: Military leave will be given in accordance with applicable law.
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An employee requesting any of the above listed leave must submit an employee leave
request form to his/her Division/Program Manager as soon as possible to allow for job
responsibilities to be reviewed before authorization. The Division/Program Manager will
notify the Executive Director, as appropriate, of the request and seek
approval/disapproval. The Division/Program Manager will report back to the requesting
employee.
The employee will be responsible for providing appropriate documentation of each
request of leave covered by this policy.
All employees are responsible for conformance with this policy.
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EMPLOYEE BENEFITS
PURPOSE: To establish the official position of COADA-CB on employee benefits for
employees of the organization and to assign specific responsibility for implementation of
the policy.
POLICY: It is the policy of COADA-CB to provide a competitive benefits package as a
way to recruit and retain qualified and competent employees.
PROCEDURE: The following sections provide an overview of the organization’s
employee benefits and outlines specific processes pertaining thereto:
Health, Long Term Disability and Life Insurance.
1. COADA-CB will make medical, dental, vision, life insurance, accidental death and
dismemberment, and long term disability coverage available. Employees routinely
working in excess of 32 hours or more per week are eligible for this benefit and COADACB will pay the “employer portion” defined annually for this benefit.
2. Each employee may be required to contribute an amount towards insurance coverage
to maintain these benefits. The Finance Committee of COADA-CB’s Board of Directors
will determine the amount of the employee contribution. Payments for coverage will be,
automatically, deducted from the employee’s paycheck.
3. An employee may elect to purchase health, vision, life, accidental death and
dismemberment, and dental coverage for dependants (as defined in the plans) at a rate to
be established annually by the current insurance carrier. Payments for dependent
coverage will be, automatically, deducted from the employee’s paycheck.
4. An employee, spouse, and dependent children may be eligible for continuation of
insurance coverage upon termination from employment and/or other qualifying
conditions under the Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA). Upon termination of employment, it is the employer’s responsibility to notify
the employee by certified mail or personal interview to accept or reject COBRA coverage
and to offer an explanation of rules and regulations for continuation of coverage as well
as the cost to purchase the coverage.
5. Human Resources will provide written information on the health, dental, long-term
disability, and life insurance plans available to new and current employees of COADACB. Benefits of medical and dental insurance begin the first of the month following an
initial full calendar month (30) days of continuous employment.
6. The employee is responsible for completing the initial required forms by the end of the
second week of employment to enroll in these plans, as appropriate. In addition, the
employee must comply with other deadlines of completion of required forms or risk
losing his/her eligibility for coverage.
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7. Human Resources will provide additional information on benefits to employees, but it
is the employee’s responsibility to check with the plan administrator regarding specific
questions, unique problems, or issues. In the case of a break in service due to termination
or lay off, Human Resources will inform the employee their eligibility regarding
continuation of insurance coverage upon termination from employment and/or other
qualifying conditions under the Consolidated Omnibus Budget Reconciliation Act of
1986 (COBRA).
Wellness Program:
1. COADA-CB employees are eligible for participation in an optional wellness program.
COADA-CB will establish a corporate membership at a selected health/fitness center.
COADA-CB will pay 50% of the corporate membership rate for the employee, with the
discretion to adjust the percent contribution in the future. Family members may
participate in the corporate membership with the employee paying 100% of the cost for
the family member(s).
2. Human Resources will provide membership information and enrollment forms.
Interested employees are responsible for contacting the selected health/fitness center to
complete enrollment.
3. COADA-CB will provide payroll deduction services for the total membership
contributions owed by the employee [less the COADA-CB contribution] and remit the
contributions to the selected health/fitness center.
Retirement:
1. Eligible COADA-CB employees will be provided with a SEP Savings Plan
administered by COADA-CB and COADA-CB will deposit a percentage of the
employee’s salary into discretionary contributions each calendar year for employees who
have worked for 3 of the last 5 years. The percentage will be determined by management
based on funding and is subject to change at any time. COADA-CB will pay the initial
setup and annual custodial cost of maintaining this account with the discretion of
changing in the future.
2. The employee is also eligible to make voluntary contributions into a 403B for tax
deferred growth. COADA-CB will pay the initial setup and annual custodial cost of
maintaining this account with discretion of changing in future years. An employee can
participate at the first of the month of employment and enroll during any active
enrollment period.
3. Human Resources will provide employees with retirement plan administrator contact
information of the SEP and 403B tax deferred growth.
4. COADA-CB contributions made on behalf of an employee will cease upon termination
of employment or during unpaid leave. The employee must contact the fund
administrator representative for voluntary plan continuation.
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Workers’ Compensation:
1. Workers’ Compensation applies only to physical injuries sustained in the course of
employment. It does not apply to injuries sustained while the employee is intoxicated or
under the influence of alcohol or other drugs, involved in “horseplay”, or going to or
from work.
2. Injured employees, as described above, are entitled to medical aid and hospital services
which are reasonably required at the time of injury and as may be necessary to recover
from the injury. The employee will conform to rules and requirements of the workers’
compensation insurance policy.
3. The amount of financial compensation for an employee will be determined in
compliance with applicable state and federal laws.
4. Accrued sick leave, vacation, and/or personal/floater leave may be utilized during an
absence caused by an on-the-job injury. In no case may an employee receive more than
100% of his/her regular salary through the utilization of accrued leave and workers’
compensation benefits.
5. An employee may not return to work following a job-related injury, unless a licensed
physician approves the return with a written medical release.
6. An employee who is injured on the job must notify his/her Division/Program Manager
and or Executive Director within 24 hours in non-life threatening situations or
immediately if the situation is life threatening. The Division/Program Manager and or
Executive Director must notify Human Resources who will immediately contact the
workers’ compensation insurance carrier to report the injury.
7. The employee must comply with the rules and regulations set by the workers’
compensation insurance and applicable state and federal laws to receive benefits.
8. Human Resources is responsible for ongoing contact with an employee who claims a
work-related injury and/or who is receiving workers’ compensation. Human Resources
should, also, maintain close contact with the insurance carrier. The employee must
provide the following information to Human Resources in a timely manner:
A. Initiation date and amount of any workers’ compensation benefits awarded;
B. Requested utilization schedule of any accrued leave plus workers’ compensation
benefits to eliminate payment over 100% of salary. (Example: If workers’
compensation pays 50% of the employee’s salary, accrued leave can be utilized to
compensate the employee for the other 50% of the salary.) The combined workers’
compensation benefits plus accrued leave cannot exceed 100% of the regular salary;
and
C. Submission of semi-monthly signed timesheets to authorize the payment of the
accrued leave benefits during the absence. Pay cannot be authorized without a
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signed timesheet from the employee indicating the employee’s desire to utilize
leave.
9. At no time should the Executive Director, Division/Program Manager or other
employee make any commitments or statements pertaining to COADA-CB’s liability
in regard to an employee’s injury or illness.
All employees of the organization are responsible for conformance with this policy.
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Employee Discipline
PURPOSE: To establish the official position of COADA-CB on the organization’s
disciplinary process for monitoring business and clinical conduct of employees and to
assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to maintain a professional environment that is
conducive to good order and discipline, dignity and respect and quality care. Therefore,
the organization will ensure that all employees clearly understand the organization’s
expectations regarding proper behavior and more critically, the organization’s
disciplinary system.
PROCEDURE: COADA-CB seeks to maintain standards of employee dress, conduct,
and ethics, which promote effective delivery of services at COADA-CB. The following
guidelines represent the organization’s specific procedures in support of this policy:
Dress Standards:
1. As a representative of COADA-CB, an employee’s appearance is a direct reflection on
the level of professionalism in the agency. Employees will present a professional image
at all times: bathed, neatly groomed, and dressed appropriately.
2. The Executive Director reserves the right to determine inappropriate attire that may
result in a person being requested to leave work and return dressed appropriately for their
position. Hourly paid employees asked to leave for such purposes will be unable to
recapture their lost time while they are away from work. Permission to wear more casual
attire may be requested from the Executive Director for special projects.
Consistent employee discipline will be used which includes:
1. Constructive efforts by the Division/Program Manager to help employees achieve fully
satisfactory standards of conduct and job performance and used for the correction of an
employee’s unsatisfactory performance or negative behavior.
2. Written documentation of problems and disciplinary warnings given with corrective
measures to be taken by the employee. Disciplinary action may begin at any step or level
of severity and does not have to include each level. COADA-CB generally recognizes
four levels of discipline:
A. Verbal warnings,
B. Written warnings,
C. Administrative Leave With or Without Pay
D. Discharge.
3. The Executive Director must approve any disciplinary action for a gross or severe
violation as well as any administrative leave or discharge of any employee prior to any
action by a Division/Program Manager.
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4. Probationary employees of COADA-CB who fail to adhere to standards of conduct or
whose performance is unsatisfactory will be terminated. Disciplinary situations
involving regular employees shall be dealt with by progressive discipline and or
termination if appropriate, to assure equitable treatment and acceptable conduct
standards.
5. In applying disciplinary procedures or actions, these factors listed will be considered as
a guide and may vary as appropriate:
A. The seriousness of the violation or offense;
B. The employee’s past record and length of employment; and
C. The circumstances surrounding this particular incident.
6. Depending upon the facts and circumstances involved in each situation, management
may choose to begin disciplinary action at any step. In general, discipline at COADACB shall constitute the following:
A. A verbal warning shall be used for minor violations. A copy of the verbal warning
will be placed in a separate file. If the situation does not improve within a
reasonable time frame set by the Division/Program Manager, the Division/Program
Manager may repeat the verbal warning or use the next level of discipline. A
record should be kept to document the verbal warning, the date of the warning, its
content, and time frame for improvement.
B. A written warning shall be used for repeated violations or for a more substantial
violation. The Division/Program Manager will set a time frame for improvement.
A copy of the written warning will be placed in the employee’s file. If the situation
does not improve, the Division/Program Manager may repeat the step or use the
next step. The written warning notice will be discussed, in person, with the
employee by the Division/Program Manager. The employee will be given an
opportunity create a corrective action plan and to comment in writing and will be
asked to sign the notice to acknowledge receipt of the formal written notice.
C. Administrative leave may be utilized for serious violations when immediate action
is required while an investigation is being conducted to determine the employee’s
future status. The length of the administrative leave depends upon the time needed
to investigate the violation. This administrative leave may be with or without pay
depending on the infraction. Administrative leave may also be used when the
employee fails to respond to previous attempts of discipline. The Executive
Director must approve all administrative leaves.
D. Termination for cause may be utilized for serious violations with or without the
previous use of any of the lesser disciplinary steps. Discharge may also be used for
continued failure to respond appropriately to prior disciplinary action and may be
deemed appropriate regardless of the prior disciplinary actions. The Executive
Director shall approve all discharges of COADA-CB employees. If an alleged
violation or continued failure to respond to disciplinary action for other violations is
reported to or discovered by the Executive Director, the employee may be
discharged upon completion of the investigation with written documentation to
explain the reasons for the discharge. This written notice will become part of the
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employee’s file. The employee will be notified, in person if appropriate, or by
telephone and/or registered mail. The Executive Director may hold a hearing to
review charges or allegations prior to discharge.
E. Insubordination will not be tolerated and may be grounds for termination.
If any employee does not comply with COADA-CB’s policies and procedures, he/she is
subject to disciplinary action up to and including termination.
All employees of the organization are responsible for conformance with this policy.
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Termination
PURPOSE: To establish the official position of the organization on the termination of
employees who are determined to be unsuitable for continued employment with the
organization and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of the organization that COADA-CB will establish and
implement specific guidelines for the termination of employees. In the event that an
employee must be terminated, the organization shall ensure that the termination is
appropriate as defined within this policy and more critically, is conducted in accordance
with all applicable laws, codes, rules and regulations.
PROCEDURE: The following guidelines govern employee terminations in the
organization:
Voluntary and Involuntary Termination:
The categories of termination/separation and their definitions are as follows:
1. Voluntary termination occurs when the employee initiates the separation through one
of the following:
A. Written or oral resignation; with or without notice.
B. An absence of three or more consecutive working days without notice to COADACB.
C. Failure to return from an approved leave of absence at the expiration of the leave.
D. Retirement; which usually includes qualification for benefits under the retirement
plan.
2. Involuntary termination occurs when the employee does not initiate the separation. The
following are examples of involuntary termination:
A. Reduction-in-force due to COADA-CB’s economic status or other reasons such as
reorganization.
B. Release without fault in which an employee is not qualified or adapted for the type
of work assigned and no appropriate change of assignment is available.
C. Death of an employee in active employment.
D. Discharge where the employee is terminated from the payroll for violation of
employee standards of conduct, absenteeism, unsatisfactory job performance, or
gross misconduct.
E. Disability when medical evidence shows an employee is totally and permanently
unable to perform his/her usual work assignment.
3. COADA-CB is an “at will employer.” Therefore, an employee may resign at any time,
with or without notice. COADA-CB, also, retains the same rights to terminate an
employee at any time, with or without notice. COADA-CB may request a minimum of a
one week advance notice of voluntary termination from professional and support
employees. COADA-CB may request a minimum of a two week advance notice of
voluntary termination from Division/Program Managers.
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4. COADA-CB cannot always provide advance notice to employees for involuntary
termination other than for a reduction-in-force. At least two weeks notice will be given
to an employee who is being terminated due to a reduction-in-force.
A. In some cases, the Executive Director may authorize pay in lieu of notice for an
employee.
B. When an employee of COADA-CB is to be released, separated due to a reductionin-force or discharged, the Executive Director must approve these actions.
5. When an employee is separated for any reason other than theft or gross misconduct,
he/she is entitled to only the following benefits and leave:
A. An employee, spouse, and dependent children may be eligible for continuation of
insurance coverage upon termination from employment and/or other qualifying
conditions under the Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA). Upon termination of employment, it is the employer’s responsibility to
notify the employee by certified mail or personal interview to accept or reject
COBRA coverage and to offer an explanation of rules and regulations for
continuation of coverage as well as the cost to purchase the coverage.
B. Eligible COADA-CB employees who have been provided with a SEP Savings Plan
and received COADA-CB deposits of 2% of the employee salary into discretionary
contributions will be able to determine the status of maintaining the account on a
personal level. COADA-CB contributions will cease upon termination of
employment or during unpaid leave. The employee must contact the fund
administrator representative for voluntary plan continuation. COADA-CB will pay
not pay the annual custodial cost of maintaining this account.
C. Employees who have made voluntary contributions into a 403B for tax deferred
growth will be able to determine the status of maintaining the account on a personal
level. COADA-CB will pay not pay the annual custodial cost of maintaining this
account. Payroll contributions will cease upon termination of employment or
during unpaid leave. The employee must contact the fund administrator
representative for voluntary plan continuation.
D. Accrued vacation will be paid in full upon termination and normally included in the
final paycheck.
6. A COADA-CB employee who is voluntarily resigning should notify his/her
Division/Program Manager in writing. If a notice period is offered, the
Division/Program Manager should inform the employee whether the notice period would
be necessary after consultation with the Executive Director.
7. The Executive Director must confirm in writing (mailed to the last known address) the
voluntary termination of an employee who is absent more than three work days without
notice or who does not return on the expiration date of a leave of absence.
8. The Executive Director will periodically assess employee staffing patterns by
reviewing the current economic status and funding sources of COADA-CB. A
reduction-in-force may be necessary based on this analysis. The Executive Director will
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give at least two weeks notice in advance to any employee who is involuntarily
terminated due to a reduction-in-force.
9. If the Division/Program Manager determines that an employee is not qualified or able
to perform the work assigned and provides adequate documentation, the Executive
Director may authorize involuntary termination of the employee (release without fault).
The Executive Director may authorize up to 10 days pay in lieu of notice, depending
upon the circumstances.
10. If the Division/Program Manager determines that an employee has violated the
standards of conduct, has unacceptable levels of absenteeism, has unsatisfactory job
performance, etc. the Executive Director, may authorize involuntary termination
(discharge). The Division/Program Manager will notify the employee in writing of
his/her discharge from the agency, including reasons for discharge. This letter will
become part of the employee’s file.
11. Human Resources generally is responsible for assuring that the employee returns all
COADA-CB’s property, keys, manuals and teaching materials, etc. before the final
paycheck will be issued, no later that the next regular payday.
12. Before a final paycheck will be issued, the employee must complete all travel and
miscellaneous expense reports and reconcile outstanding funds owed or due. A
requisition should be completed for all employees qualified to receive accrued vacation
pay. The final paycheck will be issued no later than the next regular payday.
Exit Interviews:
1. Prior to leaving COADA-CB, terminated employees are asked to participate in an exit
interview with Human Resources. This is a voluntary process where the terminating
employee will have the opportunity to comment on various aspects of employment with
COADA-CB.
2. If an employee is involuntarily terminated, the exit interview should be conducted on
the last day of employment; preferably in the last scheduled hour for that employee.
3. If an employee is voluntarily terminated, the exit interview should be conducted either
the last day or one or two days prior to the termination date.
4. The exit interview will cover, in writing or verbally, at least the following:
A. Job duties, workload, and advancement opportunities;
B. Salary and benefits;
C. Quality of supervision;
D. COADA-CB’s policies, practices, and working environment;
E. Reasons for leaving; and
F. Recommendation for improvement
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5. Human Resources will obtain the new address (if applicable) of the employee for
forwarding the W-2 forms.
All employees – and especially those with supervisory responsibilities – are responsible
for conformance with this policy.
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Performance Appraisal Review
PURPOSE: To establish the official position of the organization on employee
performance appraisals and to assign specific responsibility for implementation of the
policy.
POLICY: It is the policy of COADA-CB that employees will be periodically evaluated
on the basis of job performance and overall contribution to the organization to enable the
employee to grow and succeed in their job. The organization will conduct all job
evaluations in accordance with the procedures contained herein and more critically, with
generally accepted standards of practice in the human resource management field.
Performance reviews may be conducted in the event of a promotion or change in duties
and responsibilities.
PROCEDURE: The following guidelines will govern all performance appraisals
conducted on employees of COADA-CB:
1. Each employee will be reviewed on standard job performance criteria, job
expectations, performance objectives and duties specific to the position the employee
holds. Results of the evaluation are documented in the employee personnel records.
2. The evaluation process includes establishment of performance objectives for the next
evaluation period and identification of training and development opportunities related to
the established performance objectives.
3. The Division/Program Manager will perform a comprehensive review of the
employee’s work. Any employee, who feels the evaluation conducted was inaccurate and
cannot resolve the matter during discussion with the appropriate administrative person,
may request an evaluation conference. Any employee who does not agree with an
evaluation has the right to write why he/she disagrees and have it put in the file with the
performance appraisal.
4. The employee will be given a copy of the completed evaluation form before the
scheduled evaluation conference with the Executive Director and Division/Program
Manager in order to have an opportunity to review forms for discussion and comments.
5. The employee will be required to sign the review form acknowledging the evaluation
was discussed with the Executive Director and/or Division/Program Manager and the
employee was given the opportunity to comment. The employee’s signature is not
construed to mean agreement.
6. All information in the review is confidential and will be provided only by on a “need to
know” basis. When considering employees the appropriate Division/Program Manager
will take into consideration documents such as letters of commendation, discipline
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consultation forms, attendance records, other employment-related records and funds
available.
7. A copy of the performance evaluation will be made available to the employee. All
original forms will be secured in the employee personnel file.
All employees are responsible for conformance with this policy.
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Employee Qualification Requirements
PURPOSE: To establish the official position of COADA-CB on employee testing
patterns for the organization and clarify only qualified employees, volunteers, and student
workers shall be utilized for each program/service provided and to assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization shall employ an adequate
number of qualified employees at all times to accomplish the organization’s mission and
ensure that programs and services assist patients in attaining optimal objectives.
PROCEDURE: The following procedures will guide the organization in all practices
pertaining to the employee testing of programs and services:
General Employee Testing Requirements:
1. COADA-CB shall have an adequate number of qualified employees to comply with
DSHS rules, provide the services described in the program description, and protect the
health, safety, and welfare of patients/participants.
2. Each program shall have set limits on caseload size that ensure effective service
delivery.
3. Each program shall justify the caseload size, in writing, based on the program design,
characteristics, and needs of the population served and any other relevant factors.
4. COADA-CB shall have an employee designated to serve in the capacity as manager of
each program. Division/Program Manager is the position title assigned to this employee.
The individual must have appropriate education and training and at least two years of
experience providing related services.
A. The Division/Program Manager of a prevention program must have at least two
years of experience in substance abuse prevention.
B. The Division/Program Manager of an intervention program must have at least two
years experience in intervention. At least one year of experience must be specific to
the program’s target population.
C. The Division/Program Manager of a treatment program must be a Qualified
Credentialed Counselor [QCC] with at least two years of post-licensure experience
providing chemical dependency treatment; with at least one year of experience
providing services to the program’s target population (adult and/or adolescent).
5. The Division/Program Manager shall spend and document sufficient time at the
program site to provide appropriate oversight and supervision.
6. Chemical dependency counseling, education, and life skills training shall be provided
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by counselors or individuals who have the specialized education, expertise, and/or
experience needed to teach the material.
7. Direct care employee qualified requirements shall include:
A. Qualified Credentialed Counselor (QCC) provide chemical dependency counseling
services;
B. The QCC is responsible for planning, directing, and supervising the implementation
of treatment services;
C. All employees shall be trained in non-violent crisis intervention;
D. All employees shall be certified in CPR;
E. Not allow its patients to serve as employees; and
F. Not allow former patients to be hired until at least two years after discharge from
active treatment at COADA-CB.
8. The Division/Program Manager is responsible to ensure that the employees, including
volunteers and students:
A. Demonstrate competency in areas of job duties before allowing them to work
without immediate supervision;
B. Document appropriately; and
C. Comply with COADA-CB’s policies and procedures.
9. Mental health services shall be provided by:
A. A qualified mental health professional; or
B. An LCDC who has received additional training and achieved competence in
working with chemically dependent individuals with co-occurring mental health
conditions. At a minimum, the training must include 45 education hours in mental
health and 2,000 hours of documented work experience under the supervision of a
qualified mental health professional.
10. Counselors shall not provide group or individual counseling focused on trauma,
abuse, or sexual issues; unless they are licensed and have specialized education/training
and supervised experience in the subject. At a minimum, LCDC providing these services
must have 45 education hours and 2,000 hours of documented work experience under the
supervision of a qualified mental health professional.
11. Additional requirements for Adolescent programs (DSHS 448.905):
A. COADA-CB shall maintain separation between adults and adolescents; except
during family-based treatment activities.
B. The clinical services, lectures, and written materials shall be age-appropriate and
easily understood by patients/participants.
C. COADA-CB shall allow regular communication between an adolescent
patient/participant and the patient's/participant’s family and shall not, arbitrarily,
restrict any communications without clear individualized clinical justification.
D. COADA-CB shall ensure that employees that plan, supervise, or provide adolescent
treatment have specialized education or training as required in DSHS Rules Chapter
448.603.
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E. Patients shall be under direct supervision at all times.
F. The treatment plan shall address adolescent needs, issues, and family relationships.
G. The program shall involve the adolescent's family or an alternate support system in
the treatment process or document why a support system is not in place.
H. The program shall prohibit adolescent patients from using tobacco products on the
program site. Employees and other adults (volunteers, patients, and visitors) shall
not use tobacco products on-site.
12. Relating to Counselor Interns:
A. COADA-CB admission criteria for Counselor Interns (CI) do not allow an applicant
to be admitted to participate in the CI training program without:
• Documentation that the applicant has successfully registered with DSHS (NOTE:
this process includes having submitted: application and background fees; a current
photograph; notarized/signed licensure application; two sets of fingerprints in
accordance with DSHS guidelines; documentation of completed education hours
and practicum; and documentation of high school diploma or GED); and
• Signed the ethics agreement, (450.124 b2) which is consistent with Chapter 150
Counselor Licensure §150.121.
B. COADA-CB’s Treatment Division Manager shall supervise the CI and practicum
training.
C. COADA-CB shall establish the following level system to classify interns according
to hours of supervised work experience:
• Level I: 0-1000 hours of work experience;
• Level II: 1001-2000 hours of work experience; and
• Level III: 2001-4000 hours of work experience.
• Graduate Status; over 4000 hours of documented work experience.
D. The CTI shall have an organizational structure that includes all intern levels in
writing and provide the intern with a copy of the documentation.
E. COADA-CB shall work with the intern and the practicum supervisor to establish
goals using the commission’s Knowledge, Skills, Abilities, evaluation tool including
• Set weekly objectives based on areas that need improvement.
• Assignment to each intern that relate to the intern’s KSA goals and objectives.
• Monitor of the intern’s progress towards goals and objectives and provide verbal
and written feedback during weekly supervision meetings.
• Provide reading and/or video assignments that address areas needing improvement.
F. All interns shall work under the direct supervision of a QCC.
G. During an intern’s first 1000 hours of supervised work experience (Level I), the
QCC supervisor must:
• Be on duty at the program site where the intern is working;
• Observe and document the intern performing assigned activities at least once every
two weeks;
• Provide and document a one hour of face-to-face individual or group supervision
each week; and
• Sign off on all clinical assessments, treatment plans, and discharge summaries
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completed by the intern.
H. During an intern’s second 1000 hours of supervised work experience (Level II), the
QCC supervisor must:
• Be on duty at the program site where the intern is working;
• Observe and document the intern performing assigned activities at least once
every month;
• Provide and document one hour of face-to-face individual or group supervision
each week; and
• Sign off on all clinical assessments, treatment plans, and discharge summaries
completed by the intern.
I. During an intern’s last 2000 hours of supervised work experience (Level III), the
QCC supervisor must:
• Be available by phone while the intern is working;
• Observe and document the intern performing assigned activities as determined
necessary by the CTI coordinator;
• Provide and document one hour of face-to-face individual or group supervision
each week; and
• Sign off on all clinical assessments, treatment plans, and discharge summaries
completed by the intern.
J. After an intern receives graduate status, the CTI coordinator or QCC designee shall:
• Be available by phone while the intern is working;
• Provide and document one hour of face-to-face individual or group supervision
each week; and
• Sign off on all clinical assessments, treatment plans, and discharge summaries
completed by the intern.
K. A QCC shall not supervise more than five interns.
L. COADA-CB shall review and sign each intern’s Supervised Work Experience
Form(s).
M. COADA-CB shall not allow an intern to accrue more than 40 hours of supervised
work experience per week.
N. Only work experience primarily related to chemical dependency counseling and
other core functions can be counted towards supervised work experience.
O. COADA-CB shall use all forms mandated by the DSHS.
P. COADA-CB shall maintain the following documentation for four years:
• Verification of current credentials of all QCC supervisor employees;
• Supervision assignments; and
• Intern files, which shall include:
(1) Application and documentation of eligibility;
(2) Ethics agreement signed by the student;
(3) Documentation of all QCC supervision activities;
(4) Documentation of intern levels and accumulated hours;
(5) Copy of the Supervised Work Experience Form (when applicable).
Q. COADA-CB shall give the student a copy of all information contained in the intern
file.
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R. COADA-CB shall ensure that interns designate their status by using "intern" or "CI"
when signing patient record entries.
All employees are responsible for conforming to this policy.
EMPLOYEE TRAINING (448.605)
PURPOSE: To establish the official position of COADA-CB on initial and ongoing
employees training and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to provide both initial and ongoing training for
employees and more specifically, to provide training on all topics required by accrediting
organizations, DSHS and all other applicable laws, codes, rules and/or regulations.
PROCEDURES: The following guidelines govern the organization’s employees training
program:
COADA-CB shall provide all employee training and supervision necessary to ensure
compliance with the DSHS rule provision of appropriate and individualized treatment as
well as protection of patient/participant health, safety and welfare.
COADA-CB shall ensure that all employees receive training based on an employee’s
development plan.
