1. We’re all in this Together! Moving From Good to Great! CARF Update June 2014

2. Agenda Welcome Review Learning Objectives Discuss New/Revised Policies and New/Revised Forms Short Quiz Questions & Answers 2

3. Learning Objectives At the end of this session you will be able to: Identify new policies and or policy changes. Name at least three new forms that have been added to the administration of our patients. Describe changes to existing forms and explain the purpose of the changes. 3

4. Why Are We Having This Training? As a result of our CARF Certification several recommendations were made by CARF as it relates to the management of our business. Today we will review our corrective actions and/or our solutions to those proposed recommendations. 4

5. Why Are We Having this Training? – Cont. Keep in mind, the changes range from:  A slight modification to an existing form  A new form  Or new policy No matter how big or small the change we want to ensure we all have the same information. 5

6. Let’s Review Policy Changes and Clarifications First! Technology Plan Conflicts of Interest Inclement Weather Training & Development 6

7. Technology Plan Kolmac will begin to evaluate the need for assistive technology at least once per year. Kolmac will also evaluate the need for assistive technology at any point deemed necessary such as the hiring of a staff member with disabilities or the admission of a patient with disabilities. 7

8. Conflicts of Interest Licensed clinicians can only do private practice with active Kolmac patients if; 1.the patient is not attending the same office the clinician works and it is approved by the Clinical Director. 2.the clinician works less than 4 hours per week and it is approved by the Clinical Director. See Handout for the entire Conflict of Interest Policy 8

9. Conflicts of Interest Clinical Directors and Asst. Directors may not do private practice with any Kolmac patient, regardless of what office the patient is in, unless they originally referred the patient to Kolmac. 9 See Handout for the entire Conflict of Interest Policy

10. Inclement Weather In the event a non-exempt employee’s office is closed, or the office is open but staff do not feel safe coming into work due to the weather, non- exempt employees will either need to take Leave Without Pay (LWOP) or use Paid Time Off, if they are eligible for PTO. If your office is closed by Corporate all non- exempt employee’s who are eligible for PTO and who were not previously scheduled off, will be paid their regularly scheduled hours. 10

11. Training and Development In Service Training may assist licensed staff with obtaining the required continuing education units (CEU’s) in their respective fields. Instructions on how to print a training log or In-Service Certificate is included in the training and development policy (see handout). 11

12. Now It’s Time to Review the Forms… 12

13. The date the form was created or revised should be at the bottom of the form. Rev. 5/12/14 etb It may be on the Left or Right of the form! RE: 5/15/2014 13

14. New: Patient Emergency Information Card 14

15. Next Print - Patient Emergency Information Card 15 First Name Last Name 6/16/14

16. New- Patient Emergency Information Card Process Patient Emergency Information Cards will be stored in a Black Index Card Box in a secured location. When evacuating the building, staff will take;  The Black Index Card Box  The Health and Safety Binder  The roster of any groups in session 16

17. New- Patient Emergency Information Card Admin is responsible for having the patient complete the Patient Emergency Information Card at orientation and for weekly updates.  The Black Index Card Box should be updated weekly by;  checking to ensure every active patient has a card and  removing any inactive patients cards.  Cards of patients who are no longer with the Kolmac Clinic should be removed from the Black Index Card Box and placed in the patients file. 17

18. Change: Clinical Supervision Form Added 18 On Page 2 of 2

19. Added to Patient Orientation  Patient Orientation Checklist Form  Showing patients the emergency exits, location of the fire suppression equipment, first aid supplies and the restrooms.  Showing patients at least one of our posted evacuation plans and informing the patient that the plans can be found in every office near the door. 19

20. New: Patient Orientation Checklist 20

21. New: Patient Orientation Checklist 21 What happens with the Patient Orientation Checklist once completed …

22. New: Brief Initial Screening Form 22 3 pages

23. Change: Psychosocial Evaluation Form 23 Page 2 of 7

24. Change: Psychosocial Evaluation Form 24 ADDED Page 2 of 7 WE WILL REVIEW A PATIENT SAFETY PLAN FORM NEXT

25. Change: Psychosocial Evaluation Form 25 Page 2 of 7

26. Change: Psychosocial Evaluation Form 26 Page 3 of 7

27. Change: Psychosocial Evaluation Form 27 Page 3 of 7

28. Change: Psychosocial Evaluation Form 28 Page 4 of 7

29. Change: Psychosocial Evaluation Form 29 Page 4 of 7

30. Change: Psychosocial Evaluation Form 30 Page 5 of 7 ADDED

31. Change: Psychosocial Evaluation Form 31 Page 5 of 7

32. Change: Psychosocial Evaluation Form 32 Page 6 of 7 ADDED

33. Change: Psychosocial Evaluation Form 33 Page 7 of 7 ADDED

34. New: Patient Safety Plan (Referenced under Harm to Self on Psychosocial Evaluation) 34

35. New: Patient Safety Plan Do patients get a copy of this form? When should you do a new Patient Safety Plan for a patient? Do you need releases for those contacts listed on the Patient Safety Plan? 35

