NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS by E18n5B

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									NORTHPOINTE BEHAVIORAL
 HEALTHCARE SYSTEMS




   Provider Network Manual


            2010




                             1
NBHS CARE MANAGEMENT
Provider Network Manual

Table of Contents
     INTRODUCTION

     SECTION 1 - Provider Responsibilities                        page 6

     SECTION 2 - Glossary of Terms and Definitions                page 11

     SECTION 3 - Policies and Procedures for Professional
                 Service Monitoring                               page 18

     SECTION 4 - Credentialing of Providers                       page 23

     SECTION 5 - Code of Ethical Practices                        page 30

     SECTION 6 - Policies and Procedures for the Individual
                 Plan of Service                                  page
     SECTION 7 - Recipient Right, Grievance and Appeal Policies
     page 49
     SECTION 8 - Reporting Unusual Incidents

     SECTION 9 - Access to Continuum of Services

     SECTION 10 - Usage of Northpointe Information Systems

     SECTION 11- Billing Procedures

     SECTION 12 - Individual and Facility Applications

     SECTION 13 - Regional Provider Network Offices

     SECTION 14 - Network Design

     SECTION 15 - Sentinel Events



                   Table of Organization




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NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS CARE MANAGEMENT

Provider Network Manual




               Welcome to Northpointe Behavioral Healthcare Systems’
                                Provider Network

This manual has been developed as a reference guide for our network providers. It
gives you an overview of our Network design, discusses those Northpointe policies and
procedures we require our providers to follow, and gives you other information you
will find useful as a provider of services. Throughout the manual, phone numbers are
listed so you may access the appropriate staff when you have questions.

If you have any comments or questions while reading this manual you may call our
Contract Manager at (906) 779-0644.

Thank you for joining the Northpointe Behavioral Healthcare Systems Provider
Network. We look forward to a long and rewarding relationship with you as we work
to provide quality cost efficient care to our consumers.

                               IMPORTANT NOTICE

This manual explains many important aspects of Northpointe Behavioral Healthcare
Systems’ Provider Network. This manual, in conjunction with the provider contract,
outlines the procedures and requirements that providers must follow to be included in
the Northpointe Provider Network.

Northpointe Behavioral Healthcare reserves the right to interpret any term or provision
in this manual and to amend it at any time. To the extent that there is an inconsistency
between the manual and the provider contract, Northpointe reserves the right to
interpret such inconsistency. The interpretation shall be binding and final.




                      Northpointe Behavioral Healthcare Systems
                       Dickinson, Iron and Menominee Counties
                        Phone 906.774.0522 * Fax 906.774.1570




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NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS PROVIDER NETWORK


Provider Network Manual Introduction

Northpointe Behavioral Healthcare Systems is committed to excellence in the delivery
of services to persons with mental illness, developmental disability, and children
with severe emotional disorders. This commitment will be demonstrated throughout
the region by offering services, which are effective, efficient, and responsive to the
consumers we serve, as well as the communities in which they live.

As an assurance to our stakeholders – the Consumers, the Department of Community
Health, the community and to our employees – Northpointe Behavioral Healthcare
Systems will require that all providers of behavioral health services in the Network be
qualified to deliver those services.


The credentialing and privileging process is designed to ascertain a provider’s formal
education, training, experience, and competence. Executive authorization is granted for
a Provider to perform specific services for a designated length of time. Providers who
are privileged to deliver certain types of services must continue to meet the
requirements, which have been established, to maintain good standing in the Network.

As we continue in a managed care environment, it is important for us to not only create
a competent and qualified Provider network, but to insure that we are included on the
provider panels of many of the qualified health plans within the region. Demonstrating
the competency of our individual and facility providers through a solid credentialing
and privileging process makes a strong statement about the quality of out Behavioral
Health system. It is a critical component in achieving the Northpointe mission.

Principal Strategies and Objectives
The principal strategies and objectives, which will be included in every aspect of the
Provider Network for Northpointe Behavioral Healthcare Systems, shall be as follows:


      Promotion of access to the least restrictive level of care required for a Consumer’s
       condition or disorder.
      Provision of quality care that is evidenced by Consumer satisfaction and clinical
       outcomes.
      Integration of person centered planning into all clinical activities.
      Management of financial and other resources to contain or reduce cost.
      Arrangement for care that is delivered quickly, locally and in a person centered
       manner.
      Development of a service delivery system that emphasizes prevention and
       wellness.




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The provider Network of Northpointe will assure network competencies and the
sufficient amount of resources for choice, quality and market competition.

This manual has been prepared as a guide to Northpointe’s policies and procedures for
individual practitioners, programs and facilities. It provides important information
regarding the managed care features incorporated in the Provider Contract.

The manual has been designed to be a useful tool for Participating Providers and their
staff. The Table of Contents provides and outline, which identifies important
information organized in a logical manner to follow your interaction with the
Northpointe Consumers.

Northpointe understands that our relationship with Providers is essential in the
commitment to an effective and efficient quality of clinically necessary care. We look
forward to a mutually cooperative and beneficial relationship.

Northpointe is part of the NorthCare affiliation. NorthCare is the prepaid health plan
that oversees Northpointe’s Medicaid dollars. NorthCare is part of Pathways and the
affiliation members are Copper County Community Mental Health Center, Gogebic
CMH, Hiawatha Behavioral Health, Pathways and Northpointe.




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NBHS CARE MANAGEMENT                                                             Section 1

Provider Network Manual

                               Provider Responsibilities

Introduction

In order to provide quality services to Consumers it is necessary for Northpointe Behavioral
Healthcare Systems and the participating providers to establish and maintain a cooperative
relationship. The provider is encouraged to direct any questions and concerns about the
managed care program to any of the County Directors. Beneficiaries must be excluded from any
dispute between the participating provider and the Northpointe affiliates.

The Contract Manager, located at 715 Pyle Drive, Kingsford, MI 49802, manages Northpointe’s
Provider Network. The phone number is (906) 779-0644, Monday through Friday, between the
hours of 8:00am – 4pm CST. Participating providers may call any of the local county offices
during the same hours Monday through Friday.

Individual Treatment Planning

Providers shall be responsible for development and/or implementation of individual treatment
plans designed through a person centered process of self-determination. The treatment plan will
outline the specialty services and supports for each consumer while safeguarding the consumer’s
right to least restrictive environment and their health and safety. Provider agencies shall
establish advisory boards and fill positions with consumers. Providers must demonstrate that
the provider’s governing board considers the input of the advisory board. The advisory board
must evaluate policies and procedures impacting enrollees.


Incident Reporting

Providers must notify Northpointe’s Recipient Rights Officer at (906) 863-1519, or the appropriate
County Director immediately by telephone of serious injury or loss of life sustained by a
Northpointe Consumer. Written notification must follow within 24 hours. Northpointe must
also be notified immediately of any consumer’s elopement or discharge against medical advice.
Please see Section 8 for further details. Go to www.nbhs.org to view Recipient Rights policies in
the Provider Manual link.


Confidentiality and Release of Information

Confidentiality is an important professional and administrative aspect of Northpointe’s policies
and procedures. Whenever a participating provider begins treating a Northpointe Consumer, the
participating provider must have the consumer, or as appropriate, the parent or legal guardian
sign a consent form authorizing the release of clinical information to Northpointe. Please see
Section 8 for further details



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Providers agree to comply with all state and federal laws including by way of example HIPAA as
the same applies to any information which Northpointe providers to the Provider concerning its
consumers. The Provider agrees specifically that it will comply with HIPAA and its privacy
protection provisions as they relate to consumer information. To the extent necessary for the
Provider to disclose information concerning any of Northpointe’s consumers, to any third party,
the Provider agrees to comply with notification provisions of HIPAA. The Provider agrees that
this provision of the Agreement shall apply to its agents and employees, and moreover agrees
that it will, if it has not done so already, educate its employees and agents with respect to the
confidentiality provisions of HIPAA as the same relate to privacy rights of Northpointe’s
consumers.

Participating providers are responsible to ensure that they have any necessary consumer
consents.

Provider Availability

All Northpointe Providers must be available for network referral appointments within the
appointment time frame standards listed below:

        Emergency – Clinician will respond to the call immediately, and will see the consumer
        within 24 hours. In life threatening emergencies the provider will direct the consumer to
        the closest emergency room facility.
             Defined as a condition that presents a real, significant, and imminent danger to
                 self or others as demonstrated by a suicide/homicide attempt of a specific plan
                 with means.
        Urgent – Clinician will make contact with the consumer within 12 hours and will see the
        consumer within 48 hours.
             Defined as a condition requiring prompt attention but is not life threatening or
                 posing a danger to self or others
        Routine – The consumer will be seen for the initial assessment within 5 days.
             Defined as a condition (may be ongoing) in which the consumer needs help with
                 to improve functioning and/or quality of life.

Record Keeping Requirements

Participating providers must establish a separate file for every case upon initial contact with the
Consumer. Facilities subject to JCAHO, CARF, COA, AOA, and other national accrediting
organizations must meet the record keeping standards of such organizations. Participating
providers who are not subject to these accrediting organizations must establish a medical record
system, which includes the following information:
     Consumer demographic information
     Presenting problems, precipitants and severity of symptoms
     Psychiatric and substance abuse history
     Relevant medical history, to include medication history
     Social, family supports and vulnerabilities
     Mental status exam
     Risk assessment
     DSM-IV TR five axial diagnoses
     ICD-9 CM diagnosis
     Treatment plan developed through a person centered principals




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Progress notes for each contact must include objective specific outcome/progress, based on
theraputic/habilitative interventions provided, linked to measurable/attainable goals in the
treatment plan and linked to assess therapeutic/habilitative needs in the assessment.

Any questions regarding record keeping requirements should be directed to the appropriate
County Director or the Contract Manager.

Obligation to Report/Duty to Warn

Participating providers must comply with all applicable state and federal child abuse and other
reporting laws. It is the participating provider’s responsibility to understand and comply with
the professional and legal requirements in the state.