1. Employees development plans must include, but are not limited to, initial and ongoing
training on the following:
A. All topics as required by DSHS in facility licensure rules;
B. Training and education in the program’s services;
C. Appropriate training related to job responsibilities/expectations;
D. Rights of the persons served;
E. Prevention of workplace violence;
F. Confidentiality requirements;
G. Reporting of incidents and adverse events;
H. Annual training in cultural awareness and sensitivity related to COADA-CB
patient/participant population;
I. Established annually, based on the program design and identified employee’s needs.
2. Initial orientation training shall be completed during the first 30 calendar days of
employment, including:
A. Patient/participant rights;
B. Patient/participant grievance procedures;
C. Confidentiality of “protected health information” as defined by HIPAA and 42 CFR
Part 2;
D. Patient/participant abuse neglect, and exploitation;
E. Requirements for reporting abuse, neglect, and other serious incidents;
F. Cultural competency;
G. Standards of conduct (ethics);
H. Emergency and evacuation procedures;
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I. Incident reporting; and
J. Prevention of workplace threats and violence.
3. All direct care employees shall be provided training:
A. For at least 2 hours annually in issues relating to abuse, neglect, and exploitation
and illegal, unprofessional, and unethical conduct;
B. That complies with the interagency memorandum of understanding on abuse
training: (§448.603 (d) (1);
C. For at least 4 hours related to tuberculosis, HIV, Hepatitis B and C, and sexually
transmitted diseases during the first 90 days of employment;
• The training shall be based on the DSHS workplace and Education Guidelines for
HIV and Other Communicable Diseases.
• The facility shall provide all employees with updated information about these
diseases every year.
D. CPR certification, 1st Aid Basic Training; and
E. For at least 4 hours of face-to-face training in nonviolent crisis intervention during
the first 90 days of employment;
• The instructor shall have successfully completed a course for crisis intervention
instructors or have equivalent training and experiences; and
• The training shall teach employees how to use verbal and other non-physical
methods for prevention, early intervention, and crisis management.
4. Each employee, volunteer, or student worker conducting intake or screens applicants
for admission shall complete 8 hours of training in the program’s intake and screening
procedures annually.
A. The first eight hours shall be completed during the first 90 days of employment and
before an employee conducts an intake or screens applicants for admission.
B. The training shall cover the DSM-IV diagnostic criteria for substance-related
disorders, and shall also include at least two hours annually on other mental health
diagnoses.
5. All counselors and counselor interns working in the adolescent program shall have or
receive at least eight hours of specialized education or training in emotional, mental
health, and chemical dependency problems specific to adolescents and appropriate
adolescent treatment strategies. This training shall be completed within the first 90 days
of employment or COADA-CB will accept documented training from another
organization completed during the year prior to employment, if it meets DSHS
requirements.
6. Human Resources shall:
A. Ensure that all new employees, including practicum student volunteers, receives
timely orientation and training.
B. Ensure that all employees, including practicum student volunteers, receives annual
and other ongoing training as required by COADA-CB’s policies and procedures;
inclusive of DSHS requirements.
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C. Perform period assessments of employees training needs.
7. The Division/Program Managers shall develop activities/resources based on the needs
identified in the periodic assessments:
A. In-service training programs;
B. Reference materials;
C. COADA-CB may approve limited training through workshops and seminars for
employees based upon the relevance of the contents of the training to his/her job
duties, the cost of the training, the workload of the employee, and the needs of the
agency;
D. COADA-CB may choose to pay the cost of the educational training and/or provide
time away from the office to attend such training.
E. Attendance and payment for the training must be approved, in writing/ in advance,
by the Division Manager and the Executive Director.
F. The employee must submit information on the requested training and an outline of
the cost and time commitment to the Division/Program Manager who will review
the request and consult with the Executive Director.
G. The cost of the training (including travel and related expenses) as well as the
financial status of the agency will also be considered in reaching a decision. The
Division/Program Manager is responsible for indicating whether the time away from
work is feasible and whether the employee’s responsibilities can be adequately
covered.
H. Employees who are approved for educational training must attend the training
which is paid for in advance or have their non-attendance authorized by the
Executive Director. The employee is responsible for completing any required
reports on the training and submitting them to his/her Division/Program Manager as
well as all financial documentation.
8. COADA-CB will provide training on “abuse, neglect and unprofessional or unethical
conduct as required by DSHS Rules and Licensure Standards and will specifically:
A. Review the policy and procedures for standard of conduct, standard of ethics and
incident reporting requirements;
B. Include the definitions of abuse, neglect, and exploitation as noted in DSHS Rules
and Licensure Standards.
9. Any employee who attends trainings, receives certifications, or receives membership
fees paid by COADA-CB may be held liable for reimbursement of incurred expenses if
voluntary termination results within 12 months of the incurred expenses as determined by
the Executive Director and determined on an individual case basis.
All employees are responsible for conformance with this policy.
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DRUG FREE WORKPLACE POLICY
PURPOSE: To establish the official position of COADA-CB on a drug free workplace
policies and procedures and to assign specific responsibility for implementation of the
policy.
POLICY: Our position regarding substance use and abuse is the same whether alcohol,
marijuana, illegal drugs, prescription drugs, or controlled substances are involved.
Accordingly, the agency prohibits:
A. The use, possession, sale, purchase, manufacture, distribution, concealment or
transfer of any prohibited substance (except medications properly taken and
prescribed by a medical practitioner), or drug paraphernalia while on the job, on
agency time, operating agency vehicles (including leased or rented vehicles), or on
agency property. COADA-CB reserves the right to inspect packages or articles
brought on to agency property.
B. An employee reporting to work or remaining at work after having used or ingested
prohibited substances, or while under the influence of such drugs or alcohol.
C. An employee having a detectable level of prohibited substances present in one's
system while on the job, on agency time, operating agency equipment, operating
agency vehicles (including leased or rented vehicles), or on agency property.
The term "prohibited substance" includes, but is not limited to, marijuana, heroin, opium,
morphine, codeine, cocaine, amphetamines, barbiturates, tranquilizers, PCP, mescaline,
peyote, and LSD, other controlled substances and any other drugs, chemicals, or
abnormal substances which may affect the individual's perceptions while they are
working. The term is also deemed to include alcohol and any form of alcoholic
beverages.
The definition of agency is any facility owned or managed by COADA-CB, including
offices, buildings, common and storage areas, grounds, parking lots, etc.
A violation of this policy constitutes grounds for disciplinary action up to and including
termination. COADA-CB reserves the right to contact appropriate law enforcement
officials when it deems necessary.
COADA-CB is committed to providing a safe work environment and to fostering the well
being and health of its employees. The agency recognizes that the work environment is
safer and more productive without the presence of illicit or inappropriate drugs and/or
alcohol at work. Furthermore, employees have the right to work in a drug-free
environment, and to work with co-workers who are free from the effects of such
prohibited substances. Employees who use or abuse substances are a danger to
themselves, their co-workers, patients, public, and agency assets.
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All employees are responsible for conformance with this policy.
Drug Testing Procedures
PURPOSE: To establish the official position of COADA-CB as it pertains to drug and
alcohol testing and to assign responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to maintain a drug free work environment for
its employees, patients, and outside stakeholders.
PROCEDURE: Drug and alcohol testing will be conducted by an independent medical
facility selected by COADA-CB that conforms to recognized standards of specimen
collection. The independent medical facility will utilize a laboratory for specimen
analysis of drugs and/or alcohol that has been certified by the National Institute on Drug
Abuse (NIDA). The standards utilized by the independent medical facility and laboratory
will assure that testing is performed only by trained personnel with a concern for the
personal privacy and dignity of each employee, while assuring a confidential, elaborate
chain of custody procedures for samples and proper identification.
All employees and applicants will be required to complete and sign the appropriate
consent form before the actual testing takes place. Refusal to sign a consent form will be
regarded as failure to comply with this policy and will result in immediate termination or,
in the case of the applicant, termination of employment consideration.
Drug and/or alcohol testing will be through breath, urine sample, and/or other collection
methods to determine the presence of any illegal or unauthorized drug(s) and/or alcohol.
The testing facility of the agency reserves the right to request that a new specimen be
provided where it has reasonable cause to believe that the specimen has been or is being
altered or substituted. Such a reasonable suspicion may necessitate same sex observation
of the collection process.
Individuals required submitting to testing following a work-related accident, incident, or
reasonable suspicion will not be allowed to return to work until the lab results have been
processed and submitted to Human Resources.
Initial test results for the presence of drugs or alcohol will be classified as either positive
or negative. Failing a drug test is defined as a confirmation of initial test results, which
shows positive evidence of the presence of alcohol or a prohibited substance in the body.
If the initial test is positive, an appropriate confirmatory test will be performed to confirm
the presence of the illegal or unauthorized drug(s) and /or alcohol in the employee's
system. The levels for determining a positive test result will be in accordance with NON
DOT standards upheld by the NIDA certified laboratory.
The employee being tested claims the test results were positive because of medically
supervised use of legally supplied prescription drugs identified prior to testing, he/she
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must supply the designated medical facility and/or the agency with proof of the
prescription and current medical supervision.
Positive Test Results
An employee who receives a verified positive test result following an alcohol breath test
and or a drug screening, will be subject immediate termination.
All employees are responsible for conformance with this policy.
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Random Employee Selection for Drug/Alcohol Testing
PURPOSE: To establish the official position of COADA-CB on the administration of
random alcohol and or drug tests to employees and to assign specific responsibility for
implementation of the policy.
POLICY: COADA-CB mandates all employees subject to unannounced random drug
and or alcohol testing in order to preserve employee reputation for integrity, honesty and
responsibility, foster public trust, and as a condition of employment. COADA-CB
considers its mission to be consistent with illegal drug use and drug interdiction
responsibilities.
PROCEDURE: The following guidelines govern the manner in which random drug and
or alcohol tests may be initiated:
1. COADA-CB requires the random selection process for drug and or alcohol testing of
an employee at any time while employed at COADA-CB with or without evidence of
drug and or alcohol use and will be include all levels of management up to the Executive
Director.
2. All communication regarding random drug testing selection will be handled in a
confidential manner. Human Resources will approach the employee in a private and
confidential manner and will never imply the suspected use of drug and or alcohol use.
3. The employee will be required to report to the assigned laboratory for the drug and or
alcohol random testing within 30 minutes of notification of random selection for a
predetermined method of drug testing, e.g. urine, blood, hair sample, breath alcohol test,
etc.
4. COADA-CB will pay for all employer requested drug testing of employees.
5. Test results are received from the laboratory and cleared for reporting and mailed
directly to Human Resources. Positive results will be released to only those who need to
know.
6. If drug test is positive for non-prescribed, illegal drugs, or blood content level above
.02, COADA-CB may terminate an employee based upon positive results of illicit drugs
and or the presence of alcohol breath content.
7. At the discretion of the Executive Director, or Board President in situation involving
Executive Director, COADA-CB may or may not elect to pay for substance abuse
assessment.
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An employee selected for random drug testing may not obtain a deferral of testing unless
a compelling need necessitates a deferral on the grounds that the employee is:
A. In a leave status (sick, annual, administrative, or leave without pay); or
B. In official travel status away from the test site or is about to embark on official
travel scheduled prior to testing notification.
An employee whose random drug test is deferred will be subject to an unannounced test
within the following 45 days.
All employees are responsible for conformance with this policy.
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Post Accident Drug Testing or Reasonable Suspicion
PURPOSE: To establish the official position of COADA-CB on the administration of
drug tests to employees and to assign specific responsibility for implementation of the
policy.
POLICY: It is the policy of the COADA-CB to require any employees involved in an
on-the-job accident, incident, and vehicle collision to submit to a drug and/or alcohol test
within 8 hours of the incident or reasonable suspicion.
PROCEDURE: The following guidelines govern the manner in which drug tests may be
initiated on employees of the organization:
1. COADA-CB Executive Director may:
A. Require drug testing of an employee at any time while employed at COADA-CB
with or without evidence of drug use;
B. Require drug testing of an employee at any time while employed at COADA-CB if
having frequent or prolonged absences;
C. Request a drug test on only one employee without asking for drug testing from
other employees;
D. Require drug testing of an employee based on hearsay of alleged drug use.
2. The employee must be escorted to the laboratory for the drug testing by private or
public transportation, by the Division/Program Manager or Human Resources
representative, or Board President in the situation involving the Executive Director.
3. Request for required drug testing of an employee will be made in a private and
confidential manner.
4. COADA-CB will pay for all employer requested drug testing of employees.
5. COADA-CB may determine the method of drug testing, e.g. urine, blood, hair sample,
breath alcohol test, etc.
6. COADA-CB employee may or may not receive prior warnings or counseling prior to
the request for drug testing.
7. All communication regarding drug testing, assessment and/or treatment will be
handled in a confidential manner and on a need to know basis.
8.COADA-CB will terminate an employee based upon positive results of illicit drugs and
or alcohol above .02
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9. COADA-CB will terminate an employee if the Executive Director, or Board President
in situation involving Executive Director, if alcohol and/or prescribed medication is
perceived to be interfering with adequate job performance.
10. At the discretion of the Executive Director, or Board President in situation involving
Executive Director, COADA-CB may or may not elect to pay for substance abuse
assessment.
11. If an employee receives a verified positive test result following a work related
accident, his or her workers' compensation benefits may be reduced or denied under state
statutes.
"Involved in an on-the-job accident or injury" means not only the one who was injured,
but also any employees who was involved with the incident or injury in any way. A
controlled substance is unauthorized if the employee does not have a valid prescription
for that substance at the time of its use or possession. Passing an alcohol/drug test is
defined as initial or confirmation test results, which do not show evidence of the presence
of alcohol/ and or illegal drug or unauthorized controlled substance in the body. Failing a
drug test is defined as a confirmation of initial test results, which shows positive evidence
of the presence of alcohol or a prohibited substance in the body. Reasonable Suspicion
includes actions, activities, or behavior which may justify reasonable suspicion or
probable cause to believe an employee is using or has used illegal or unauthorized drugs
and/or alcohol, or is under the influence of such drugs or alcohol. This list is not meant
to be exhaustive.
A. Odor of alcohol on the breath.
B. Walking or talking erratically.
C. Dramatic personality changes, especially if they occur in the middle of the day
such as emotional outbursts or an out-of-character change in physical appearance.
D. Bloodshot eyes, slurred speech, poor coordination, safety violations, physical
altercation, unusual behavior.
E. Coming to/returning to work in an obviously abnormal condition.
F. Sloppy work where the employee is not able to present a reasonable explanation.
G. Memory or concentration lapses where the employee is not able to present a
reasonable explanation.
If there is reasonable suspicion and/or evidence that the employee is currently under the
influence of a Prohibited Substance, transportation to the designated medical facility for
testing will be arranged, or if he/she refuses testing, transportation home will be offered
and employee will be immediately terminated from employment.
All employees are responsible for conformance with this policy.
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Employee Behavior Regarding Alcohol and Other Drug Use
PURPOSE: To establish the official position of COADA-CB on employee behavior as it
relates to the use of alcohol and/or other drugs and to assign specific responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that it will strive to foster a workplace that is
free of the effects of tobacco, (including the use of “smokeless” tobacco products)
alcohol and/or other drug use. Toward that end, this policy specifically prohibits the
possession, sale, use or consumption of tobacco, alcohol and/or other drugs while
performing job duties while on or off the premises and provides for a specific course of
action to be taken if alcohol and/or drug use is suspected.
PROCEDURE:
The following guidelines represent the organization’s specific
procedures in support of this policy:
1. Employees shall promote a drug, tobacco, and or alcohol free work environment
refrain from:
A. The inhalation or use of all tobacco forms, consumption of alcohol, illicit drugs,
and/or controlled substances not prescribed by their personal physician, or from a
licensed dentist, podiatrist, physician assistant or advanced practice nurse practicing
within licensure requirements, during COADA-CB’s work hours or at the COADACB work site locations;
B. The possession of tobacco, alcohol, illicit drugs, and/or controlled substances not
prescribed by their personal physician, or from a licensed dentist, podiatrist,
physician assistant or advanced practice nurse practicing within licensure
requirements, at COADA-CB’s work locations or work hours.
C. The unlawful manufacture, distribution, or dispensing of tobacco, alcohol, illicit
drugs and/or a controlled substance in COADA-CB’s work locations or during
work hours;
2. The employees of COADA-CB serve as role models in the community for responsible
behavior regarding tobacco, alcohol and/or other drug use. The employees shall not:
A. Publicly display inappropriate behavior in the community related to use of tobacco,
alcohol, illicit drugs, and/or controlled substances not prescribed by their personal
physician, or from a licensed dentist, podiatrist, physician assistant or advanced
practice nurse practicing within licensure requirements; and
B. Publicly consume any form of tobacco, alcohol, or use illicit drugs, and/or
controlled substances not prescribed by their personal physician, or from a licensed
dentist, podiatrist, physician assistant or advanced practice nurse practicing within
licensure requirements, while in the representative role of a COADA-CB employee
(e.g. health fairs, meetings, consultative situations, school functions, jails, civic
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clubs, churches, other agencies, community education/training situations, etc.).
3. A COADA-CB employee may notify the Division/Program Manager at COADA-CB
of any known above violations to A, or B above. At any time, the employee may also
notify the Executive Director directly without going through their Division/Program
Manager. The Board of Directors is to be notified if the Executive Director is involved.
4. Upon notification, the Division/Program Manager shall inform the Executive Director,
within 24 hours during the workweek and within 72 hours during weekends and holidays.
5. The Executive Director, or the Board of Directors if applicable, will implement the
disciplinary action. The disciplinary action may:
A. Result in employee information referral for smoking cessation treatment;
B. Result in a employee chemical dependency assessment and treatment at another
licensed chemical dependency facility;
C. Result in notification of the employee’s licensing/certification board;
D. Result in employee requirement to submit to drug testing;
E. Result in a combination of the above; or
F. Result in termination of employment.
All employees are responsible for conformance with this policy.
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Fitness for Work
PURPOSE: To establish the official position of COADA-CB on its expectations
regarding the fitness of employees to safely perform their job functions as a way to
provide a healthy safe environment for all employees, patients and participants and to
assign responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all employees are expected to be mentally
and physically fit for work at all times and able to perform the essential functions of their
jobs as described in their job descriptions. Further, it is the policy of COADA-CB that the
organization reserves the right to address any and all incidents of suspected behavior that
indicate that an employee is unfit for work.
PROCEDURE: The following guidelines support this policy and provide direction for
Division/Program Managers in dealing with any suspected incident of an employee being
unfit for work. It is not possible for COADA-CB to anticipate every situation. For that
reason, the following procedures are guidelines; which may vary with existing
circumstances:
1. At all times, COADA-CB management shall maintain a safe workplace and take
immediate action when necessary to ensure a safe workplace.
2. Employees are expected to voluntarily take advantage of sick leave, leave of absence
for medical reasons, with or without pay whenever they are not fit for work. The
guidelines may be applied to employees whom the Division/Program Manager suspects
and/or determines are not fit for work.
3. If an employee violates any other COADA-CB policy while apparently unfit for work,
he/she shall be subject to disciplinary action up to termination.
4. Generally, a Division/Program Manager shall have another manager observe the
actions of an employee before taking action on a belief that the employee is not fit for
work. The two managers may then take one or more of the following steps:
A. Request an explanation from the employee;
B. Reasonably accommodate any restrictions on abilities revealed by the employee;
C. Apply other COADA-CB policies, such as the sick leave policy;
D. Request the employee to provide a statement from his/her physician that he/she is
capable of safely performing his/her job duties;
E. Provide information to the employee regarding COADA-CB benefits;
F. Consult with another manager as described above; and
G. In order to maintain a safe work place, employees whom any manager judges to
pose an immediate danger may be sent home, immediately, by providing safe
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transportation.
5. Any employee, who disagrees with the actions taken by the manager with respect to
the fitness for work policy, may follow the procedures contained in the grievance policy.
6. All information concerning the health of an employee is to be maintained in
confidence and revealed only to those persons with a need to know.
All employees are responsible for conformance with this policy.
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Emergency Medical Information
PURPOSE: To establish the official position of COADA-CB as it pertains to medical
information on patients and employees that might be needed in emergency situations and
to assign responsibility for implementation of the policy.
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POLICY: It is the policy of COADA-CB that emergency medical information will be
maintained on all COADA-CB patients and employees. Further, this policy requires that
such information will be made readily available to emergency responders in the case of a
valid medical emergency involving a patient or employees. Inherent to this policy is the
recognition that medical information must be afforded protection from inadvertent loss,
compromise or disclosure. Therefore, it is the policy of COADA-CB that emergency
medical information will be afforded the same degree of protection as other patient and
employee records. This policy recognizes that federal law prohibits an employee’s
health/medical information from being maintained in the employee’s file/record.
Therefore, it is the policy of COADA-CB that employee emergency medical is
maintained in a central location separate from the employee records.
PROCEDURE:
Emergency medical information will be completed by each
patient/participant and kept in a centrally located area. Similarly, employees will be
asked to provide emergency medical information for use only in emergency situations.
The Executive Director and Division/Program Managers will ensure that completed
forms are maintained in a manner as to protect the confidentiality of employees medical
information but so that the information can be quickly accessed in the event of an
emergency. Patients and employees have a basic and fundamental right to refuse to
provide such information to their employers upon written documentation. Therefore, no
patient or employee of COADA-CB shall be forced, coerced or otherwise required to
provide information against his/her will.
All employees will complete and update as changes occur an “Employees Emergency
Medical Information and Consent Form.” Employees must report any prescription
medication which they are prescribed by a physician immediately prior to commencing
work. The Division/Program Manager will review the prescription information with the
occupational safety/health officer to determine if alternative working accommodations
are needed and available. If deemed unsafe to work due to the prescription medication
use, employees may use any available paid time off after consulting with the
Division/Program Manager.
All employees are responsible for conformance with this policy
Vehicle Safety Inspection and Liability Reporting
PURPOSE: To establish the official position of COADA-CB as it is committed to
promoting safety and responsible driving for its entire employees in addition to providing
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COADA-CB proof of continuous proof of automobile liability insurance and to assign
responsibility for implementation of the policy.
POLICY: To ensure the vehicle to which the employee drives is maintained in a safe
driving condition. COADA-CB requires all employees that operate leased/rented/own
vehicles during the performance of their jobs to submit proof of automobile liability
insurance coverage and a quarterly self reported vehicle inspection checklist to ensure
these vehicles are checked for road-worthiness.
PROCEDURE: The following guidelines support this policy and provide direction for
employees to submit ongoing proof of auto liability insurance requirements and to
complete a self report of the safe and operable condition of the vehicle through the use of
quarterly inspection report.
1. As a condition of employment, all licensed drivers who conduct performance related
activity for COADA-CB are required to obtain and submit ongoing proof of liability
insurance requirements as set forth by the State of Texas Department of Transportation.
2. The employee shall take immediate action to maintain the safe operation of vehicle
use.
3. Employees are required to submit vehicle inspection report quarterly as scheduled by
Human Resources. The information must include the employee name, date of inspection,
and license tag number.
A. The self report contains a list of items to be checked as satisfactory or unsatisfactory
unsatisfactory conditions should be explained in the remarks section of the vehicle
inspection report.
B. The report must be signed by the employee making the inspection and reviewed by
management before the vehicle may continue to be operated for off premise agency
related tasks and or assignments.
Human Resources will review the reports for accuracy and provide reminder
notifications. If not corrected, the Executive Director will be informed. The employee
will be subject to progressive disciplinary actions.
All employees are responsible for conformance with this policy.
Health and Safety Program
PURPOSE: To establish the official policy of COADA-CB on health and safety and to
assign specific responsibility for implementation of the policy.
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POLICY: COADA-CB recognizes its ethical, moral and legal obligation to provide
services in a physical environment that protects the health, safety and welfare of patients,
employees, visitors, and the community to the extent allowable by law. Therefore, it is
the policy of COADA-CB, that: (1) health and safety will be a priority concern in daily
operations (2) the agency will support and maintain an active health and safety program
at all locations; and (3) the agency’s health and safety program will be directed,
monitored and overseen by employees who are specifically tasked with that
responsibility.
PROCEDURE: The organization’s “Health and Safety” program will consist of:
1. Designation of a Health and Safety Officer with ultimate responsibility for (a)
maintaining a healthy and safe environment, (b) daily oversight of the health and safety
program and (c) ensuring that the health and safety program is fully implemented on a
daily basis;
2. One external inspection conducted annually at each COADA-CB facility;
3. Internal, i.e. “self inspections” conducted quarterly at all program and administrative
location;
4. Written emergency plans and procedures that address at a minimum provisions for
dealing with (a) fires, (b) bomb threats, (c) natural and other disasters, (d) power failures
and outages, (e) medical emergencies, and (f) workplace threats and violence;
5. Procedures that address provisions for handling evacuees, providing temporary shelter
and continuity of services in the case of an emergency;
6. Adequate fire detection and suppression equipment at all program locations;
7. Emergency lighting;
8. Smoke detectors in all facilities;
9. Fire extinguishers in all facilities;
10. Ready access to current information on all patients and employees that would be
needed in the case of emergency situation by medical employee;
11.Written procedures for reporting and managing all adverse events and incidents such
as alleged cases of patient abuse, neglect, and/or exploitation;
12. Written policies regarding the use of tobacco products;
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13. Implementation of an infection control plan that calls for the use of “standard
precautions” at all locations as necessary and the communication of the plan to all
employees ;
14. Immediate access to adequate first aid equipment and supplies at all locations and
administrative offices;
15. Emergency lighting, smoke detectors and fire extinguishers at all locations;
16. Employees training and current certification on first aid and CPR as required by
DSHS licensing/regulatory authority and/or national accreditation standards;
17. Written first aid plans;
18. Written procedures that provide for the identification, use, safe handling, storage and
disposal of hazardous materials and medications; and
19. Policies and procedures for handling contraband.
Appearance, cleanliness and the physical condition of both the interior and exterior of the
all facilities are a reflection of the agency and the employees is directly related to the
organization’s health and safety efforts. Therefore, it is emphasized that all employees
have an obligation to ensure that their personal offices reflect a professional appearance.
All employees are responsible for facility cleanliness. The Division/Program Manager
and the Health and Safety Officer is responsible for initiating the repair and maintenance
and/or upkeep of equipment. The management will provide oversight of exterior grounds
including trash and debris or any other situation or condition that detracts from the
professional appearance. The management is responsible for ensuring that any potential
safety, fire or health hazard is corrected as economically and as quickly as possible. As
but one example, Division/Program Managers are responsible for ensuring that
counseling offices, group rooms, rest rooms, refrigerators, cooking areas, etc. are kept
clean and sanitary.
The Division/Program Manager is responsible for the physical safety of all employees,
patients and visitors on COADA-CB premises, giving due consideration to the liability
that is attached to the operation of a treatment facility that is accessible by the public.
Every effort should be made to reasonably protect employees, patients and visitors while
they are on COADA-CB premises.
All employees are responsible for conformance with this policy.
Health and Safety Inspections
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PURPOSE: To establish the official position of COADA-CB on the conduct of internal
and external health and safety inspections and to assign responsibility for implementation
of the policy.
POLICY: COADA-CB is dedicated and committed to providing services in locations
and facilities that protect the health, safety and welfare of patients served visitors and
employees. Toward that end, it is the policy of COADA-CB that all clinics will undergo
periodic internal and external health and safety inspections as a way to maintain an
environment that protects the health and safety of patients and employees alike. The
Health and Safety Officer defines internal health and safety inspections as those
conducted quarterly. External inspections are defined as those conducted by local fire
department employee, representatives of insurance carriers, local building code
inspectors, health and safety experts not employed by COADA-CB. It is the policy of
COADA-CB that internal health and safety inspections will be conducted at least
quarterly at every program location. One external inspection will be conducted at every
location annually. The assigned employee whom conducts the inspection will file a
report that will be maintained on file by the Health and Safety Officer for an indefinite
period of time will complete a “Quarterly Health and Safety Inspection Checklist”. The
Health and Safety Officer will also maintain copies of inspection reports from external
inspections on file. Additionally and in all matters pertaining to health and safety
inspections, COADA-CB will defer to state licensing requirements in the event that such
requirements differ from this policy.
PROCEDURE: The Executive Director is ultimately responsible for the implementation
of this policy and specifically, for ensuring that internal and external health and safety
inspections are scheduled, conducted and documented as required herein. Management
and the Health and Safety Officer are responsible for the correction of any deficiencies
/discrepancies noted as a way to ensure that COADA-CB always provides an
environment that protects the health and safety of all interested stakeholders.
