NSMHA Policies & Procedures

North Sound Mental Health Administration

Improving the mental health and well being of individuals and families in our communities
A Regional Support Network for Island, San Juan, Skagit, Snohomish & Whatcom Counties.

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Section 1000: Administrative

1001.00	Complaint, Grievance, Appeal & Fair Hearing Policy: General Policy Requirements
1002.00	Complaint & Grievance
1003.00	Appeal Policy
1004.00	Fair Hearing Policy
1005.00	Notice Requirements
1006.00	Policy Development and Review
1006.01	QMC-QMOC Policy Subcommittee Charter
1007.00	Primary Source Verification Credentialing, Re-Credentialing, Appointment and Privileging of Contracted or Employed Staff
1008.00	Provider Network Selection and Management
1009.00	Critical Incident Reporting and Review Requirements CIRC Quality Assurance and Improvement Process
1010.00	NSMHA Accident Prevention Program
1010.01	Accident Investigation Report
1010.02	Emergency Numbers
1010.03	Fire Escape Map
1010.04	Notifying NSMHA Staff of an Emergency Situation
1010.05	Bomb Threat Checklist Form
1011.00	Framework for All NSMHA Activities - Core Values and Principles
1011.01	Framework for all NSMHA Activities - Core Values and Principles
1012.00	NSMHA Project Work Process
1013.00	NSMHA Hazard Communication Policy
1013.01	MSDS Identity
1013.02	MSDS Table of Contents
1013.03	Hazardous Chemicals within NSMHA
1014.00	Establishing a Safety Committee
1015.00	Assurance of Adequate System Capacity and Services
1016.00	Response to Requests from Regulatory Agencies
1017.00	Corrective Action
1018.00	Delegation of North Sound Mental Health Administration (NSMHA) Functions and Responsibilities
1018.01	Form: Sample Delegation Plan
1019.00	Notifying Consumers of Provider Termination
1020.00	Inpatient Provider Appeal and Dispute