The Provider is required to comply with all applicable State and Federal statures regarding the
obligation to report and duty to protect. Northpointe’s Recipient Rights office needs to be aware
of any such situation.

Re-credentialing and Information Updates

Northpointe must receive prior or immediate written notice of any additions, deletions, or
changes (including the effective dates) related to any of the following:

        Re-credentialing
             Verification of current state licensure or certification (annually)
             Verification of current federal DEA certification for M.D’s or D.O.’s
             Verification of current individual malpractice liability insurance within limits,
               dates of coverage and provider’s name
             Verification of criminal background check
             Fingerprint clearance
             Verification of non-inclusion on the excluded or restricted provider list of the
               Office of Inspector General and the general accounting office
             Verification of non-inclusion on the sexual offender register
             Current resume/curriculum vita (every two years)
             Facility accreditation with JCAHO, CARF, COA, AOA and/or other national
               accrediting organizations

        Updated Information
            Tax identification numbers (W-9 form must be completed for Tax ID numbers)
            Change of corporate address and telephone numbers
            Change of practice sites and telephone numbers
            Change of address for claim payments
            Name changes
            Clinical subspecialties
            Admitting privileges (Practitioners only)
            Changes, additions, or deletions of facility programs
            Changes in facility ownership
            Changes of practice ownership or principal interest
            Termination or resignation of any clinical staff
            Notification of any suites filed against practice/principals
            Notification of any restrictions regarding licensure and accreditation
            Addition of new clinical staff




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It is understood that a contractual requirement that all changes/updated information required
above, be immediately mailed to:
        Contract Manager
        Northpointe Behavioral Healthcare Systems
        715 Pyle Drive
        Kingsford, MI 49802

Participating Provider Coverage

A participating provider must contact a Northpointe affiliate, or designee to discuss alternative
provider coverage arrangements in any situation when he or she is unable to keep Northpointe
Consumers in active treatment. Notification to a Northpointe affiliate or the Contract Manager is
required regardless of the reasons for utilizing an alternative provider (i.e.: coverage while on
vacation).

Any after hour coverage arrangements just be communicated to Northpointe initially and
immediately upon any change. Northpointe reserves the right to refer consumers in accordance
with their policies.

The American with Disabilities Act (ADA)

Northpointe Management requires participating providers to comply with all regulations of The
Americans with Disabilities Act in the provision of care to Northpointe Behavioral Healthcare
Systems consumers.

Non-Discrimination

Providers must be equal opportunity providers and shall not discriminate with regard to race,
color, sex, religion, national origin, age, height, weight, marital status, veteran status, handicap or
any other protected category.

Clinical Record Reviews

The Provider will allow all Health Care Financing Administration (HCFA), State of Michigan
and/or accreditation onsite reviews.

Northpointe Behavioral Healthcare Systems will at times conduct reviews of clinical records
regarding the treatment of Consumers. These reviews will be conducted on-site at the provider
location, during normal business hours, upon prior notice from Northpointe Behavioral
Healthcare Systems. It is important that the participating providers cooperate fully with these
reviews. Northpointe Behavioral Healthcare Systems will be reviewing records for a number of
purposes, including but not limited to, the following areas:
     Quality Management
     Claims submission integrity
     Unusual occurrences
     Record keeping
     Corporate Compliance
     Credentialing Compliance

Provider Dis-enrollment




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Either Northpointe Behavioral Healthcare Systems or participating Provider may choose to
terminate the provider agreement.

If a participating Provider chooses to resign from the network, Northpointe Behavioral
Healthcare Systems must be notified in writing ninety (90) calendar days prior to the effective
dates as indicated in the participating Provider contract. Northpointe Behavioral Healthcare
Systems will acknowledge receipt of the participating Provider’s request and confirm the dis-
enrollment date.

If Northpointe Behavioral Healthcare Systems chooses to dis-enroll a participating Provider,
written notification of the dis-enrollment including the effective date, will be given as specified in
the participating Provider contract. Immediate dis-enrollment may occur as a result of any one of
the following:
      Conviction of a felony
      Unethical clinical and/or business practice
      Failure to comply with Northpointe Behavioral Healthcare Systems corrective action plan

It is understood that the Provider, in the event of dis-enrollment, is obligated to cooperate with
Northpointe Behavioral Healthcare Systems in transitioning consumers and records of treatment.




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NBHS CARE MANAGEMENT                                                              Section 2

Provider Network Manual

                                   Glossary of Terms
A glossary of terms is included below in order to promote a better understanding of the Provider
Network Manual and the service delivery processes that will be required. If there are additional
terms or definitions that would be helpful, please contact Northpointe Behavioral Healthcare
Systems.


DEFINITIONS:

Advisory Board: A group of individuals with an interest in Northpointe activities that advise
and recommend program/service changes. This board has consumer representation.

Best Value: A process used in competitive negotiated contracting to select the most
advantageous offer by evaluating and comparing factors in addition to cost or price.

Case Manager/Supports Coordinator: The staff person who works with the consumer to gain
access to and coordinate the services, supports and/or treatment, which the consumer wants or
needs.

Competitive Negotiation: The process of selecting several short-listed vendors using particular
criteria and then negotiating with each to obtain the best proposal based on clear objectives.

Competitive Sealed Bids: Following an invitation to bid, confidential bids are received, tabulated
and evaluated. Awards are then made to the lowest responsive and responsible provider.

Consultant: Any individual, organization, group, association, partnership, firm, joint venture,
corporation or any combination thereof providing professional service to Northpointe who is not
an employee of Northpointe.

Consumer: An individual currently receiving services through Northpointe typically diagnosed
as having a mental illness and/or a developmental disability.

Controlled Condition: At least two staff members are present when opening mail.

Cultural Competency: An acceptance and respect for difference, a continuing self-assessment
regarding culture, a regard for and attention to the dynamics of difference, engagement in
ongoing development of cultural knowledge, and resources and flexibility within service models
to work toward better meeting the needs of the minority populations. The cultural competency
of an organization is demonstrated by polices and practices.

Deliverables: Services or work product to be performed. To include status reports,
recommendations, analysis and other reports and documentation as required.




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Deficit Reduction Act (DRA) - The DRA addresses the Integrity of Medicaid claims to prevent
fraud, abuse and waste.

Developmentally Disabled: Developmental Disability means either of the following:
       A) If applied to a n individual older than five years, a severe, chronic condition that
          meets all of the following requirements;
                Is attributed to a mental of physical impairment or a combination of mental
                   and physical impairments.
                Is manifested before the individual is 22 years old.
                Is likely to continue indefinitely.
                Results in substantial functional limitations in three or more of the following
                   areas of major life activities:
                                1) Self-care
                                2) Receptive and expressive language
                                3) Learning
                                4) Mobility
                                5) Self-direction
                                6) Capacity for independent living
                                7) Economic self-sufficiency
                Reflects the individual’s need for a combination and sequence of special,
                   interdisciplinary, or generic care, treatment, or other services that are lifelong
                   or extended duration and are individually planned and coordinated.

        B) If applied to a minor from birth to five, a substantial developmental delay or a
           specific congenital or acquired condition with a high probability of resulting in
           developmental disability as defined in item (A) if services are not provided.

Emancipated Minor - The termination of the rights of the parents to the custody, control, services
and earnings of a minor, which occurs by operation of law or pursuant to a petition filed by a
minor with the probate court.

Emergency: Defined as a condition that presents a real, significant, and imminent danger to self
or others as demonstrated by a suicide/homicide attempt of a specific plan with means. A
clinician will respond to the call immediately, and will see the consumer within 24 hours. In life
threatening emergencies the provider will direct the consumer to the closest emergency room
facility.

Emergency Situation - A situation when the individual can reasonably be expected, in the near
future, to physically injure himself, herself, or another person; is unable to attend to food,
clothing, shelter or basic physical activities that may lead to future harm, or the individual’s
judgment is impaired leading to the inability to understand the need for treatment resulting in
physical harm to self or others

Ethical Practices: Delivery of service by agency staff which would be interpreted by a reasonable person
as necessary, suitable to condition and humane.

Evaluation Criteria: Criteria listed in a solicitation letter, RFQ or RFP against which the proposer
and/or proposal will be evaluated for purposes of determining which proposer and/or proposal
will be awarded a contract.




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Family Member - A parent, stepparent, spouse, sibling, child, or grandparent of a primary
consumer, or an individual upon whom a primary consumer is dependent for at least 50 percent
of his or her financial support.

Fiscal Intermediary - A fiscal intermediary (FI) is an independent legal entity (organization or
individual) that acts as a fiscal agent of Northpointe for the purpose of assuring fiduciary
accounting for the funds comprising a consumer’s individual budget. Duties of a FI shall be
specified in the contractual language between the FI and Northpointe or its designated
subcontractor. The primary purpose of a FI is to receive funds making up a consumer’s
individual budget, and to make payments authorized by the consumer to providers and/or other
parties to whom a consumer using an individual budget may be obligated. Examples of entities
that might serve in the role of a FI include bookkeeping or accounting firms and local ARC or
other advocacy organizations.

Guardian: A person appointed by the court to exercise specific powers over an individual who is
a minor, legally incapacitated of developmentally disabled.

Health Insurance Portability and Accountability Act of 1996 (HIPAA): Public Law 104-191, 1996
to improve the Medicare program under title XVIII of the Social Security Act, the Medicaid
program under Title XIX of the Social Security Act, and the efficiency and effectiveness of the
health care system, by encouraging the development of a health information system through the
establishment of standards and requirements for the electronic transmission of certain health
information.

The Act provides for improved portability of health benefits and enables better defense against
abuse and fraud, reduces administrative costs by standardizing format of specific healthcare
information to facilitate electronic claims, directly addresses confidentiality and security of
patient information-electronic and paper-based, and mandates “best effort” compliance.

