FAMILY SERVICE OPERATIONS
& SUBSIDIARIES
Family Service Association
Family Service Development
Family Service Enterprise

SECTION I

FAMILY SERVICE OPERATIONS

GOVERNANCE

PART A: ADMINISTRATIVE POLICIES

PART A: ADMINISTRATIVE POLICIES

INDEX

POLICY NO.

Authority...... 1

Handling of Emergency Personnel Decisions...... 2

Leases, Contracts, Negotiations...... 3

Responsibilities of Program Managers...... 4

Board Communication...... 5

Dealing with Funding Sources...... 6

Equal Employment Opportunity and Affirmative Action Statement...... 7

Employee Hiring Policy...... 8

Hours of Operation...... 9

Media Releases...... 10

Guidelines for Advisory Committees...... 11

Conflict of Interest...... 12

Review of Personnel Records...... 13

Evaluation of Independent Contractors...... 14

Safety in the Work Place...... 15

Safety Precautions Outside of Workplace...... 16

Drug Free Work Place Policy...... 17

Naloxone Policy...... 18

Consumer Gratuities...... 19

Gift Solicitation...... 20

Employee Bonus System...... 21

Student Interns...... 22

Agency Use of Legal Counsel...... 23

Employee Background Checks...... 24

Central Registry Background Check...... 25

Staff Exemptions from Trainings...... 26

Supervision...... 27

Cell Phone...... 28

Laptop and Flash Drive Backup...... 29

Key Card System...... 30

Texting Consumers...... 31

Preventing Fraud, Waste and Abuse, and the Federal False Claims Act...... 32

Prohibition Against Retaliation for Good Faith Reporting of Noncompliance (Whistleblower Protections) 33

Violence, Mistreatment and Abuse...... 34

Dealing with Abusive Behavior and Difficult Situations...... 35

Operational Staffing Plan...... 36

Definition of Consumer Consent for Treatment/ Services...... 37

Copayments and Billing...... 38

Agency Committees...... 39

Electronic Health Record (EHR)...... 40

PART A: ADMINISTRATIVE POLICIES

CORPORATE COMPLIANCE PROGRAM

TABLE OF CONTENTS

Policy Number

Introduction...... CCP-1

Risk Management...... CCP -2

Obligation to Report...... CCP -3

Reporting Procedures...... CCP -4

Corporate Compliance Officer...... CCP -5

Corporate Compliance Committee...... CCP -6

Board Member Oversight...... CCP -7

Training...... CCP -8

Contact Information...... CCP -9

Investigations...... CCP -10

Monitoring...... CCP -11

Corrective Action Programs...... CCP -12

Effectiveness Review...... CCP -13

PART A: ADMINISTRATIVE POLICIESPolicy No. 1

AUTHORITY

Policy

The President, CEO, of Family Service Association is responsible for the Agency's operations.

Procedures:

  1. If the President, CEO is unavailable, the following levels of authority will be in place:
  2. Chief Administrative Officer
  3. VP Behavioral Health
  4. VP Family and Community Services
  5. Controller
  6. Manager of program(s) involved
  7. Supervisor-On-Call
  8. All reasonable attempts will be made to ensure consultation with the appropriate party. If appropriate parties are unavailable, then the next level of authority will be brought into place in emergency situations.
  9. The table of organization shall reflect the authority and accountability of staff persons within the agency.
  10. If position changes, the organizational chart shall be updated within 30 days.
  11. Approval must be received by the President/CEO and if appropriate by the Board of Trustees.

Effective Date:10/87

Revised Date:10/98

Revised Date:4/00

Revised Date:3/03

Revised Date:01/14
PART A: ADMINISTRATIVE POLICIESPolicy No. 2

HANDLING OF EMERGENCY PERSONNEL DECISIONS

Policy

Personnel actions needing a decision when the President, CEO is on vacation, out sick or otherwise out of the office and cannot be reached may be handled by a member of the Senior Team.

