Standard Operating Procedure Manual
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Standard Operating Procedure Manual Overview The purpose of this Standard Operating Procedure Manual (SOP) is to provide to employees with written instructions of the regularly recurring work processes and repetitive activities followed by the ADM Board. The procedures set forth in this manual apply to ADM Board employees, interns and volunteers and shall be followed to provide structure and guidance, ensuring that consistent implementation within the organization. You should also be advised that the Executive Director has sole discretion, and reserves the right to adopt new work rules, procedures and policies, and to modify, alter, delete, suspend, change or discontinue existing policies and procedures at any time, with or without notice. You will be informed of changes as they occur. While you may wish to print this manual for your own use, we discourage this. The official and most up to date version of this operating procedure manual resides on the employee communication page. Standard Operating Procedures Overview i Standard Operating Procedure Table of Contents October 2017 Operations Procedures The operations procedures provides guidance on activities related to administration, administrative support, community relations, finance , information technology, information technology security and human resources of the organization. Administration A08 Public Records Request A10 Consumer Scholarships A12 Whistleblower Reporting A13 Reports of Unusual Incidents Administrative Support AD01 General Office Procedures AD02 Board of Directors' Meeting & Committee Meeting Notification and Support AD03 Request for Client Information AD05 Equipment Maintenance AD07 Patient Care System AD08 Office Supply Orders AD10 Monitoring Report Surveys Community Relations COM9 Media Relationships COM10 Updating Online Communication channels including ADM Board Website and Social media sites COM 11 Public Speaking Requests Standard Operating Procedures 2016 Page 1 Finance F1 Cash Receipts F2 Purchasing Procedure F3 Securing and Safeguarding Personal Health Information (PHI) F4 Vendor Account Maintenance F7 Purchase Order – Increase, Decrease, and Discharges F8 Travel, Training, Seminar & Other Business Expense Reimbursement F9 Federal Funding Request F11 Ability to Pay Exception Request F13 Out of County (OOCTY) Remittance Processing F14 Time Sheet and Payroll Processing F17 Void Check and Replacement Check F19 Non-Medicaid Contract Termination F20 Payroll – Adjustments F21 Capping Community Prevention and Community Services F22 Paycheck/Direct Deposit Distribution F23 Financial Compliance Auditor Responsibilities F24 RA Processing F25 Agency Financial & Compliance Audit Reports F26 Preparation of and Subsequent Review of Submitted Provider Budget Applications F27 Capital assets F28 Non-Capital Assets F29 Banner and Kronos Permissions F30 Non- Medicaid Provider Contracts Standard Operating Procedures 2016 Page 2 Human Resources HR1.0 Employee Attendance HR1.1 Employee Grievance HR1.2 Family Medical Leave Act HR1.3 Professional Developments & Training HR1.4 Working at Home HR 1.5 New Hire Orientation HR1.6 Employee Professional Development Plans HR1.7 Reasonable Accommodations HR1.8 Immigration Reform and Employment Eligibility HR1.9 Keys and Key Cards HR1.10 Personnel File Checklist HR1.11 Drug Free Workplace HR1.12 Student Internships and Field Placement Information Technology ITP01 MACSIS General ITP02 MACSIS Member/Eligibility Extract Processing ITP03 MACSIS Claims Files Processing ITP05 MACSIS Claims Files Processing ITP06 MACSIS Retro-Medicaid File Processing ITP07 MACSIS Retroactive Medicaid Script Processing and Agency Reports ITP08 OPLST Reports ITP09 Electronic Remittance Advice (RA) Processing ITP10 Distribution of Remittance Advice (RA) Files to Providers ITP11 MACSIS Caution/Outliers Report Distribution Standard Operating Procedures 2016 Page 3 ITP12 MACSIS Claims Files Reports Processing ITP13 MACSIS Critical Errors Reports Processing ITP14 MACSIS Held Claims Processing IT15 MACSIS Pricing Processing ITP16 Great Office Solution Helper (GOSH) Information Technology Security ITSP01 Access Authorization, Establishment and Modification ITSP02 Access Control ITSP03 Assigning Computer Resources to Employees ITSP04 Password Management ITSP05 Information Systems Activity Review ITSP06 Security Incident Response and Reporting TSP07 Guarding Against, Detecting, and Reporting Malicious Software ITSP08 Data Back-up Plan ITSP09 Data Destruction ITSP10 File Transfer Protocol (FTP) ITSP11 Device and Media Controls ITSP12 ePHI Data Encryption ITSP13 External Unauthorized Access to ePHI ITSP14 Security Reminders ITSP15 Virtual Private Network (VPN) ITSP16 BDR File Restore Standard Operating Procedures 