HIPPA mandates that the following must be implemented:
   1. Guard data integrity, confidentiality, and availability
   2. Access control (user-based, role-based, context-based)
   3. Audit controls (user-based, role-based)
   4. Data authentication (automatic log-off, unique user ID, password, PIN, biometrics, token,
      or telephone callback)
   5. Guard against unauthorized access
   6. Communications/network controls (access controls, encryption, integrity controls or
      message authentication)
   7. Network (alarm, audit trail, entity authentication, event reporting, user-based, role-
      based, or context-based access)

Individual Budget
An individual budget is a fixed allocation of public mental health resources, and may also
include other public resources whose access involves the assistance of Northpointe, denoted in
dollar terms. These resources are agreed upon as the necessary cost of specialty mental health
services and supports needed to accomplish a consumer’s plan of services/supports. The
consumer served uses the agreed upon and authorized funding to acquire, purchase and pay for
specialty mental health services and supports as outlined in the consumer’s plan of service.




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Individual Plan of Service “IPOS”
A written Individualized Plan of Service directed by the individual as required by the Mental
Health Code. This may be referred to as a treatment plan or a support plan.

Least Restrictive Environment: It is the policy of Northpointe that:
        A. Services shall promote the best interests of the individual receiving services
        and shall be designed to increase independence, improve quality of life, and
        support community integration and inclusion;

        B. Services for children and families will be designed to strengthen and preserve
        the family unit if appropriate;

        C. Services for each recipient shall be suited to his/her condition and be
        developed using a person-centered planning process. These services will be
        provided in a safe, sanitary, and humane treatment environment.

        D. Services shall be offered in the least restrictive setting that is appropriate and
        available.

Legal Inquiry: Any matter including civil, criminal, or administrative law.

Limitation: A limit placed on the resident's right to receive mail as written and documented in
the resident's Individual Plan of Service.

Limited English Proficiency - Persons who cannot speak, writes, read, or understand English
language in a manner that permits them to interact effectively with health care providers and
social service agencies.

MDCH: Michigan Department of Community Health

Minor: An individual under the age of 18 years.

Natural Support - A person who is involved in an individual’s life other than just for pay.

Person Centered Planning: “Person-centered planning” means a process for planning and
supporting the individual receiving services that builds upon the individual’s capacity to engage
in activities that promote community life and that respects the individual’s preferences, choices,
and abilities. The person-centered planning process involves families, friends, and professionals
as the individual desires or requires.

Plan - A plan means the consumer’s Individual Plan of Services and/or Supports as developed
using a person-centered planning process.

Primary Clinician: The staff member in charge of implementing the consumer’s plan of service.

Private: Secret, not intended to be made known publicly, confidential.

Professional Services: Those services provided by independent contractors within the scope of
their practice including nursing, physicians, therapist, residential services, day program services,
inpatient services, and all other services to staff and/or consumers of Northpointe.




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Proposal: Refers to written and oral information submitted by a proposer in response to a
Solicitation Document, (RFP or RFQ).

Proposer: Refers to those responding to a solicitation document RFP or RFQ.

Qualified Provider: A qualified provider is an individual worker, a specialty practitioner,
professional, agency or vendor that is a provider of specialty mental health services or supports
that can demonstrate compliance with the requirements contained in the contract between the
Department of Community Health and Northpointe or its designated subcontractor, including
applicable requirements that accompany specific funding sources, such as Medicaid. Where
additional requirements are to apply, they should be derived directly from the consumer’s
person-centered planning process, and should be specified in the consumer’s plan, or result from
a process developed locally to assure the health and well-being of consumers, conducted with the
full input and involvement of local consumers and advocates.

Reasonable Time: Meeting the criteria of not seriously taxing the effective functioning of the
agency.

Restriction: An exclusion of a particular item as stated in the written policies of NBHS and
applies to all residents.

RFP:    A request for proposal.

RFQ:    A request for qualifications.

RMHA: Responsible Mental Health Agency – A Community Mental Health services Program
responsible for arranging and/or coordinating the provision of services for the consumer.

Root Cause Analysis – A structured and process-focused framework for identifying and
evaluating the basis or causal factors involved in producing a sentinel event. The analysis should
include the development of an action plan that identifies the steps that will be implemented to
lessen the risk that similar events would happen again.

Routine – Defined as a condition (may be ongoing) in which the consumer needs help with to
improve functioning and/or quality of life. The consumer will be seen for the initial assessment
within 5 days.

Selection Panel: A multi-disciplinary team of three or more people created to evaluate submittals
against the stated evaluation criteria for the purpose of making a selection.

Self-Determination: Self-determination incorporates a set of concepts and values that emphasize
a core belief that people who require support from the public mental health system as a result of
a disability should take part in defining what they need in terms of the life they seek, have access
to meaningful choices, and assume personal control over their lives. Self-determination is based
on four principles. These principles are:

           FREEDOM: The ability for individuals, with assistance from significant others (e.g.,
            chosen family and/or friends), to plan a life based on acquiring necessary supports
            in desirable ways, rather than purchasing a program. This includes the freedom to
            choose where and with whom one lives, who and how to connect to in one’s




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            community, the opportunity to contribute in one’s own ways, and the development
            of a personal lifestyle.

           AUTHORITY: The assurance for a person with a disability to control a certain sum
            of dollars in order to purchase these supports, with the backing of their significant
            others, as needed.

           SUPPORT: The arranging of resources and personnel--both formal and informal--to
            assist the person in living his/her desired life in the community, rich in community
            associations and contributions.

           RESPONSIBILITY: The acceptance of a valued role of the person in the community
            through employment, affiliations, spiritual development, and caring for others, as
            well as accountability for spending public dollars in ways that are life enhancing.
            This includes the responsibility to use public funds efficiently and to contribute to
            the community through the expression of responsible citizenship

Sentinel Event – An unexpected occurrence involving death or serious physical or psychological
injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The
phrase “ or risk thereof” includes any process variation for which a recurrence would carry a
significant chance of a serious adverse outcome. Such events are called “sentinel” because they
signal the need for immediate investigation and response.

Serious Emotional Disturbance - A diagnosable mental, behavioral, or emotional disorder
affecting a minor that exists or has existed during the past year for a period of time sufficient to
meet diagnostic criteria specified in the most recent diagnostic and statistical manual of mental
disorders published by the American Psychiatric Association and approved by the Dept. of
Community Health and that has resulted in functional impairment that substantially interferes
with or limits the minor's role or functioning in family, school, or community activities. The
following disorders are included only if they occur in conjunction with another diagnosable
serious emotional disturbance:
         A.      Substance abuse disorder;
         B.      A developmental disorder;
         C.      "V" codes in the diagnostic and statistical manual of mental disorders.

Serious Mental Illness - A diagnosable mental, behavioral, or emotional disorder affecting an
adult that exits or has existed within the past year for a period of time sufficient to meet
diagnostic criteria specified in the most recent diagnostic and statistical manual of mental
disorders published by the American Psychiatric Association and approved by the Dept. of
Community Health and that has resulted in functional impairment that substantially interferes
with or limits 1 or more major life activities. Serious mental illness includes dementia with
delusions, dementia with depressed mood, and dementia unless the dementia occurs in
conjunction with another diagnosable serious mental illness. The following disorders also are
included only if they occur in conjunction with another diagnosable serious mental illness:
        A.        A substance abuse disorder;
        B.        A developmental disorder;
        C.        A "V" code in the diagnostic and statistical manual of mental disorders.

Solicitation Document: A RFP or RFQ that consists of a package of documents or materials sent
to potential proposers when soliciting proposals. Materials would include scope of work,
evaluation criteria, submittal requirements and required forms.



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Solicitation Period: The time between the date when a solicitation document (such as an RFP or
RFQ) is advertised or distributed and the dates the proposals are to be reviewed.

Submittal Information: Information submitted by a proposer in order to evaluate their
qualifications to perform the work or provide service.

                        TDD (Telecommunications Device for the Deaf)

Uncensored: Without rebuke, reproach or disapproval; free from criticism; not judged or
condemned.

Unimpeded: Without hindrance, barricade or other obstacles.

Urgent: Defined, as a condition requiring prompt attention but is not life threatening or posing a
danger to self or others. Clinician will make contact with the consumer within 12 hours and will
see the consumer within 48 hours.

Urgent Situation - A situation in which an individual is determined to be a t risk of experiencing
an emergency situation in the near future if he or she does not receive care, treatment or support
services




                                                                                                17
NBHS CARE MANAGEMENT                                                               Section 3

Provider Network Manual


                                Policies and Procedures for

                    Professional Service Procurement Process


Provider Network Targets
Range of Service: Northpointe Behavioral Healthcare Systems Provider Network contains the
complete continuum of care. This includes psychiatrists, licensed psychologists, masters level
practitioner, occupational, physical, speech language therapists and others. It establishes a range
of services from facilities including: adult and adolescent/child inpatient, prevocational,
vocational, psychosocial rehabilitation, specialized community supports, intensive outpatient and
a range of specialty services.

Proximity of Services: Northpointe Behavioral Healthcare Systems’ Goal is to ensure that
services are proximal to Consumers. Timely access is a significant quality of care issue. The
geographic dispersal of Consumers in rural communities affects effort and time required to access
treatment. Ease of access affects follow through and after care, and therefore, significantly
impacts positive treatment outcome. For these reasons, every effort is made to accommodate
Consumer usage.

Size of Network: The size of the Provider Network is dependent upon several variables.
Providers are contracted consistent with Consumer need. Every effort is made to avoid “waiting”
list situations.


Inpatient & Community Support Providers: General Requirements

A fully developed Provider Network includes a full range of inpatient, outpatient and community
support services. The most common type of inpatient facility is the community hospital with a
psychiatric unit. Next in frequency is the private psychiatric hospital, followed by a community
hospital or a freestanding facility, and finally non-hospital community support treatment centers.

Inpatient panel configuration includes:

       A ratio of Consumers to Provider facilities that insures that emergent care is available in
        the Provider Network.




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       Hospital inpatient psychiatric care is used only for those individuals admitted in urgent
        or emergent situations. Northpointe Behavioral Healthcare Systems must perform a Pre-
        Screen authorization prior to admittance.