Procedure:

  1. The existing Personnel Policies pertaining to the situation must be followed.
  1. The appropriate Officer or Vice President is authorized to make a decision under the following guidelines:
  1. The decision is put into writing
  1. The employee is notified of the decision in writing
  1. A copy of the written decision is placed in the employee's Personnel File
  1. A copy is placed in President's mail box for his notification upon his return.
  1. For those instances involving personnel decisions that are confusing, unusual, or of an emergency nature, every effort is to be made to contact the President, CEO by telephone so that he is aware of the situation.

Effective Date: 8/91

Revised Date: 10/98

Revised Date:4/00

Revised Date:3/03

PART A: ADMINISTRATIVE POLICIESPolicy No. 3

LEASES, CONTRACTS AND NEGOTIATIONS

Policy

The President/CEO is responsible for maintaining and approving leases and contracts (equipment, vehicles, and buildings) subjected to the policies approved by the Board of Trustees.

Procedures:

Any expenditure over $5,000.00 requires at least three bids.

Effective Date:6/91

Revised Date: 4/00

Revised Date:3/03

Revised Date:8/09

PART A: ADMINISTRATIVE POLICIESPolicy No. 4

RESPONSIBILITIES OF PROGRAM MANAGERS

Policy

The Agency has a policy regarding the responsibilities of program managers.

Procedure:

  1. Program managers must communicate, in a timely fashion, to the appropriate Officer or Vice-President, any personnel issues, problems, concerns or situations.
  2. Personnel policies and procedures are approved by the Board of Trustees and cannot be changed or modified for any individual employee.
  3. All contracts, letters of intent, agreements, etc., that bind this Agency to a specific obligation must have prior approval by the President, including offers of employment. Any negotiations on the part of program managers must be ratified at the earliest possible time by the appropriate Officer or Vice-President or President to prevent inappropriate or unintentional obligations by the Agency. This includes developing working relationships with other agencies or individuals.
  4. Non-clinical communications with funding agencies must be reported to the appropriate Officer or Vice-President prior to the contact being made if at all possible. If not possible, information relayed or received must be transmitted to the appropriate Officer or Vice-President or the President as soon as possible.
  5. Any change in staff job descriptions, responsibilities, work schedules or Agency forms must be approved by the appropriate Officer or Vice-President.
  6. Program managers may not authorize major repairs to Agency facilities or equipment. This can only be done by the CEO or CFO.
  7. Approval must be obtained prior to initiating or responding to media contacts. This does not include submitting requests to the media for volunteers, recruitment or routine program announcements.
  8. Staff assignments to Board committees are made by the President. Communications with Agency Board members is not a responsibility of program managers or other staff. Staff should refer any request from Board members to the appropriate Officer or Vice-President or President.
  9. Any spending of monies must be approved by the appropriate Officer or Vice-President.

Effective Date:4/87

Revised Date: 4/00

Revised Date:3/03

Revised Date:8/09

PART A: ADMINISTRATIVE POLICIESPolicy No. 5

BOARD COMMUNICATION

Policy

Communications with the Boards of Trustees are made by the President, CEO, of Family Service Association.

Procedures:

  1. Communications with members of the Agency's Board of Trustees is not a responsibility of Program Managers or other staff.
  1. Staff should refer any request from Board members to the President or appropriate Officer or Vice-President.

Effective Date: 1/87

Revised Date:4/00

Revised Date:3/03

Revised Date:8/09

PART A: ADMINISTRATIVE POLICIESPolicy No. 6

DEALING WITH FUNDING SOURCES

Policy

The President, CEO is the authority for dealing with all funding sources of the Agency.

Procedure:

  1. Any problems with any funding source are brought to the immediate attention of the President, CEO.
  1. All final decisions as to course of action when problems arise must be approved by the President, CEO.