Management and the Health and Safety Officer will monitor the health and safety climate
and environment of all facilities under their responsibility to ensure compliance with this
policy and will work with the Health and Safety Officer and/or the Executive Director as
necessary in the correction of any and all problems, discrepancies and deficiencies.
All employees are responsible for identifying any condition that is unsafe, unhealthy or,
that poses a potential risk to patients, visitors and employees and for reporting their
observations to his/her Division/Program Manager or Executive Director.
Disaster Relief Services
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PURPOSE: To establish the official policy of COADA-CB for responding to a local,
state, or national declaration of disaster relief and to assign specific responsibility for
implementation of the policy.
POLICY: As directed through Executive Order of the Governor, DSHS is responsible for
initiating and coordinating substance abuse crisis counseling services during a state or
federally declared disaster or emergency. Immediate, on-site disaster substance abuse
crisis response will be provided by COADA-CB employees as obligated in the DSHS
Contract. As directed by DSHS, COADA-CB will be required to provide stress
management and crisis counseling to victims, survivors and responders to an event.
A disaster is any event, real and/or perceived, which threatens the well being of citizens,
overwhelms the local and state ability to respond and/or recover, affects federally owned
property, or interests.
PROCEDURES: In the event of a local, state or federal emergency declared as a state or
federal emergency by the Governor’s Division of Emergency Management (DEM),
COADA-CB employees may be called upon to assist DSHS in mitigating the
psychological trauma experienced by victims, survivors, and responders to such an
emergency. This type of response is outside the scope of normal services, requiring
planning and the ability to respond quickly and flexibly. COADA-CB may be required to
assist individual or family in returning to a normal (pre-disaster) level of functioning and
assist in decreasing the psychological and physical effects of acute and/or prolonged
stress. In the event clients already receiving mental health or substance abuse services
are impacted, COADA-CB may work with the affected individuals in conjunction with
the individual’s current support system.
COADA-CB’s responsibilities include, but are not limited to the following:
1. Provide DSHS in the form required by DSHS, with a minimum of two disaster
contacts (Primary & Secondary) and COADA-CB’s Safety Officer. The primary contact
will be the Executive Director and the Treatment Division Manager. Contact information
(work and home phone, fax, cell and/or pager numbers) must be made available and
updated as changes occur:
A. When a disaster occurs, employees should be prepared to have both their schedules
disrupted for a brief period and to work non-traditional hours (up to 12-hour days)
in non-traditional locations with little notice.
B. While it is difficult to estimate the time and resources required providing adequate
disaster substance abuse services, COADA-CB understands the impact that
providing such services can have on the center and therefore seeks to minimize
disruption.
C. Provide one additional contact for each 250,000 persons in the service area;
2. Collaborate with DSHS employees to coordinate disaster/incident response, including
but not limited to status reports, the provision of screening, assessment, outreach, referral,
crisis counseling, stress management and/or appropriate services as necessary;
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3. Assign employees to assist DSHS to meet assessment services needs for morgues,
schools, hospitals, disaster recovery centers, and other necessary services during local,
state or federal emergencies. Employees may also be asked to attend community and
governmental meetings, both as presenters and to provide substance abuse or mental
health support.
4. Participate in disaster mental health, substance abuse education and public health
training programs as necessary. Training services include, but are not limited to:
A. Crisis Counseling Program (CCP) - A short term disaster mental or substance abuse
health program which includes outreach, screening and assessment, counseling,
information, referral, and public education.
B. Disaster Program Training - Variety of disaster mental health training programs
including PTSD, Children and Trauma, Loss and Grief, individual stress
management, individual and group debriefing, education and follow-up.
C. Community Crisis Consortium building - technical assistance provided to local
service providers and governmental agencies to assist in the establishment of
local/regional consortiums.
D. Community Drills - participation in local, state and federal disaster training
exercises.
COADA-CB qualified employees shall provide services which include but are not limited
to outreach, screening and assessment, counseling (individual and group), stress
management, information and referral, and public information. In addition, COADA-CB
employees may be required to assist DSHS in the following locations: the State
Operations Center (SOC), Disaster Recovery Centers (DRC's) and the Federal/State Joint
Field Office (JFO
The Executive Director and/or designated employees are responsible for conformance
with this policy.
Emergency Plans and Procedures
PURPOSE: To establish the official position of COADA-CB on emergency plans and
procedures and to assign specific responsibility for implementation of the policy.
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POLICY: As part of its commitment to providing a healthy and safe environment for
patients, employees and visitors, it is the policy of COADA-CB that emergency plans and
procedures will be developed and implemented to address a variety of emergency
situations. These include, but are not limited to: (a) workplace threats and violence; (b)
fires; (c) medical emergencies; (d) natural disasters; (e) other disasters; and (f) power
failures. As part of this policy, all emergency procedures will include provisions for
handling evacuees, temporary shelter, and a continuation of essential services.
PROCEDURE: The following general guidelines and procedures for emergencies apply
in at all COADA-CB facilities:
Fire
In the event of a fire, the first step that should be taken is the immediate evacuation of all
patients and employees. At the same time – or as soon as it can be practically
accomplished – the local fire department should be notified/alerted via the 911
emergency notification systems or, the activation of installed fire alarms. Under no
circumstances shall any employee attempt to re-enter any facility that is on fire. All
persons evacuated from the facility should be physically accounted for by the
Division/Program Manager or senior employees on site and if necessary, evacuated to a
safe location. In the event that the Division/Program Manager is not on-site during the
fire, he/she will be notified immediately of the situation and briefed on the details. The
Division/Program Manager will immediately contact the Executive Director. Afterwards,
an incident report shall be prepared and submitted in accordance with COADA-CB’s
policy on incident reporting.
Bomb Threats
In the event of a bomb threat, the facility will be evacuated immediately and local law
enforcement will be contacted without delay (911 notifications). No patient or
employees will be allowed to re-enter the clinic without authorization from a of the law
enforcement team who responds to the bomb threat call. The Division/Program Manager
will inform the Executive Director as soon as possible but with the understanding that the
evacuation and safety of patients and employees is top priority.
Natural or Other Disasters
For the purposes of this policy, however, natural disasters are defined as, but not limited
to: (a) tornadoes; (b) earthquakes; (c) floods; (d) storms; and (e) other acts of nature over
which man has no control. However, all emergency procedures shall provide for: (1) the
immediate evacuation of all patients, employees and visitors to a safe location (as predetermined by the Executive Director and/or Division/Program Manager or as identified
in a local community action plan) if so directed by local law enforcement officials; (2)
immediate evacuation of all patients to a safe location (as pre-determined or as identified
in a local community action plan) if it appears to the Division/Program Manager or senior
employees that to remain in the facility would subject any person to physical injury or
harm; (3) accounting for all patients, employees and visitors to local law enforcement
officials/authority; (4) securing the facility to prevent unauthorized entry during the
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emergency and to protect property and patient records; and (5) immediate notification to
the Executive Director. In the event that an evacuation cannot be conducted in time to
avoid a natural disaster and persons are forced to remain in any COADA-CB facility
during the disaster, persons shall remain away from windows and doors as a way to
protect themselves from glass and other debris that may be driven by wind or rain.
Additionally, all persons should congregate in an interior room and seek shelter under
desks or other substantial office furniture that would provide shelter from falling objects
and/or debris.
All employees should immediately notify appropriate law
enforcement/emergency assistance employee via telephone or cell phone to advise them
of their situation and seek advice regarding a further course of action. An incident report
shall be prepared and submitted in accordance with COADA-CB policy.
Power Failures
In most situations, power failures represent more of an inconvenience than a real threat to
health and safety. A power failure of any significant duration will simply result in the
closing of the facility/program. Because of the South Texas climate in summer months,
power outages that result in the lack of air conditioning – even for short durations – may
potentially pose a risk to the health and comfort of patients, employees and visitors.
Therefore, the Executive Director and Division/Program Managers will determine the
appropriate course of action at their facilities in the event of a power outage. Every
attempt will be made to communicate with utility company officials to determine the
estimated duration of the outage so that a reasonable decision can be made regarding
clinic/facility operations and more specifically, if operations should be temporarily
suspended. In the event of a power outage that requires any facility to be closed, the
Division/Program Manager will communicate as quickly as possible with the Executive
Director to discuss the situation and determine if additional action is necessary.
Medical Emergencies
In the event of a medical emergency, the first priority should be to determine if the
person is breathing and if his/her heart is beating so that cardiopulmonary resuscitation
(CPR) can be administered, if required. For medical emergencies that involve fainting,
lapses of consciousness, chest pains, convulsions, severe bleeding, and other similarly
serious symptoms, the 911 emergency notification system should be used to summon
professional medical assistance. Ideally, one or more employees will attend to the victim
while other employees notify appropriate medical emergency. Until such help arrives,
employee shall render any and all such aid and comfort as is indicated by the situation
and, that can be provided within the scope of their professional training and/or formal
training in first aid and CPR. Only those with formal training and current certifications in
it will administer first aid and/or CPR. Any person suffering a medical emergency
should be kept calm and warm to avoid going into shock. While emergency employee is
en route to the clinic/location, employees shall access the emergency medical information
and make information available to medical employee upon their arrival. The
Division/Program Manager or other management employees shall be immediately
notified of the situation and briefed on the details. After the emergency, an “Incident
Report” shall be prepared and submitted in accordance with COADA-CB policy.
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Workplace Threats and Violence (Safety during Violent or Other Threatening Situations)
In the event that any person acts in an aggressive or combative manner, the overriding
rule in all cases must be to always avoid or minimize physical injury to self or others.
Every effort should be made to use verbal/non-contact de-escalation techniques to deescalate/defuse any situation that appears to pose the potential for personal harm or
injury. In the event that such de-escalation is not possible and a violent incident occurs,
employees should seek to protect themselves and others by either evacuating the premises
or seeking shelter in a locked office/area. In the event that escape is not possible,
employees should cooperate with any demands made of them and, avoid any action that
would exacerbate the situation. In some cases, the preferred course of action will be to
ask other patients and employees to leave the premises until the situation can be resolved.
In other situations, the most prudent course of action will be to engage in verbal dialogue
to attempt to de-escalate the situation. In still other cases, the severity of the situation
may dictate that the employees request immediate emergency assistance from local law
enforcement through the 911-notification system. For clarification, direct physical
confrontation is viewed as an undesired course of action although this policy recognizes
that employees might well find themselves in situations in which they are forced to
defend themselves from physical assault. In all situations and incidents involving
workplace threats and violence, employees should notify the Division/Program Manager
or other management employees as soon as the incident is discovered or the situation
develops.
In addition to the general guidelines above, the following steps provide specific guidance
for each emergency plan:
1. COADA-CB has established and implemented procedures for dealing with medical
emergencies. These procedures include:
A. In the case of a medical emergency, employees will always stay with the
patient/participant until help arrives.
B. Use CPR and First Aid techniques as needed in the event of a medical emergency
until medical help arrives.
C. Contact Emergency Services (telephone 911) for advice, instruction, or
transportation in situations requiring continuation of CPR or where patient is not
ambulatory.
D. Provide a copy of the Emergency Medical Release Form to emergency employee.
E. An incident report will be completed within 24 hours in accordance with P & P.
F. The Executive Director will ensure that all employees are currently certified in first
aid and CPR, and are familiar for handling a medical emergency.
G. The Executive Director will also ensure that all emergency phone numbers are
posted by all telephones at program sites.
2. In the case of a psychiatric emergency, employees will take steps to isolate the person,
and calm him/her down without endangering the patient/participant, visitor or employees.
If it becomes necessary, employees will call 911 for assistance. An incident report will
be completed within 24 hours in accordance with policy and procedure.
A. A qualified credentialed counselor may provide all crisis interventions or counselor
intern working under direct supervision.
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B. The Health and Safety Officer will also ensure that all emergency phone numbers
are posted by all telephones at program sites.
C. Treatment Division Manager shall ensure that the counselor has an avenue for a
person experiencing a psychiatric emergency to speak with a trained mental health
counselor within two hours of the initial call during and after normal business
hours.
D. Qualified counselors shall be trained to transfer calls to third party (mental health
counselor, nurse, etc.) while staying on the line with the individual in crisis.
E. Qualified employees will also ensure that all employees who may answer the phone
receives annual emergency response training, including crisis intervention
techniques and available community resources. Training for employees that
provides crisis intervention shall also include motivational interviewing and brief
interventions and therapies.
F. An incident report shall be filed within 24 hours in accordance with policy and
procedure.
3. In the event of the recognition of a face-to-face potential psychiatric crisis, the
following procedures shall be followed:
A. The direct care employees closest by physical proximity to the patient or the closest
therapeutic relationship with the patient:
• Assess the situation to determine action necessary.
• Take precautions to enhance the safety of the patient, other patients or employees.
• Maintain distance of at least an arms length away.
• Calmly attempt early intervention SATORI techniques, including verbal
techniques.
• If attempts at de-escalating are not successful, efforts will be made to calmly
move the patient from the immediate area (this is especially important if there are
other patients present or the environment is not safe).
• Employees should position themselves closest to the door so that a safe and quick
exit can be made.
• In addition, if the patient shows signs of potentially being a danger to self or
others, the Mental Health/Mental Retardation (MHMR) Crisis Line will be
contacted with a request for immediate psychiatric/psychological care. EMS or
Police will provide transportation.
• If SATORI techniques are insufficient to control patient’s behavior, emergency
service will be requested immediately (EMS or, if appropriate, 911).
• Under no circumstances will there be the use of physical, chemical or other type
of special treatment or restraints.
• An incident report shall be filed within 24 hours in accordance with P & P.
4. In the event a female patient is pregnant, specific instructions for pregnancy-related
emergencies shall be followed:
A. The female shall be directed (if conscious) to lie flat on the floor or employees shall
position patient on a flat surface.
B. Emergency Medical Service (EMS) shall be contacted (911) for advice, instruction
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and/or transportation to the hospital.
C. Patients or the employees personal physician shall be notified of the emergency and
hospital to which patient is being transported.
D. Employees shall ensure a copy of the Consent for Emergency Medical form has
been previously completed and a copy given to emergency employee.
E. Employees should talk to patient or employee in calm, soothing voice with words of
encouragement while awaiting EMS arrival.
F. If patient or employee begins to deliver before EMS arrival, employees should be
prepared to grab or catch the baby and guide it safely to a protective cover that
should be placed under the patient’s buttocks (a cloth, blanket, shirt or large paper
will suffice). Then prepare to begin CPR if baby is not breathing. After baby is
delivered and breathing, place on the patient’s chest and cover to keep warm.
G. An incident report shall be filed within 24 hours in accordance with policy and
procedure.
5. As soon as the medical or psychiatric crisis has been resolved, these additional
procedures shall be followed:
A. The Executive Director, Division/Program Manager shall be informed of the crisis
situation and action taken.
B. Time will be allotted to process the emergency with the treatment group or
management team when deemed necessary.
C. Documentation of the event will be placed in the patient’s record.
D. An incident report shall be completed and submitted to the Program’s
Division/Program Manager no later than the following workday.
E. The emergency shall be discussed and evaluated by the employees to assess the
effectiveness of emergency procedure and determine any of the procedures that may
require change.
6. In the event of workplace threats and violence such as hostage situations, individuals
presenting with firearms or other weapons, etc., the following procedures shall be
followed:
A. Employees will call 911 immediately for assistance and direction. If possible, stay
on the line to keep communications open with authorities.
B. Employees in the immediate area will take steps to isolate the person, and calm
him/her down without endangering the patients, participants, visitors or other
employees. If attempts at de-escalating are not successful, efforts will be made to
calmly move the individual from the immediate area. (This is especially important
if there are other patients present or the environment is not safe).
C. Employees should position themselves closest to the door so that a safe and quick
exit can be made.
D. If a counselor is readily available, he/she will calmly attempt early intervention
SATORI techniques, including verbal techniques.
E. Employees in charge shall direct employees and others as needed to enhance the
safety of the patients, participants, visitors and employees.
F. The employees in charge shall either notify, or direct other employees to notify, the
Executive Director as soon as possible.
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G. An incident report shall be filed within 24 hours in accordance with policy and
procedure.
7. In the event of the recognition of a bomb threat, the following procedures shall be
followed:
A. The police will be notified immediately by calling 911 and ask if they have any
special instructions until authorities arrive.
B. The employees shall escort all patients, participants and visitors out of the building
in an orderly fashion.
C. The employees in charge will immediately notify the Executive Director.
D. The employees will make sure that patient and participant records are secure and
make note of any suspicious packages, backpacks or other items that could conceal
a bomb without touching them.
E. Employees will follow the directions provided by the police or bomb squad.
F. Upon arrival, employees will notify the authorities of all suspicious packages,
backpacks, or other items that could conceal a bomb.
G. If an employee discovers a bomb, no one will touch it. In such case everyone will
leave the building immediately.
H. An incident report shall be filed within 24 hours in accordance with policy and
procedure.
8. In the event of chemical or biological terrorist attacks, the following procedures shall
be followed:
A. Employees in charge shall immediately remove patients, participants, visitors and
employees from the immediate area.
B. Cover the mouth and nose with a cloth or paper towel. Cover exposed skin if
possible.
C. Move to an elevated location, if possible and wait for the chemical or biological
substance to clear.
D. Employees will call 911 as soon as possible for assistance and further direction. If
possible, stay on the line to keep communications open with authorities.
E. The employees in charge shall either notify, or direct other employees to notify, the
Executive Director as soon as possible.
F. An incident report shall be filed in a timely manner.
9. All suspicious substances or packages, e.g. powder or odor coming from an envelope,
shall not be touched or manipulated.
A. Employees in charge shall immediately remove patients, participants, visitors and
employees from the immediate area.
B. The Employees in charge shall contact 911 to report any suspicious substances or
packages and stay on the line for directions.
C. The Executive Director shall be notified as soon as possible.
D. An incident report shall be filed within 24 hours in accordance with policy.
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10. In the event of a power failure, all employees shall direct patients, participants,
visitors and other employees to the outside of the building in an orderly fashion using the
illuminated exit signs.
Evacuations and Continuation of Essential Services
As part of the organization’s health and safety program, patients and employees will be
evacuated in actual emergency situations and selected emergency drills. In such cases,
ensuring safety of all evacuees will be the top priority of the Division/Program Manager
and employees. All employee will be accounted for by an actual “head count” to ensure
that all patients and employees have safely evacuated the facility. Since COADA-CB
operates on an outpatient basis, it is unlikely that any emergency would result in the need
for emergency shelter. However, if shelter is needed, the Executive Director and
Division/Program Manager will coordinate with local law enforcement and other
authorities to arrange for emergency shelter as soon as it becomes obvious that such
shelter will be necessary.
Essential services are defined as emergency intervention services provided by COADACB’s Treatment Program. Therefore, the continuation of services in the event of an
emergency situation is a critical component of the organization’s emergency plans and
procedures. To ensure that procedures are in place to assure continuation of emergency
intervention services, Division/Program Managers will insure that all patients have access
to an emergency phone number or other way to contact the employees or other
emergency service employee during emergencies and “post-emergency” situations. In
the event that the organization is faced with a long-term emergency or situation that
would preclude the delivery of services, the organization will attempt to
negotiate appropriate agreements for emergency services with other providers in the
area. The Treatment Division Manager will maintain copies of such agreements on file.
In the event of an actual evacuation, the local fire department and law enforcement
authorities will be notified by the quickest means possible.
Tests of Emergency Plans and Procedures
As a way to maintain employee readiness to handle emergency situations, each
emergency plan/procedure will be tested at least annually. At least one time per year, the
test must include an emergency evacuation of patients and employees. Tests of
emergency procedures will include drills for fire, bomb threats, natural/other disasters,
power failures/outages, medical emergencies, and workplace threats and violence. The
tests of emergency plans and procedures must include evacuation of patients and/or
employees as appropriate to the drill being conducted. Documentation must be
maintained as a way to prove to surveyors that drills have been conducted. Once
completed, the forms will be reviewed and signed by the Health and Safety Officer who
is responsible for analyzing the effectiveness of the drill for performance improvement
purposes and, the identification of any operational changes that may need to be made or
affirmation of existing practices. The completed forms will be maintained on file along
with all other health and safety program documentation. In the event that the tests result
in any recommendation for corrective actions, program changes or the need for fiscal
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expenditures, Division/Program Managers will discuss those recommendations with the
Health and Safety Officer and/or Executive Director for resolution.
Demonstration of Employees Competency in Health and Safety Practices
On a day-to-day basis, Division/Program Managers are responsible for ensuring that each
employee of COADA-CB clearly understands the organization’s health and safety policy
and more critically, knows how to appropriately respond in an actual emergency
situation. This includes, but is not limited to: (1) understanding and implementing those
safety practices in the workplace that would minimize the risk of accident, injury or
death; (2) identification of unsafe conditions or environmental factors that could
potentially result in accident, injury, or death and/or represent a potential risk to the
health of patients and/or employees; (3) knowledge of those procedures to be followed in
case of an actual emergency; (4) knowledge of those steps to be taken to ensure the safe
evacuation of patients and/or employees during emergency situations; (5) identification
of those events, situations and/or circumstances that are defined by the organization as
reportable incidents; and (6) knowledge of the organization’s policy and procedures for
reporting critical incidents.
All employees will demonstrate competency relative to the organization’s health and
safety program by (1) attending formal training at least annually on health and safety
(including the six items identified above) and (2) participating in drills and tests of the
organization’s emergency plans and procedures.
Division/Program Managers are responsible for implementation of this plan as part of a
comprehensive health and safety program at the clinics they manage and supervise.
Division/Program Managers will ensure that all patients and employees are fully aware of
the emergency procedures contained herein. The Health and Safety Officer is responsible
for oversight and implementation of this policy.
Inclement Weather
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PURPOSE: To establish the official position of COADA-CB on those procedures to
follow in the event that inclement weather poses the potential for interruption, cessation
of programs and services, and to assign responsibility for implementation of the
policy.
POLICY: It is the policy of COADA-CB that inclement weather procedures will be
developed and implemented when necessary.
PROCEDURE: The following guidelines describe the organization’s expectations and
procedures relative to inclement weather:
1. As a service agency dependent financially on contributions and grants, COADA-CB
intends to be available (by telephone a/or in person) to the public during all regularly
established workdays and hours.
2. In case of inclement weather, (severe ice, snow, flooding, hurricanes, natural disasters,
etc.), the Executive Director or her/his designee will determine whether the offices will
remain open or closed for business.
3. In the event that the weather changes abruptly (tornado, hurricane or other severe
strong winds and rain), the Executive Director or her/his designee will determine if there
is a potential danger to patients, participants, visitors and other employees due to the
immediate weather conditions.
4. The Executive Director, Police or other law enforcement authorities shall notify the
employees in management positions of the need to escort patients, participants, visitors
and other employees to safety within the building or otherwise. The management will
then notify the employees to escort all patients, participants, visitors and other employees
to an internal room without windows. The escorting process shall be done in a calm,
organized manner. Telephone communication will be used if available to contact family
and/or others who may need information concerning individuals. Patients, participants,
visitors and employees shall stay in the secured area until directed otherwise.
5. If the Executive Director determines when weather conditions warrant the closing of
the office, there will be an announcement made to the division managers and notification
given to the answering service. The Division/Program Manager is responsible for
contacting each employee under their supervision to inform them of the decision to close
the office. If the office is open or re-opens and an employee has an extenuating situation,
it is up to the individual employee to contact his/her manager to determine how to
proceed safely back to work.
All employees are responsible for conformance with this policy.
Accessibility and Accessibility Plans
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PURPOSE: To establish the official position of COADA-CB on patient, employees and
visitor access (accessibility) to the organization’s clinics and facilities, identify the
elements of the organization’s accessibility plan; and assign specific responsibility for
implementation of the policy.
POLICY: COADA-CB recognizes the need to provide services that are easily and
readily accessed by patients, employees and visitors. Toward that end, COADA-CB will
make every reasonable effort to eliminate any and all barriers that might potentially limit
services to persons seeking services at COADA-CB programs. This policy fully
recognizes that all COADA-CB facilities may not be fully accessible by all people
seeking services. However, the organization is committed to providing reasonable
accommodations at all clinic locations. COADA-CB will establish and maintain an
adequate referral network with other providers and provider organizations as a way to
meet the needs of those persons who need services that cannot be readily accessed in
COADA-CB’s facilities. Each facility owned and operated by COADA-CB will develop
and maintain an Accessibility Plan that addresses the needs of patients, employees,
visitors and other interested stakeholders.
The basic Accessibility Plan for COADA-CB consists of:
1. An acknowledgment that barriers to service extend beyond those of the physical
property. Such barriers can include, but are not limited to: (a) negative and
condescending attitudes by employees and employees toward patients and/or the local
community; (b) architectural barriers such as narrow doorways and/or steps that would
limit access to persons using a wheelchair for mobility; (c) environmental barriers such as
clinic locations in dark, remote or unsafe parts of the local community; (d) financial
barriers such as unusually high dosing charges in remote locations where few other
treatment resources are available; (e) employment barriers; (f) communication barriers,
i.e., employees who do not speak the primarily language of the majority of patients
served; (g) transportation barriers such as clinic locations that are not readily accessed
without their own means of private transportation; and (h) other barriers not covered
above but identified by patients, the responsible Division/Program Manager and
employees and/or other interested stakeholders;
2. Management review of all requests from patients and employees for reasonable
accommodations and decisions based on individual need, the good of the organization
and the existing business/fiscal climate. For emphasis, this element of the plan DOES
NOT automatically guarantee that each and every request for reasonable accommodation
will be approved by management. It does, however, ensure a fair, impartial and
expeditious review of the request.
3. An annual review of the plan as a way to monitor access to the organization and more
critically, make improvements where necessary and when indicated. The annual review
will result in the development of a status report that will include: (a) the identification of
time lines for the removal of identified barriers, (b) an assessment/evaluation of progress
being made in the removal of those barriers, (c) an honest appraisal of any areas that still
require improvement, and (d) specific recommendations for improving access to services.
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For clarification, the purpose of the annual review is to honestly and objectively evaluate
accessibility to service provision and more critically, to work toward full access through
the elimination of all identified barriers. The requirement for the annual status report can
be satisfied by updating the Accessibility Plan and/or by developing a new Accessibility
Plan for the next year;
4. An annual review by Division/Program Managers of all recommendations made by
employees regarding access to the facilities under their supervision/management control
and written recommendations to the Executive Director;
5. Implementation of accessibility plans will address the integration of patients into their
local community of choice, so as to advocate for reducing and eliminating barriers in
these community settings;
6. A conscientious organization effort to lease/rent/purchase facilities that are fully
accessible by persons who use assistive devices as a means of enhancing their physical
mobility;
7. An annual review of the Accessibility Plan by the Executive Director with
recommendations for changes/improvements to enhance accessibility and remove barriers
noted;
8. A written status report prepared annually to reflect the status of identified barriers, an
evaluation of progress made toward barrier elimination, a corrective action plan to
identify any remaining barriers; and the subsequent approval of a time line and specific
course of action(s) to address any barriers noted;
9. Consideration of any and all patient and stakeholder input pertaining to accessibility;
10. Efforts to work toward full compliance with all federal, state and local requirements
pertaining to accessibility at all clinic locations, and;
11. Expeditious identification and review of any request – either by patient and/or
employees – for “reasonable accommodations” and prompt decision-making relative to
that request. (For clarification, COADA-CB will make every attempt to accommodate
such requests but reserves the right for ultimate decision-making regarding such
requests).
PROCEDURE: Division/Program Managers are primarily tasked with implementation of
this policy and more specifically, with conducting an annual accessibility review at all
clinic locations and developing a “clinic-specific” Accessibility Plan. The Executive
Director will review the organization’s accessibility plan annually (as well as any
recommendations made by the Division/Program Managers to improve accessibility) and
when appropriate, address accessibility issues in the organization’s strategic plan. All
employees are charged with the identification of barriers to service and for bringing those
barriers to the attention of the appropriate management employees.