       Freestanding hospitals are limited due to the lack of availability of medical services
        within them for acute patients.

       Specialized Residential care is used in preference to inpatient care and Intensive
        Outpatient is used in preference to Residential

Behavioral Health Providers: General Requirements

Behavioral Health Providers are selected based upon the practitioner’s ability to respond in a
prompt and clinically effective manner to mental, psychological, emotional, and situational issues
of Consumers. The Network Provider must, contractual and NBHS employed, include at least
the following:

       An adequate number of facilities, which can provide emergency assessments and
        evaluations, diagnosis and coordination of referrals.
       An adequate number of free standing psychiatrists, contractual and NBHS employed, to
        evaluate, prescribe, and monitor medications, as well as manage inpatient cases.
        Psychiatrists must be skilled in treating severely and acutely ill individuals;
       A balance of professional disciplines including dynamic, experimental, behavioral and
        cognitive clinical practitioners who practice individually or in a facilities with
        multidisciplinary teams;
       A range of evidence based modalities including individual, group, play and family
        therapies;
       A range of Behavioral Health care which offers services to children, adolescents, adults
        and older adults;
       A full continuum of care, which includes access to impatient beds, partial hospitalization,
        specialized community supports, intensive outpatient, clinic services and supplemental
        independent providers in areas of specialty available within the region;
       Provision for psychological testing, neuropsychological testing, ancillary medical testing,
        and monitoring, and other diagnostics in special circumstances to resolve diagnostic and
        treatment issues;
       Primary, secondary, and tertiary prevention activities including aftercare, support groups
        workshops and behavioral health promoting activities;
       Linkages with public and community programs to access care for the severely mentally
        ill.


Network Development Assumptions

A full continuum of behavioral healthcare is targeted to be readily available for each area served.
The assumptions for developing a network are based upon an awareness of this availability of
care. The goal is to establish a high quality network with a full range of services. By managing
high volumes of referrals to a few select providers, quality and cost are easier to insure.




                                                                                                 19
               NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS

PURPOSE:
To serve the best interests of the consumers, Northpointe will provide a uniform and centralized
approach to monitoring all administrative/clinical professional contract and internal programs
(i.e.: residential, community living support, vocational, day program, etc. services) including
possible sanctions.

APPLICATION:
This policy applies to every Northpointe administrative/clinical professional service provider.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:

A. The procedures set forth in this document shall be used for monitoring all administrative and
   /or clinical professional contract services and internal programs retained by Northpointe to
   assure compliance with statutes and guidelines applicable to federal and State of Michigan
   health care programs; and to adhere to all legal, regulatory, fiscal and program requirements,
   contract compliance and/or improve the quality of services and supports available to
   consumers.

B. Contracts will be maintained only with quality providers who meet accreditation, licensure,
   and/or contractual standards.

DEFINITIONS:

Professional Services: Those services provided by independent contractors within the scope of
their practice including nursing, physicians, therapy, residential services, community living
support services, inpatient services, computer server management, software design and
development, grant writing and all other services to staff and/or consumers of Northpointe.

Plan of Correction: Following a review, a formal written request for a POC will be sent to the
provider and/or Executive Director from Northpointe’s contract management staff. Said
correspondence will specifically address the contract performance and/or compliance issues and
request from the provider a written response, within a specified time frame, which details a
proposed plan to correct the contract performance and/or compliance issue and corresponding
time line for said correction to be achieved.

Site Review Team: The specific contract/service type will determine the composition of the team.
The team may view the contract/site-related material from an environmental, licensing, clinical,
administrative and recipient rights perspective. This team may consist of the Contract Manager,
Recipient Rights officer, and representation from the Departments of Medical Services,
Environmental Safety, and Site Review Specialists, Chief Information Officer, Chief Financial
Officer, County Directors and other functional experts as deemed appropriate.

PROCEDURES:
1.   Contract/Service Management
     Action by: Site Review Team

        a. Routine collection, review and analysis of all contract/service required information,
           data reporting requirements, and compliance with Recipient Rights protection


                                                                                                  20
    mechanisms.

b. Review reports or other information obtained from or provided by relevant public
   regulatory bodies or accreditation organizations (i.e.: State of Michigan, Department
   of Consumer and Industry, CARF, etc.)

c. Completion of contract/service specific performance objectives.

d. A formal survey/audit/evaluation of each service site will be conducted at least one
   time per contract year.

    1. This monitoring survey/audit/evaluation will be conducted by a designated
       site review team to insure professional service contract compliance. (See
       monitoring form)

    2. The contract provider will be notified, in writing of Northpointe’s intent to
       survey/audit their service.

    3. An exit interview will be conducted at the conclusion of the
       survey/audit/evaluation.

    4. A written summary of the survey/audit/evaluation will be sent to the service
       provider.

    5. Any deficiencies will be detailed in this report with a time frame for a plan of
       correction

    6. Northpointe may invoke sanctions if it makes a determination that a provider:
              • is not in substantial compliance with published standards and with
                established local, State and federal regulations;

                • that the provider has misrepresented or falsified information reported to
                  Northpointe, the State or to the federal government; or

                • that the provider has failed substantially to provide necessary covered
                  services to recipients or failed substantially to follow the terms of their
                  contract with Northpointe.

    7.   Sanctions may involve actions including, but not limited to:
          a. monetary penalty imposed on the employee;
          b. imposition of temporary monitoring of employee or contract service;
          c. suspension of provider/contract;
          d. termination of provider/contract

    8. Before imposing a sanction on a provider, Northpointe shall provide the provider
       with timely written notice that explains both of the following:

           a. The basis and nature of the sanction.

           b. The opportunity for a hearing to contest or dispute Northpointe’s
              finding and intended sanction, prior to the imposition of the


                                                                                           21
                      sanction.

           9. A hearing under this section is subject to the provisions governing a contested
              case under the Administrative Procedures Act of 1969, 1969 P.A. 306, MCL
              24.201 to 24.328, unless otherwise agreed to in the sub-contract between
              Northpointe and the provider.

           10. The plan of correction will either be accepted or rejected for specific reasons.

           11. An accepted plan of correction may require a follow up visit to insure
               compliance.

           12. The provider may appeal the findings within 14 days of receipt of the report.

           13. A rejected plan of correction or failure to meet contract standards may be
               grounds to initiate contract cancellation. This process will be detailed in the
               individual contracts.

       e. All monitoring information will be maintained in the central contract/service file and
       will be reviewed prior to renegotiating a new contract, renewing a service and on a
       schedule established by the review team.

2.       Provider Grievance and Appeals Mechanism

       A. Provider Grievance Appeals
           1. Formal complaints should be directed to the Chief Executive Officer (CEO) of
               Northpointe. This may be done by completing the Employee Problem
               Resolution Form, the Consumer Complaint and Appeal form or calling 1-800-
               750-0522. If you need assistance with filing a grievance, call 1-800-750-0522
               and as for assistance. An investigation of the complaint will be conducted by
               the staff assigned by the CEO within seven (7) working days from receiving the
               complaint. A written summary of the outcome of Northpointe’s examination of
               the complaint will be given to the complainant at the conclusion of the
               investigation or the seven (7) days whichever is sooner. Should the complainant
               disagree with the results of the investigation, they may contact NorthCare at 1-
               906-225-7253.
           2. In a situation where two providers are in disagreement about the provision of
               services for a specific consumer, Northpointe’s Utilization staff will review the
               case and make a determination about appropriate services and the Board of
               Financial Responsibility. The review will be completed within 48 hours of the
               receipt of all necessary documentation. This review will not delay the consumer
               receiving services and the timeliness indicators will still apply. If the results of
               this review are unsatisfactory to the CMH Boards, the Department of
               Community Health Contract Manager will be asked to review the case for a final
               decision.

         B. Other Contract Providers Appeals

           1. The specific mechanism for appeals of decisions regarding authorization and
payment will be established within the contract between Northpointe and the provider.



                                                                                                  22
NBHS CARE MANAGEMENT                                                             Section 4

Provider Network Manual

                    Credentialing of Providers
PURPOSE:
The credentialing process establishes that an employee or prospective employee is qualified
to render behavioral health services by collecting, verifying and evaluating information on
the individual’s education, experience, competency, and quality of care provided.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that all providers serving
Northpointe consumers shall be properly credentialed and competent to practice in their
field. Additionally,

    A. All providers shall meet all applicable licensing, scope of practice, contractual, and
       Medicaid
       Manual requirements.
    B. Verification of credentials with primary sources shall be completed for all
       prospective employees prior to any final offer of employment.
    C. Verification of credentials with primary sources shall be completed for employees
       when initially earned (e.g., an upgrade of licensure).
    D. Credentials shall be reviewed at the time of the annual performance review.

APPLICATION:
All Northpointe physicians and other healthcare professionals, who are licensed by the
State, as well as non-licensed providers of care or support.

DEFINITIONS:
Credentialing: The process of reviewing, verifying, and evaluating a practitioner’s
credentials (i.e., professional education, clinical training, licensure, board and other
certification, clinical experience, letters of reference, other professional qualifications, and
disciplinary actions) to establish the presence of the specialized professional background
required for membership, affiliation, or a position within a healthcare organization or
system. The result of credentialing is that a practitioner is granted membership in a
medical staff or provider panel.