Effective Date: 6/91

Revised Date:3/03

PART A: ADMINISTRATIVE POLICIESPolicy No. 7

EQUAL EMPLOYMENT OPPORTUNITY AND

AFFIRMATIVE ACTION STATEMENT

Policy

Equal employment opportunity, regardless of race, creed, color, national origin, age, sex, marital status, religious belief, and handicap is the policy of Family Service Association.

Procedures:

  1. Equal employment opportunity includes, but is not limited to, the areas of recruitment, selection, hiring, training, promotion, transfer, layoff, return from layoff, compensation and fringe benefits. It includes policies, procedures, and programs for recruitment employment, training, promotion, and retention of minorities and handicapped persons and women.
  2. The President, CEO, is responsible for compliance and implementation of the Agency's EEO plan.
  3. Employment practices are reviewed to determine whether the protected classes are receiving fair and equal consideration for job opportunities at all levels. Affirmative Action will be taken to encourage minorities and women to apply for positions within Family Service Association.
  4. Promotion decisions are based only on valid requirements. Promotional decisions will be made to further the principle of equal employment opportunity.
  5. All personnel actions, such as compensation, benefits, transfers, layoffs, return from layoffs, training, education, tuition assistance, social and recreational programs, will be administered without regard to race, national origin, ancestry, color, sex, marital status, religion, age, handicap, political affiliations, arrest or other non-job-related personal criteria.
  6. As all employees have the responsibility of maintaining high standards of honesty, integrity, impartiality, and conduct to assure the proper performance of the Agency's business, no employee's conduct which violates these standards will be condoned.
  7. Sexual harassment is a form of employee misconduct which will not be tolerated. Violators will be dealt with seriously through the disciplinary process of the Personnel Guidelines.
  8. The Equal Employment Opportunity and Affirmative Action Policy Statement will be communicated among the executive, managers and all other employees of the Agency.
  9. All managers are accountable for ensuring compliance with the Equal Employment Opportunity policy.

Effective Date:9/89

Revised Date:3/03; 8/03

PART A: ADMINISTRATIVE POLICIESPolicy No. 8

EMPLOYEE HIRING POLICY

It is the policy of the Agency to follow the procedures listed below in the hiring of employees.

Procedures:

  1. Human Resources will prescreen employment resumes/applications and forward appropriate resumes/applications to Program Managers for openings within their programs.
  2. Program Managers will screen applicants for employment at the direct service and support level of employment, and Schedule and conduct interviews with applicants.
  3. Request that applicant brings three (3) written recommendation letters to interview (mandatory).
  4. Request any documents or information that will assist in making an appropriate hiring decision. Items include, but not limited to, driver’s license, degree, professional license, etc.
  5. Make a recommendation for employment by completing the
  6. Personnel Job Offer Recruitment Form.
  7. No mention or promise of a specific salary should be discussed or negotiated with a potential employee at this time. However, it is appropriate to receive any salary recommendations from the potential employee.

NOTE: The Program Manager will inquire as to whether or not the candidate or their family member(s) are currently receiving services with Family Service Association. If the candidate is offered the position, he/she must choose to continue being a consumer or accepting the position with the Agency.

  1. The Program Manager will forward the Personnel Job Offer Recruitment Form with package to Human Resources for a compliance review.

NOTE: It is acceptable for the Program Manager to communicate to the potential employee who is being considered for employment to apply the required information (compliance review) for employment consideration to them for Human Resource’s compliance audit.

  1. Human Resources will ensure each job offer package is reviewed and is in compliance with FSA Hiring procedures to include:
  2. FSA Employment Application
  3. Resume
  4. 3 written recommendation letters
  5. Professional License and/or Driver’s License check

PART A: ADMINISTRATIVE POLICIESPage 2 of 3

EMPLOYEE HIRING POLICY

  1. Diploma/Credentials
  2. Social Security Card
  3. Proof of Legal Status
  4. Reference Checks – employment and personal
  5. Board certified or Board eligible by the American Board of Psychiatry or the American Osteopathic Board of Neurology and Psychiatry (Adult/Child), if applicable

Note: Only originals of those documents listed above are to be presented to the Human Resources Manager, where photocopying and initialing of review of original documents will be made. Under no circumstances will copies of above-listed documents be acceptable.