Section 1500: Clinical

1501.00	Accessibility/Travel to Service Locations for Medicaid Consumers
1502.00	Accessibility, Engagement, and Utilization of Services for High Need Individuals in Open Episodes not Engaging in Treatment
1503.00	Access Standards
1504.00	Assessments for Ongoing Services
1505.00	Authorization for Ongoing Outpatient Services
1506.00	Availability of Services
1508.00	Clinical Practice Guidelines
1509.00	Consent for Treatment
1510.00	Intra-Network Consumer Transfers and Coordination of Care
1510.01	Guidelines for Transfer or Coordination of Care by Service
1511.00	Choice or Change of Mental Health Care Provider (MHCP)
1515.00	Interpreter and Translation Services
1516.00	Minimum Requirements and Certification for Mental Health Professionals
1516.01	Exception Request Form for Mental Health Professionals (MHP)
1516.02	Waiver Request Form for Mental Health Professionals (MHP)
1517.00	Coordination of Care with Primary Care Physician and Other Health Care Providers
1518.00	Mental Health Advance Directives
1519.00	Provider-Enrollee Communications
1520.00	Second Opinion
1521.00	Cultural and Linguistic Competence
1522.00	Out of Network Referrals
1523.00	Outreach to Homeless Individuals and Families
1524.00	Access to Housing and Consumer Choice in Housing
1524.01	NSMHA Board of Directors Housing Opportunities Principles
1528.00	Mental Health Screening Prior to Nursing Home Placement
1528.01	PASRR Initial Evaluation
1528.02	PASRR Followup Evaluation
1528.03	PASRR Invalidation Statement
1528.04	PASRR Documentation for Interrupted Evaluation
1528.05	RPIDFORM - Jarvinen
1529.00	Children's Long-term Inpatient Program (CLIP) Care Coordination
1529.01	RSN/CLIP Agreement - Appendix A
1530.00	Cross System Coordination
1531.00	Employment Support Services
1532.00	Residential Placement - Reauthorization
1533.00	Reintegration of Consumers into the Community
1534.00	Single Bed Certification - Western State Hospital
1536.00	State Hospital Care and Discharge Coordination
1536.01	WSH-RSN Working Agreement
1539.00	Continued Stay/Re-Authorization Criteria
1540.00	Criteria for Closing an Episode of Care/Planned Discharge from Treatment
1541.00	Rationale and Use of Seclusion and Restraints at Evaluation and Treatment Facilities
1542.00	Evaluation and Treatment Facilities Admission Medical Clearance Criteria
1543.00	Nursing Assessment and Treatment Planning for Residents at Evaluation and Treatment Facilities
1545.00	Voluntary Hospital Certification - Tribal Community Members
1546.00	Medication Management Transfers to Primary Care Providers
1547.00	Customer Service
1549.00	Disaster Preparedness
1550.00	Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
1551.00	Individual Service Plans
1553.00	Evidenced-based, Research-based, Consensus-based, and Promising or Emerging Best Practices
1555.00	Freestanding Evaluation and Treatment Facilities
1556.00	Clinical Eligibility and Care Standards (CECS)
1556.01	Clinical Eligibility and Care Standards (CECS) Manual
1557.00	Safety Policy
1558.00	Mental Health Specialist
1559.00	Co-Occurring Disorder Screening and Assessment (GAIN)
1560.00	Care Advocacy
1561.00	Revocation of Less Restrictive Court Order/Conditional Release Court Orders
1562.00	Monitoring of Less Restrictive Orders
1563.00	Program of Assertive Community Treatment (PACT)
1563.01	Washington State Program of Assertive Community Treatment Standards
1564.00	Day Support Services
1565.00	Children & Adolescent Level of Care Utilization System CALOCUS & Level of Care Utilization System LOCUS
1565.01	Children & Adolescent Guidelines
1565.02	Adult and Older Adult Guidelines
1565.03	CALOCUS Grid
1565.04	LOCUS Grid
1566.00	Fidelity Supported Employment Service
1566.01	SAMHSA Fidelity Chapters
1567.00	Intensive Outpatient Program for Adults (IOP)
1568.00	High Intensity Treatment - Wraparound
1568.01	Wraparound Referral Form
1568.02	Wraparound Family Guide
1568.03	SNCD Wraparound
1571.00	Inpatient Certification and Authorization
1571.01	Community Psychiatric Inpatient Instructions and Requirements
1572.00	Inpatient Continuity of Care
1574.00	State Only Funding Plan Mental Health Services
1575.00	Evaluation & Treatment Facility Authorization
1576.00	Medicaid Personal Care (MPC)
1577.00	Evaluation & Treatment Facilities Refusal & Review Process
1578.00	Western State Hospital Admission Screening

Section 1700: Crisis Services

1701.00	Crisis Respite Standards for Adults
1702.00	ICRS Outreach Safety Screening, Pre- and Post-Dispatch to an Unstaffed Location
1703.00	Duration of Crisis Services
1704.00	Crisis Services - General Policy
1705.00	Domestic Violence Screening/Assessment
1705.01	Crisis Services' Domestic Violence Assessment Form
1705.02	Domestic Violence Victims Referral Resources
1705.03	Perpetrator Treatment Resources
1706.00	Safeguarding of Property
1707.00	Crisis System Clinical Dispute Resolution
1716.00	Accessing DD/MH Crisis Support Services
1717.00	Urgent Contacts and Follow-up Services
1719.00	Utilization of Crisis Respite for Hospital Discharge Planning
1720.00	Administration of the Involuntary Treatment Program
1721.00	Medical Status Criteria for Crisis and ITA Assessment

Section 2000: Compliance

2001.00	Business Ethics and Regulatory Compliance Program
2002.00	Prohibition on Certain Physician Relationships
2003.00	Utilization Management Compensation
2004.00	Management Certifications