STANDARDS:
A.      Credentialing and re-credentialing must be conducted and documented for the following
healthcare providers:

                1. Physicians (M.D.s and D.O.s)
                2. Physician Assistants



                                                                                                23
                3. Licensed and Limited Licensed Master’s Social Workers
                4. Licensed, Limited Licensed and temporary Limited Licensed
                   Psychologists
                5. Licensed and Limited Licensed Bachelor Social Worker
                6. Registered Social Service Technicians
                7. Registered Nurse
                8. Licensed Practical Nurse (LPN)
                9. Nurse Practitioner
                10 Occupational Therapist
                11. Occupational Therapist Assistant
                12. Physical Therapist
                13. Physical Therapist Assistant
                14. Speech Pathologist
                15. Dietician
                16. Limited Licensed or Licensed Professional Counselor
                17. Certified Addictions Counselor (CAC) Level I, CAC Level II, CAC
                    -Michigan, CAA-IC                & RC
                18. Certified Clinical Supervisor (CCS), CCS-IC & RC, CCS-Michigan
                19. Certified Criminal Justice Professional (CCJP)
                20. Non-degreed individuals who have attained three (3) years (6000 hours)
                   of experience
                     and has taken and received a passing score on one of the following:
                     a. Fundamental of Alcohol and Other Drug Problems (FAODP) exam
                    b. Fundamentals of Substance Abuse Counseling (FSAC) exam

B.       Northpointe’s credentialing and re-credentialing processes shall not discriminate
against:
                 1. A healthcare professional, solely on the basis of license, registration or
certification; or
                 2. A healthcare professional who serves high-risk populations or who
specializes in the treatment of conditions that require costly treatment.

C.     Northpointe shall prohibit employment or contracts with providers who are
       excluded from participation under either Medicare or Medicaid.

D.      Northpointe shall maintain a credentialing file for each credentialed provider.
        This file shall contain:
                 1. A completed provider credentialing application
                 2. Information obtained through primary source verification
                 3. Credentialing checklist
                 4. Any other pertinent information used in determining whether or not the
                     provider met the credentialing standards

E.     Initial Credentialing
       At the time of initial credentialing, all prospective providers shall complete
       Northpointe’s Provider Credentialing Application.
       This application includes:


                                                                                                 24
           1. Lack of present illegal drug use
           2. Any history of loss of license and/or felony convictions
           3. Any history of loss or limitation of privileges or disciplinary action
           4. Attestation by the applicant of the correctness and completeness of the
              application
           5. An evaluation of the provider’s work history for the prior five years

       The credentialing application shall be filed in a credentialing file along with
       verification from primary sources of:
           1. Licensure or certification
           2. Board certification, or highest level of credentials attained, if applicable, or
               completion of any required internships, residency programs, or other post-
               graduate training.
           3. Documentation of graduation from an accredited school
           4. National Practitioner Databank (NPDB)/Healthcare Integrity and Protection
               Databank (HIPDB) query, or in lieu of the NPDB?HIPDB query, all of the
               following must be verified:
                   I.      Minimum of five year history of professional liability claims
                           resulting in a judgment or settlement;
                   II.     Disciplinary status with regulatory board or agency; and
                   III.    Medicare/Medicaid sanctions

           5. If the individual practitioner undergoing credentialing is a physician, the
           physician profile information obtained from the American Medical Association
           may be used to satisfy the primary source requirements of (1), (2), and (3)
           above.

F.      Temporary or provisional credentialing of providers may be granted when it is in
the best interest of Medicaid Beneficiaries that providers be available to provide care prior
to formal completion of the entire credentialing process. Temporary or provisional
credentialing shall not exceed 150 days. Northpointe shall make a decision regarding
temporary or provisional credentialing within 31 days of receipt of the completed provider
credentialing application.
        For consideration of temporary or provisional credentialing, at a minimum, a
provider must complete Northpointe’s provider credentialing application and primary
source verification must be completed on:

            1. Licensure or certification;
            2. Board certification, if applicable, or the highest level of credential attained;
            3. Medicare/Medicaid sanctions.

       Northpointe’s HR director shall review the information obtained with the interview
team and the team will determine whether to grant provisional credentialing.

G.    Re-credentialing Providers:
      Re-credentialing of providers at Northpointe is an ongoing process and is
documented annually at the time of the employee’s performance review. The annual


                                                                                              25
review includes an update of information obtained during the initial credentialing
application, license verification (as indicated by the date of license expiration), any
corrective action taken, trainings that have been completed and QI record review results.

        Northpointe conducts bi-annual criminal background checks and monitors and
intervenes, if appropriate, provider sanctions, complaints and quality issues pertaining to
the provider.
        This includes:
            1 Medicare/Medicaid sanctions
            2 State sanctions or limitations on licensure, registration or certification.
            3 Member/consumer concerns which include grievances (complaints) and
                appeals information.
            4 Provider quality issues.

H.     Deemed Status:
       For any provider that delivers healthcare services to another CMHSP/SA provider,
Northpointe may recognize and accept credentialing activities conducted by the other
provider. In such situations, Northpointe shall maintain copies of the credentialing
CMHSP/SA provider’s decisions in the individual’s file.

I.     Credentialing Oversight
       Northpointe’s Human resource Department conducts primary source verification,
background checks, and reviews the credential file for completeness and correctness.

       Northpointe’s initial credentialing is completed by the supervisor of the prospective
provider and Northpointe’s HR Director. Another manager and/or a peer of the prospective
provider may be involved in the interview team. Northpointe does not use participating
providers in any other part of the credentialing process.

       Northpointe’s re-credentialing is completed by the supervisor of the provider with
one-over review by the supervisor’s supervisor. All updated information is provided by
Northpointe’s Human Resource Department.

J.     A provider that is denied credentialing or re-credentialing by Northpointe shall be
informed of the reasons for the adverse credentialing decision in writing by Northpointe.

K.      Northpointe shall make an appeal process available for situations when
credentialing or re-credentialing is denied, suspended or terminated for any reason other
than lack of need. This process shall be consistent with applicable Federal and State
requirements.

L.      Northpointe shall report any known improper conduct of any credentialed provider
that results in suspension or termination as a provider for Northpointe to appropriate
authorities (i.e., DCH, licensing, the Attorney General, etc.), as consistent with current
Federal and State requirements, including those specified in the DCH Medicaid Managed
Specialty Supports and Services Contract.



                                                                                              26
M.      All costs associated with obtaining and maintaining credentials, certifications and
licensures required by Northpointe shall be paid for by the staff member, unless indicated
in a formal written agreement signed by Northpointe CEO.

N.      The presence of any past or current disciplinary action by the State Licensing
Board, or documented by the National Practitioner Database, or any other regulatory
authority and/or the existence of any pending malpractice suits or previous adverse
malpractice judgments will be examined. Any employee with a previous or pending
disciplinary actions(s) or malpractice suit(s) shall have an individual review completed by
Northpointe’s CEO or designee before any final job offer is made. Any current employee
with whom disciplinary action of malpractice suit is made shall have an individual review
completed by Northpointe’s CEO or designee before any action is deemed necessary. If
deemed necessary, corrective action, up to and including dismissal, may be given.

CREDENTIALING PROCEDURES:

A.     Initial Credentialing
            1 The credentialing process begins once the interview team (usually
                consisting of the supervisor of the position, the HR Director and one other
                manager or staff member) completes the interview and selects a job
                applicant as the top candidate for an open position.

           2   The HR Director requests the following information on the candidate:
               a. Original transcripts from the school in which the candidate received
                  his/her degree that is required for the position.
               b. Copy of professional license or application for license
               c. Copy of degree that is required for position
               d. DEA certificate (if applicable)

           3. The HR Director sends out requests for three written references (using
           Northpointe’s professional reference form) to individuals personally acquainted
           with the individual’s professional and clinical performance. Written letters of
           reference are acceptable, if the letter sufficiently addresses competencies for the
           position. All verbal references must be documented and followed up in writing.

           4. The HR Director gives a Northpointe Provider Credentialing Application to
           the candidate to complete and return. Once the form is returned, an inquiry to
           the National Practitioner’s Database is completed.

           5. A credentialing checklist is completed to indicate when the following
           information has been received:
               a. Original transcripts
               b. Copy of license and verification
               c. Copy of degree
               d. Three written letters of reference



                                                                                           27
            e. Results from the NPDB inquiry,

            The information is reviewed by the review team and the team decides if a
        job offer should be made. Documentation of this decision is made in the
        credential file.
        6. A contingent job offer is made to the candidate by the HR Director. The
        offer is contingent upon the results of a criminal background check, which
        includes fingerprinting and a drug screen.

        7. To complete the fingerprinting, Northpointe’s Personnel Specialist (or
        designee) gives the prospective employee the Long Term Care Workforce
        Background Check Application Form to complete. The form is returned to the
        Personnel Specialist, who enters the information into the Michigan Long Term
        Care Background Check data base. The background checks that are completed
        are ICHAT, Nurse Aid Registry (NAR), Offender Tracking Information System
        (OTIS), Public Sex Offender Registry (PSOR), and the US HHS
        Medicare/Medicaid Exclusion List (OIG). If all of these come back with a “no
        exclusionary findings”, the Personnel Specialist prints out the Long Term Care
        Workforce Background Check Fingerprint Request Form and forwards it to the
        appropriate supervisor. The supervisor sets up a fingerprint appointment at the
        closest location to the applicant. The Personnel Specialist will receive an email
        when the fingerprints are done; then goes to the website to print the Fingerprint
        Response Form. This form will indicate if there was a match to the fingerprints
        or not. If not, a copy of this form is sent to the supervisor and the hiring
        procedure continues. If there was a hit on the fingerprints, there will be
        notification on the form whether it is exclusionary from employment or not and
        a decision is made by the supervisor and the HR Director whether to continue
        with the hiring process.

        8. Upon successful completion of the fingerprinting process, the supervisor
        arranges for a drug-screen to be completed at the local Occupational Health
        Clinic. Negative drug screens result in setting the start date for employment.

B.   Re-Credentialing Procedures
        1. Re-credentialing of providers at Northpointe is an ongoing process and is
           documented annually at the time of the employee’s performance review.
          The annual review includes:
                   a. and update of information obtained in the initial credentialing
                      application,
                   b. license verification (as indicated by the date of the license
                      expiration),
                   c. any corrective action taken,
                   d. trainings that have been completed,
                   e. QI record review results,
                   f. criminal background check (as indicated by the date of the last




                                                                                         28
                        completion of the criminal background check.