36. Change: Person Centered IOP Plan 36 Added Page 2 of 6

37. Change: Person Centered IOP Plan 37 Page 3 of 6

38. Change: Person Centered IOP Plan 38 Page 3 of 6

39. Change: Person Centered IOP Plan 39 Page 4 of 6

40. Change: Person Centered IOP Plan 40 Page 5 of 6

41. Change: Person Centered CC Plan 41 On all 6 pages SAME FORMAT & PROCESS AS THE IOP PLAN

42. Change: Chart Review Form 42 Page 1 of 2

43. Change: Chart Review Form Added 4. The goals and service/treatment objectives of the persons served were: a.Based on: 1.The results of the assessments…………………………………..... 2.The input of the persons served as evidenced by; a.Completion of the IOP SNAP.................................................. b.The use of person first language on the IOP Tx Plan………. c.Completion of the CC SNAP………………………………… d.The use of person first language on the CC Tx Plan………… 1.Revised when indicated, as evidenced by: a.Timely updates on IOP Tx Plan…………………………….. b.Timely updates on CC Tx Plan……………………………… 43 Page 2 of 2

44. Change: Chart Review Form 7. The person-centered plan was reviewed and updated in accordance with the Organization’s policy, as evidenced by; a.Timely completion of the IOP Tx Plan (within 14 days of admission) b.IOP Tx Plan is signed by a LICENSED clinician…………………… c.Timely completion of the CC Tx Plan (before admission into CC)…. d.CC Tx Plan signed by a licensed clinician…………………………… Added 44 Page 2 of 2

45. Change: Transition Summary 45 Page 1 of 2

46. Change: Transition Summary Added 46 Page 2 of 2

47. Change: Transition Summary 47 Page 2 of 2

48. Change: Recovery Plan 48

49. Change: Grievance Procedure Form Distributed at Patient Orientation 49 ADDED

50. Change: Admission Medical Review Form 50 Page 1 of 2

51. New: Pregnancy Test Acknowledgement Used before the administration of medications for withdrawal management patients located on the bottom of the Admission Medical Review Form 51 Page 2 of 2

52. New: Supervision Acknowledgement 52

53. Change: IOP/CC Individual Session Note 53 Page 1 of 2

54. Question: Can you name the policies that we have added and/or revised? Technology Plan Conflicts of Interest Inclement Weather Training and Development 54

55. Question: Can you name at least one new form/process that has been added to the administrative management of our patients? Patient Emergency Information Card Patient Orientation Checklist Brief Initial Screening Form Patient Safety Plan Pregnancy Test Acknowledgment on the Medical Review Form Supervision Acknowledgement Form 55

56. Question: What two instances should the Transition Summary form be used? 1. For patients transferring from one level of care to another 2. For patients transferring from one office to another 56

57. Question: What is new to the Patient Orientation Process? Showing patients the emergency exits, location of the fire suppression equipment, first aid supplies and the restrooms. Showing patients at least one of our posted evacuation plans and informing patients that plans can be found in every office near the door. The Patient Orientation Checklist Form 57

58. Question: What is the purpose of the Patient Orientation Checklist? This form assist us with documenting our patient orientation process. 58

59. Question: When should the Patient Safety Plan form be used? To be completed by the Clinician (at any time) if the patient is at risk for dangerous behaviors 59

60. Question: The Initial Patient Screenings Form eliminates what screens? Beck Brown ADD Scale MDQ Dissociative Experience Scale 60

61. Question: Does the IOP Session Note replace the Case Management Notes? Yes 61

62. Question: We now have a Session Note for both: IOP and CC 62

63. Question: Can you name what has changed as a result of our CARF accreditation or as a part of our “Good to Great” model? Clinical Supervision Form Psychosocial Evaluation Form Person Centered IOP Plan Person Centered CC Plan Clinical Chart Review Transition Summary Recovery Plan Grievance Procedure Form Admission Medical Review Form IOP Individual Session Note 63

64. Questions and Answers 64