Section 2500: Privacy

2501.00	Uses and Disclosures - Business Associate
2501.01	Procedure: 2501 A
2501.02	Model Business Associate Agreement Form
2502.00	Administrative Requirements for the Implementation of HIPAA
2503.00	De-identification and Limited Data Sets
2503.01	Procedure: 2503 A
2504.00	Designated Record Set
2504.01	Procedure: 2504 A
2505.00	Disposal of PHI
2505.01	Procedure: 2504 A
2506.00	Documentation
2506.01	Procedure: 2506 A
2507.00	Confidentiality
2507.01	Form 2507 A
2508.00	Marketing
2508.01	Procedure: 2508 A
2509.00	Minimum Necessary
2509.01	Procedure: 2509 A
2510.00	Notice of Privacy Practices
2510.01	Procedure: 2510 A
2510.02	Form 2510 A
2511.00	Opportunity to Agree or Object - Disclosure to Individuals Involved in the Consumer's Care
2511.01	Procedure: 2511 A
2512.00	Copying and Printing Protected Health Information (PHI)
2513.00	Uses and Disclosures for Research Purposes
2513.01	Procedure:2513 A
2514.00	Right to Access Protected Health Information
2514.01	Procedure: 2514 A
2514.02	Form 2514 A
2515.00	Individual's Right to Amend PHI
2515.01	Procedure: 2515 A
2515.02	Form 2515 A
2516.00	Right to an Accounting of Disclosures
2516.01	Procedure: 2516 A
2516.02	Form 2516 A
2517.00	Right to Confidential Communication
2517.01	Procedure: 2517 A
2517.02	Form 2517 A
2518.00	Right to Restrict Uses and Disclosures of Protected Health Information
2518.01	Procedure: 2518 A
2518.02	Form 2518 A
2519.00	Safeguarding PHI
2520.00	Training of the Workforce
2520.01	Procedure: 2520 A
2521.00	Uses and Disclosures: Authorizations - Revised
2521.01	Core Elements, Required Statements, Defective Authorizations, Prohibition on Conditioning of Authorizations, Revocation of Authorization and Documentation
2521.02	Procedures for Completion or for Processing an Authorization - Procedure 2521A
2521.03	Authorization to Receive and/or Release Information Form
2521.04	Prohibition on Redisclosure of Confidential Information
2522.00	Uses and Disclosures of PHI from Individuals for Treatment, Payment, or Healthcare Operations
2522.01	Procedure: 2522 A

Section 3000: Fiscal

3001.00	Advance Contracts
3002.00	Annual Report
3003.00	Audits
3005.00	Budget Modification
3006.00	Cash Disbursements
3007.00	Cash Receipts
3008.00	Cellular Phones
3009.00	Closeout
3010.00	Conflict of Interest
3011.00	Consultant Contracts
3012.00	Cost Principles
3013.00	Email and Internet
3014.00	Employee Reimbursement for Non-Travel expenses
3015.00	Fair Labor Standards Act
3016.00	Financial Reporting
3017.00	Fiscal Monitoring
3018.00	Imprest Fund - Petty Cash Funds
3019.00	In-Kind Donations and Services
3020.00	Inventory
3021.00	Investment of Excess Cash
3022.00	Laptop Computers
3023.00	Leases
3024.00	Minority and Women Owned Businesses and Enterprises
3025.00	Oversight of Subrecipient Audits
3026.00	Payroll
3027.00	Public Records
3028.00	Purchasing
3029.00	Record Retention
3030.00	Reimbursement for Travel - Advisory Board Members
3031.00	Reimbursement for Travel - NSRSN Staff
3032.00	Signature Authority
3033.00	Storage of Software and Diskettes
3034.00	Tax Reporting
3035.00	Timesheets
3036.00	Treatment of Assets
3037.00	Contractor Incident Report
3037.01	Contractor Incident Report Form
3038.00	Vendor vs. Subrecipient Auditing Guidelines
3040.00	Transportation Requests
3041.00	Signature Stamp
3042.00	Credit Card Account
3044.00	Third Party Resources Requirements
3045.00	Eligibility Verification
3046.00	Flex Funds