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Reasonable Accommodations
It is the policy of COADA-CB that every request for reasonable accommodations by
patients and/or employees will, upon receipt (identification) be immediately reviewed
and expeditiously considered. This policy does not guarantee that every request will be
approved. The policy recognizes that fiscal constraints and other business considerations
will dictate the organization’s ultimate action in such matters. It does, however, commit
the organization to an expeditious review of all considerations.
Division/Program Managers will review all accommodation requests. In the event that
the Division/Program Managers cannot comply with the request or the request will result
in an undue financial expenditure, the request will be forwarded to the Executive Director
who is the final decision-making authority for such matters.
All employees are responsible for conformance with this policy.
Satellite Services
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PURPOSE: To establish the official position of COADA-CB on the provision of services
at locations other than COADA-CB’s facilities and to assign specific responsibility for
implementation of the policy.
POLICY: The leadership of COADA-CB recognizes that the delivery and/or provision of
prevention and/or treatment services in community locations is often required as a way to
support a full continuum of care for those persons residing in the local area. Therefore, it
is the policy of COADA-CB that prior to the delivery of such services, employees will be
fully trained on the potential hazards and liability associated with working away from the
organization’s facilities. At the core of this policy are the organization’s moral and
ethical responsibility to protect the health, welfare and safety of persons served and the
organization’s employees.
PROCEDURE: The following guidelines shall be followed in providing services away
from/outside of the organization:
1. No employee will provide services away from the organization without the specific
approval of the responsible Division/Program Manager;
2. To the greatest extent possible, services will be provided by teams and/or pairs of
employees;
3. Assigned employees will carry cell phones as a way to communicate with the
organization and emergency on call employees in the event of an emergency;
4. Employees will keep the responsible Division/Program Manager informed as to their
“whereabouts” and itinerary at all times when the employee is away from the
organization;
5. In the event of an emergency, employees will (a) immediately contact local law
enforcement via the most expedient means and (b) the responsible Division/Program
Manager or Executive Director as soon as law enforcement has been notified; and
6. Employees who provide services away from the organization will be qualified and
trained in first aid and CPR and will hold current certification in both.
All employees are responsible for conformance with this policy.
Environment and Safety Awareness
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PURPOSE: To establish the official position of COADA-CB on the organization’s
physical and safety environment and to assign specific responsibility for implementation
of the policy.
POLICY: COADA-CB is committed to the protection of the health and safety of all
employees, patients, participants, family and other “stakeholders” who have the occasion
to conduct business/receive services in the organization’s facilities and/or at
client/participants homes or locations. Toward that end, it is the policy of COADA-CB
that it will maintain a healthy and safe environment at all times and in doing so, will
comply with all applicable laws, codes, rules and regulations. Inherent in this policy is
the understanding that all employees will, to the greatest extent possible and consistent
with the business and fiscal climate, actively work to identify any potential barriers
and/or dangers associated with service.
PROCEDURES: The following guidelines describe the organization’s specific approach
and processes for establishing and maintaining an appropriate environment:
1. The facility shall comply with the Americans with Disabilities Act and all other
applicable federal and state laws.
2. The environment shall enhance the positive self-image of patients, participants,
families, visitors and employees.
3. Health and safety inspections of all facilities:
A. Internal inspections conducted quarterly to determine ongoing compliance with the
ADA and the organization’s health and safety program;
B. Conducted at all sites that are owned, rented, or leased by COADA-CB.
C. One external inspection conducted by an outside entity annually.
D. All inspections and/or potentially threatening situations documented, including:
• Identification of areas covered.
• Recommendations for improvement.
• Actions taken in response to the inspection or identified threatening situation.
4. Emergency drills/tests of emergency plans and procedures
A. Emergency drills/tests conducted annually at each location that is owned rented, or
leased by COADA-CB.
B. Drills/tests include: Fires, bomb threats, natural disasters, power failures, medical
emergencies and safety during violent or other threatening situations.
C. All drills/tests documented with written analysis of the tests of the emergency plans
and procedures prepared by an employee to document effectiveness of each test,
identify corrective action taken, etc. Documentation is reviewed by the Health and
Safety Officer or other designated official.
5. Miscellaneous procedures.
A. Emergency telephone numbers are posted near all telephones or on the assigned cell
phone.
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B. First Aid outline posted where all first aid supplies are kept.
C. Adequate first aid supplies on site in all facilities or in the vehicle for off site visits.
D. Buildings/facilities are clean and well maintained.
E. Buildings/facilities have adequate space, furniture, and supplies.
F. Organization has private space for confidential interaction and counseling.
G. Organization prohibits smoking inside buildings, on location premises, and vehicles
and during structured program activities;
H. Employees are prohibited from providing, distributing or facilitating patient or
participant access to tobacco products;
I. Employees and other adults (volunteers, patients, and visitors) are prohibited from
using tobacco products in the presence of children or adolescent participants on the
program site; and
J. The program prohibits children and adolescents from using tobacco products on the
program site or during structured program activities.
K. COADA-CB prohibits firearms and other weapons, alcohol, illegal drugs, illegal
activities, and violence on the program site. (See policy on contraband)
L. COADA-CB will continue to provide a clean, safe, and healthy work environment.
Employees are expected to work safely, observe safety rules and regulations, and
keep their work place neat and clean.
M. All employees will be instructed in the proper method of fire suppression
equipment by the Health and Safety Officer.
N. All on-the-job injuries or accidents, regardless of severity, shall be reported to the
employee’s Division/Program Manager and the Chief of Staff immediately.
O. Upon employment, the Division/Program Manager is responsible for instructing the
new employee on safety-related policies and the proper method to operate any
equipment.
P. Employees who conduct home based services will survey the need for assistance for
personal safety measures.
6. To report on-the-job injuries or accidents regardless of severity, the following steps
should be followed:
A. If medical attention is needed, the employee or nearest bystander should contact
the Executive Director and/or the employees person in charge immediately.
B. This person will provide assistance and take or direct emergency measures prior to
transport to medical facilities, if necessary.
C. If emergency medical attention is necessary, the employee or bystander should
immediately call the emergency number (911) to secure emergency medical aid.
D. If no medical attention is required at the time of the accident, the employee must
complete an incident report the specifics of the accident within 24 hours to his/her
Division/Program Manager.
E. The employee and others who contributed to the injury or accident must submit to a
drug and or alcohol test within 30 minutes of the on-the-job injury or accident.
All safety hazards and/or threatening situation discovered will be reported to the
Division/Program Manager or Executive Director as soon as possible. All employees are
responsible for the safety of the patients/participants when they are on COADA-CB’s
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premises and will take any action necessary to protect the patients/participants from
harm. Any employees that discover unsanitary items will also report these items to the
Executive Director as soon as possible but will, under no circumstance, leave an
unsafe/unhealthy situation unaddressed.
All employees are responsible for conformance with this policy.
First Aid, CPR and Infection Control
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PURPOSE: To establish the official position of COADA-CB on the provision of first aid
and CPR and infection control practices and assigns specific responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB that the employees will be trained and prepared
to provide first aid and CPR during emergency situations. Furthermore, it is the policy of
the organization that it will follow and implement “universal precautions” during the
delivery of emergency medical services as a way to minimize the risk of infection.
PROCEDURE: Employees shall adhere to the following procedures in reporting child
abuse incidents, either suspected or confirmed:
Basic first-aid procedures
1. In the event of a medical emergency, employees shall provide needed first-aid, CPR,
and/or have someone call, 911. Always stay with the individual if possible until help
arrives.
2. In the event that someone receives a gunshot wound, control bleeding by applying
pressure to the wound with a clean cloth or paper towel. If no sterile dressing is available,
arrange transport to the emergency room.
3. In the event that some is stabbed with a knife or other sharp object, leave the object in;
do not remove it. Stabilize object, so that it will not go in or come out. Arrange transport
to the emergency room.
4. In the event that someone gets an irritant in his or her eyes, flush the eyes with water
and arrange transport to a clinic.
5. In the event that someone potentially fractures a limb, splint the extremity and wrap, so
that limb is stabilized and arrange transport to the emergency room.
6. In the event of swelling resulting from a contusion or bite, the general rule is applying
ice for the first 24 hours; then heat. Always, be aware of the body’s response. If it is
uncomfortable don’t do it.
7. Know 911, the location of the closest emergency room/clinic and/or hospital
Universal Precautions
1. Wipe up liquid spills to prevent someone from slipping and falling.
2. Wash hands frequently; especially, before eating and after using the restroom.
3. Keep the work area free of clutter and potential safety hazards.
4. Be alert to potential safety hazards and report these to the Executive Director and or
Division/Program Manager as soon as possible.
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5. Remain calm. Re: THINK BEFORE YOU ACT.
6. Stay home if sick and contagious (coughing and sneezing) to prevent spreading an
infectious condition around to others (patients, participants, visitors, other employees,
etc.).
Incident reports
1. Must be completed and submitted in accordance with COADA-CB’s policy on
incident reporting.
Miscellaneous procedures and requirements
1. Employees, patients, participants and visitors are not to handle hazardous materials.
2. First aid materials are kept readily available at all times.
3. Sufficient number of employees shall be trained in basic first aid and CPR certified so
that at least one employee is present in each program at all times. Note: This training
includes prevention and control of infections and communicable diseases.
4. First aid outlines with emergency procedures are posted in areas where first aid kits are
kept.
All employees of the organization are responsible for conformance with this policy.
Incident Reporting
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PURPOSE: To establish the official policy of COADA-CB on event/incident reporting
and to assign specific responsibility for operational implementation of the policy.
POLICY: The accurate and timely reporting of significant events involving COADACB’s patients, employees, facilities or community reputation – and that occur either on or
off COADA-CB property/premises – is of paramount importance to the organization’s
leadership and all significant events will be expeditiously reported to the Executive
Director as well as to DSHS, as required.
For purposes of this policy, the following situations, conditions and/or circumstances
must be reported under this policy: (1) incidents involving restraint or injury; (2)
communicable diseases; (3) infection control; (4) violence or aggression; (5) sentinel
events (incidents involving death, injury, significant property destruction, etc.); (6) use or
possession of weapons; (7) vehicular accidents involving employees conducting official
business on behalf of the organization; (8) bio-hazardous accidents, (9) miss-use of licit
or use/possession illicit substances and (10) other situations, events, conditions or
circumstances that are required by DSHS rules or regulations to be reported via the
incident reporting system. It should be noted the use of seclusion is specifically
prohibited by COADA-CB policy and must be reported to DSHS.
PROCEDURE: Employees will immediately report all significant incidents as defined in
this policy using the Incident Reporting Form and ensure that a copy is centrally
maintained on file. Division/Program Managers will immediately notify the Executive
Director who will be responsible for determining: (1) potential causes; (2) if the event
represents part of an ongoing trend; (3) actions for improvement; (4) results of
performance plans; (5) necessary education and training for employees, (6) prevention of
recurrence; and (7) compliance with internal and external reporting requirements.
Debriefings will follow all significant incident reports and will include all employees
involved to (1) discuss the incident and its antecedents, (2) identify any procedural and/or
policy changes that need to be made to prevent a reoccurrence of the incident and more
critically, (3) to ensure that employees have an opportunity to discuss and disclose their
feelings, emotions and reactions to the incident.
To conform with this policy, employees shall complete an individual report for all
significant employee related incidents and or patient/participant incidents.
1. Patient/participant incidents include, but are not limited to:
A. Actual incidents of suspected abuse, neglect, exploitation, or any violation of
patient rights;
B. Accidents and injuries;
C. Medical emergencies;
D. Behavioral and psychiatric emergencies;
E. Illegal or violent behavior;
F. Loss of a patient/participant report;
G. Release of confidential information without patient consent;
H. Fire and other natural disasters;
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I. Significant disruption of program operation; and
J. Death of an active patient/participant (on or off program site).
2. Incident reports shall document:
A. What happened (detail of incidents);
B. How it happened (sequence of events);
C. When it happened (exact or approximate date and time);
D. Where it happened (exact or approximate location);
E. Individuals involved;
F. Action taken;
G. What happened to the patient/participant; and
H. The time and date the report is written with all appropriate signatures.
3. DSHS shall be notified of all investigations in regard to suspected abuse, neglect,
exploitation, or other violations of patient rights.
A. Actual incidents of suspected abuse, neglect, exploitation, or other violations of
patient rights shall be reported accordingly in specified time frame:
• Immediately, but no later than 24 hours of such notification by employees, a
verbal report shall be made of all allegations by the Executive Director to DSHS
at (800) 832-9623. If the allegation involves the Executive Director, it shall be
reported directly to COADA-CB governing board and DSHS investigations
department.
• The person who reported the incident shall submit a written incident report to the
Executive Director within 24 hours.
• The Executive Director will submit a written report within two (2) working days,
after receiving notification, to DSHS. This report shall include:
(1) Name of the patient/participant;
(2) Name of person the allegations are against;
(3) A copy of the incident report; and
(4) List of other individuals, organizations, and law enforcement officials notified
regarding the incident.
• The Executive Director shall also notify the legal consenter. If the
patient/participant is the legal consenter, family and significant other(s) may be
notified only if the patient/participant gives written consent.
• COADA-CB shall investigate the incident/complaint and take appropriate action
unless otherwise directed by DSHS investigation department.
• The governing body or its Designee shall take action needed to prevent any
confirmed incident from recurring.
• COADA-CB shall:
(1) Document all investigations, result of actions, and keep the documentation in a
secured central file;
(2) Enforce the policies and procedures and provide appropriate sanctions for
confirmed violations.
B. Other serious incidents shall:
• Include a copy of incident report; and
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• Be reported, in writing, within 72 hours of the event discovery, to the
Division/Program Manager who will submit this information as soon as possible to
the Executive Director;
C. To be reported to DSHS investigation department @ 1-800-832-9623 immediately
upon discovery:
• Violation of laws;
• Violation of rules;
• Violation of employees professional and ethical codes of conduct;
• Fires and natural disasters;
• Suicide attempt by an active patient or participant (on or off the program site)
• Substantial disruption of program operation;
• Death of an active patient/participant (on or off the program site);
• Medical and psychiatric emergencies that result in admission to an inpatient unit of
a medical or psychiatric facility; and
• Illegal, unethical, or unprofessional conduct;
• Violent behavior on the program site that results in injury or a police report; and
• Legal, regulatory, or contractual action taken against the program.
D. COADA-CB shall comply with all other reporting requirements as specified by law
including:
• Requirements specified in the Texas Human Resources Code Section 48.3b
relating to the abuse of the elderly;
• Requirements specified in the Texas Family Code Section 34.01 relating to the
abuse of children;
• Requirements listed in the Civil Practice and Remedies Code, Section 81.0006
relating to allegations involving sexual exploitation; and
• Required financial and utilization data as requested by The Texas Department of
Health.
E. The Treatment Division Manager shall ensure:
• All levels of services remain in compliance with all applicable reporting
requirements;
• Corrective action is taken as required by DSHS or other legal authority;
• Incident reports are maintained in a secured central file; and
• Results submitted to the QMT of the annual incident reviews, which are to be
conducted of all incident reports to:
(1) Identify patterns;
(2) Evaluate the effectiveness of employees response;
(3) Evaluate actions taken (e.g. additional corrective or preventive action).
COADA-CB recognizes that the more critical issue is the prevention of incidents,
situations and conditions that pose health and safety risks to all stakeholders and
therefore, potential liability for the organization and prompt medical attention, if needed,
to persons involved in the incident.
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All employees are responsible for conformance with this policy.
Weapons, Firearms and Other Contraband
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PURPOSE: To establish the official position of COADA-CB on the handling and
disposal of any contraband brought into facilities owned, rented or leased by COADACB and to assign specific responsibility for implementation of the policy.
POLICY: The leadership of COADA-CB believes that patients, employees and visitors
are entitled to an atmosphere that is free from threats to their physical safety. Therefore,
it is the policy of COADA-CB that all tobacco, firearms, alcohol, illegal drugs, legal
drugs that could be abused and/or used in an illegal manner and other forms of
contraband – as defined by COADA-CB– are prohibited in all facilities. No policy can
cover all conceivable items or situations that may occur and involve contraband. For the
purpose of this policy, contraband shall be defined as any item or substance which (1) is
illegal to possess and/or (2) has the potential to cause injury or death or inflict physical
harm or damage to patients, employees, visitors, facilities or furnishings. This policy
specifically prohibits bringing any gun, knife, or other contraband weapon into any
facility.
PROCEDURE: The following procedures will be followed when dealing with suspected
and/or confirmed contraband:
1. In the event that an employee encounters a patient, employees or other visitor who is in
possession of contraband as defined in this policy, verbal notification should be made to
the Executive Director and Division/Program Manager or other management employees
as quickly as possible. In turn, the Executive Director or Division/Program Manager will
(1) ask the person to leave the facility and/or (2) contact local law enforcement to deal
with the situation. Common sense and clinical insight/judgment should always dictate
the best ways to handle situations involving contraband but must always consider any
risks to personal safety that might result from direct confrontation by employees. If
contraband is discovered the Executive Director will call the local law enforcement for
contraband confiscation and investigational purposes.
2. COADA-CB shall:
A. Prohibit smoking inside facility buildings, location premises, and vehicles.
B. Not allow employees to provide, distribute, or facilitate patient or participant access
to tobacco products;
C. Not allow employees and other adults (volunteers, patients, and visitors) to use
tobacco products in the presence of children or adolescent participants on the
program site; and
D. COADA shall prohibit the use of tobacco on all sites and within 15 feet of an
entrance doorway.
E. The program shall prohibit children and adolescents from using tobacco products on
the program site or during structured program activities.
3. COADA-CB shall prohibit tobacco, firearms and other weapons, alcohol, illegal drugs,
illegal activities, and violence on the program sites.
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4. Patient orientation will include an explanation that illicit, licit tobacco, drugs, and
alcohol are not to be brought to program, along with the prohibition of firearms and other
weapons.
5. Employees shall refrain from:
A. Use of controlled substances not prescribed by their personal licensed medical
practitioner practicing within licensure requirements, during COADA-CB’s work
hours;
B. The unlawful manufacture, distribution or dispensing of tobacco, alcohol, illicit
drugs and/or a controlled substance in COADA-CB’s work locations or work hours.
C. Possession of controlled substances not prescribed by their personal licensed
medical practitioner practicing within licensure requirements, at COADA-CB’s
work locations or work hours;
6. The employees of COADA-CB serve as role models in the community for responsible
behavior regarding alcohol and/or other drug use. The employees shall not:
A. Publicly display inappropriate behavior in the community related to use of tobacco,
alcohol illicit drugs, and/or controlled substances not prescribed by a personal
licensed medical practitioner within licensure requirements; and
B. Use tobacco, alcohol, illicit drugs, and/or controlled substances not prescribed by
their personal licensed medical practitioner practicing within licensure
requirements, while in the representative role of a COADA-CB employee, e.g.
health fairs, meetings, consultative situations, school functions, jails, civic clubs,
churches, other agencies, community education/training situations, etc.
7. Any employee may notify the appropriate Division/Program Manager at COADA-CB
of any known violations of items above. At any time, the employee may notify the
Executive Director directly without going through the Division/Program Manager.
The Board of Directors is to be notified if the Executive Director is involved.
8. Upon notification, the Division/Program Manager shall inform the Executive Director,
or Board of Directors if the Executive Director is involved in the situation, within 24
hours during the work week and within 72 hours during weekends and holidays.
9. The Executive Director, or the Board of Directors if applicable, will implement the
disciplinary action. The disciplinary action may:
A. Result in referral for smoking cessation information and treatment;
B. Result in notification of the employee’s licensing/certification board.
C. Result in employee placed on probationary status;
D. Result in employee requirement to submit to random drug testing;
E. Result in a combination of the above; or
F. Result in termination of employment.
All employees are responsible for conformance with this policy.
HIV in the Workplace
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PURPOSE: To establish the official position of COADA-CB on dealing with HIV in the
workplace and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to fully comply with all applicable state and
federal laws, codes, rules and regulations pertaining to HIV in the workplace. Toward
that end, all employees will benefit from specific information and procedures to guide
them in the performance of their duties in the event that they encounter or supervise
persons who may be infected with HIV.
PROCEDURE: The following guidelines are provided in support of this policy:
1. It is COADA-CB’s intent to comply fully with the provisions of Section 504 of the
Rehabilitation Act of 1973, (as amended), the Texas Commission on Human Rights Act
of 1983, which recognizes AIDS as a medical disability of handicap and prohibits
discrimination based on AIDS, and Section 5.03 of Senate Bill 959 concerning the
development and implementation of workplace guidelines.
2. COADA-CB recognizes the need for increased awareness and understanding of AIDS
and HIV infection in order to deal with the sensitive and growing concerns of employees
in the workplace.
3. COADA-CB’s position on HIV infection in the workplace is based on the best
available medical and scientific opinions; including statements from the U.S. Public
Health Service’s Centers for Disease Control; that is, there is no evidence that HIV is
transmitted through casual contact in ordinary social or occupational settings or
conditions.
4. Should significant new findings contrary to the above information regarding the
transmission of HIV become available and supported by the U.S. Public Health Service’s
Centers for Disease Control, agency procedures and practices may be amended to reflect
such new findings.
5. An employee or patient infected with HIV will be treated as any other. This includes,
but is not limited to, granting requests for reasonable accommodations for employees
who are infected with HIV, unless the requests impose an undue hardship on the agency;
treating all medical information about a person with HIV infection confidentially; and
providing information leading to access to medical care, health and other benefits.
6. All employees will be given in-service education programs to provide a greater
knowledge of HIV infection and related conditions in order to minimize any undue stress
or disruptive conduct due to fears and misinformation about the transmission of HIV.
This will help ensure employees recognize and avoid personal behaviors that might cause
them to become infected.
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7. Division/Program Manager will be provided with training on AIDS to prepare them to
deal with employee concerns and other issues related to AIDS in the workplace. These
programs will be used to educate Division/Program Managers on generally accepted
research on AIDS in the workplace, to provide advice on how to recognize and handle
situations which arise in their division, and to convey COADA-CB’s guidelines for
maintaining the confidentiality of any medical or other information about employee’s
health status.
8. The HIV Education Curriculum will include: Modes of Transmissions, Methods of
Prevention, Occupational Precautions, Current Laws and Regulations and Rights of an
AIDS/HIV – Infected Individual, and Texas Laws: Behaviors Associated with HIV
Transmission.
9. Any employee, who believes that he or she has been discriminated against because of
AIDS or HIV infection or sero-positive test results, should contact his/her
Division/Program Managers to discuss the matter informally and may initiate action
through the agency’s grievance procedures.
10. Based on the Federal Privacy Act, the Texas Commission on Human Rights Act, the
Texas Communicable Disease Prevention and Control Act, and medical documentation
or information provided by an HIV-infected employee to medical or management
employee must be considered confidential and private information and may not be
released without the employee’s knowledge and consent. When HIV-related symptoms
occur, it is the employee’s responsibility to provide medically verified information
relating to his/her ability to perform job duties. Such information will be kept in a
separate file, which can only be accessed by the Executive Director or other designated
official.
11. Refusal to work with HIV-infected co-workers or patients will be carefully monitored
and documented. Only with the consent of the HIV-infected employee can appropriate
COADA-CB officials such as Division/Program Managers, medical employees, be
informed of the employee’s status. If requested, Human Resources will monitor the
insurance status of the HIV-infected employee to assure continuation of coverage.
Anyone who has access to confidential information is charged with maintaining strict
confidentiality and privacy. The non maintenance of strict confidentiality regarding the
medical status of an HIV-infected employee is a serious offense and may be subject to
discipline, termination and or litigation.
12. Extended Sick Leave: The request for Extended Sick Leave will follow normal
procedures. However, to maintain confidentiality regarding the nature of the illness, the
request should be reported to the Division/Program Managers who will then report it to
the Executive Director. The information will be kept in a separate, locked file in the
Human Resources Department.
13. On-the-Job Exposure: An employee may request the agency to pay the cost of HIV
testing and counseling if the employee documents to the agency’s satisfaction that the
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employee may have been exposed to HIV while performing duties of employment with
the agency.
14. For the purpose of qualifying for workers’ compensation or any other similar benefits
or compensation, an employee who claims work-related exposure to HIV must provide
the agency with a written statement of the date and circumstances of the exposure.
COADA-CB shall comply with the Americans with Disabilities Act, the Texas Health
and Safety Code (Chapter 85), and Standard Precautions for Infection Control as outlined
by The Centers for Disease Control and Prevention.
All employees are responsible for conformance with this policy.
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Agency Transportation
PURPOSE: To establish the official position of the organization on the use of vehicles
operated by employees of the organization in the conduct of official business, including
the transport of other employees, patients or participants, and to assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that agency vehicles will be used only for the
conduct of official COADA-CB business and be liability insured, safe, and in operable
condition. Inherent in this policy is a specific provision against transporting patients or
participants in private vehicles owned by employees; in the event they choose to do so in
violation of this policy, the organization’s vehicular insurance coverage will not pay for
any damages or injuries incurred and the employee will be liable for incurred expenses.
PROCEDURE:
The following procedures pertain to all transportation activities
conducted by the organization; COADA-CB employees are not permitted to transport
COADA-CB participants/patients in private vehicles without:
1. Consent for Transportation and Waiver of Liability and Hold Harmless Agreement
forms shall be documented and placed in patient record prior to patient being transported
via COADA-CB’s vehicle to include:
A. Signature of adult patient/participant, who is also legal consenter; and
B. Signature of legal consenter when patient/participant is 16 years of age or under.
2. Guidelines for use of COADA-CB’s vehicle are as follows:
A. Any vehicle used to transport a participant/patient will have appropriate insurance
coverage for business use with a current safety inspection sticker and license.
B. The vehicle will have a copy of the vehicle insurance coverage and procedures for
handling emergencies, including roadside and personal emergencies that may occur
during vehicle operation.
C. Drivers must have a valid driver’s license.
D. Drivers and all front seat passengers must wear seatbelts at all times the vehicle is
in operation.
E. A vehicle shall not be used to transport more passengers than designated by the
manufacturer.
F. Drivers shall not use cellular phones while driving.
G. Use of tobacco products is not allowed in the vehicle.
H. Every vehicle used for patient/participant transportation shall have a fully stocked
first-aid kit and ABC fire extinguisher that is, easily, accessible but secured so that
these items are not loose in the vehicle.
I. The Division/Program Manager must approve use of the vehicle prior to transporting
patients/participants.
J. Use of COADA-CB’s vehicles must be scheduled in travel log prior for the purpose
of transporting patients/participants.
K. On field or day trips, employees driving vehicle shall provide rest stop at reasonable
intervals; provide transportation to the nearest emergency room in case of an
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emergency with patient/participant, provide copy of patient consent for emergency
medical care form; notify the Division/Program Manager who shall, in turn, notify
appropriate family and the Executive Director; and not make unauthorized stops of a
personal nature for either driver or patient/participant.
L. All drivers shall utilize a transportation log to include, at a minimum:
• Date and time;
• Destination;
• Patient/participant’s name and number;
• Driver(s);
• Purpose of trip; and
• Beginning and ending mileage to each point.
3. As an alternative to the use of COADA-CB or personal vehicles to transport
patient/participants, COADA-CB has established an account with a local taxi service.
Use of this option requires:
A. Prior approval by the Division/Program Manager;
B. Contact the approved taxi service;
C. Email the Finance Business Manager a notice of the taxi use and estimated mileage;
D. COADA-CB will be invoiced by the taxi service.
4. COADA-CB will only provide insurance coverage for the individual employees using
agency vehicles to transport patient/participant and/or families or in the conduct of other
official agency business. Employees who conduct business in personal vehicle will
assume the insurance liability through their private insurance selection to claim vehicular
loss and or damage. COADA-CB will not be liable for employees or patient/participant
and/or families when personal vehicle is used for transportation.
All employees who operate vehicles belonging to COADA-CB are responsible for
conformance with this policy.
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Use of Students, Interns and Volunteers
PURPOSE: To establish the official position of COADA-CB on the use of students,
interns and volunteers in programs operated by the organization and to assign specific
responsibility for implementation of the policy.
POLICY: COADA-CB utilizes the services of practicum student interns and volunteers
in its programs. Therefore, it is policy of the organization that the use of practicum
student interns and volunteers will be approved by the organization’s leadership with
appropriate documentation on file to clarify responsibilities and protect both parties.