C.     Appeal Process

        1. Upon denial, suspension or termination of credentialing or re-credentialing, the
individual may submit a written request to Northpointe’s HR Director.
        2. This request must be submitted within five (5) working days of receipt of the
denial, and must indicate, in writing, the reason for the appeal.
        3. The request must be presented by the individual before Northpointe’s Personnel
Committee at the next scheduled committee meeting. A quorum of the committee must be
present to hear the request or a delay will occur until a majority is present. Additionally,
Northpointe’s CEO, HR Director and the supervisor of the individual shall be present at the
meeting.
        4. After the request has been presented, the Personnel Committee shall deliberate
immediately and forward a recommendation to Northpointe’s Board of Directors.
        5. The Board’s decision shall be given to the individual at the Board meeting (if the
individual is present) and in writing. A copy of the written response shall be given to
Northpointe’s HR Department.




                                                                                          29
NBHS CARE MANAGEMENT                                                  Section 5

Provider Network Manual


                           Code of Ethical Practices
PURPOSE:
The provision of services to individuals experiencing problems related to mental health
or developmental disabilities is a public trust that requires integrity, compassion,
dedication to truth, belief in the dignity, worth and the right to self-determination of all
human beings, and respect for individual and group differences. Accordingly,
Northpointe provides to all staff a framework for ethical care practices and ethical
business practices.

APPLICATION:
All Northpointe Behavioral Healthcare Systems staff and services.

POLICY:
Northpointe Behavioral Healthcare Systems has an ethical responsibility to the
consumers and the community it serves, as well as the staff employed by Northpointe.
Therefore, it is the policy of Northpointe Behavioral Healthcare Systems that:

A.     Ethical business practices will be utilized and enforced.

B.     Ethical care practices will be utilized and enforced.

Northpointe will endeavor to accommodate employee requests to be excused from
providing care or services due to cultural values, ethics or religious beliefs.

DEFINITION:
Ethical Practices: Delivery of service by agency staff which would be interpreted by a
reasonable person as necessary, suitable to condition and humane.

Ethical Conduct: Working in a manner that is honest, legal and respectful of others.
Ethical conduct also describes behavior that falls within the boundaries established by
the organization’s mission, vision and values statements.

STANDARDS:
A.  Ethical Business Practices

        1.    Northpointe's mission statement and strategic plan shall provide an
ethical framework for business operations. All procurements will be conducted in a
manner that encourages open and free competition.


                                                                                          30
       2.      Upon admission to services, full information is given to the consumer on
the source of Northpointe's reimbursement for his/her care and any limitations placed
on duration of services.

        3.      Consumers and their respective insurers/funding entities shall only be
billed for services provided by Northpointe staff or contractual staff.

       4.       Any marketing practices shall focus on providing information about
services that are available and reflect the level of licensure and/or accreditation.

       5.      Northpointe shall clarify its relationship with other healthcare providers,
educational institutions, and payers of services through contractual agreements, service
agreements or some other formalized arrangement.

       6.      Northpointe shall review relationships with other entities carefully, to
avoid conflict of interest and to ensure that Northpointe's mission to its consumers and
the community is not harmed by any relationship.

Before entering into a contractual agreement with a provider or vendor, Northpointe
reviews the relationship for potential for conflict of interest.

B.      Ethical Care Practices

       1.      All consumers served by Northpointe shall be treated with dignity and
respect,
               and in accordance with state law and relevant accreditation, professional
licensure
               standards and professional code of ethics.

        2.     All consumer rights shall be protected. All Northpointe staff will
complete training on Recipient Rights at the time of hire. Any violation of these rights
shall be reported to the Office of Recipient Rights.

       3.      All consumers of Northpointe services shall receive an Individual Plan of
Service (IPOS), based on person-centered planning principles, which serves as the
working document. Ethical and cultural differences shall be considered when
developing the IPOS.

      4.      Personal, cultural, and ethical values and beliefs of providers of
Northpointe services shall not negatively impact consumers’ care and/or treatment.

        5.     All Northpointe staff shall refrain from improper inducements for
referrals.

        6.     All Northpointe staff shall not, directly or indirectly, solicit, accept or
agree to accept, any gift of money or goods, loans or services or other preferred


                                                                                             31
arrangements for personal benefit under any circumstances which would tend to
influence, or have the appearance of influencing, the manner in which they perform
their duties. An employee shall not grant or make available to any person a
consideration, treatment, advantage or favor beyond that which is the general practice to
grant or make available to the public at large.

      7.     All Northpointe staff recognize their obligation to report to an
appropriate member of the management team any act of unethical conduct of any staff
member, or any case of gross negligence or professional incompetence.

Staff shall strive to know their limitations and to stay within the bounds of these
limitations in practice. Staff shall follow any established best practice guidelines.

       9.      Staff shall be diligent in the performance of duties, professional in
provision of services and avoid any personal conflicts of interest.

       10.    Staff shall display personal behavior in both the workplace and
community which reflects respect for self and others, respect for Northpointe and its
Board and respect for Northpointe’s consumers.

PROCEDURE:
A.   Ethical Practice Agreement

        1.     All new employees are given a copy of the Code of Ethical Practices
Policy and Procedure, Corporate Compliance Policy and Procedure and the “Ethics and
Corporate Compliance in Healthcare” handbook to review during orientation.
        2.     All new employees are asked to sign an Ethical Practice Agreement
               form.
The Ethical Practice Agreement form is filed in the employee's personnel file.
Annually, at the time of an employee’s performance review, the employee will review
Northpointe’s Code of Ethical Practices.

B.       All staff are encouraged to contact a manager with any questions or for any
clarification of this policy.

C.     Managing Staff Requests

In the event that a staff member has a conflict with a consumer's cultural values, ethics
or religious beliefs that may impact the consumer's care, the staff shall contact their
immediate supervisor and request, in writing, a case transfer. The request shall include
the cultural, ethical or religious reasons, as well as the aspect of care or service he/she
wishes to be excused. The supervisor shall review the request to justify appropriateness
and determine whether accommodation is possible. If accommodation is possible, the
supervisor shall notify the staff and others who need to be involved in the
accommodation. If the accommodation is prevented because of an emergency situation,
the staff is expected to perform assigned duties so as not to negatively affect delivery of
care or services. If accommodation is not possible, the employee will be allowed to


                                                                                         32
explore other job opportunities within Northpointe where accommodations might be
possible. If a staff member does not agree to render appropriate care or services in an
emergency situation because of personal beliefs, the staff shall be placed on a leave of
absence from their current position and the incident reviewed.

In the event that a personal/social relationship develops between any staff and a
consumer, to whom the staff is rendering services, the staff shall contact their immediate
supervisor and request a case transfer.

All staff have an administrative chain of command and formal grievance procedure
should they need to utilize it. This is reviewed with staff during their orientation at
Northpointe.

NON-RETALIATION CLAUSE:
The above policy also prohibits any act of retaliation against an employee who, in good
faith, has filed a complaint pursuant to this policy or for otherwise assisting in the
investigation of a complaint. Any supervisor, agent, or employee of the employer who
is found to have taken actions determined to be retaliatory in nature against a
complainant shall be subjected to immediate corrective action up to and including
immediate discharge. Any person who believes they were retaliated against for
exercising his or her rights under this policy should immediately file a complaint with
Northpointe’s Human Resources Department or any supervisory personnel.




                                                                                           33
NBHS CARE MANAGEMENT                                                               Section 6

Provider Network Manual

                             Policies and Procedures
                                        for
                            Individual Plan of Service
                                     Using the principals of:

                                   Person Centered Planning
                                             and
                                      Self Determination



PURPOSE:
To assure the process used to develop the individual plan of service, which includes the option of
self-determination, is consistent with the requirements of the Mental Health Code.

POLICY:
It is the policy of Northpointe that all mental health services and supports and/or designated
alternative services for recipients with Mental Illness and/or Developmental Disability have an
individual plan of service developed through a person-centered planning process including the
option of self-determination, regardless of age, disability, or residential setting. The individual
plan of service may include a treatment plan, support plan, or both. The choice voucher system is
available for children.

DEFINITIONS:
Care Manager / Clinical Care Manager: The staff person who works with the individual to
gain access to and coordinate the services, supports and/or treatment that the individual wants or
needs.

Choice Voucher: An arrangement that gives the parent(s) of the child who is receiving services
and supports from the CWP, control within specified conditions and limitations over the
resources allotted for services agreed upon in the IPOS. The parent, by becoming the employer,
hires the staff to work with their child. A fiscal intermediary acts as the payer of costs incurred
by the child. The process is the same as self-determination.

Consumer: An individual currently receiving services through Northpointe typically diagnosed
as having a mental illness and/or a developmental disability.




                                                                                                 34
Emancipated Minor: The termination of the rights of the parents to the custody, control,
services and earnings of a minor, which occurs by operation of law or pursuant to a petition filed
by a minor with the probate court.


Emergency Situation: A situation when the individual can reasonably be expected, in the near
future, to physically injure himself, herself, or another person; is unable to attend to food,
clothing, shelter or basic physical activities that may lead to future harm, or the individual’s
judgment is impaired leading to the inability to understand the need for treatment resulting in
physical harm to self or others

Family Member: A parent, stepparent, spouse, sibling, child, or grandparent of a primary
consumer, or an individual upon whom a primary consumer is dependent for at least 50 percent of
his or her financial support.

Fiscal Intermediary: A fiscal intermediary (FI) is an independent legal entity (organization or
individual) that acts as a fiscal agent of Northpointe for the purpose of assuring fiduciary
accounting for the funds comprising a consumer’s individual budget. Duties of a FI shall be
specified in the contractual language between the FI and Northpointe or its designated
subcontractor. The primary responsibility of a FI is to receive funds making up a consumer’s
individual budget, and to make payments authorized by the consumer’s IPOS to providers and/or
other parties to whom a consumer may be obligated. Examples of entities that might serve in the
role of a FI include bookkeeping or accounting firms and local ARC or other advocacy
organizations.