Section 3500: Human Services

3501.00	NSMHA Employee of the Quarter Program
3501.01	NSMHA Employee of the Quarter Nomination Instructions
3501.02	NSMHA Employee of the Quarter Nomination Form
3502.00	NSMHA Personnel Policy & Procedures
3502.01	NSMHA Personnel Policies and Procedures Manual
3503.00	Staff Training

Section 4000: Information Systems

4001.00	Information Systems Policy & Procedures
4001.01	Acknowledgement of Receipt Information System Policy & Procedures
4002.00	Access Codes and Passwords
4003.00	Audit Vulnerability Scan
4004.00	Automatically Forwarded Email
4005.00	Email and Internet Security
4006.00	Email Retention
4007.00	Malicious Software Prevention
4008.00	Modem Connectivity
4009.00	Privacy and Security Plan
4010.00	Remote Access
4011.00	Server Security
4012.00	Wireless Network Communication
4013.00	Workstation/Laptop Acceptable Use
4014.00	Data Backup
4015.00	Verification of Accuracy of Data
4016.00	Asset Disposal
4016.01	Donation Request Form

Section 4200: Consumer Information Systems

4201.00	Certification of Utilization Information Relating to Payment Under the Medicaid Program
4202.00	Timeliness of Consumer Information Data
4203.00	Controls and Oversight of Providers Information Systems
4203.01	NSMHA Consumer Information System Committee Charter
4204.00	Timeliness of Encounter Data Submission to MHD
4205.00	Contractor/CMHA Data to be Submitted to NSMHA-CIS
4206.00	Loading of MMIS Data
4207.00	Primary and Backup Systems for Electronic Submission of Data to MHD
4208.00	Consumer Information System Recoverability
4209.00	Use of NSMHA Information System for Utilization Review and Resource Management

Section 4500: Consumer Affairs

4501.00	Advisory Board Requests for Support Staff Services
4502.00	Anti-Retaliation
4503.00	Registering and Responding to a Complaint of Retaliation
4504.00	Functional Independence Policy
4505.00	Enrollee Rights
4506.00	Enrollee Rights - Compliance with Federal and State Laws
4507.00	Consumer Transportation Requests
4508.00	Reasonable Accommodation/Access to Services
4509.00	Annual Advisory Board Expense Projection Development
4510.00	Advisory Board Conferences, Seminars, and Trainings
4510.01	NSMHA AdB Training and/or Conference Request Form
4510.02	NSMHA AdB Advance Travel/Reimbursement Request Form
4511.00	Advisory Board Purchasing and Other Expenses
4511.01	NSMHA AdB Mthly Reimbursement Request Form
4512.00	Advisory Board Travel Expenses
4512.01	Advisory Board Travel Advance/Reimbursement Request Form
4512.02	Advisory Board Monthly Reimbursement Request Form
4512.03	Advisory Board Training/Conference Request Form
4513.00	Advisory Board Allowed and Disallowed Expenses
4513.01	Advisory Board Monthly Reimbursement Request Form
4513.02	Advisory Board Travel Advance/Reimbursement Request Form
4513.03	Advisory Board Training/Conference Request Form
4514.00	Advisory Board Functions
4515.00	Advisory Board Representation
4516.00	Ombuds Services
4517.00	Quality Review Team
4518.00	Public Awareness of Mental Health Services

Section 5000: Contract/Audit

5001.00	Administrative, Fiscal, & Quality Assurance/Improvement Contract Compliance Monitoring
5002.00	Sub Contractual Relationships and Delegation
5003.00	Limitations on Enrollee's Financial Obligations
5004.00	Contractor Certification and Licensure
5005.00	Complying with MHD Published Directives
5006.00	Provider Contract Termination - Notification to MHD

Section 5500: Quality Management

5501.00	Utilization Review of Outpatient Services
5502.00	Quality Management of the North Sound Mental Health Administration
5504.00	Outpatient Record Review

Section 6000: Tribal Liaison

6001.00

7.01 Plan

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North Sound Mental Health Administration