  1. On an annual basis, the Human Resources Manager will investigate each licensed employee to ensure that the license is active and in good standing. This information will be accessed at the State of New Jersey Website at: where active status may be verified. If it is determined that the license is not active, the employee will be given 30 days to re-activate her/his license. The employee will not be allowed to practice at Family Service Association until her/his license is re-activated or renewed.
  2. After Human Resources reviews the Job Offer package for compliance, the Job Offer package will be forwarded to the appropriate Senior Manager for approval.
  3. If a program manager is being hired, the President will review the Officer's or Vice President's recommendation.
  4. If there is concurrence between the manager and an Officer or Vice President that the candidate could be hired, the recommendation and appropriate paperwork is shared with the President/CEO, by the appropriate Officer or Vice President.
  5. At this point, salary is set and the candidate may then meet with the appropriate Officer or Vice President, if requested. If he/she approves the candidate,this information can then be communicated to the potential employee and an offer of employment can be made.
  6. Once a date of employment is mutually agreed upon, Human Resources will prepare a letter of hire for the President's, or their designee’s, signature to the new employee.
  7. For the Outpatient program and other relative programs needing credentialed staff, Human Resources Generalist will investigate with credentialing companies to verify credentialing status of employee. If employee is not credentialed, the appropriate insurance applications will be given to employee for processing.

PART A: ADMINISTRATIVE POLICIESPage 3 of 3

EMPLOYEE HIRING POLICY

  1. The employee’s first day will consist of New Hire Processing and will be scheduled for a two hour Agency Orientation with a Senior Admin speaker. For all employees, a Program/Unit Orientation will be completed. (See Outline and Checklist for the Program/Unit Orientation.) The new employee will receive a copy of the Program/Unit Orientation Checklist to be completed by the new employee’s Program Manager.
  2. Physicals are to be completed within 45 days of hire.
  3. All documents relating to the new employee should be returned to Human Resources by the end of the second week of employment, including but not limited to: company orientation checklist, program/unit orientation checklist, employment checklist, etc.

Effective Date: 8/88

Revised Date: 4/00; 10/01; 3/03; 8/03; 10/07; 2/11, 4/11

FAMILY SERVICE ASSOCIATION

PROGRAM/UNIT ORIENTATION

Please ensure that the new employee has received an explanation and/or a copy of the information listed below.
  1. Introduction to program Staff
  2. Overview of Employment
  3. Program Description and Sources of Funding
  4. Program Contract and Manual
  5. Employee evaluation and objectives
  6. Five year plan (Company)
  7. Training required for this position
  8. Service Population
  9. Overview of referral services that are available
  10. Crisis Intervention & Service Interventions
  11. Language assistance when needed
  12. Governmental services available
  13. Customer Service Skills
  14. Demographics of population served
  15. Consumer Rights
  16. Maintaining dignity
  17. Personal choice
  18. Special considerations based on need
  19. Confidentiality
  20. Protection from discrimination
  21. Promoting self sufficiency
  22. General Procedures
  23. Time & Attendance
  24. Receiving messages
  25. Agency vehicle policy & procedures
  26. Location of charts and forms
  27. Program operations manual & operating hours