PROCEDURE: Before any practicum student intern or volunteer actually begins work at
any program operated by COADA-CB, the Division/Program Manager must receive prior
approval from the Executive Director. Under no circumstances will a volunteer or
practicum student intern be allowed to work in any COADA-CB program if the
practicum student interns and/or volunteer are not fully qualified as required by law. No
practicum student intern will be allowed to provide services without direct supervision of
the Division/Program Manager or other legally qualified employees.
As a condition for affiliation with the organization, the following documentation will be
prepared and maintained: (a) a complete description of job duties and functions, (b) a
description of the volunteer/intern’s scope of practice, including any limitations thereto,
(c) other criteria to guide the intern, including but not limited to expectations and
guidelines pertaining to clinical supervision, (d) a description of the orientation and
training process for the student intern, (e) a description of how the student intern’s
performance will be evaluated and reported to the sponsoring academic institution, (f) a
description of the organization’s dismissal policies and specifically, those situations,
conditions and/or actions that would constitute grounds for immediate dismissal, and (g)
a statement of expectations regarding confidentiality and more specifically, the protection
of patient information as required by 42 CFR Part 2 and the Health Insurance Portability
and Accountability Act.
Volunteers will normally be processed through the Volunteer Center and coordinated by
the designated volunteer coordinator. All volunteers are to complete volunteer
applications and confidentiality agreements, as well as sign in logs.
Division/Program Managers are responsible for conformance with this policy on a daily
basis.
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Clinical Supervision
PURPOSE: To establish the official position of COADA-CB on clinical supervision of
employees with responsibility for the delivery of clinical services; define expectations
regarding clinical supervision, and to assign formal responsibility for implementation of
the policy.
POLICY: COADA-CB is committed to the highest quality treatment services and
recognizes the importance of clinical supervision – as well as professional development
and continuing education training – as a way to enhance counselor competency.
Therefore, it is the policy of COADA-CB that all clinical counselors receive regular
clinical supervision – including specific feedback about their clinical and/or counseling
skills. Within the context of this policy, the requirement for clinical supervision applies
to all direct care employees.
The primary focus of clinical supervision is:
1. Evaluation of and improvement in employees competencies related to assessment and
referral skills;
2. Accuracy of assessment and referral skills, when applicable;
3. Assurance of ongoing appropriateness and improvement in clinical interventions by
employees and relative to the individualized need of the patient;
4. Assessment of treatment effectiveness as evidenced by the patient’s accomplishment of
treatment goals and objectives and the patient’s feedback relative to her/his treatment;
5. Timely, pertinent and ongoing feedback to clinical employees to enhance clinical skill
development;
6. Evaluation, assessment and continual improvement in all other counselor core
competencies for counselors providing direct care services.
PROCEDURE: The clinical supervision program will also include the evaluation and
development of those professional competencies required by each of the direct service
employees to (1) assist patients in accomplishing their treatment goals and objectives,
and (2) to support the organization in the accomplishment of its mission statement and
other established goals and objectives. Clinical supervision is also intended to identify
any corrective and/or remedial actions that may be identified during the ongoing
evaluation process that is so critical to effective supervision. Clinical supervision can
take any number of forms. It can be provided as part of informal case discussions, a peer
review process, patient sessions, chart reviews or in more formal ways such as structured
feedback sessions conducted on a regular basis or, as part of a performance review. In
the event that the DSHS dictates specific requirements pertaining to clinical supervision,
COADA-CB will defer to those requirements as a condition for continued state licensure.
Division/Program Managers are responsible for implementation of this policy and
specifically, for ensuring that clinical counselors are part of a formal clinical supervision
process and that they regularly receive feedback about their clinical skills and
competencies. The Executive Director is responsible for insuring that the Treatment
Division Manager meets this requirement.
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SECTION 3
QUALITY IMPROVEMENT
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Performance Improvement Plan
PURPOSE:
To establish the formal position of COADA-CB on performance
improvement, describe the organization’s Performance Improvement Plan (PIP) and to
assign formal responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization will establish and maintain
a formal PIP as a way to continually monitor the effectiveness and efficiency of all
programs and services. The PIP will conform to DSHS Interagency Collaboration and
Reporting 447.105 Subchapter A, Standard of Care Rule 448.503 Reporting Measures,
Subchapter E Facility Requirements, and Quality Management 448.504 to monitor,
evaluate program implementation, performance, and provide a formal mechanism for
reviewing the DSHS performance measures and other relevant program data and issues.
PROCEDURE: The following procedures apply to the organization’s PIP:
The PIP involves a number of systematic activities to comprehensively monitor,
coordinate and evaluate the services delivered to individuals receiving services from
COADA-CB. The program uses predetermined, objective standards to demonstrate
measurable improvements. The PIP addresses service coordination among COADA-CB’s
internal programs and with various community programs and outlines standardized
performance-monitoring activities implemented by COADA-CB.
The PIP establishes a structured methodology that enables the organization’s leadership
to perform an ongoing systematic planning, monitoring, evaluation, and revision process
in an objective and comprehensive manner that results in improved performance of
services regardless of external factors. It is representative of a review, analysis of the
community and consumer needs, desires, and preferences as compared to the services that
are currently provided using evidenced based curriculums approved by DSHS and the
National Registry of Evidence Based Programs and Practices (NREPP).
COADA-CB uses the Substance Use Disorders (SUD) standards/guidelines of care,
which have been developed by the Center for Substance Abuse Prevention (CSAP),
Center for Substance Abuse Treatment (CSAT) and DSHS Rules. The modifications of
The Texas Department of Insurance utilization review rules (Sections 3.8001-3.8026 and
3.8019 – 3.8026, Subchapter HH, Chapter 3, Title 28, Texas Administrative Code) will
be the guidelines used by COADA-CB to make decisions regarding the type and duration
or length of stay (LOS) of SUD services.
Goals
COADA-CB’s PIP is based on goals and objectives that are reviewed and revised
annually by the Quality Management Team (QMT) and the organization’s leadership.
The goals for COADA-CB’s PIP are consistent with those of the organization and
include:
A. Increase awareness of SUD in the service delivery area.
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B. Provide consistently accessible care to youth and adult in the service delivery area
in need of outpatient substance abuse treatment.
C. Provide the level, frequency and LOS of care that is clinically appropriate to the
needs of the individual according to the availability of resources in the community.
D. Prevent future SUD problems through education and early intervention in the
service delivery area.
Specific Activities
The Quality Management Program (QMP) involves a strategy to facilitate the
accomplishment of the PIP. The PIP specifies that QMT activities be undertaken over a
prescribed period of one year, and that specific methodologies and activities be
undertaken. The QMT meets monthly and reviews the following on as needed basis:
A. Review DSHS performance measures, daily capacity averages and other related
program data, identify issues and implement appropriate action to improve service
delivery;
B. Review and revise PIP goals and objectives;
C. Determine effectiveness of the QMP through development and evaluation;
D. Review and evaluate consumer satisfaction surveys;
E. Review and evaluate family satisfaction surveys;
F. Evaluate community needs for substance abuse prevention, intervention, treatment,
and other substance abuse related services;
G. Evaluate and monitor access to services;
H. Promote individualized planned treatment;
I. Review prevention, intervention, and treatment program processes;
J. Review and analyze data obtained from the various programs;
K. Implement an effective organizational communication and coordination systemwithin and external to the agency;
L. Evaluate adequacy of employees training and cross-training availability;
M. Maintain compliance with DSHS and Federal standards;
N. Maintain compliance with scientific evidence based guidelines;
O. Review and determine effective use of volunteers;
P. Review findings of program self-evaluations;
Q. Review consumer complaints/grievances and corrective actions taken;
R. Review incident reports for patterns;
S. Review safety tests and responses;
T. Review and update policy and procedure manuals;
U. Review data collection and recording systems;
V. Review and evaluate cost effectiveness of services with related outcomes;
W. Review clinical information;
X. Review information technology system, including CMBHS;
Y. Review human resources capabilities, including cultural diversity competency;
Z. Review intake and accessibility processes, including waiting list; and
AA. Review transportation issues.
BB. Maintain compliance with curriculums approved by the NREPP and DSHS.
CC. Review current continuum of care structure of interlinked treatment modalities.
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DD. Review treatment matching process to increase treatment retention, improve
treatment outcomes.
Quality Record Reviews
A. The QMP provides information for record reviews. Information collected for the
record review is used to identify deficiency in training needs for improved quality of
services.
B. The results of employees records reviewed and patient/participant results/outcomes
are provided to the QMT in a timely fashion. Employees will also receive timely
feedback, so that necessary improvements can be implemented.
C. The Division/Program Managers will submit an annual written summary of the
professional review results to the QMT.
D. The QMT will address deficiency concerns. Employees affected will receive
individual reports in person and it will be documented as part of their evaluation.
Outcome Management System
A. An outcome management system is included in a systematic program selfevaluation approach to ensure accomplishment of the goals and objectives for each
service program.
B. The outcome measures serve as performance indicators that assist COADA-CB
governance and management authorities to evaluate, improve and market services.
C. The outcome management system uses the collection of specific data for overall
program analysis and curriculum effectiveness.
D. The goals and objectives of the program are consistent with the overall goals of
COADA-CB and DSHS.
E. The Division/Program Managers use the outcome management system monthly to
evaluate their program and make improvements if needed.
F. The Division/Program Managers present the analysis of the program selfevaluation/outcomes to the QMT at each meeting.
Community Needs Assessment
Community needs are determined from gathering and compiling community information
from available planning reports, research, community profiles, and informal surveys. The
QMT may contact other service providers in the service area to assess if others have
conducted a formal and/or informal community needs assessment.
Active QMT
The team provides administrative direction and oversight of the program by routinely
monitoring and evaluating service-related delivery processes and products. The QMT
will maintain an agenda and minutes of each meeting convening at least monthly, but
may gather more frequently to achieve the PIP goals and objectives. Minutes will include
the QMT meeting date and time, place, names of present and absent members, summary
of issues discussed on meeting agenda, assignments given, and other documentation of
QMT actions.
Accountability to the Organization’s Leadership
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The Executive Director serves as the QMT liaison to COADA-CB governing board and
heads the QMT. Membership of the QMT includes all COADA-CB management
personnel. Other members may be asked to attend the QMT meetings for purposes of
representing missing, sharing information, or to assist with specific tasks. Various
members may be assigned tasks to be performed outside of the QMT meeting that need to
be completed and reported back to the QMT at a later date.
Monitoring of Consumer Complaints/Grievances
The Executive Director will collect, review, and submit all programmatic complaints to
the QMT. The QMT will evaluate the programmatic complaints to assess for patterns
and/or opportunities to improve programs. All allegations of participant or patient abuse,
neglect, and exploitation are not considered programmatic complaints and will be
handled according to policy.
Coordination of Quality Management Activity with COADA-CB’s Programs
The QMT will perform an evaluation of the coordination and collaboration activities
between various programs within COADA-CB. The program coordination is a
continuous process that supports a seamless service delivery system. This may extend to
coordination of other community agencies, if not addressed in individual programs.
Findings from community needs assessments, outcome management/measures, QMT
activities, all employees meetings, divisional employees meetings and other applicable
information will be included in the programmatic coordination and collaboration
assessment to improve programmatic effectiveness.
Annual Management Summary
The Annual Management Summary (AMS) will include the results of implementing the
PIP. This report describes the results of the outcome management system, quality
performance improvement data, the impact of the PIP, and other information collected
and analyzed by the organization. The PIP is based, at least in part, on on-going planning
activities, information management, assessing community needs, measuring outcomes,
QMT activities and other PIP initiatives to continually improve COADA-CB’s services.
Assessment of the effectiveness of corrective actions taken to correct organizational
deficiencies will be included in the AMS. The AMS will be drafted by the Executive
Director, and then presented to the QMT for review. The AMS report will be distributed
to the Board of Directors. Employees will have access to the AMS for review. At the
discretion of the Executive Director, the summary will be provided to referral and
funding sources and/or regulatory “stakeholders” of COADA-CB.
Performance Improvement Plan
Annually, the PIP is drafted in conjunction with input from a variety of sources: results
from previous year PIP, satisfaction survey results, outcome data, financial analysis,
community feedback, governing board feedback, employees input, complaints, incidents,
and other quality reviews. The initial drafted PIP is submitted to the QMT for review and
revision and is then submitted by the Executive Director to the Board of Directors.
All employees involved in the performance improvement plan of business practices are
responsible for conformance with this policy.
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Outcomes Management
PURPOSE: To establish the official position of COADA-CB on outcomes management
and assign specific responsibility for implementation of the policy.
POLICY: COADA-CB is dedicated to the continuous improvement of
prevention/intervention/treatment services. It is the policy of COADA-CB to use
outcomes management data on a periodic basis to: (1) evaluate the effectiveness of
prevention/intervention/treatment services; (2) evaluate the efficiency of
prevention/intervention/treatment services; (3) evaluate access to services; (4) evaluate
satisfaction of participants/clients/patients and stakeholders; and (5) make any changes in
services that may be indicated by evaluation and the analysis of data. The performance
goals for the program shall be based on the COADA-CB delivery of providing
prevention/intervention/ treatment and are higher than the accepted standards of the
substance abuse treatment field.
PROCEDURE: The following general guidelines pertain to/describe the collection,
analysis and distribution of outcomes management data:
1. COADA-CB uses input from stakeholders to formulate accurate outcome
measure data that is gathered from person(s) served and includes family, employees,
funding sources, regulatory agencies; and other sources.
2. The outcomes management system includes program goals and objectives for
each
program,
measures
of
effectiveness,
measures
of
efficiency,
measurement/evaluation of access to service, assessment of the services and overall
satisfaction by persons served.
3. The outcome management system includes measurement at the beginning of
services; the end of service or at appropriate intervals and at points of time following
services.
4. The results of the outcomes management system are used for program
improvement, decision-making by the organization’s leadership, public education,
improved client retention rate, continuum of care and finally, to support advocacy
services for those seeking/in need of services and other populations that may be
underserved in the local area.
5. The following are the specific program data reviewed and analyzed as part of
the agency outcomes management system. The Division/Program Manager performs an
on-going self evaluation submitted to the QMT quarterly.
A. Performance outcomes for Youth Prevention Universal (YPU): that includes
outcome data of # youth receiving education; # youth involved in Alcohol and Other
Drugs (AOD) alternative activities; # adults involved in AOD alternative activities; #
youth attending minor and tobacco presentations; # adults attending minor and tobacco
presentations; # prevention presentations that include minors and tobacco information; #
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of youth attending tobacco alternative activities; and # of adults attending tobacco
alternative activities; # of AOD presentations; #of youth attending AOD presentations; #
of adults attending AOD presentations; # of youth receiving information; # of adults
receiving information.
YPU Performance Measures: Measurement through utilization of pre-and post-tests for
educational services including: (1) measurement of the satisfaction of the persons served,
(2) fidelity to curriculum and quality assurance, (3) budget review each month, (4)
reporting and complying with outcome for 3rd grade level of youth who improved or
maintained high scores in their social competence and life skills and reporting and
complying with outcome for 4th, 5th, and 7th grade levels for youth who increased
perception of harm scores in their social competence and life skills, and (5) complying
with DSHS definitions of performance outcomes measures requirements as completion
rate of 85% and success rate of 90%.
B. Data evaluation for Community Coalition Partnerships (CCP) includes: outcome
data of # of coalition meetings conducted; # of coalition recruitment efforts; # of new
coalition members recruited; # of new written community agreements; # of renewed
written community agreements; # of coalition members attending coalition meetings; # of
media contacts focused on the three prevention priorities of alcohol (underage drinking),
marijuana, and prescription drugs; # of social media messages focused on the three
prevention priorities of alcohol (underage drinking), marijuana, and prescription drugs; #
of media awareness activities focused on the three prevention priorities of alcohol
(underage drinking), marijuana, and prescription drugs; # of alcohol and other drugs
(AOD) presentations focused on the three prevention priorities of alcohol (underage
drinking), marijuana, and prescription drugs; # of youth receiving alcohol and other drugs
(AOD) information focused on the three prevention priorities of alcohol (underage
drinking), marijuana, and prescription drugs; # of adults receiving alcohol and other
drugs (AOD) information focused on the three prevention priorities of alcohol (underage
drinking), marijuana, and prescription drugs; # of youth attending alcohol and other drugs
(AOD) presentations focused on the three prevention priorities of alcohol (underage
drinking), marijuana, and prescription drugs; # of adults attending alcohol and other
drugs (AOD) presentations focused on the three prevention priorities of alcohol
(underage drinking), marijuana, and prescription drugs; and # of environmental,
regulatory, or legal strategies implemented or changed focused on the three prevention
priorities of alcohol (underage drinking), marijuana, and prescription drugs.
C. Performance Outcomes for Pregnant, Postpartum Intervention (PPI) that includes: #
of pregnant, postpartum, or Department of Family Protective Services (DFPS) referred
adults and youth screened for substance abuse risk factors; # of pregnant, postpartum or
DFPS-referred adult screened for substance abuse risk factors; # of pregnant youth with a
PPI open case prior to 28 weeks gestation and through the delivery; # of pregnant adults
with a PPI open case prior to 28 weeks gestation and through the delivery; % of all youth
clients pregnant at case open who participated in programmatic activities through four
weeks postpartum; % of all adult clients pregnant at case open who participated in
programmatic activities through four weeks postpartum; % of pregnant youth delivering
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at full-term; % of pregnant adults delivering at full-term; % of pregnant youth delivery at
healthy weight; % of pregnant adults delivery at healthy weight; % of pregnant youth
reporting abstinence from date of open case to delivery; % of pregnant adults reporting
abstinence from date of open case to delivery; % of all youth clients receiving
reproductive health visits; % of all adults clients receiving reproductive health visits; %
of all youth clients whose children receive all recommended well-child visits during the
time the client’s case was open; % of all adult clients whose children receive all
recommended well-child visits during the time the client’s case was open.
Program Self-Evaluation Criteria will include: measurement of the satisfaction of the
clients/participants service initially and upon closing case with PPI program; Program
Manager and program staff availability for training in the Nurturing Parenting
curriculum; the completion of a resource directory of agencies who partner with PPI
program; the tracking of referrals sources and follow up with referral agencies; the
review of 5 charts monthly to ensure complete charting submitted to the DSHS and
maintaining a review of charts for 2013-2014 fiscal year; the evaluation of service plans
made at initial appointments and update any new information at least quarterly for each
client.
D. The Treatment Division Manager performs a Self-Evaluation process on the
Adolescent program monthly that includes outcome data evaluations for percent of youth
who successfully complete treatment services; percent abstinent at discharge; percent
admitted to/involved in ongoing treatment/recovery episode/ (supportive residential,
outpatient, 12-step groups, and other ongoing support services); percent with no arrest
since admission; and percent attending school or vocational training
E. The Treatment Division Manager performs a Self-Evaluation process on the Adult
program monthly that includes outcome data evaluations for percent of adults who
successfully complete treatment services; percent abstinent at discharge; percent
discharged to stable housing; percent admitted to/involved in ongoing treatment/recovery
episode/ (supportive residential, outpatient, 12-step groups, and other ongoing support
services); percent with no arrest since admission; and percent employed at discharge.
The Executive Director and Division/Program Managers are responsible for the
implementation of this policy and will ensure that outcomes management data is
collected from a sufficient number of participant/client/patients to ensure that meaningful
outcomes data is actually received and reviewed by the organization’s leadership. The
QMT will periodically review the outcomes data and as described elsewhere in this
manual, make recommendations to the Board of Directors for administrative and/or
program changes. The Executive Director will ensure that any changes in programming
or administrative or program operations are documented with such documentation
maintained on file as evidence that results of the outcomes management system have
been used for continuous improvement purposes.
All employees involved in the performance improvement plan of business practices are
responsible for conformance with this policy.
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Quality Record Reviews
PURPOSE: To establish the official position of COADA-CB on quality record reviews
and to assign specific responsibility for implementation of the policy.
POLICY: COADA-CB is committed to continuous quality improvement as a way to
enhance its treatment services and more specifically, to the periodic review of patient
records as a way to validate the quality of service delivery, appropriateness of services
and patterns of service utilization. The organization recognizes that periodic review of
patient records is necessary to maintain "quality control" of clinical documentation and
provide valuable feedback to professional employees. Therefore, it is the policy of
COADA-CB that an on-going review from the QCC team of all active records will be
conducted to determine quality and appropriateness of services rendered, patterns of
service utilization, and any patterns of grievances, appeals and incidents and will compile
results quarterly to the QMT. The process must also include a review of patient records
from each counselor/case manager as well as a review of a minimum of 20% of all closed
records each quarter. All reviews will be documented. This policy also requires an ongoing review of all grievances and appeals submitted by patients as a way to identify
significant trends and where appropriate, a course of action to improve programs,
services and quality of care.
It is the policy of COADA-CB to measure effectiveness, efficiency, access to service and
customer satisfaction on a representative sample of all patients. The review must include
both active and closed charts as part of the sampling. The term-closed charts refer to the
charts of those patients who have been discharged from treatment in the past 12 calendar
months.
PROCEDURE: The following procedures pertain to the conduct of quality reviews:
1. Reviews will be conducted by QCC team who are trained and qualified to conduct
such reviews.
2. Reviews will include a representative sample of patient charts/records to include both
active and closed records.
3. Reviews will address whether:
A. Patients were provided with a complete orientation;
B. Patients were actively involved in making informed choices regarding their
treatment;
C. Initial screenings/assessments were thorough, complete and timely;
D. Treatment goals and objectives were based on results of the initial assessment
with a appropriate input from patients;
E. Services delivered/provided were related to the treatment goals and objectives;
F. Services were documented in accordance with COADA-CB’s policy on clinical
documentation;
G. The treatment plan was reviewed and updated as appropriate; and
H. Update discharge plans upon completion of the program.
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4. No single employee will be the sole reviewer of cases/services for which he/she was
primarily responsible.
5. Information collected from the quality review process will be reported to the applicable
employees for the purposes of professional development and will be used to improve the
quality of services.
6. Patient record review forms must be signed by the Division Manager. Additionally,
the Division Manager will use the results of the review process to assist clinicians in
improving their treatment and clinical documentation skills and in the planning of future
training events.
7. Division Manager, with oversight by the Executive Director, will review the quality
record reviews of treatment services.
8. The results of the reviews will be provided to the QMT in a timely manner.
Information collected for the record review is used to identify training needs and to
improve the quality of its services.
9. Employees will also receive timely feedback from the reviews and be provided with
review results so that necessary improvements in clinical documentation and/or service
delivery can be implemented. The feedback will be provided individually and will be
documented as part of their performance evaluations.
10. The quarterly review will address whether:
A. Persons served were provided with a complete orientation;
B. Persons served were actively informed in making informed choices regarding
the services they received;
C. Assessments of persons served were thorough, complete, and timely;
D. Service goals and objectives of the persons served were based on the results of
the assessments and input of the person served;
E. Actual services were related to the service goals and objectives;
F. Services were documented in accordance with COADA-CB’s policy; and
G. The individual plan was reviewed and updated in accordance with
organizational policy.
It should be noted that CMBHS provides for an automatic record verification process so
that the service bill accurately reflects the actual services that were provided and dates of
service provision coincide with the billed episodes of care.
QMT is responsible for ensuring that quality reviews are conducted and documented on a
representative sample of all patient records in accordance with this policy and/or as
required by DSHS.
All employees involved in the performance improvement plan of business practices are
responsible for conformance with this policy.
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SECTION 4
GENERAL PROGRAM STANDARDS
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Fully Informed Consent/Refusal for Service
PURPOSE: To establish the organization’s official position on fully informed consent
and fully informed refusal and to assign specific responsibility for implementation of the
policy.
POLICY: It is the policy of COADA-CB that no services will be provided to a
patient/participant until such time as it is clear that that person has consented to receive
services. Inherent in this policy – and others pertaining to “patient/participant rights” – is
the recognition that all persons served by the organization have a fundamental right to
accept and/or reject services after they have had an opportunity to have all program
services as well as program rules and rights and responsibilities clearly explained to them
in an understandable manner.
PROCEDURE: The following procedures will be followed in implementing this policy:
1. No person will be admitted to any COADA-CB program until such time as he/she
signs a consent form to document her/his willingness and desire to enter the program.
2. All potential patients/participants have a right to an explanation and description of
COADA-CB services.
A. COADA-CB offers screening, assessment, intervention, treatment, referrals
education, and prevention services for adults and youth who are having problems
with alcohol and/or other drugs.
B. Services are provided by qualified, credentialed counselors, educational specialists,
program specialists, and supervised Counselor Interns (CI) who are working toward
licensure.
C. Patients/participants have the right to request a different counselor and or education
specialist and the rights to file a grievance if they feel they have been treated
unfairly.
D. Patients/participants are to have involvement in all aspects of their individual plans.
E. Services are provided in a manner that is responsive to each person’s unique
characteristics, needs, and abilities.
3. All treatment patients have the right to receive information about payment/fees for
services prior to receiving services.
A. Patients will never be turned away because of the inability to pay.
B. COADA-CB is licensed and funded by Medicaid, DSHS, and other insurance
companies.
C. COADA-CB works on a sliding scale fee, which will be discussed with patients by
employees. If a patient is covered by insurance, COADA-CB will seek
preauthorization of the required services.
4. All treatment patients have the right to receive information that all services provided
are confidential.
5. All sessions are conducted in privacy by trained employees.
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6. No patients/participants information is released without written permission with the
exception of the following situations, which state regulations and ethical principals
require:
A. Reports of child abuse, neglect, or exploitation;
B. Court Order and Subpoena;
C. Crime committed on COADA-CB’s property;
D. Medical Emergencies;
E. Patient/Participant is intoxicated/high and insists on driving; and/or
F. Threats of suicide or homicide.
7. All patients/participants have the right to receive information that COADA-CB aspires
to provide quality services for the community, enhanced by education and research.
A. Counselor Interns are employees hired to gain supervised experience.
B. In an effort to evaluate and upgrade our services, COADA-CB employees conducts
patient and family satisfaction surveys and program outcome studies.
8. All individuals denied services are provided an explanation.
A. Individuals who do not meet admission requirements into the program will be
provided rational for denial of admission.
B. Individuals who are in need of services not provided at COADA-CB shall receive
referrals to other appropriate service providers located within reasonable proximity
to the patient’s home as needed.
All employees involved in the intake and/or orientation of new patients are responsible
for conformance with this policy.
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Patient and Participant Bill of Rights
PURPOSE: To establish the official position of COADA-CB on patient and participant
rights and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all patients and participants will be
afforded all rights required by the DSHS, and as mandated by ethical standards of care.
Inherent in this policy is the expectation that rights will be clearly explained to all
patients and participants in a manner that is clearly understandable.
PROCEDURE: The following guidelines represent the organization’s process for ensuring that
all patients and participants are afforded their rights:
1. COADA-CB shall comply with the DSHS as required for patient and participant rights.
2. Documents describing patient and participant rights as specified by DSHS are:
A. The Participant Bill of Rights;
B. The Patient Bill of Rights;
C. A notice on reporting complaints and violations which includes the Commission
Compliance Division; its mailing address; its toll-free phone number; and
Participant Grievance procedure.
3. These documents listed in item 2 above shall be displayed:
A. In a prominent public location that is readily available to participants, patients,
visitors, and employees;
B. At eye level and not buried under other documents; and
C. Legible in both English and Spanish at each licensed site.
4. It is the responsibility of COADA-CB employees to ensure that patients’ and
participants’ legal and human rights are respected and protected at all times.
5. Patient’s have the right to review their records with a counselor present to answer
questions and provide explanations as needed.
6. A Patient Bill of Rights Form shall include the details of the rights to which
participants are entitled while in the program. The Patient Bill of Rights shall include the
following:
A. The right to a humane environment that provides reasonable protection from harm
and appropriate privacy of personal needs;
B. The right to be free from abuse, neglect, and exploitation of any sort;
C. The right to be treated with dignity and respect;
D. The right to appropriate treatment in the least restrictive setting available that meets
the individual needs;
E. The right to be told about the program's rules and regulations before you are
admitted;
F. The right to be told before admission about (a) the condition to be treated, (b) the
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treatment itself, (c) the risks, benefits and side effects of all proposed treatment and
medications, (d) the probable health and mental health consequences of refusing
treatment, and (e) other treatments that are available and which ones, if any, might
be appropriate.
