Changes to Policies Effective 2/1/17

**Several policies required a change in how Zumbro House made reference to the person’s served. The words “consumer” and “individual” were changed to “person” for consistency in all policies.

Incident Response, Reporting and Review Policy:

  1. Definition of a serious injury was updated to “instances of a self-injurious behavior or suicide attempt when the injury results in hospitalization of the person or the need for medical treatment” and “emergency use of manual restraint”.
  2. Non-emergency medical intervention was removed from I. Policy, as it does not meet the definition of an incident per 245D.02.
  3. “Oronoco” County was changed to “Olmstead” County.
  4. Finished sentence in H.6. “Follow all directions by the medical personnel.”
  5. Removed reference to Maltreatment of Minors as we do not serve minors.
  6. Formatting changes.
  7. Revised revision date for the policy to 2/1/17.

Emergency Response, Reporting, and Review Policy

  1. Removed “location of fire hydrant” from section II. A
  2. Added electrical companies by program site for power outages.
  3. In numbers 4 - 6, “medical and program books” was removed. Added “laptop, tablet, and both chargers” due to use of electronic health records starting 3/1/17.
  4. In B.3. Emergency contacts, I replaced “on the data sheet for each individual” located in “the individual’s program book” with “emergency packet for” located in “iCare Manager”.
  5. In Section III, I replaced “emergency report” with “incident report”. Removed the word “written” from “written reports” as these reports may be electronic.
  6. In Section V, “emergency reporting form” was changed to “incident log”.
  7. Updated staff titles.
  8. Formatting changes.
  9. Policy revision date changed to 2/1/17.

Emergency Use of Manual Restraint Policy

  1. Permitted actions and procedures were updated to coincide with DHS’s regulation.
  2. Policy revision date changed to 2/1/17.

Maltreatment of Minors Mandated Reporting and Internal Review Policy

This policy was deleted effective 2/1/17 as Zumbro House, Inc. do not support minors.

Facility Sanitation and Health Policy

  1. Formatting changes.
  2. Change of employee titles.
  3. Policy revision date changed to 2/1/17.

Safe Transportation Policy

  1. Formatting and punctuation changes only.
  2. Policy revision date changed to 2/1/17.

Data Privacy Policy

  1. III.E.:deleted “and will make an entry in the person’s progress notes as to the person who accessed the record…..”.
  2. Removed “training on individual rights during” in III.G.1 . The sentence now reads, “The topic is covered in the formal staff orientation training.”
  3. Policy revision date changed to 2/1/17.

Grievance Policy

  1. Added “authorized or legal representative” in II.A. andII.C.8.
  2. Removed Home Care Services from this policy as this does not apply.
  3. Policy revision date changed to 2/1/17.

Record Keeping Policy – Program

  1. II.A.: deleted number 2. The census report is automatic in iCare, the new electronic health record.
  2. II. B. 1. a. The Service Initiation Form is now the Admission Profile in iCare. Letter f now includes, “when the CSSP identifies the need for coordination between the service providers and includes contact person, telephone number, service provided, and staff responsible for coordination.” “Written” and “progress or daily log notes” was removed from letter k.
  3. II.B.3. “paper records” replaced “information”
  4. II.B.4. “seven years” was replaced with “indefinitely”.
  5. II.B.5 “three years was replaced with “five years”
  6. II.B.6: added, “electronically. Paper records will be maintained” in a secure…. Removed “at each site”.
  7. II.D.4. : removed “must be” and replaced with “will be maintained electronically. Paper records will be”…
  8. Deleted II.E.
  9. Changed revision date to 2/1/17.

HIPAA Compliance Policy

  1. Formatting changes.
  2. Removed any word “written” or “form”
  3. Changed employee titles.
  4. In section, “what is part of the individual record set”, “progress notes” was removed, added “electrionic” to MARs, changed “risk management plan” to “service and abuse plans and supplemental records”, and removed “program plans”.
  5. Changed revision date to 2/1/17.

Service Continuity and Coordination Policy

  1. Replaced IDT with ST/Support Team. This is the new terminology for 245D.
  2. Changed “Community Services and Support Plan” to “Coordinated Services and Support Plan”.

4. Changed “Program Director” to “Designated Coordinator” to coincide with lingo from the rule.

5. II.C. Health Coordination: revised this section to read better, took out notation that the Health Needs Change Notice is a form. Also added specifics for when to notify teams – per the rule.

6.Changed revision date to 2/1/17.

Individual Rights Policy

1. Changed III.A. to reflect wording verbatim from the rule, “Persons receiving services and their legal representatives (if any), will be provided with a copy of the person’s service recipient rights and an explanation of those rights within five working days of service initiation and annually thereafter.”.

2. Corrected the acronym CSSP to “Coordinated Services and Support Plan” in III.E.

  1. Changed revision date to 2/1/17.

Quality Improvement Policy

  1. Employee title changes, formatting, and punctuation were the only changes.
  2. Changed revision date to 2/1/17.

Safe Medication Assistance and Administration Policy

The bulk of changes included changing from paper Medication Administration Records to electronic medication administration records as part of the move to electronic health records set for 3/1/17. Also removed references to staff re-training and disciplinary actions in the event of medication or treatment errors. Changed revision date to 2/1/17.