Independent Facilitator: An individual who will facilitate the negotiation of a mutually
responsible IPOS between the consumer and Northpointe. A consumer engages a facilitator to
ensure their needs are identified and adequate planning occurs. The facilitator ensures the
consumer has a plan that addresses those issues that are important TO the consumer and those
issues that are important FOR the consumer (e.g. health and safety concerns). The facilitator
helps the consumer understand the process of person centered planning. The Independent
Facilitator does not represent the consumer at a hearing or in a court of law.

Guardian: A person appointed by the court to exercise specific powers over an
individual who is a minor, legally incapacitated, or has developmental disabilities.

Individual Budget: An individual budget is a fixed allocation of public mental health resources,
and may also include other public resources whose access involves the assistance of Northpointe,
denoted in dollar terms. These resources are agreed upon as the necessary cost of specialty
mental health services and supports needed to accomplish a consumer’s plan of services/supports.
The consumer served uses the agreed upon and authorized funding to acquire, purchase and pay
for specialty mental health services and supports as outlined in the consumer’s plan of service.

Minor: An individual under the age of 18 years.

Natural Support: A person who is involved in an individual’s life other than just for pay.

Person-centered planning: Person –centered planning means a process for planning and
supporting the individual receiving services that builds upon the individual’s capacity to engage
in medically necessary activities that promote life in the community and that respects the



                                                                                                35
individual’s preferences, choices, and abilities. The person-centered planning process involves
families, friends, and professionals as the individual desires or requires.

Individual Plan of Service “IPOS”: A written Individualized Plan of Service directed by the
individual as required by the Mental Health Code to meet the medically necessary needs of the
individual. The IPOS document specifies the amount, duration and scope of the services and
supports to be provided. This may be referred to as a treatment plan or a support plan.

Qualified Provider: A qualified provider is an individual worker, a specialty
practitioner, professional, agency or vendor that is a provider of specialty mental health
services or supports. All providers must demonstrate compliance with the requirements
contained in the contract between the Department of Community Health and Northpointe
or its designated subcontractor, including applicable requirements that accompany
specific funding sources, such as Medicaid. Additional requirements should be derived
directly through the person-centered planning process, and be specified in the consumer’s
plan, or result from a process developed locally to assure the health and well-being of
consumers, conducted with the full input and involvement of local consumers and
advocates.

Self-Determination: Self-determination incorporates a set of concepts and values that emphasize
a core belief that people who require support from the public mental health system as a result of a
disability should take part in defining what they need in terms of the life they seek, have access to
meaningful choices, and assume personal control over their lives. Self-determination is based on
four principles. These principles are:

           FREEDOM: The ability for individuals, with assistance from significant others
            (e.g., chosen family and/or friends), to plan a life based on acquiring necessary
            supports in desirable ways, rather than purchasing a program. This includes the
            freedom to choose where and with whom one lives, who and how to connect to in
            one’s community, the opportunity to contribute in one’s own ways, and the
            development of a personal lifestyle.

           AUTHORITY: The assurance for a person with a disability to control a certain sum
            of dollars in order to purchase these supports, with the backing of their significant
            others, as needed.

           SUPPORT: The arranging of resources and personnel--both formal and informal--to
            assist the person in living his/her desired life in the community, rich in community
            associations and contributions.

           RESPONSIBILITY: The acceptance of a valued role of the person in the
            community through employment, affiliations, spiritual development, and caring for
            others, as well as accountability for spending public dollars in ways that are life
            enhancing. This includes the responsibility to use public funds efficiently and to
            contribute to the community through the expression of responsible citizenship.




                                                                                                  36
Urgent Situation: A situation in which an individual is determined to be at risk of experiencing
an emergency situation in the near future if he or she does not receive care, treatment or support
services.

PROCEDURE:

Northpointe shall ensure that their service planning and delivery processes are designed to
encourage and support consumers to control and direct their specialty mental health services and
supports arrangements as defined by the IPOS.

I. Values and Principles Underlying Person-Centered Planning - Person-
    centered planning is a highly individualized process designed to respond to the expressed
    needs/desires of the individual.

       A. Each individual has strengths, and the ability to express preferences and to make
          choices.

       B. The individual’s choices and preferences shall always be considered if not always
           granted.

       C. Each individual has gifts and contributions to offer to the community and has the
          ability to choose how supports, services and/or treatment may help them utilize their
          gifts and make contributions to community life.

       D. Person-centered planning processes maximize independence, create community
          connections and work toward achieving the individual’s dreams, goals, and desires.

       E. A person’s cultural background shall be recognized, valued and accommodated where
          possible in the decision-making process.

       F. The IPOS is prepared using the information from the primary assessment and
          interpretive summary within 30 days after initial or annual Psychosocial Assessment.
          The IPOS includes information from family members/legal guardian, when applicable
          or permitted.

       G. The IPOS is recognized as the authorization for medically necessary services
          according to the clinically appropriate Level of Service in the NorthCare Benefit Plan
          (see UM Plan).

           1. The IPOS for DD consumers authorizes services for a full year.
           2. The IPOS for MI consumers authorizes services for up to 6 months. A Periodic
           Review to evaluate present or other potential services from the IPOS is required in
           order to continue the authorization for another 6 months.
           3. If the IPOS should expire, all services authorized will also expire and
           appointments may be cancelled. A new IPOS must be completed to restart services.

       H. The IPOS is based on the needs and desires of the consumer and focuses on his/her
          integration into the local community; the family when appropriate, natural support
          systems; and other needed services beyond the scope of the program. The goals of the
          IPOS are expressed in the words of the person served; reflective of the informed



                                                                                                  37
         choice of the consumer/guardian; appropriate to the person’s culture and age and
         based on the person’s strengths, needs, abilities and preferences.

         Specific service or treatment objectives are reflective of the expectations of both the
         consumer and the treatment team. The objectives are understandable to the consumer,
         measurable, achievable, time specific, and appropriate to the treatment setting. The
         frequency of specific treatment options, legal requirements when applicable, and
         information on, or conditions for, transition to other services.

         The IPOS includes, when applicable, information on, or conditions for community-
         based service options that are available for persons in long-term residential support
         programs.

         Medically fragile persons in residential treatment facilities receive services that are
         provided in accordance with all regulatory requirements.

         When the consumer has co-occurring disabilities/disorders, the IPOS specifically
         addresses those issues in an integrated manner. The delivery of services and specific
         interventions that support the IPOS is verified by signed and dated Progress Notes and
         Periodic Reviews.

         The primary clinician assumes responsibility for ensuring implementation of the
         IPOS; ensuring that the consumer is oriented to his/her services; promotes the
         participation of the consumer in discussing plans, goals and status. The clinician also
         identifies and addressed gaps in service provision; shares information on how to
         access community resources relevant to consumer needs; advocates for the consumer;
         and communicates information regarding progress on the consumer to the appropriate
         persons. The family/guardian are involved when applicable or permitted. The
         clinician facilitates the transition process including arrangements for the follow up
         services; coordinates services provided outside of the organization and identifies the
         process for after hours contact.

         The consumer must engage in active services as authorized in their Treatment Plan in
         order to continue in psychiatric services. The psychiatric services may be
         suspended/limited until the consumer not only meets with their assigned care manager
         to discuss services, but also attends services as authorized. An Advanced Notice will
         be given should any service be reduced or terminated.

II.   Essential Elements
      1. Person-centered planning is a process in which the individual is provided with
         opportunities to reconvene any or all of the planning processes whenever he/she
         wants or needs.
      2. The process encourages strengthening and developing natural supports by inviting
         family, friends, and allies to participate in the planning meeting(s) to assist the
         individual with his/her dreams, goals, and desires.
      3. The development of natural supports shall be viewed as an equal responsibility of
         Northpointe and the individual. Northpointe, in partnership with the person, is
         expected to develop, initiate, strengthen, and maintain community connections and
         friendships through the person-centered process.
      4. The individual is provided with options of choosing external independent facilitation



                                                                                                   38
    of her/her meeting(s), unless the individuals receive short-term outpatient therapy
    only, medication only, or is incarcerated.

5. Pre-IPOS information is completed at the time of the initial assessment or the annual
   assessment, which must be completed no less than 7 days prior to the date of the
   IPOS. The consumer is educated on:
      Dreams, goals, desires and topics about which he/she would like to talk
      Topics he/she does not want discussed at the person-centered planning meeting
      Who to invite
      Medical necessity
      Where and when the meeting will be held
      Who will facilitate (i.e. Independent Facilitator)
      Who will record
      Explanation of NBHS services
      Community Services/Inclusion
      Natural Supports
      Ability to communicate
      Self Determination/Children’s waiver choice voucher/HSW/education

6. All potential support and/or treatment options (including the NorthCare Benefit Plan
   and array of mental health services including Medicaid-covered services and
   Alternative Services and Mental Health Code-required services) to meet the
   expressed needs of the individual are identified and discussed with the individual.
   a. Health and safety needs are identified in partnership with the individual. The
       plan coordinates and integrates services with primary health care.
   b. The individual is provided with the opportunity to develop a crises plan.
   c. Each IPOS must contain the date the service is to begin, the specified amount,
       scope, HCPC codes, duration, length of face to face contacts in minutes and
       units, frequency, intensity and who will provide each authorized service and
       where they will be provided.
   d. Alternative services are discussed.