G. The right to accept or refuse treatment after receiving this explanation.
H. If you agree to treatment or medication, you have the right to change your mind at
any time (unless specifically restricted by law);
I. The right to a treatment plan designed to meet your individualized needs and the
right to take part in developing that plan;
J. The right to meet with employees to review and update the plan on a regular basis;
K. The right to refuse to take part in research without affecting your regular care;
L. The right not to receive unnecessary or excessive medication;
M. The right not to be restrained or placed in a locked room by yourself unless you are
a danger to yourself or others;
N. The right to have information about you kept private and to be told about the times
when the information can be released without your permission;
O. The right to communicate with people outside the facility. This includes the right to
have visitors, to make telephone calls, and to send and receive sealed mail. This
right may be restricted on an individual basis by your doctor or the person in
charge of the program; if it is necessary for your treatment or for security, but even
then, you may contact an attorney or DSHS at any reasonable time;
P. The right to be told in advance of all estimated charges and any limitations on the
length of services that the facility is aware of;
Q. The right to receive an explanation of your treatment or your rights if you have
questions while you are in treatment;
R. If you consented to treatment, you have the right to leave the facility within four
hours of requesting release’ unless a physician determines that you pose a threat of
harm to yourself and others;
S. The right to make a complaint and receive a fair response from the facility within a
reasonable amount of time;
T. The right to complain directly to DSHS at any reasonable time;
U. The right to get a copy of these rights before you are admitted; including the
address and phone number of the DSHS; and
V. The right to have your rights explained to you in simple terms (in a way you can
understand) within 24 hours of being admitted.
7. If a patient’s right to free communication is restricted in any way, the Division
Manager shall document the clinical reasons for the restriction and the duration of the
restriction in the patient record. The Division/Program Manager shall also inform the
patient and, if appropriate, the patient’s consenter of the clinical reasons for the
restriction and the duration of the restriction.
All employees are responsible for conformance with this policy.
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Patient/Participant Grievances/Complaints
PURPOSE: To establish the official position of COADA-CB on patient/participant
grievances and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all patients and participants will be
afforded the opportunity to submit a formal grievance or complaint at any time for review
by COADA-CB management.
PROCEDURE: The following guidelines represent the organization’s process for the
submission and review of patient/participant grievances and complaints:
Definition
A grievance/complaint is any dissatisfaction expressed by a complainant, orally or in
writing, to COADA-CB employees, with any aspect of COADA-CB operation; including
but not limited to, dissatisfaction with organizational administration, service provisions,
the way a service is provided, facility, employees (including volunteers and students),
program rules and regulations, denial of services, referral and coordination processes,
and/or may include patient/participant abuse, neglect, or exploitation.
A grievance/complaint is not a misunderstanding or misinformation that is resolved
promptly by supplying the appropriate information or clearing up the misunderstanding
to the satisfaction of the patient/participant.
Distribution of the Grievance Procedure to Patients/Participants
The employees shall give each patient/participant a copy of the grievance/complaint
procedure within 24 hours of admission and explain it in clear, simple terms that the
patient/participant understands.
Patient/Participant Rights Pertaining to Grievances and Complaints
The grievance procedure shall afford patients/participants with the right to:
1. File a grievance about any violation of patient rights or DSHS rules;
2. File a grievance with any employees, volunteer, or student worker;
3. Submit a grievance in writing and get help writing it if they are unable to read or write;
4. Submit a grievance directly to DSHS at any time; 1100 W. 49th Street, Austin, TX
78756
5. Request pens, paper, envelopes, postage, and access to a telephone for the purpose of
filing a grievance;
6. Have a reasonable, specific deadline for completing the process; and
7. Obtain the address and toll-free telephone number of DSHS.
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Grievance/Complaint Response Procedures
The grievance/complaint organizational response is as follows:
• Employees, volunteer, or student worker will acknowledge the
grievance/complaint in writing within 24 hours (72 hours on weekends)
• Evaluate the grievance thoroughly and objectively, obtaining additional
information as needed;
• Employees, volunteers, or student workers will submit the written
grievance/complaint to the Division/Program Manager as soon as possible; within
24 hours (72 hours on weekends);
• The Division/Program Manager will notify the Executive Director within 24 hours
of all written grievance/complaints received. The Executive Director may elect to
manage the grievance/complaint at any time.
• The Division/Program Manager will take action to resolve all
grievances/complaints promptly and fairly;
• The Division/Program Manager or Executive Director will inform the
patient/participant of the findings and recommendations within seven (7) calendar
days;
• If the Division/Program Manager cannot resolve the grievance/complaint within
three (3) calendar days, then the written grievance/complaint will be submitted to
the Executive Director for resolution;
• The Executive Director will take action to resolve all forwarded
grievances/complaints promptly and fairly;
• If the grievance/complaint cannot be resolved, the Executive Director will forward
the written grievance/complaint, inclusive of an explanation to DSHS;
• All grievance/complaint documentation shall be kept in a secured central file; and
• All programmatic grievance/complaints, resolved and unresolved, shall be
brought before the PIC for review and evaluation for future planning. Employee
grievance/complaints will be brought before the Executive Director and not the
PIC, unless the Executive Director deems it would benefit the performance
improvement process of the agency.
Specific Prohibitions Regarding the Processing and Handling of Grievance/Complaints
The employees shall not discourage, intimidate, harass, or seek retribution against
patients/participants who try to exercise their rights or file a grievance; or restrict,
discourage, or interfere with patient/participant communication with an attorney or with
DSHS for the purposes of filing a grievance/complaint.
Documentation and Annual Review
All grievances and appeals are maintained in a log/record. The PIC will review
programmatic complaints at each meeting to monitor for trends or patterns than will
assist in identification of changes or other areas for performance improvement. For
clarification, the PIC does not review seclusion because COADA-CB does not use
seclusion procedures and does not restrict the rights of patients/participants.
All employees are responsible for conformance with this policy.
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Onsite Crisis Intervention
PURPOSE: To establish the official position of COADA-CB on the provision of crisis
intervention services and to assign specific responsibility for implementation of the
policy.
POLICY: It is the policy of COADA-CB that the organization will provide crisis
intervention services in support of those patients and participants who may be in
emotional and/or behavioral distress.
PROCEDURE: The following guidelines describe the procedures to be followed in the
delivery of crisis intervention services:
1. If an individual or family present at COADA-CB appearing to be in a crisis, the intake
agent will contact the nearest counselor employees as soon as possible for crisis
intervention.
A. The individual and/or family will not be left alone for any length of time, e.g. not
more than 30 to 60 seconds.
B. The counselor will stay calm and determine the probable source of the crisis.
C. The counselor will assess the situation to determine action necessary.
D. For nonviolent individuals or patients presenting in a crisis, a brief counseling
session will be provided to stabilize the situation temporarily, other health care
professionals may be contacted for referral, if needed, and an appointment will be
made for the following workday with the individual or patient’s primary counselor
for re-evaluation of patient’s needs and level of care.
• Counselor will take precautions to enhance the safety of the patient, other patients
or employees.
• Counselor may need to implement SATORI techniques if crisis is or becomes out
of control.
• If SATORI techniques are insufficient to control individual or patient’s behavior
and direct danger is present, employees will immediately call 911 for emergency
assistance.
• For all individuals or patients who present in a crisis, the counselor will complete
a basic mental health assessment to determine a potential danger to self or others.
The mental health assessment will assess for psychiatric emergencies, which
include but are not limited to: (a) psychiatric behavior, (b) acute of persistent
confusion or hallucinations, (c) acute paranoia, agitation, or decreased attention
span, (d) homicidal or suicidal behavior, (e) uncontrollable aggressive behavior
and (f) other acutely abnormal or bizarre behavior.
• If the patient shows signs of being a potential danger to him or others, the Mental
Health/Mental Retardation (MHMR) Crisis Line will be contacted with a request
for immediate psychiatric/psychological care. EMS or Police will provide
transportation, if transportation is needed.
• If the patient or individual exhibits strange behavior and shows no sign of being a
danger to self or others and/or has left the facility, the police will not be notified.
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•The patient requiring intervention by emergency services, such MHMR Crisis Line
as EMS or law enforcement shall be re-evaluated/assessed to determine the
appropriate care.
• Patient may require a mental health assessment to assist the counselor in
determining if outpatient chemical dependency rehabilitation is appropriate
placement at that time. If inappropriate for treatment at that time, patient will be:
(a) referred to a more appropriate facility capable of providing
evaluation/treatment/intervention; and (b) reconsidered for readmission to
program only after completion of recommended evaluation, treatment or
intervention. If it becomes necessary, employees will call 911 for assistance and
an incident report will be completed within 24 hours in accordance with policy
and procedure.
2. Only a qualified credentialed counselor or counselor intern working under direct
supervision shall provide crisis interventions:
A. The Treatment Division Manager will ensure that counselors have appropriate
counseling skills.
B. The Treatment Division Manager and Health and Safety Officer will also ensure
that all emergency phone numbers are posted by all telephones at program sites.
C. Counseling employees shall be trained to transfer calls to third party (mental health
counselor, nurse, etc.) while staying on the line with the individual in crisis.
D. The Executive Director or her/his designee will also ensure that all employees who
may answer the phone receives annual emergency response training, including
crisis intervention techniques and available community resources. Training for
employees that provides crisis intervention shall also include motivational
interviewing and brief interventions and therapies.
E. The patient requiring intervention by emergency services, such as EMS or law
enforcement shall be re-evaluated/assessed to determine the appropriate care.
Patient may require a mental health assessment to assist counselor in determination
if outpatient chemical dependency rehabilitation is appropriate placement at this
time. If inappropriate for treatment at this time, patient will be: (a) referred to a
more appropriate facility capable of providing evaluation/treatment/intervention;
and (b) reconsidered for re-admission to the program only after completion of any
recommended evaluation, treatment or intervention.
All employees are responsible for conformance with this policy.
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Treatment Screening and Access to Services
PURPOSE: To establish the formal position of COADA-CB on assessments and access
to services by prospective patients and participants and assign specific responsibility for
implementation of the policy.
POLICY: It is the policy of COADA-CB to promote access to all COADA-CB programs
and Services and will be a part of the organizations responsibility to address the range of
client needs wherever and whenever a client presents for care. When clients present at a
COADA-CB facility that is able to provide some type of needed service, those clients
will be carefully guided to an appropriate level of service, with a follow-up by staff to
ensure that clients receive proper care. COADA-CB’s adoption of CSAT's “no wrong
door” policy will ensure that clientele needing treatment will be identified and assessed
and will receive treatment, either directly through COADA-CB’s treatment
programs, and/ or an appropriate referral, no matter where the client presents.
PROCEDURE: The following guidelines govern those screenings conducted by
COADA-CB as part of its responsibilities:
1. Access to COADA-CB’s services is via the telephone, walk-in (face-to-face), or
referral from another source (probation, school, another substance abuse service provider,
etc.).
A. COADA-CB shall implement and enforce the policy prohibiting discrimination
against an individual or group based on race, religion, and ethnicity, country of
origin, age, disability (including mental illness), sexual orientation, or gender.
B. COADA-CB shall, also, ensure that no person or group of persons is restricted from
receiving the same services or the same quality of services available to others.
C. COADA-CB shall make all facilities and programs accessible to persons with
disabilities as required by the Americans with Disabilities Act.
D. COADA-CB shall use the performance improvement process to conduct a selfinspection to evaluate compliance and implemented a corrective action plan to
address identified deficiencies.
E. COADA-CB shall maintain documentation of formal agreements and contracts to
address identified deficiencies in access to program services for people with
disabilities.
2. COADA-CB shall complete and document a financial assessment of each applicant
before admission:
A. COADA-CB shall use financial eligibility criteria, forms, and assessment
procedures established by DSHS unless it has received written approval from DSHS
to use alternative instruments.
B. A person who has access to another public or private funding source that pays for
substance abuse services for the individual’s diagnosis is not eligible for DSHS
funded services and actions will be taken to obtain pre-authorization for services if
needed.
C. A person whose adjusted income is at or below 200% of the federal poverty
guidelines is eligible for free services.
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D. A person whose adjusted income is above 200% of the federal poverty guidelines
shall be charged for services according to DSHS sliding fee scale.
E. For adolescents, ability to pay shall be determined by parental or family income,
unless:
• The adolescent applies for treatment without parental knowledge;
• The adolescent refuses to consent to parental notification; and
• The adolescent is a ward of the state.
F. If an adolescent program determines that conditions in subsection C above are met,
the adolescent’s income may be used to determine financial eligibility.
G. If the patient is physically unable to respond to the request for financial and other
eligibility information due to intoxication or other behavioral health issue, the
financial assessment may be delayed, but it shall be completed within five days of
admission.
H. COADA-CB shall provide appropriate referrals for all persons who are found to be
ineligible. Documentation shall include:
• Date(s) of application and denial;
• Identifying information;
• The reason the person was denied admission; and
• Organizations to which the patient was referred.
3. COADA-CB shall complete and document:
A. A substance abuse screening is initially used to determine if the individual has a
potential substance abuse problem and will require a comprehensive clinical
assessment.
B. If the screening indicates a potential substance abuse problem, a licensed chemical
dependency counselor performs a comprehensive chemical dependency assessment.
C. After the substance abuse dependency assessment is completed, the counselor is
able to make a diagnostic impression from the information collected.
D. Every patient admitted to COADA-CB youth or adult treatment program shall meet
the DSM-IV criteria for substance abuse or dependence.
E. COADA-CB shall match individual patient needs with appropriate treatment
intensity. If COADA-CB does not provide the level of service required by the
individual, then a referral is made to the appropriate service placement and a
follow-up is conducted.
F. Preference shall be given in the following populations per priority order:
• pregnant injecting drug users;
• pregnant substance abusers;
• injecting drug users;
• parents with children in foster care; and
• veterans with honorable discharges.
4. COADA-CB shall accept applicants from every region in the state when space is
available. If two applicants are of equal priority status, preference may be given to an
applicant living in the provider’s region.
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5. COADA-CB shall obtain written authorization from the consenter before providing
any treatment. The consent form shall be dated and signed by the patient, the consenter,
and the employee’s person providing the information, and shall document that the patient
and consenter have received and understood the following information:
A. The specific condition to be treated;
B. The recommended course of treatment;
C. The expected benefits of the treatment;
D. The probable health and mental health consequences of not consenting;
E. The side effects and risks associated with the treatment; and
F. Any generally accepted alternatives and whether an alternative might be
appropriate.
6. Before admission, COADA-CB shall, also, provide the patient and consenter with the
following information in writing:
A. The estimated average daily charge, including an explanation of any services that
may be billed separately;
B. The qualifications of the employees that will provide the treatment;
C. The name of the primary counselor;
D. The Patient Bill of Rights;
E. The Patient Grievance Procedure;
F. The program rules, including rules about visits, telephone calls, mail, and gifts; as
applicable;
G. Violations that can lead to disciplinary action or discharge;
H. Any consequences or searches used to enforce program rules;
I. The facility’s services and treatment process; and
J. Opportunities for family or significant other(s) to be involved in treatment.
The information listed in #6 above will be explained to the patient and/or
“consenter” in simple, non-technical terms within 24 hours of admission:
If an emergency or the patient’s physical or mental conditions prevent the
explanation from being given within 24 hours, employees shall document the
circumstances in the patient record and present the aforementioned
explanation/orientation as soon as possible. Documentation of the
explanation/orientation shall be dated and signed by the patient, the consenter,
and the employee’s person providing the explanation. The patient record shall
include a copy of the Patient Bill of Rights dated and signed by the patient and
consenter. If possible, all information shall be provided in the consenter's primary
language.
All employees involved in the screening and/or assessment of prospective
patients/participants are responsible for conformance with this policy.
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COPSD Access to Services
PURPOSE: To establish the formal position of COADA-CB on Co-Occurring
Psychiatric and Substance Use Disorders (COPSD) access to services by prospective
patients and participants and assign specific responsibility for implementation of the
policy.
POLICY: It is the policy of COADA-CB to promote access to all COADA – CB,
community programs and services and will be a part of the organization’s responsibilities
in this regard and more critically, to adhere to all required mandates and guidelines
pertaining to COPSD service.
PROCEDURE: The following guidelines govern COPSD programs conducted by
COADA-CB as part of its responsibilities:
Access to Services
1. In determining an individual’s initial and ongoing eligibility for any service, an entity
may not exclude an individual based on the following factors:
A. The individual’s past or present mental illness;
B. Medications prescribed to the individual in the past or present;
C. The presumption of the individual’s inability to benefit from treatment or the
individual’s level of success in prior treatment episodes.
2. Providers must ensure that a client’s refusal of a particular service does not preclude
the client from accessing other needed mental health or substance abuse services.
3. Providers must establish and implement procedures to ensure the continuity between
screening, assessment, treatment and referral services provided to clients.
Additional Requirements for COPSD Programs
1. The services provided to a client with COPSD must:
A. Address both psychiatric and substance use disorders;
B. Be provided within established practice guidelines for this population; and
C. Facilitate individuals in accessing available services they need and choose,
including self-help groups.
2. The services provided to a client with COPSD must be provided by employees who are
competent in the areas identified in §448.908 of this title (relating to Specialty
Competencies of Employees Providing Services to Clients with COPSD).
Specialty Competencies of Employees Providing Services to Clients with COPSD
1. Providers must ensure that services to clients are age-appropriate and are provided by
employees within their scope of practice who have the following minimum knowledge,
technical, and interpersonal competencies prior to providing services.
A. Knowledge competencies:
• Knowledge of the fact that psychiatric and substance use disorders are potentially
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recurrent and relapsing disorders and that although abstinence is the goal, relapses
can be opportunities for learning and growth.
• knowledge of the impact of substance use disorders on developmental, social, and
physical growth and development of children and adolescents;
• knowledge of interpersonal and family dynamics and their impact on individuals;
• knowledge of the current Diagnostic and Statistical Manual of Mental Disorders
(DSM) diagnostic criteria for psychiatric disorders and substance use disorders and
the relationship between psychiatric disorders and substance use disorders;
• knowledge regarding the increased risks of self-harm, suicide, and violence in
individuals;
• knowledge of the elements of an integrated treatment plan and community support
plan for individuals;
• basic knowledge of pharmacology as it related to individuals with a mental
disorder;
• basic understanding of the neurophysiology of addiction;
• knowledge of the phases of recovery for individuals;
• knowledge of the relationship between COPSD and DSM Axis III disorders; and
• knowledge of self-help in recovery.
B. Technical competencies:
• ability to perform age appropriate assessments of clients; and
• ability to formulate an individualized treatment plan and community support plan
for clients.
C. Interpersonal competencies:
• ability to tailor interventions to the process of recovery for clients;
• ability to tailor interventions with readiness to change; and
• ability to engage and support clients who choose to participate in 12-step recovery
programs.
2. Within 90 days of the effective date of this rule, providers must ensure that employees
who provide services to clients with COPSD have demonstrated the competencies
described in subsection (a) of this section. These competencies may be evidenced by
compliance with current licensure requirements of the governing or supervisory boards
for the respective disciplines involved in serving clients with COPSD or by
documentation regarding the attainment of the competencies described in subsection (1)
of this section.
Treatment Planning of Services to Clients with COPSD
1. The treatment plan must identify services to be provided and must include measurable
outcomes that address COPSD.
2. The treatment plan must identify services to be provided and must include measurable
outcomes that address COPSD.
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3. The treatment plan must identify the family ' need for education and support services
related to the client's mental illness and substance abuse and a method to facilitate the
family ' receipt of the needed education and support services.
4. The client and, if requested, family, must be given a copy of the treatment plan as
permitted by law.
All employees involved in the COPSD prospective treatment plan are responsible for
conformance with this policy.
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Clinical Assessments
PURPOSE: To establish the official position of COADA-CB on the clinical assessment
process and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to utilize the CMBHS screening tool to gather
assessment information that will ultimately result in individualized and goal-oriented,
person-centered treatment planning. The assessment process is separate and distinct from
the initial screening conducted by COADA-CB. Assessments are conducted as
appropriate when initial screening indicates that further assessment and evaluation is
clinically warranted.
PROCEDURE: The following guidelines govern COADA-CB’s assessment processes:
1. COADA-CB uses the DSHS approved screening tool in the CMBHS which
corresponds approximately to a Diagnostic and Statistical Manual of Mental Disorders
(DSM) drug abuse or dependence diagnosis. A formal assessment will be performed to
comprehensively evaluate the nature of the problem.
2. COADA-CB’s uses the DSHS approved assessment tool in CMBHS which gathers
sufficient information to develop an individual, person-centered treatment plan that
includes the following information: General, Medical, Substance, Legal, Family,
Psychiatric, the Clinicians assessment of patients rating of symptoms, Axis I-V
diagnostic impressions and the patient’s current stage in treatment. A formal
recommendation is done in the assessment by the clinician for the appropriate level of
service if any. Appropriate referrals to agencies, which provide authorization for
treatment and or actual services, are contacted.
3. COADA-CB’s primary assessment process gathers sufficient information to develop
an individual, person-centered treatment plan for each patient/participant that includes
information about:
A. Personal strengths
B. Individualized needs
C. Abilities and/or interests
D. Preferences
E. Presenting problems
F. Urgent needs, including suicide risk
G. Previous behavioral health services including diagnostic and treatment information
and efficacy of current or previously used medication
H. Physical health history and current status
I. Diagnosis(es)
J. Mental status
K. Current level of functioning
L. Pertinent current and historical life situation information such as age, gender,
employment history, legal involvement, family history, history of abuse,
relationships including natural supports
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M. Issues important to the patient
N. Use of alcohol, tobacco and/or other drugs
O. Need for, and availability of, social supports
P. Risk-taking behaviors
Q. Level of educational functioning
R. Advance directives, when applicable
S. Medication use profile and
T. Adjustment to disabilities/disorders
4. Assessments will be conducted by qualified employees who are knowledgeable to
assess the specific needs of prospective patients and trained in the use of applicable
assessment tools.
5. Assessments will include information obtained from the person served, family (when
applicable or permitted), friends and peers (when appropriate and permitted) and other
appropriate and permitted collateral sources.
6. Primary assessments will be conducted within specified time frames, result in the
preparation of an interpretive summary that is based on the assessment data, used in the
development of the individual plan and identifies any co-occurring disabilities/disorders
that should be addressed in the development of the individual plan.
7. Reassessments, when appropriate, are conducted in accordance with the program’s
established time frames or when otherwise indicated.
All employees are responsible for conformance with this policy.
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Admission Determination and Placement
PURPOSE:
To establish the official position of COADA-CB on admission
determination, the appropriate placement of patients entering the organization’s
programs/services and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to utilize appropriate trained and credentialed
employees to make decisions regarding new patient admissions and placements. Inherent
in this policy is the requirement that the organization will utilize an industry standard set
of patient placement criteria as a way to ensure the accuracy of all placements and
referrals and standardize all admission decisions.
PROCEDURE:
The following guidelines govern COADA-CB’s admission
determination and placement process:
1. Initial and ongoing assessments are conducted:
A. In a manner that is respectful and considerate of the person’s specific needs;
B. To identify the expectations of the prospective patient;
C. With the appropriate use of assistive technology or resources, as needed;
D. In a manner that is responsive to the changing needs of the person(s) served;
E. With consideration given to provisions for communicating the results of the
assessments to employees, patients and others as appropriate; and
F. With the understanding that some disclosures may legally bind COADA-CB to
engage in mandated reporter activities.
2. For every applicant admitted to treatment, the patient record shall include
documentation signed by the authorizing professional showing that the individual met all
applicable admission criteria, including the DSM diagnostic criteria.
3. All admissions to Intensive Outpatient and Aftercare Outpatient Treatment shall be
authorized or denied by a QCC as defined by DSHS.
4. The admission determination shall adhere to the Texas Administrative Code Title 28,
Part 1, Chapter 3, Subchapter HH based on Texas Department of Insurance (TDI)
admission criteria for Intensive Outpatient Treatment §3.8019 and for Outpatient
(Aftercare) §3.8023. COADA-CB shall determine the appropriate level of service and
match individual applicant needs with appropriate treatment intensity and setting.
5. If COADA-CB does not offer a program/service appropriate for the applicant as
determined by the TDI criteria, COADA-CB shall make an appropriate referral.
6. If an appropriate provider is not accessible to the applicant, COADA-CB shall arrange
for treatment (through admission or referral) in a program with the most appropriate level
of care accessible to the applicant.
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7. The patient record shall contain documentation demonstrating either that the patient
met the TDI admission criteria or justification for the reason for admission into interim
services if the criteria were not met.
8. COADA-CB will update the admission process to match any revisions adopted by the
TDI.
9. As part of the admission process, COADA-CB shall assess each applicant’s risk for
HIV infection, Tuberculosis, and other sexually transmitted infections. Risk assessments
shall follow guidelines described in the Workplace and Education Guidelines for HIV
and Other Communicable Diseases and are associated with Chapters 447 and 448,
governing development of policy and procedure for education and use of standard
precautions to prevent exposure to communicable diseases, including HIV.
10. COADA-CB’s admission criteria will give preference to DSHS priority populations
in following priority order:
A. Pregnant injecting drug users;
B. Pregnant substance abusers;
C. Injecting drug users;
D. Other clients referred by DFPS; and
E. All others presenting for treatment services.
11. The program’s admission criteria shall not automatically exclude individuals
based on:
A. Physical or mental health history;
B. Current physical or mental health diagnoses or treatment/services received;
C. Past or present prescription medications;
D. Assumptions of ability to benefit from treatment without documented current
behavioral evidence;
E. Substance abuse;
F. Ability to read and write; or
G. Pregnancy.
12. COADA-CB shall not automatically deny admission to a previous patient based on
prior treatment. If the applicant has been admitted to the facility three or more times in
the past 12 months, COADA-CB may consider this information (including circumstances
of prior discharges) in determining whether to admit the applicant. COADA-CB shall not
deny admission based on prior treatment if the applicant has only one or two prior
admissions.
13. COADA-CB shall not automatically deny admission based on a perceived threat of
harm to self or others. If COADA-CB determines that an individual is a current risk to
self or others, COADA-CB may require an evaluation from a qualified mental health
provider prior to admission.
14. COADA-CB shall not routinely require a period of abstinence prior to admission or
require treatment patients to complete detoxification, unless the patient meets TDI
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admission criteria for detoxification services per RULE §3.8007 Hospital or 24-hour
Residential and RULE §3.8027 for Outpatient Detoxification Treatment Service.
15. COADA-CB shall develop and implement written procedures to identify patients
exhibiting conditions or behavior that may suggest unmet mental health needs. COADACB shall collaborate with and provide referrals to available resources (including qualified
and credentialed mental health professionals) to address the patient’s mental health needs.
16. COADA-CB shall provide appropriate referrals for all persons who are denied
treatment. Documentation shall include:
A. Date(s) of application and denial;
B. Identifying information;
C. The reason the person was denied admission; and
D. Organizations to which the patient was referred.
All employees involved in the admission and/or placement of patients are responsible for
conformance with this policy.
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Length of Stay Guidelines
PURPOSE: To establish the formal position of COADA-CB on length of stay guidelines
and assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to utilize appropriate trained and credentialed
counselors to make decisions regarding new patient admissions and placements. Inherent
in this policy is the requirement that the organization will utilize an “industry standard”
set of patient placement criteria as a way to ensure the accuracy of all placements and
referrals and standardize all admission decisions.
PROCEDURE: The following guidelines govern the organization’s admission
determination and placement process:
1. Length of stay in treatment shall be determined by the needs of the individual patient
and multiple levels of care shall be used to provide a continuum of care for each
individual patient.
2. COADA-CB has adopted TDI length of stay (LOS) guidelines to provide a tool for
monitoring service utilization.
3. When the patient is admitted, the projected LOS shall be documented in the patient
record and shall not exceed TDI Guidelines.