FAMILY SERVICE ASSOCIATION

PROGRAM/UNIT ORIENTATIONPage 2 of 3

  1. Signing out charts
  2. Sick and vacation requests
  3. Office supplies requisitions
  4. Purchase Orders
  5. Petty cash procedures
  6. Compensatory time procedures
  7. Maintenance requests
  8. Location of satellite offices
  9. Judicial and regulatory guidelines including consent decrees
  1. Daily Stats
  2. Daily logs
  3. Consumer attendance sheets
  4. Cancellation & No-show Procedures
  5. Charting
  6. Screening
  7. Intake/Assessment Treatment Plan
  8. Opening cases
  9. Consent for Treatment
  10. Data forms (Screening, Billing, Consumer Data Form, Non IC, Change Form)
  11. Authorization to release and obtain information
  12. Evaluations – Psychological & Psychiatric
  13. Referral forms
  14. Health history
  15. Medical Bill of Rights
  16. Consumer Health Education (3 forms)
  17. Progress Notes
  18. Transfer and Closing Procedures
  19. UR Responsibilities
  20. DSMIV-R

FAMILY SERVICE ASSOCIATION

PROGRAM/UNIT ORIENTATIONPage 3 of 3

  1. Third Party Expectations
  2. Interaction with managed care organizations (MCO)
  3. Treatment Plans for MCO’s and/or Funders
  4. Clinical evaluations to determine appropriate levels of care
  5. Outlining criteria for referrals
  6. Interaction with primary care providers and medical and social service delivery systems
  7. Monitoring consumer compliance
  8. Meeting Schedules
  9. Unit staff meetings
  10. Supervision
  11. Monthly Forms
  12. Caseload summaries
  13. Phone logs
  14. Expense forms
  15. Scheduling Consumers
  16. Consumer notification
  17. Risk Management
  18. Suicide & emergency protocol
  19. Handling air and blood borne pathogens
  20. Emergency Procedures
  21. Fire Evacuation
  22. TB prevention

Date of Hire: ______

______

Employee’s Signature

______

Manager’s Signature

NEW HIRE ORIENTATION AGENDA

9:00 AM – 9:30 AM

Who We Are/Culture

Mission/Vision/Values

FSA/FSE/FSD

Organizational Chart & Leadership (e3)

Q&A

9:30 AM – 9:55 AM

Trauma Informed Care

9:55 AM – 10:40 AM

FSA Program Overview

Outpatient Counseling

First Day

Children’s Partial Care: Rainbow Place & Safe Harbor

Family Life Center

Family Success Centers: Spruce & New Day

Kinship Legal Guardianship / Kinship Wraparound

Neighborhood Builders

EHT School Based Youth Services

HEDS Case Management

Parents as Teachers

S.A.I.F.

Board & Care / MHCCC / FSA Training Institute

10:40 AM – 10:55 AM

Employee Life

Corporate Wellness Program

Tilton Fitness

AtlantiCare Life Center

EAP

BJ’s, Sam’s

EOM/EOY/MOQ

10:55 AM – 11:10 AM

Professional Development

Mandatory Items

Regulations

Corporate Compliance

myLearningPointe

All Staff Training

Other Opportunities

Evaluations

Q&A

11:10 – 11:50 AM

Cultural Competence

11:50 – 12:00 PM Closing

PART A: ADMINISTRATIVE POLICIESPolicy No. 9

HOURS OF OPERATION

Policy

Family Service Association will be open for operation subject to the needs of the program(s).

Procedures:

  1. All programs will operate in accordance with the requirements with that program's contract. Program operations are developed to ensure maximum access of consumers to services.
  1. If program needs require a temporary deviation from regularly scheduled hours, the Program Manager must obtain approval from the appropriate Officer or Vice-President
  1. If program needs require a permanent change in Agency hours of operation, a recommendation by the appropriate Officer or Vice-President will be made to the President, who will make the final decision.

Effective Date:8/88

Revised Date:10/98

Revised Date:4/00

Revised Date:3/03

PART A: ADMINISTRATIVE POLICIESPolicy No. 10

MEDIA RELEASES

Policy

All information released about Family Service Association and the services it provides must have prior approval.

Procedure:

Releases (written, oral, or visual) to media are to be made by staff of the Program Manager level or above.

Program Managers must obtain approval from the appropriate Officer or Vice-President prior to initiating or responding to media contacts. This does not include submitting requests to the media for volunteers, recruitment, or routine program announcements.