2016 Page 4 Clinical Services Procedures The clinical services procedures provide guidance on activities related to planning, implementation, monitoring, and evaluation of Provider contract agencies’ clinical and support services of the organization. This section of the manual includes procedures on Chief Clinical Officer, Clients rights and the clinical services of the operation. Chief Clinical Officer CC01 Ohio MHAS Incident Reporting CC02 Treatment Over Objection/Capacity Assessment CC03 Health Officer Qualifications and Appointment Process Client Rights CR01 Investigating Complaints Abuse and Neglect CR04 Communication with Persons Who Are Visually Impaired CR05 Civil Rights of Clients CR09 Investigating Complaints and Grievances CR10 Reporting and Record Keeping for Client Rights Investigations Clinical Services CS01 Continuing Education Applications CS05 Clinical Record Review CS08 Crisis Intervention Team (CIT) Statistical Sheet/Psychiatric Emergency Services (PES) Comparison CS09 Quarterly Probate Court / Mental Health Issues Meeting Report CS20 Multiple Agency Community Service Information System (MACSIS) Outpatient Residency Determinations CS22 Independent Peer Review CS27 AoD Agency Referral Satisfaction Surveys CS28 Incident Reporting Standard Operating Procedures 2016 Page 5 CS29 Alcohol and Other Drug Residential Treatment Waiting List Management CS42 Conditional Release Forms CS58 CQI Corrective Action Reviews CS59 CQI Prevention Reviews CS61 Continued Stay Procedure for AoD Residential Treatment CS 62 Mental Health Statistics Improvement Plan (MHSIP) Consumer Survey Standard Operating Procedures 2016 Page 6 Administration Standard Operating Procedure Department: Administration Procedure Number: A 08 Procedure Title: Public Records Requests 1. PURPOSE As a political subdivision of the State of Ohio, the County of Summit Alcohol, Drug Addiction and Mental Health Services (ADM) Board is subject to the rules of Ohio Public Records Statute, Section 149.43 ORC, and strictly adheres to the Ohio Public Records Act. This procedure is to provide clear direction on how to make a public records request to the ADM Board and how it is processed. 2. DEFINITIONS A. Availability of Records All records shall be promptly prepared or made available for inspection to any person at all reasonable times during regular business hours, with exception of published holidays. As required by Ohio Law, records will be organized and maintained so that they are promptly available for inspection and copying, except if legal review and or redaction are required, then the records shall be provided within a reasonable period of time. B. E-mail Documents in electronic format are records as defined by the Ohio Revised Code when their content relates to the business of the office. C. Personal Notes Personal notes of ADM Board staff generally do not meet the definition of a record. Notes have been found not to be public records if they are: 1. Kept as personal papers, not official records; 2. Kept for the employee’s own convenience (for example, to help recall events). 3. Other employees did not use or have access to the notes. D. Public Records Documents kept by the ADM Board office, with certain exceptions as defined by applicable federal and state laws, and the ORC 149.43, and have the following characteristics: 1. Stored on a fixed medium (paper, electronic, or other format); and, 2. Created, received by, or comes under the jurisdiction of the ADM Board office; and 3. That documents the organization, function, policies decision, procedures, operations or other activities of the ADM Board. E. Public Records Log A document listing all public record requests made during the calendar year. Procedure Number: A 08 Page 1 of 4 F. Records Request No specific language is required to make a records request. However the requester must describe the records requested with sufficient clarity to allow the ADM Board to identify, retrieve and review the records. 1. If a Requester makes an ambiguous or overly broad request, or has difficulty in making a request for copies or inspection of public records such that the ADM Board cannot reasonably identify what records are being requested, the ADM Board shall provide the Requester with an opportunity to revise the request by informing the Requester of the manner in which records are maintained; 2. or deny the records request. G. Record Retention Schedule (RC-2) The Schedule of Records Retention and Disposition (RC-2) lists the records created and maintained by the ADM Board. The RC-2 is approved by the Summit County Records Commission. H. Redaction Obscuring, deleting, withholding specific records covered by an exception to the Public Records Act. The ADM Board is required to give the requester an explanation for any part of a record withheld,