4. All facilities shall implement procedures to monitor LOS according to TDI guidelines.
A. COADA-CB shall conduct the first treatment plan review no later than midway
through the patient’s projected LOS and will include a comparison of the patient’s
status with the TDI continuing stay criteria.
B. If the patient meets the continuing stay criteria, COADA-CB shall revise the
treatment plan and the estimated LOS (not to exceed the TDI guidelines).
C. If the patient does not meet the continuing stay criteria, COADA-CB shall confirm
that the patient meets the discharge criteria.
D. COADA-CB shall conduct a treatment plan review before the discharge date
E. If the patient has reached the maximum recommended LOS but is not ready for
transfer or discharge, justification for extending treatment shall be documented in
the patient record. The patient’s status shall be reviewed regularly, and the patient
shall be moved to a less restrictive level of care as quickly as clinically appropriate.
F. COADA-CB has interpreted the TDI Guidelines to apply them to COADA-CB’s
defined levels of service. COADA-CB will update the length of stay process to
match any revisions adopted by the Texas Department of Insurance:
• Outpatient (Intensive Outpatient): 4-12 weeks, meeting at least 10 hours weekly
( and/or based on patient need) for adults and adolescents; based on criteria in
3.8019 in Title 28 Texas Administrative Code Part 1; Chapter 3.
• Outpatient (Aftercare): Up to 6 months for adults and adolescents; based on criteria
in 3.8019 in Title 28 Texas Administrative Code Part 1; Chapter 3.
All clinical employees involved in LOS decisions are responsible for conformance with
this policy.
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Waiting List and Interim Services
PURPOSE: To establish the official position of COADA-CB on the preparation and
maintenance of waiting lists, the provision of interim services for those patients and
participants who may not be able to be admitted immediately because of insufficient
capacity, and to assign responsibility for implementation of the policy.
POLICY: It is the policy of the organization that criteria for the priority of admissions
will be developed and used in conjunction with waiting lists to help manage pending
admissions.
PROCEDURE: The following guidelines apply to the development of admission priority
criteria and waiting lists:
1. COADA-CB shall maintain a waiting list or other organized and documented system to
track eligible individuals who have been screened but cannot be treated immediately
because of insufficient capacity.
2. Eligible individuals who cannot enter treatment due to other circumstances may be
placed on the waiting list, but COADA-CB shall not hold empty slots for anticipated
patients for more than 48 hours.
3. COADA-CB shall establish criteria that place priority populations at the top of the
waiting list.
4. When individuals are placed on a waiting list, they shall also be provided, or referred
to an entity, to provide testing, counseling, and treatment for HIV, tuberculosis, and
sexually transmitted diseases.
5. COADA-CB shall consult the state’s facility capacity management system to facilitate
prompt placement in an appropriate treatment program within a reasonable geographic
area.
6. COADA-CB shall implement written procedures to maintain contact with individuals
waiting for admission.
7. Waiting list shall include documentation on:
A. The person’s needs;
B. Length of time on the waiting list;
C.A continual review and updating of the list;
D. Contact with the persons on the list based on each person’s needs;
E. Any and all contacts with the persons on the waiting list is maintained
8. Waiting list information is incorporated into the CMBHS.
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9. When a program does not have capacity to admit an injecting drug user or pregnant
female, the program shall place the individual in another treatment facility or provide
reasonable access to interim services (when another treatment facility is not available).
A. Interim services shall be offered within 48 hours.
B. Interim services shall include Outpatient Counseling, while on the waiting list for
more intensive level of services, counseling and education about HIV and
tuberculosis (TB), including the risks of needle-sharing, the risks of transmission to
sexual partners and infants, and steps that can be taken to prevent transmission.
C. Referrals for HIV or tuberculosis treatment shall be provided if necessary.
D. For pregnant females, interim services shall, also, include counseling about the
effects of alcohol and drug use on the fetus and referrals for prenatal care.
E. The program shall maintain documentation of interim services provided.
10. COADA-CB shall ensure that each individual who requests and is in need of
treatment for intravenous drug abuse is admitted to an appropriate program not later than
120 days after making the request. Interim services must be provided within 48 hours as
described above.
All employees are responsible for conformance with this policy.
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Patient/Participant Orientation
PURPOSE: To establish the official position of COADA-CB on the orientation of new
patients/participants and assign specific responsibility for implementation of the policy
and to assign responsibility for implementation of the policy.
POLICY: It is the policy of the organization that each person admitted to treatment or
enrolled in an education program will receive a comprehensive orientation that meets the
specific requirements of DSHS.
PROCEDURE: The following steps and guidelines will be followed in providing
orientation for new patients/participants:
Each person admitted receives an orientation that is appropriate to his or her needs and
the type of services provided is understandable to the person served, and includes:
A. Rights and responsibilities of patients/participants
B. Grievance and appeal procedures
C. Ways in which input is given regarding quality of care, attainment of outcomes, and
satisfaction patient/participants
D. An explanation (in Spanish if necessary) of the organizations services, expectations
and hours of operation.
E. Procedures for accessing after-hours services
F. The organization’s code of ethics
G. Requirements for follow-up with persons ordered to treatment, as applicable
H. An explanation of any and all financial obligations, fees, and financial arrangements
for services provided by the organization
I. Familiarization with the premises including emergency exits, and or shelters, fire
suppression equipment and first aid kits
J. The program’s policies regarding seclusion and restraint, smoking, and contraband
including illicit or licit drugs and weapons brought into the program
K. Identification of the employee responsible for service coordination
L. A copy of the program rules that identifies any restrictions the program may place
on patients/participants; all events, behaviors or attitudes that may lead to the loss of
rights or privileges that have previously been restricted
M. Education regarding advanced directives, if appropriate
N. Identification of the purpose and process of the assessment process
O.A description of the program and or treatment planning process and expectations for
the patient’s/participant’s participation
P. Information regarding transition criteria and procedures and
Q. When applicable, an explanation of the organization’s services and activities (in
Spanish if necessary) include (a) expectations for consistent court appearances (as
applicable), and (b) the identification of any therapeutic interventions used by
COADA-CB including sanctions, interventions, incentives, and administrative
discharge criteria.
All employees responsible for conducting orientation of new patients/participants will
conform to this policy.
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Individualized Treatment Plan
PURPOSE: To establish the official position of COADA-CB on the development of
individualized treatment plans to guide the provision and delivery of treatment services
and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of the organization to utilize a DSHS approved and standardized
assessment process to gather information that will ultimately result in individualized and
goal-oriented, person-centered treatment planning.
PROCEDURE: For clarification, the following guidelines govern the organization’s
assessment processes:
1. The individual plan of care is developed with the active participation of the person
served, and:
A. Is prepared using the information from the primary assessment, interpretive
summary and problem list;
B. Is based on the needs of the persons served and focuses on his/her integration and
inclusion into:
• The local community
• The family, when appropriate;
• Natural support systems;
• Other needed services.
C. Involves the family of the person served, when applicable or permitted;
D. Identifies any needs beyond the scope of the program;
E. Specifies the services to be provided by the program;
F. Specifies referrals for additional services;
G. Is communicated to the person served in a manner that is understandable;
H. Is provided to the person served whenever possible; and
I. Is reviewed periodically with the person served for continuing relevance, and is
modified as needed.
2. The individual plan includes the following components:
A. Goals expressed in the words of the person served;
B. Goals reflective of the informed choice of the person served or parent/guardian;
C. Goals appropriate to the person’s culture and age;
D. Goals that are based on the person’s strengths, needs, abilities and preferences;
E. Specific service or treatment objectives that reflect the expectations of the person
served and treatment team;
F. Service or treatment objectives that reflect the person’s age, development, culture
and ethnicity;
G. Service or treatment objectives that are responsive to the person’s
disabilities/disorders or concerns;
H. Treatment goals and objectives that are understandable to the persons served;
I. Goals and objectives that are measurable, achievable, time specific and appropriate
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to specific treatment interventions;
J. Frequency of treatment interventions;
K. Information on, or conditions for, transition to other services; and
L. When applicable, the identification of legally imposed requirements and fees.
3. When the person served has co-occurring disabilities/disorders:
A. The individual plan specifically addresses those issues in an integrated manner; and
B. Services are provided by employee either within the organization or by referral,
which are qualified to provide services for persons with such disabilities/disorders.
4. Signed and dated progress notes document:
A. Completion of portions of the individual plan;
B. Significant events or changes in the life of the person served; and
C. The delivery of services that support the individual plan.
5. A designated individual(s) assists in coordinating services for each person served by:
A. Assuming responsibility for ensuring the implementation of the individual plan;
B. Ensuring that the person served is oriented to services;
C. Promoting the participation of the person served on an ongoing basis in discussions
of his or her plans, goals and status;
D. Identifying and addressing gaps in service provision;
E. Sharing information on how to access community resources relevant to her/his
needs;
F. Advocating for the person served when necessary;
G. Communicating information regarding progress of the persons served to the
appropriate persons;
H. Facilitating the transition process, including arrangements for follow-up services;
I. Involving the family or legal guardian, when applicable or permitted;
J. Coordinating services provided outside the organization; and
K. Identifying the process for after-hours contact and/or services.
All employees with responsibilities for individual plan development and/or monitoring
will ensure conformance with this policy.
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Discharge and Recovery Support Services
PURPOSE: To establish the official position of COADA-CB on the provision of
discharge and recovery support services and to assign specific responsibility for
implementation of the policy.
POLICY: It is the policy of the organization that a written discharge plan will be
developed at the earliest point in service delivery process as clinically indicated. DSHS
calls for the development of a discharge plan.
PROCEDURE: For clarification, the following guidelines will govern the development
of discharge plans:
1. A discharge plan as defined by DSHS will be prepared for each patient as a way to
ensure continuity of service. The plan will be based on the needs of the person served
and will support ongoing recovery or treatment/service gains:
A. Identifies the person’s current progress in his or her own recovery or move toward
well-being;
B. Documents gains achieved during participation in the program;
C. Identifies strengths, needs, abilities and preferences at discharge;
D. Is developed with the input and participation of persons served, family (when
applicable or permitted), a legally authorized representative (when appropriate),
employees, the referral source (when appropriate and permitted), and other
community services (when appropriate and permitted).
E. Identifies the person’s need for support systems or other types of services that will
assist in continuing his or her recovery or well being;
F. Includes information on the person’s medication(s) (when applicable);
G. Addresses referral source information, such as contact name(s), telephone number,
service locations, hours, and days of operation;
H. Includes communication of information on options available if symptoms recur or
additional services are required/needed.
I. Individuals who participate in the discharge planning process receive copies of the
plan.
2. When the discharge plan indicates the need for additional services or supports,
employee is identified who will be responsible for follow-up after transition to:
A. Maintain the continuity and coordination of needed services;
B. Determine with the patient whether further services are needed; and
C. Offer or refer to needed services, when possible.
3. When an unplanned discharge occurs, the counselor is responsible for follow-up;
A. Determine with the patient whether further services are needed; and
B. Offer or refer to needed services, when possible.
4. When a person is discharged or removed from a program for assault/aggressive
behavior, follow-up occurs:
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A. To ensure linkage to appropriate care; and
B. Within 72 hours “post-discharge”.
5. Individuals receive a copy of their discharge plan when they leave the treatment
service.
6. Individuals are informed and invited to participate in the alumni support meetings.
All employees involved in discharge planning are responsible for conformance with this
policy.
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Seclusion and Restraint
PURPOSE: To establish the official position of COADA-CB on seclusion and restraint
and to assign responsibility for implementation of the policy.
POLICY: COADA-CB believes that patients should receive services in an environment
that is free from all forms of physical force, abuse, and punishment. All direct care
employees are trained in SATORI therefore, it is the policy of COADA-CB that no form
of seclusion or restraint other than SATORI non-violent intervention practices will be
applied.
PROCEDURE: All employees are responsible for conformance with this policy.
Division/Program Managers are responsible for monitoring of all operations to ensure
strict conformance with this policy. It should be noted that COADA-CB’s policy on
dealing with assault and/or aggressive behavior is contained in the company’s policy on
emergency plans and procedures.
All employees will ensure conformance with this policy.
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Patient Searches
PURPOSE: To establish the official position of COADA-CB on patient searches and to
assign responsibility for implementation of the policy.
POLICY: COADA-CB believes that patients should receive services in an environment
that is free from all forms of physical searches. Therefore, it is the policy of COADA-CB
that no form of patient searches will be applied or practiced in any clinic operated by the
organization.
PROCEDURE: All employees are responsible for conformance with this policy.
Division/Program Managers are responsible for monitoring of all operations to ensure
strict conformance with this policy. It should be noted that COADA-CB’s policy on
dealing with suspected possession of weapons, contraband, or illegal substances, is
contained in the company’s policy on emergency plans and procedures.
All employees will ensure conformance with this policy.
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Patient Records
PURPOSE: To establish the official position of COADA-CB on the development and
maintenance of patient records and to assign responsibility for implementation of the
policy.
POLICY: It is the policy of the organization that a confidential record will be prepared
for each individual receiving service. Inherent in this policy is the expectation and
requirement that all records be developed and maintained in a manner consistent with the
requirements of DSHS. (For clarification, COADA-CB uses the DSHS automated
medical record system, CMBHS and therefore, has little latitude in the content and/or
format of patient records.)
PROCEDURE: The following guidelines will apply to the development and maintenance
of patient records:
1. The record of each individual served is maintained so that confidentiality is always
protected.
2. COADA-CB uses the DSHS automated medical record system, CMBHS and maintains
information in the patient record that is:
A. Organized;
B. Clear;
C. Complete;
D. Current;
E. Legible.
3. All documents generated by the organization that require signatures include original
(or electronic) signatures.
4. The record for each individual includes:
A. The date of admission;
B. Information about the individual’s personal representative, conservator, guardian, or
representative payee, if any of these have been appointed, including the name,
address, and telephone number.
C. Information about the person to contact in the event of an emergency, including the
name, address, and telephone number.
D. The name of the person currently coordinating the services of the person served.
E. The location of any other records.
F. Information about the individual’s primary care physician, including the name,
address, and telephone number when available.
G. Health care reimbursement information, if applicable.
H. The individual’s:
• Health history;
• Current medications;
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• Preadmission screening, when conducted;
• Documentation of orientation;
• Assessments;
• Individual plan of care, including reviews; and
• Discharge Plan, when applicable.
I. The discharge plan and summary that:
• Includes the date of admission;
• Identifies the presenting condition;
• Describes the extent to which established goals and objectives were achieved;
• Describes the services provided;
• Describes the reasons for discharge;
• Identifies the status of the person served at discharge;
• Lists recommendation for services or supports; and
• Includes the date of discharge from the program.
J. Correspondence pertinent to the person served;
K. Authorizations for release of information; and
L. Documentation of internal or external referrals.
5. Entries to the records of the individuals served follow COADA-CB policy that
specifies time frames for entry.
6. If duplicate information or reports from the main record of an individual served exist,
or if working files are maintain, such materials:
A. Are not substituted for the main record;
B. Are considered secondary documents, with the main record of the individual served
receiving first priority; and
C. Are maintained in such a manner as to protect confidentiality.
7. Documentation in the individual’s record shall be complete and current:
A. All required documents should be factual and accurate.
B. Authentication shall include signature, credentials when applicable, and date. If the
document relates to past activity, the date of the activity shall also be recorded.
C. Documentation shall be permanent and legible.
D. When it is necessary to correct a required document, the error shall be marked
through with a line, dated, and initialed by the writer.
All employees with responsibilities records will ensure conformance with this policy.
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Reporting Child Abuse
PURPOSE: To establish the official position of COADA-CB on child abuse reporting
and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all incidents of suspected, alleged or
confirmed child abuse will be immediately reported in accordance with all state and
federal laws, codes, rules and regulations. Further, it is the policy of the organization that
employees will receive training on the organization’s procedures for child abuse
reporting.
PROCEDURE: Employees shall adhere to the following procedures in reporting child
abuse incidents, either suspected or confirmed:
1. Any employee having knowledge of an alleged incident involving child abuse or
neglect must submit a written incident report to his/her Division/Program Manager. This
includes situations in which an employee receives a patient’s/participant’s complaint
alleging acts or omissions which may constitute child abuse or neglect, or substantial
reasons to believe such incidents may have occurred.
2. If an employee has cause to believe that the child of a patient/participant has been
abused or neglected, he/she should notify his/her Division/Program Manager. The
Division/Program Manager will submit a written incident report to the Executive Director
who will report to DSHS or local law enforcement authorities within 24 hours as
described in the Texas Family Code, Chapter 34; particularly Sections 34.01 and 34.02.
The report shall include, at a minimum, name and location of the child and alleged
perpetrator(s), the nature of the abuse/neglect, and any other actions taken by employee’s
persons.
3. The date, time, and place of the incident should be documented in the
patient’s/participant’s file.
All employees are responsible for conformance with this policy.
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Reporting Abuse, Neglect, and Exploitation
RULE §448.214-Duty to Report & RULE §448.509-Incident Reporting specifically
described in RULE §448.703 of this title relating to Abuse, Neglect, and Exploitation.
COADA-CB scope of services includes a Youth Intensive Outpatient and Aftercare
Outpatient as well as Relapse Prevention Services, Adult Intensive Outpatient Treatment,
Aftercare Outpatient as well as Relapse Prevention Services.
PURPOSE: To establish the official position of COADA-CB on reporting abuse, neglect,
and exploitation and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that all incidents of suspected, alleged or
confirmed abuse, neglect, or exploitation will be immediately reported in accordance
with all state and federal laws, codes, rules and regulations. Further, it is the policy of the
organization that employees will receive training on the organization’s procedures for
abuse, neglect, and exploitation.
PROCEDURE: Employees shall adhere to the following procedures in reporting abuse,
neglect, or exploitation incidents, either suspected or confirmed:
1. Any person who receives an allegation or has reason to suspect that a client or
participant has been, is, or will be abused, neglected, or exploited by any person shall
immediately inform the DSHS's investigations division and the provider's Executive
Director or designee. If the allegation involves the Executive Director, it shall be reported
directly to the provider's governing body.
A. The person shall also report allegations of child abuse or neglect to the Texas
Department of Protective and Regulatory Services as required by TEX. FAM.
CODE ANN. §261.101 (Vernon 2002 & Supp. 2004).
B. The person shall also report allegations of abuse or neglect of an elderly or disabled
individual to the Texas Department of Protective and Regulatory Services as
required by TEX. HUM. RES. CODE ANN. §48.051 (Vernon 2001 & Supp. 2004).
2. If the allegation involves sexual exploitation, the Executive Director or designee shall
comply with reporting requirements listed in TEX. CIV. PRAC. & REM. CODE ANN.
§81.006 (Vernon 1997 & Supp. 2004).
3. The Executive Director or designee shall take immediate action to prevent or stop the
abuse, neglect, or exploitation and provide appropriate care.
4. The Executive Director or designee shall ensure that a verbal report has been or is
made to the Commission's investigations division as required in subsection (a) of this
section.
5. The person who reported the incident shall submit a written incident report to the
Executive Director within 24 hours.
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6. The Executive Director or designee shall send a written report to the DSHS’s
investigations division within two business days after receiving notification of the
incident. This report shall include:
A. The name of the client or participant and the person the allegations are against;
B. The information required in the incident report or a copy of the incident report; and
C. Other individuals, organizations, and law enforcement notified.
7. The Executive Director or designee shall also notify the consenter. If the client is the
consenter, family may be notified only if the client gives written consent. If the consenter
is not the client, the chief executive officer may withhold notification to the consenter if
this action may place the client at additional risk. In this situation, the chief executive
officer will notify the DSHS's investigations division in writing of this decision.
8. The provider shall investigate the complaint and take appropriate action unless
otherwise directed by the DSHS's investigations division. The investigation and the
results shall be documented.
9. The governing body or its designee shall take action needed to prevent any confirmed
incident from recurring.
10. The provider shall:
A. Document all investigations and resulting actions and keep the documentation in a
segregated file;
B. Have a written policy that clearly prohibits the abuse, neglect, and exploitation of
clients and/or participants;
C. Enforce appropriate sanctions for confirmed violations; including, but not limited
to, termination of personnel with confirmed violations of client or participant
physical or sexual abuse or instances of neglect that result in client or participant
harm.
All employees are responsible for conformance with this policy.
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SECTION 5
CORE PROGRAM DESCRIPTIONS
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Overview of Program Services
PURPOSE: To establish the official position of COADA-CB on the development and
operation of a comprehensive continuum of programs and services and to assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB that the organization will develop and maintain
a comprehensive array of programs and services and, that those services will be clearly
described for the benefit of patients/participants and employees.
PROCEDURE: COADA-CB shall define and deliver quality patient/participant services
and programs by identifying the priority and target population, stating the purpose of
such services and programs, and establishing minimum operational and programmatic
requirements.
Services provided include:
1. Community education on current issues concerning alcohol and drug abuse, its effects,
and related issues;
2. 24-hour telephone hotline providing education, information, referral, and crisis
resolution to anyone in need;
3.Walk-in services, which shall include information, education, assessment, referral, and
outpatient youth and adult counseling upon request by appointment to those in need and
suffering from the effects of substance abuse and /or related issues;
4. Programs for at-risk youth, include:
A. Families and Schools Together (FAST) - middle school,
B. FAST - elementary school
C. FASTWORKS-follow-up for FAST
D. Project Towards No Drug Abuse
E. Botvin’s Life Skills
F. Outpatient treatment for youth needing substance abuse
5. Adult services and programs for supportive and intensive outpatient treatment services
for persons 18 years of age or older;
6. Outpatient treatment services for individuals under the age of 18.
7. Post Partum Intervention services provide on-site, gender specific, community-based
outreach, intervention, motivational counseling, case management, and referrals for
pregnant and post partum adult and adolescent women.
8. COADA-CB operates a continuous performance improvement system to monitor
and improve clinical and non-clinical services.
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9. COADA-CB’s capacity management may be handled through a daily review of active
clients reported through CMBHS.
10. COADA-CB maintains program documentation that includes:
A. A description of the program;
B. The philosophy of the program;
C. The program goals;
D. Description of the services to be provided to achieve the program objectives;
E. Identification or a description of special populations, and mechanisms to address
their needs; and
F. Assurance that adequate resources are available to deliver the identified programs;
11. All services are designed and implemented to:
A. Support the recovery and/or stabilization of the persons served;
B. Enhance the quality of life of the persons served;
C. Reduce symptoms or needs and build resilience;
D. Restore and/or improve functioning;
E. Support the integration of the persons served into the community;
F. Provide patients/participants with tools to prevent relapse;
G. Provide information and education relevant to the needs of the persons served; and
with proper consent.
12. The treatment programs assists the persons served to link with local advocacy groups,
consumer/survival/ex-patient groups, self-help groups such as AA, NA, etc., and other
avenues of support as may be clinically indicated and/or appropriate.
13. Procedures are established that provide for coordination and ongoing communication
between internal and external service providers, with the appropriate consent forms
signed by the patient/participant.
14. COADA-CB provides services that are relevant to the diversity of the persons served
through:
A. Respect for ethnic, cultural and spiritual traditions and ceremonies;
B. Having a diverse board and employee’s composition;
C. Scheduling a range of hours of operation;
D. Offering printed materials in alternative formats, such as Spanish;
E. Decorating the office space in a manner that is attractive and agreeable to the
persons served; and
F. Sponsoring and participating in community events.
15. Team, in response to the needs of the person served:
A. Are appropriately qualified and meet the appropriate licensing and credentialing
requirements;
B. Demonstrate competency related to the needs of patients/participants and when
applicable, to their families;
C. Complete competency-based training related to the services provided and the
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populations served;
D. Ensures that relevant information and education is provided to patients/participants;
E. Help empower each person served to actively participate with the treatment team to
promote recovery or well being;
F. Provide services consistent with the specific needs of each patient/participant
through direct intervention with that person or others as designated by the
patient/participant;
G. Will be culturally and linguistically competent relative to the needs of persons
served;
H. Reflect the cultural composition of patients/participants;
I. Help to implement the treatment plan for each persons served; and
J. Document attendance of participants at team meetings and the results of such
meetings.
16. Ongoing clinical supervision of employees addresses:
A. The appropriateness of the treatment intervention selected relative to the specific
needs of the person served;
B. Treatment effectiveness as reflected by the person served meeting their individual
goals;
C. The provision of feedback that enhances the clinical skills of direct service
employees ;
D. Accuracy of screening, assessment and referral skills.
All employees are responsible for conformance with this policy.
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Core Program and Description of Services
Introduction
This core program description provides an oversight of all programs and services offered
by COADA-CB and are intended to partially fulfill the requirement for a complete
description of programs/services. Additional details about each program/service are
available from the responsible Division Manager or Executive Director and are
maintained in other organizational documentation.
Geographic Service Area
COADA-CB’s service delivery area in Health & Human Service consists of 12 counties:
Aransas, Bee, Brooks, Duval, Jim Wells, Kenedy, Kleberg, Live Oak, McMullen,
Nueces, Refugio, and San Patricio.
COADA-CB scope of services includes a Youth Intensive Outpatient and Aftercare
Outpatient as well as Relapse Prevention Services, Adult Intensive Outpatient)
Treatment, Aftercare Outpatient as well as Relapse Prevention Services. Universal,
Selective, Indicated Prevention/Intervention Programs, Pregnant Post Partum
Intervention, (PPI) Prevention Resource Center (PRC), and Youth Continuum of Care
Coalition (YCCC) Drug Free Community (DFC) State Incentive Grant (SIG), Alcohol
and Drug Education (AEP) programs. To the greatest extent possible, COADA-CB will
support the cross training of employees between prevention, intervention, and treatment
to add flexibility and facilitate coordination to the continuum of services delivered.
Program and Service Summary
1. Youth Intensive Outpatient Treatment. This intensive outpatient program operates
on a 5-week cycle meeting for 10 hours a week on Monday through Thursday. The
intensive outpatient treatment which targets adolescents 17 and younger who are
demonstrating involvement with alcohol and/or other drugs leading to negative
consequences. The patients are generally exhibiting dysfunctional behavior patterns as
a result of mind-altering substances, or have substance-dependent parenting systems or
significant other(s). Upon completion of the program, patients are referred to an
Aftercare program. The program includes a family component as well as Relapse
Prevention Outpatient programs.
2. Youth Outpatient Aftercare Treatment: Upon completion of the youth outpatient
treatment patients are referred to an Aftercare program. The Aftercare program meeting
individual needs from 2-9 hours per week and not to exceed six months. The Youth
Aftercare also includes a family component as well as Relapse Prevention Outpatient
programs.
3. Adult Outpatient Treatment: This intensive outpatient program operates on a 5week cycle meeting for 10 hours a week on Monday through Thursday. The intensive
outpatient treatment which targets adults 18 or older who are demonstrating
involvement with alcohol and/or other drugs leading to negative consequences. The
patients are generally exhibiting dysfunctional behavior patterns as a result of mind-
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altering substances, or have substance-dependent spouse systems or significant
other(s). Upon completion of the program, patients are referred to an Aftercare
program. The program includes a family component as well as Relapse Prevention
Outpatient programs.
4. Adult Aftercare Treatment: Upon completion of the adult outpatient treatment patients
are referred to an Aftercare program. The Aftercare program meeting individual needs
from 2-9 hours per week and not to exceed six months. The adult Aftercare also includes
a family component as well as Relapse Prevention Outpatient programs.
5. Youth Prevention Universal (YPU): COADA-CB implements a school-based
prevention program, in an effort to reduce and prevent alcohol, tobacco and other drug
use among youth. The program uses the research-based, model, universal prevention
curriculum Botvin’s Life Skills designed to provide students with the necessary skills
to resist social pressure to use tobacco, alcohol, and other drugs. The program is
delivered during a standard 30-50 minute class period throughout 8 weeks, providing 8
sessions. Life Skills program reaches youth in communities before they have begun
regular use of alcohol, tobacco, and other drugs. Life Skills is currently offered in 3
counties; Nueces, Kleberg, and San Patricio.
6. Youth Prevention Selective (YPS); COADA-CB implements an after school-based
prevention program, in an effort to reduce and prevent alcohol, tobacco and other drug
use among youth and families. The program uses the research-based, model, selective
prevention curriculum Families And Schools Together (FAST) Elementary Level
aimed to strengthen families, enhance family, school, and community ties, help
children to succeed at school and at home, reduce drugs and alcohol abuse, and reduce
stress and social isolation. We also offer Project Towards No Drug (PTND), a
research-base, model, prevention curriculum targeting middle and high school youth.
FAST is an 8 week program, offered at 6 elementary schools in 2 counties; San
Patricio and Nueces. PTND programming is provided to youth 12-17 years of age
with education/skills training and alternative activities to provide awareness make
informed decisions relating to alcohol, tobacco, and other drugs. PTND is offered in
Nueces, Aransas, Kleberg, and San Patricio.
7. Youth Prevention Indicated (YPI); COADA-CB implements an after school-based
indicated program, in an effort to reduce and prevent alcohol, tobacco and other drug
use among youth and families. The program uses the research-based, model, indicated
prevention curriculum Families And Schools Together (FAST) Middle School Level.
COADA-CB has adopted the middle school FAST program because it is an
innovative, collaborative program that involves middle school youth with their whole
family in building relationships, so that parents can more easily help their youth be
successful in the home, school, and community. FAST works effectively with families
of middle school youth on two levels—through a peer group for youth and parents and
a multi-family format bringing the parent and youth together for communicative
encounters. The program is designed for the whole family to participate in 10 weekly
sessions of carefully orchestrated, research-based, interactive, family fun activities.
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Following graduation from FAST, parents run their own follow-up, multi-family
meetings for 2 years with support from FAST staff to maintain the social networks.
Currently, FAST is offered at 4 schools in Nueces County.
8. Post Partum Intervention (PPI); The intent of the PPI program is to provide on-site,
gender specific, community-based outreach, intervention, motivational counseling,
case management, treatment referral and continuing care for pregnant and post partum
women with or at risk for substance abuse problems. Families will be supported by
developing family reunification planning and services coordination for children in
foster care. PPI will intervene with the substance abuse/use of pregnant and post
partum adult and adolescent women and reduce the incidence of drug exposure of their
unborn, newborn and young children to facilitate a healthy lifestyle for all participants.
9. Drug Free Communities (DFC); The DFC program is a coalition based program
(YCCC). The intent of the DFC program is to focus on the community of Mathis
located in San Patricio County. The goals of the program are to: 1) increase
community involvement in alcohol, tobacco, and other drug (ATOD) prevention; 2)
reduce the level of ATOD use among youth. The program will focus on these goals by
providing community mobilization, media awareness campaigns, education programs,
and promote positive school and family behaviors.
10. Alcohol and Drug Education Program (ADEP): ADEP is an education program
for probationers and employees, who have received their first DWI, or other drug and
alcohol-related offense. The majority of referrals are from probation departments in
Nueces and San Patricio Counties. Other referrals come from Child Protective
Services, private employers and therapists.
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Screening and Referral
POLICY: It is the policy of COADA-CB to conduct activities as a way to specifically
increase services to those persons identified by DSHS as priority populations and
individuals who fall within the program’s target population. Once identified and
“engaged”, it is the policy of the organization to screen those individuals to determine
their appropriateness for admission to the organization’s programs/services. This policy
will require that those individuals be referred to services that are clinically appropriate.
For services that are outside the scope of COADA-CB’s capabilities and mission
statement, an appropriate referral to another provider or to the authority (if residential
services are indicated) will be provided to the patient/participant.
PROCEDURE: The following guidelines govern the organization’s activities pertaining
to screening and referral:
Activities
1. COADA-CB shall develop and implement a plan that specifically targets DSHS
priority populations and individuals who fall within the program’s target population and,
is intended to increase service delivery to the identified populations.
2. COADA-CB’s services shall offer universal, selective and indicated prevention and
treatment strategies to individuals, families, and communities.
3. Information dissemination during activities shall be provided for the purposes of
education and awareness in the community. Information dissemination shall focus on
increasing access to services for the community, including DSHS priority populations,
and ensuring the community is aware of the nature, location, and availability of COADACB’s services.
Screening Activities
1. Screening services shall be provided for the purpose of identifying initial eligibility for
admission to the organization’s programs and services or those of other providers and or
the authority if residential services are indicated.
2. COADA-CB shall provide screening and referral where indicated for individuals
needing and/or seeking treatment services and will be guided by the following:
A. The screening process shall be conducted in a confidential, face-to-face interview
whenever possible. If logistics or emergency circumstances prevent an in-person
interview, the screening process may be conducted by telephone.
B. The screening process shall be conducted by qualified credentialed counselors
(QCCs), graduates, or counselor interns working under direct supervision.
C. Screenings will be conducted with the CMBHS screening tool. The depth and
scope of the screening process shall be sufficient to determine the individual’s
needs and make an appropriate referral, if needed. The specific instruments and
procedures used during the screening process will depend on the characteristics of
the individual being screened. COADA-CB may administer all or part of an
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assessment instrument as needed to make an appropriate referral. Tools used during
the screening process, including assessment instruments, shall be age-appropriate.
D. All screenings conducted by the organization:
• Include a review of each person’s eligibility for admission based on the person’s
presenting problems, need for services, legal eligibility (when applicable);
• Assess the appropriateness of available services and the availability of funding
sources;
• Identify whether the organization can provide the services needed by the
patient/participant;
• Includes an interview with the person to be served or the referral source;
• Identify and document the immediate and urgent needs of the persons to be served;
and
• Include, as appropriate, a pre-admission, on-site visit to the organization and its
programs by the prospective patient/participant.
E. COADA-CB will provide motivational interviewing and brief interventions and
therapies to motivate and prepare individuals for treatment or self-directed change
in behavior when treatment is not indicated.
3. Documentation shall include:
A. Profile and Date of screening;
B. Zip code of the individual screened;
C. Demographics of the individual screened;
D. The completed instruments used during the screening, which includes a Risk
Assessment and diagnostic impression based on approximate DSM criteria provided
in CMBHS;
E. Referrals made, including when and where the service recipient is admitted to
services; and
F. All follow-up contacts.
4. COADA-CB shall develop and implement written procedures to identify and provide
appropriate referrals for individuals exhibiting conditions or behavior that may suggest
unmet mental health needs. COADA-CB shall also provide at least three hours of CoOccurring Psychiatric Substance Abuse Disorders training annually to all employees who
conduct screenings for mental health problem identification and referral.
Referral Activities
1. COADA-CB shall maintain a resource manual or file that contains current information
about local referral resources; including location and contact information, services
offered, and eligibility criteria. At a minimum, the resource manual or file shall include
information about all prevention, intervention, and treatment programs in COADA-CB’s
catchment area.
2. COADA-CB shall maintain written agreements with treatment providers outlining how
individuals who go through the screening process are admitted to treatment.
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3. Documentation shall include:
A. Date of screening;
B. Zip code of the individual screened;
C. Demographics of the individual screened;
D. The completed instruments used during the screening, including a diagnostic
impression based on DSM-IV criteria;
E. Referrals made, including when and where the service recipient is admitted to
services;
F. All follow-up contacts.
4. COADA-CB shall develop and implement written procedures to identify and provide
appropriate referrals for individuals exhibiting conditions or behavior that may suggest
unmet mental health needs. COADA-CB shall also provide at least three hours of annual
training on mental health diagnoses to all employees who conduct screenings or provide
problem identification and referral.
5. COADA-CB’s Program shall work with other organizations in the area to coordinate
substance abuse and other services for the individual and/or family.
6. COADA-CB’s Treatment Program uses a TDI Utilization Review Criteria to determine
referral for all levels of substance abuse services, COADA-CB services and nonCOADA-CB services.
Crisis Intervention Services
1. In the event that the screening process results in the identification of a need for crisis
intervention services, employees will ensure that such services are provided or arranged.
2. During normal business hours, Treatment employees will provide emergency services
either through walk-ins or phone calls.
This may include a brief
intervention/motivational interview or a complete assessment. COADA-CB maintains a “
24/7” emergency hotline with a mandated response time of one hour or less and can
include any number of intervention from simple interventions to full clinical assessments
with an immediate referral/actual “hand off” to other providers or provider organizations.
This specifically includes appropriate referrals for individuals exhibiting conditions or
behaviors that may suggest unmet mental health needs.
3. Call-ins or walk-ins that are not determined to be true emergencies are scheduled for a
follow-up appointment within five (5) days.
4. Crisis intervention may be a contract or a short series of contacts and will be provided
for the purpose of mitigating the crisis or helping the prospective patient/participant deal
with the crisis.
5. In providing crisis intervention services, the employees shall comply with policies and
procedures for crisis intervention services during and after normal business hours and as
outlined elsewhere in this manual.
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6. Crisis intervention shall be provided only by a QCC, graduate, or counselor intern
working under direct supervision.
7. As part of its crisis intervention service, patients will be connected to local hospitals,
local mental health/mental retardation facilities, organizations that provide detoxification
and/or any other number of local providers as clinically indicated. For clarification, the
employees will personally call to arrange for referrals and follow-up to ensure that the
referral was completed and services were actually received.
8. The organization maintains a comprehensive listing of referral sources in the region as
a way to facilitate referrals.
9. Complete records are maintained on all persons receiving crisis intervention services
as a way to ensure continuity of care.
10. Information is released, with appropriate consent forms, to other providers as a way to
ensure that all referral sources are fully aware of the information that was gathered during
the crisis intervention process.
All employees are responsible for daily conformance with this policy. Division
Managers are responsible for overall conformance with this policy and for providing
“quality control” over the organization’s treatment services.
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Outpatient Treatment
PURPOSE: To establish the official position of COADA-CB on outpatient treatment,
describe the components of COADA-CB’s treatment program and assign specific
responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to provide a comprehensive outpatient
substance abuse treatment program that addresses the clinical needs of the population
served
PROCEDURE: The following guidelines pertain to the organization’s outpatient
treatment program:
1. The purpose of the program is to intervene in the progression and development of
addiction/substance abuse. The program is specifically designed to reverse and/or
mitigate the through a cognitive-behavioral approach that recognizes substance abuse as a
chronic, progressive and potentially fatal disease. If untreated and without the
appropriate interventions, the disease will naturally progress to chronic stages that effect
the person as well as her/his family and/or significant others.
2. The program recognizes the importance of dealing quickly and appropriately with
treatment non-compliance and to ensure client retention. Specific strategies vary for
youth and adult outpatient treatment but may include:
inclusion of family
members/support systems in all treatment activities; early assessment of relapse triggers;
develop individualized relapse prevention plan; provide intensive monitoring and
support; evaluate and review lapses in compliance; use behavioral contracts to set
outcome goals; and follow up with all clients . Direct care staff will ensure a rapid
response, convey respect and intervene early to assist clients who are considered high risk
for dropping out.
3. Recognizing the importance of understanding client diversity and cultural
backgrounds, clinicians will obtain a balance in understanding clients in the context of
their cultures. Staff will use a flexible definition of family and communication style to
decrease cultural misunderstandings, mistrust or disrespect. Cultural competency will be
addressed through a variety of means, including diverse staffing, regular training, and
focus group input from clients and families.
4. The Council will make every effort to hire staff and appoint board members from the
diverse groups the program serves and incorporate elements from the culture of the
populations being served in a welcoming way.
5. The program provides services to adults and adolescents in separate treatment “tracks”
as well as different facilities. Adult programs serve persons age 18 and above while
adolescent treatment services are targeted at those individuals under age 18. The
minimum age for admission to the adolescent treatment is age 13; the Division Manager
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in the case of individuals who are developmentally appropriate can make admission
exceptions;
6. All persons residing in Region 11A are eligible for admission to the outpatient
program;
7. The recommended stay period for intensive outpatient rehabilitation/treatment services
is from four to 12 weeks, meeting at least 10 hours per week, based on the criteria in the
Texas Administrative Code TITLE 25, PART 1 TDI, CHAPTER 3, SUBCHAPTER HH,
RULE §3.8022 of this title (relating to TDI Admission Criteria for Intensive Outpatient
Rehabilitation/Treatment Service RULE §3.8019), with utilization review points, based
on the criteria in RULE §3.8020 of this title relating to Continued Stay Criteria for
Intensive Outpatient Rehabilitation/Treatment Service. The recommended stay period for
outpatient treatment services is up to 6 months, meeting at least one hour every two
weeks based on the criteria in the Texas Administrative Code TITLE 25, PART 1 TDI,
CHAPTER 3, SUBCHAPTER HH, RULE §3.8026 of this title (relating to TDI
Admission Criteria for Outpatient Treatment Service RULE §3.8023); with utilization
review points, based on the criteria in RULE §3.8024 of this title relating to Continued
Stay Criteria for Outpatient Treatment Service.
NOTE: A client will be considered to have completed the minimum duration of
retention in treatment if the client has attended at least 14 individual or group sessions.
Texas Administrative Code TITLE 25, PART 1 DSHS, CHAPTER 447,
SUBCHAPTER E, RULE §447.502.
8. The outpatient treatment programs consists of screening, intake and assessment; group
therapy, didactic and psycho-educational services, individual counseling, treatment
planning, relapse prevention, discharge planning, family education and group, 12
Step/self-help group attendance and other referrals as necessary and or clinically
indicated;
9. Outpatient treatment addresses the following core components:
A. Substance abuse issues and problems;
B. Spirituality
C. Emotional/mental health functioning
D. Cognitive functioning
E. Building self-esteem
F. Physical/medical needs
G. Social/interpersonal functioning
H. Use of leisure time
I. Family education and counseling related to the patient’s substance abuse
J. Life skills training
K. Case management
L. Disease management (symptom mitigation, coping skills and relapse prevention)
M. Legal obligations
N. Improving coping abilities
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O. Community/living skills
P. Educational/vocational/occupational issues
Q. Emergency/crisis intervention services
R. 12 Step/Self-help group opportunities
S. Recovery process and
T. Discharge planning and aftercare
10. Treatment is initiated and authorized by a QCC through the screening, assessment
and intake process.
11. The treatment team utilizes Texas Department of Insurance RULE §3.8019 and or
RULE §3.8023 for outpatient placement.
12. All patients receive a complete orientation of the treatment program including an
explanation
of
specific
patient
rights,
rules,
grievance
procedures,
confidentiality/limitations and responsibilities within 24 hours of their admission.
13. Once admitted, a schedule of treatment groups and counselor availability is provided
to all patients/participants so that the needs of the client can be met by determining when
they can come in for individual and/or family counseling sessions and activities.
14. All patients participate in the development of an Individualized Treatment Plan.
15. All clinical documentation is recorded in the CMBHS system as required by DSHS.
COADA-CB treatment employees will complete all appropriate CMBHS and agency
forms and or documentation and place in the patient record.
16. Treatment plans are reviewed when half-minus-14 days of the projected length of stay
has passed and there is no Treatment Plan Review dated after the admission.
17 The program maintains cooperative agreements with available substance abuse and
other mental health, health care and social services to meet the needs of patients and
family. Agreements to coordinate services must be in writing and renewed annually.
18. All counseling sessions and other activities that count toward the required number of
hours of service must last at least 30 minutes.
19. Family services are designed to identify family risk factors associated with the
patient’s substance abuse, improve the health and functioning of the family unit and/or to
assist individual family to support the patient in achieving and maintaining a healthy,
drug free lifestyle. All services provided to family will be age and developmentally
appropriate. Family services shall be initiated only with the knowledge and consent of the
patient. All family services must be clinically appropriate for the individual patient.
20. Family services will be provided by qualified employees including LCDC’s that have
documented education, training and experience needed to perform these services. Patients
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with needs outside the scope of the LCDC practice standards must be referred to a
qualified mental health professional such as a LMSW, LMFT, LPC or LPHA.
21. Discharge plans will be developed for all patients, in accordance with DSHS
requirements.
22. Discharge criteria will be based on the Texas Administrative Code TITLE 25,
PART 1 TDI, CHAPTER 3, SUBCHAPTER HH; RULE §3.8021 and RULE §3.8025.
Note: A client will be considered to have completed the minimum duration of retention in
treatment if the client has attended at least 14 individual or group sessions. Texas
Administrative Code TITLE 25, PART 1 DSHS, CHAPTER 447, SUBCHAPTER E,
RULE §447.502.
All employees involved in outpatient treatment are responsible for conformance with this
policy.
Youth Prevention Universal – YPU
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PURPOSE: To establish the official position of COADA-CB on providing youth
prevention universal programming, describe the components of COADA-CB’s universal
program, and assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to provide a comprehensive youth prevention
universal program that addresses the needs of the population to be served.
PROCEDURES: The following guidelines pertain to the organization’s youth prevention
universal program:
1. The purpose of the program is to provide youth with education/skills training and
alternative activities that will provide the awareness needed to make informed decisions
relating to alcohol, tobacco, and other drugs.
2. The program provides services to youth 7-11 years of age and adults in the
community.
3. The program uses the research-based, model, universal prevention curriculum
Botvin’s Life
Skills designed to provide students with the necessary skills to
resist social pressure to use
tobacco, alcohol, and other drugs. The program
is delivered during a standard 30-50 minute class period throughout 8 weeks,
providing 8 sessions.
4. Life Skills sessions include: Self- Esteem, Smoking Information, Decision Making,
Advertising, Dealing with Stress, Communication Skills, Social Skills and
Assertiveness
5. YPU serves youth in Nueces, Kleberg and San Patricio counties.
6. All youth prevention universal program scheduling is approved by the Program
Manager.
7. All programming issues must be discussed with the Program Manager. (I.e. program
scheduling, participant disclosures, CPS issues, etc.)
8. All employees shall maintain program binder with sign in sheets for all programming
being provided.
9. All program measures will be maintained by the Program Manager and staff and filed
in a secured office.
10. All program measures shall be reported monthly by the 10th of each month to CMBHS
Administrator by the Program Manager.
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11. CMBHS Administrator will report required measures to DSHS by the 15th of each
month.
12. The Program Manager is responsible for al quarterly curriculum reports.
All youth prevention universal program employees are responsible for conformance with
this policy.
Youth Prevention Selective – YPS
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PURPOSE: To establish the official position of COADA-CB on providing youth
prevention selective programming, describe the components of COADA-CB’s selective
program and to assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to provide a comprehensive youth prevention
selective program that addresses the needs of the population to be served.
PROCEDURES: The following guidelines pertain to the organization’s youth prevention
selective program:
1. YPS prevention strategies target subgroups of the general population that are
determined to be at risk for substance abuse. Recipients of selective prevention strategies
are known to have specific risks for substance abuse and are recruited to participate in the
prevention effort because of that group’s profile. Examples of selective prevention
programs for substance abuse include special groups for children of substance abusing
parents or families who live in high crime or impoverished neighborhoods and mentoring
programs aimed at children with school performance or behavioral problems.
2. The curricula being implemented in the YPS program include elementary level FAST
and PTND.
A. The program provides services to youth 5-12 years of age and their families. The
FAST Program is an innovative and collaborative prevention and parent
involvement program, in which whole families gather and participate in specific,
fun, research-based activities aimed at strengthening families and empowering
parents.
B. The PTND program services youth 13-17 years of age. PTND is a science-based
prevention program that targets middle and high school aged youth who are at risk
for drug abuse. This curriculum will be introduced weekly to students in the 6th
through 12th grade.
3. The program serves youth in Nueces, Kleberg and San Patricio counties.
4. The elementary school FAST program is an 8-week multi-family program from
6:00pm-8:30pm that is held at the school. To achieve improved child outcomes, FAST
builds the central protective factor of family cohesion. This is accomplished through the
replication of sequenced activities using research-based techniques that respect the
parent’s role as the child’s primary prevention agent
A. Multi-Family Meetings consist of:
• FAST Hellos
• FAST song and sing-a-long
• Meal hosted by a family and shared as a family unit
• Scribbles (based on art therapy)
• Feeling Charades game (communication game about feelings for the entire
family)
• Buddy time, parent self-help group time, kid’s time
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• “Special Play” quality time between parent and student. This is the most
important concept of FAST and it is based on play therapy.
• Fixed Lottery: Winning as a Family unit and each family wins once
• Closing Ritual: Announcements and Rain
5. FAST program
A. Enhance family functioning:
• Strengthen the parent-child relationship in specific, focused ways
• Empower parents, to help them become the primary prevention agents for their
own children
B. Promote child success in school:
• Improve children’s behavior and performance in school, both short term and long
term
• Empower parents in their role as partners in the educational process
• Increase children and families’ feelings of affiliation toward their school
C. Prevent substance abuse by children and families:
• Increase each family’s knowledge and awareness of substance abuse, and the
impact of substance abuse upon child development.
• Link families to appropriate assessment and treatment services, as needed
D. Reduce the stress that parents and children experience from daily life situations:
• Develop an ongoing support group for parents of at-risk children
• Link the family to appropriate community resources and services, as needed
• Build the esteem of each family member
6. Project Towards No Drug Abuse is a science-based prevention program that targets
middle and high school aged youth who are at-risk for drug abuse. This curriculum will
be introduced weekly to students. The instruction to students will provide detailed
information about the social and health consequences of alcohol, tobacco and other drug
use. The sessions will include: Active Listening, Stereotyping, Myths and Denials,
Chemical Dependency, Talk Show, Marijuana, Tobacco Basketball and Use Cessation,
Stress, Health and Goals, Self-control, Positive and Negative Thought and Behavior
Loops, Perspectives, and Decision-making and Commitment.
7. All youth selective prevention program schheduling is approved by the Education
Programs Manage.
8. All programming issues must be discussed with thhe Education Division Manager
and/or Senior Ediucation Specialist.
9. All programming issues must be discussed with Education Programs Manager and/or
Senior Education Specialist. (I.e. program scheduling, participant disclosures, CPS
issues, etc.)
10. All employees shall maintain program binder with sign in sheets for all programming
being provided.
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11. All employees shall maintain program measures binder with all required forms filed
out completely.
12. All program measures shall be reported monthly by the 10th of each month to
CMBHS Administrator and a copy to Education Programs Manager.
13. CMBHS Coordinator will report required measures to DSHS by the 15th of each
month.
14. The Education Division Manager is responsible for all quarterly curriculum reports.
All youth prevention selective program employees are responsible for conformance with
this policy.
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Youth Prevention Indicated - YPI
PURPOSE: To establish the official position of COADA-CB on providing youth
prevention indicated programming, describe the components of COADA-CB’s youth
prevention indicated program, and to assign specific responsibility for implementation of
the policy.
POLICY: It is the policy of COADA-CB to provide a comprehensive youth prevention
indicated program that addresses the needs of the population to be served.
PROCEDURES: The following guidelines pertain to the organization’s youth prevention
indicated program:
1. YPI prevention interventions identify individuals who are experiencing early signs of
substance abuse and other related problem behaviors associated with substance abuse and
target them with special programs. The individuals identified at this stage, though
experimenting, have not reached the point where clinical diagnosis of substance abuse
can be made. Indicated prevention approaches are used for individuals who may or may
not be abusing substances but who exhibit risk factors such as school failure,
interpersonal social problems, delinquency, and other antisocial behaviors, and
psychological problems such as depression and suicidal behavior, which increases their
chances of developing a drug abuse problem. In the field of substance abuse, an example
of an indicated prevention intervention would be a substance abuse program for high
school students who are experiencing a number of problem behaviors, including truancy,
failing academic grades, suicidal ideation, and early signs of substance abuse. Several of
the DSHS youth indicated programs use the evidence-based curriculum “Reconnecting
Youth,” which is designed for high school students and is TEA approved for credit.
2. The youth prevention indicated program provides youth with intervention counseling,
problem identification and referrals.
3. The program provides services to youth 10-14 years of age and their families. The
curriculum being implemented in the youth prevention indicated program is Families
And Schools Together (FAST) middle school level.
4. Middle School FAST is an innovative, collaborative program that involves middle
school youth with their whole family in building relationships, so that parents can more
easily help their youth on two levels-through a peer group for youth and parents and a
multi-family format bringing the parent and youth together for communicative
encounters.
5. Middle school recruitment begins by providing the target group with information about
the program. Also, school employees will often recommend the program to youth
experiencing difficulties in school or family.
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6. Youth are invited to participate in a peer group to discuss the program further, in order
to participate in the multi family group, the youth must get their parents to agree to a
home visit so that the program is further explained and pre testing is conducted.
7. Each youth has an individual binder maintained by the Youth Advocate (COADA-CB
employee). All education sessions, interventions, and referrals are documented in the
individual youth binder.
8. Middle school FAST consist of:
A. Youth Peer Groups-14 weeks
B. Multifamily groups-10 weeks with a weekly agenda
• FAST Hellos
• FAST song and sing along
• Meal hosted by a family and shared as a family unit
• Buddy time, parent self-help group time *Kids time and **Youth group
• One-to-one, Quality time between parent and youth
• Family Game, communication game about feelings for the entire family
• Fixed lottery, winning as a family unit and each family wins once
• Closing ritual, announoucements and rain
C. After the 10 weeks, a traditional graduation ceremony is held
D. FASTWORKS begins for 2 years, a bi-monthly meeting that keeps families
involved and offers alternative activites.
9. Referrals and information dissemination are made throughout the program. All
referrals and information must be documented and reported on monthly measures.
10. All programming issues must be discussed with Education Programs Manager. (I.e.
program scheduling, participant disclosures, CPS issues, etc.)
11. All employees shall maintain program binder with sign in sheets for all programming
being provided.
12. All employees shall maintain program measures binder with all required forms filed
out completely.
13. All program measures shall be reported monthly by the 10th of each month to
CMBHS Administrator and a copy to Education Programs Manager.
14. CMBHS Coordinator will report required measures to DSHS by the 15th of each
month.
15. The Education Programs Manager is responsible for all quarterly curriculum reports.
All youth prevention indicated program employees are responsible for conformance with
this policy.
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Post Partum Intervention - PPI
PURPOSE: To establish the official position of COADA-CB on providing post partum
intervention services, describe the components of COADA-CB’s post partum
intervention program, and assign specific responsibility for implementation of the policy.
POLICY: It is the policy of COADA-CB to provide a comprehensive post partum
intervention program that addresses the needs of the population to be served.
PROCEDURES: The following guidelines pertain to the organization’s post partum
intervention program:
1. PPI program is to provide on-site, gender specific, community-based outreach,
intervention; motivational counseling, case management, treatment referral and
continuing care for pregnant and post partum women with substance abuse problems.
2. PPI will intervene with the substance abuse/use of pregnant and post partum adult
and adolescent women and reduce the incidence of drug exposure of their unborn,
newborn and young children to facilitate a healthy lifestyle for all participants.
3. PPI must develop formal cooperative agreements with service providers and
organizations the regularly serve adult or adolescent females with or without
dependent children, including but not limited to Child Protective Services, TANF
programs, WIC offices, hospitals, STD, prenatal, and pediatric clinics, mental health
and domestic violence centers.
4. PPI shall provide curriculum-based education in the areas of reproductive health,
effects of ATOD on fetal development, parenting, fetal and child development and
family violence/safety.
5. All program services must be appropriate gender, age, ethnicity and culture of the
target population being served.
6. All program self-evaluation shall be based upon use of the Logic Model.
7. PPI shall initiate and maintain regularly scheduled monitoring of documentation,
program activities related to outcome-based goals and objectives.
8. All direct care employees associated with PPI programming must have a BSW,
LSW, MSW, LPC, and LCDC, be in training to become QCC or have 2 years case
management experience in a social work-related field.
9. All direct care employees shall be knowledgeable in clinical aspects of pregnant
post partum care including communicable diseases associated with substance use and
abuse. They must have the ability to address health concerns and risks associated with
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substance abusing, substance use/abuse and ability to address health concerns and
risks associated with substance abusing behaviors to the target population.
10. All programming issues must be discussed with Division/Program Manager and/or
Executive Director.
11. All employees shall maintain patient/participant files and follow all program
standards according to DSHS Rules.
12. All employees shall maintain program binder with necessary documentation for all
programming being provided.
13. All employees shall maintain program measures binder with all required forms filed
Out completely.
14. All program measures shall be reported monthly by the 10th of each month to
CMBHS Administrator and provide a copy to Division/Program Manager.
15. CMBHS Coordinator will report required measures to DSHS by the 15th of each
month.
All post partum intervention program employees are responsible for conformance with
this policy.
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