7. The individual has ongoing opportunities to express his/her preferences, cultural
   concerns and to make choices. This includes:
   a. Accommodations for communication shall be made with choices and options
      clearly explained. Barriers to an individual’s goals, and strengths, supports, or
      solutions to overcome barriers.
   b. To the extent possible, the individual shall be given the opportunity for
      experiencing the options available prior to making a choice/decision. This is
      particularly critical for those persons who have limited life experiences in the
      community with respect to housing, work and other domains.
   c. Individuals who have court-appointed legal guardians shall participate in person-
      centered planning and make decisions that are not delegated to the guardian in
      the Guardianship Letters of Authority.
   d. Service delivery shall concentrate on the child as a member of a family, with the
      wants and needs of the child and family integral to the plan developed and
      minors must have a goal addressing the needs of the family. Minors
      placed/residing out of the home must have a goal addressing reunification.
      Parents and family members of minors shall participate in the person-centered
      planning process unless:


                                                                                          39
                1. The minor is 14 years of age or older and has requested service without the
                   knowledge or consent of parents, guardian or person in loco parentis within
                   restrictions stated in the Mental Health Code;
                2. The minor is emancipated; or
                3. The inclusion of the parent(s) or significant family members would constitute
                   a substantial risk of physical or emotional harm to the recipient or substantial
                   disruption of the planning process as stated in the Mental Health Code.
                   Justification of the exclusion of parents shall be documented in the clinical
                   record.
       8. Individuals are provided with ongoing opportunities to provide feedback on how they
           feel about the service, support, and/or treatment they are receiving, and their progress
           toward attaining valued outcomes. Information is collected and changes are made in
           response to the individual’s feedback.
       9. Each individual is provided with a copy of his/her person-centered plan within 15
           business days after their meeting.
       10. Each consumer/guardian is educated on Independent Facilitation, Advance,
           Directives, Natural Supports, Self Determination, Crisis Planning to include “My
           Plan for Difficult Times” and Adequate Notice.

III. Illustrations of Individual Needs:
            Person-centered planning processes begin when an individual makes a request to
   Northpointe. The first step is to find out from the individual the reason for his/her request
   for assistance. During this process, individual needs and valued outcomes are identified
   rather than requests for a specific type of service. Since person-centered planning is an
   individualized process, how Northpointe proceeds will depend upon what the individual
   requests.
   This policy includes a chart of elements/strategies that can be used by the person
   representing Northpointe, depending upon what the individual wants and needs. Three
   possible situations are:
   1. The individual expresses a need which is considered urgent or emergent.
      When an individual is in an urgent/emergent situation, the goal is to get the individual’s
      crisis situation stabilized. Following stabilization, the individual and Northpointe staff
      will explore further needs for assistance and if required, proceed to a more in-depth
      planning process as outlined below. It is this type of situation where an individual’s
      opportunity to make choices may be limited.
   2. The individual expresses a need or makes a request for a support, service and/or
       treatment in a single life domain and/or of a short duration. A life domain could be any
       of the following:

             a)   Daily activities;
             b)   Social relationships;
             c)   Finances;
             d)   Work;
             e)   School;
             f)   Legal and safety;
             g)   Health;
             h)   Family relationships, etc.



                                                                                                   40
              3. The individual expresses multiple needs which involve multiple life domains for
                  support(s), service(s) or treatment of an extended duration.

              4. The following chart represents the elements/strategies that can be used depending on the
                  needs expressed by the individual.

                            ELEMENTS / STRATEGIES                                        Urgent /    Short      Extended
                                                                                         Emergent   Duration    Duration
The individual expresses his/her needs and/or desires. Accommodations for
communication will be made to maximize his/her ability for expression.                      X          X           X
The individual’s preferences, choices and abilities are respected.                         X           X          X

Potential issues of health and safety are explored and discussed. Supports to
address health and safety needs are included in the Individual Plan of Service.             X          X           X
As a result of health or safety concerns or court-ordered treatment, limitations may
exist for individual choice. However, opportunities for individuals to express their
perceived needs can occur and opportunities to make choices among limited options           X          X           X
can be given.
Person-centered planning includes pre-planning activities. These activities result in
the determination whether in-depth treatment or support planning is necessary and
if so, to determine and identify the people and information that need to be                            X           X
assembled for successful planning to take place.
In short-term/outpatient service areas, the individual is provided with information
on person-centered planning, including pre-planning at or before the initial visit.                    X
Individuals are encouraged to invite persons to the session where the plan is
developed.
In collaboration with Northpointe the individual identifies strategies and supports,
services and/or treatment needed to achieve desired outcomes.                                          X           X
Exploration of the potential resources for supports and services to be included in the
individual’s plan are to be considered in this order:
 The individual.
 Family, friends, guardian, and significant others.
 Resources in the neighborhood and community.
 Publicly funded supports and services available for all citizens.                                    X           X
 Publicly funded supports and services provided under the auspices of the
     Michigan Department of Community Health and Community Mental Health
     Services Program.
Regular opportunities for individuals to provide feedback are available. Information                   X           X
is collected and changes are made in response to the individual’s feedback.
The individual’s support network is explored with that person to determine who can
best help him/her plan. The individual and the people he/she selects together
define the individual’s desired future, and develop a plan for achieving desired
outcomes. For persons with dementia or other organic impairments, this should
include the identification of spouses or other primary caregivers who are likely to be                             X
involved in treatment or support plan implementation.
The process continues during the planning meeting(s) where the individual and
others he/she has selected who know him/her well talk about the desired future
and outcomes concentrating on the needs and wants previously identified as                                         X



                                                                                                           41
needing change.



         IV. Values and Principles Underlying Self-Determination Process

         1. A hallmark of self-determination is assuring a person the opportunity to direct a fixed
       amount of resources, which is derived from the person-centered planning process and called an
       individual budget. The person is responsible for the use of the resources in his/her individual
       budget, determining, with the assistance of family, friends, or others which services and supports he
       or she will purchase, from whom, and under what circumstances. Through this process they
       possess power to make meaningful choices in how they live their life. Northpointe shall ensure that
       their service planning and delivery processes are designed to encourage and support consumers to
       control and direct their specialty mental health services and supports arrangements.

              A. Utilization of the self-determination process, as a means for implementing individual
              plans of services and supports, shall be a voluntary option on the part of the consumer.

              B. Consumers who use the self-determination process shall have the authority to select,
              control, and direct their own specialty mental health services and supports arrangements by
              responsibly controlling the resources allotted in an individual budget designed towards
              accomplishing the goals and objectives in their plan of specialty mental health services and
              supports.

              C. Northpointe shall assure that full and complete information about the process and
              principles of self-determination and the manner in which it they may be applied is provided
              to each consumer. This shall include specific examples of alternative ways a consumer may
              control and direct an individual budget, what are considered allowable expenses in the
              budget, and the obligations associated with doing this properly and successfully.

              D. Utilization of the self-determination process shall not serve as a method for Northpointe
              to reduce its obligations to the consumer, or to avoid the provision of needed specialty
              mental health services and supports.

              E. Northpointe shall actively support and facilitate a consumer’s application of the
              principles of self-determination in the accomplishment of his/her plan of services and
              supports.

           2. The option to use self-determination shall be available to each consumer who requests the
              opportunity to implement their person-centered plan using these principles, and for whom an
              agreement on a plan of authorized specialty mental health services and supports, along with
              an acceptable individual budget, has been reached.

              A. Development of an individual budget shall be done within the person-centered planning
              process. This includes an initial determination of what natural and community supports are
              available for consumer use.

              B. The individual budget represents the expected or estimated costs to accomplish the
                 consumer’s plan through a realistic approach.



                                                                                                         42
    C. The amount of the individual budget shall be tentatively agreed to by both the consumer
       and Northpointe before it is authorized for use by the consumer. A copy of the
       individual budget, along with the individual plan that correlates with the budget, must be
       provided to the consumer prior to the implementation of the IPOS.

    D. The IPOS and Periodic Review must be in effect for Self Determination to be
       maintained.

    E. Self Determination Budgets will be brought to the Northpointe Utilization Review
       Committee.

V. Responsible and proper use of an individual budget must be of primary
concern to both Northpointe and the consumer.

       1. Mental Health funds included in an individual budget are the property and
       responsibility of Northpointe and must be used consistently within statutory and
       regulatory requirements. Authority over the direction of the budget is delegated to the
       consumer, for the purpose of achieving the goals and outcomes contained in the IPOS.
       An individual budget, once authorized, shall be considered part of the consumer’s
       approved plan of service. An individual budget shall be in effect for a specified period of
       time and therefore, must be revised when the plan is reviewed or changed.

        2. Consumers shall act as careful prudent purchasers of specialty mental health services
       and supports necessary to accomplish their plan. Arrangements for purchasing services
       shall not be excessive in cost. Consumers should aim for securing a better value, in terms
       of outcomes, for the costs involved. Existing personal and community resources shall be
       pursued and utilized prior to the authorization of a budget for a plan that includes
       Medicaid covered specialty services and supports. Northpointe shall provide guidance as
       to the range of applicable rates and may set maximum amounts that a consumer may
       spend to pay specific providers. Consistent with Northpointe policies, the consumer,
       within the boundaries of their authorized individual budget, may negotiate fees and rates
       paid to providers.

       3. An agreement shall be made in writing between Northpointe and the consumer
       outlining the responsibility and the authority of both parties in the application of the
       individual budget, including how communication will occur about its use. The agreement
       shall include a copy of the consumer’s plan and individual budget. The directions and
       assistance necessary for the consumer to properly apply the individual budget shall be
       provided to the consumer in writing when the agreement is finalized.

       4. Consumer ability to make adjustments to their individual budget

                a. The consumer may adjust the specific application of Northpointe -authorized
          funds between budgetary line items and/or categories in order to adjust the services
          and supports arrangements as necessary to accomplish his/her plan. Any changes
          made shall be under the auspices of already approved services and supports as noted
          in the individual plan. Funds allocated for specialty mental health services may not be
          used for other services/supports that are not consistent with Medicaid covered and
          available services or for supports that are not included in the plan.




                                                                                               43
                b. Unless the planned adjustment deviates from the goals and objectives in the
          consumer’s plan, the consumer does not need to seek permission from Northpointe
          nor be required to provide advance notification of an intended adjustment. However,
          when a consumer makes adjustments, these are to be communicated to Northpointe in
          a timely manner.

                  c. If an adjustment in the use of the budget is intended for a service/support
          that does not serve to accomplish the direction and intent of the person’s plan, then
          no adjustment may be made unless the plan is appropriately modified. Northpointe
          shall attempt to resolve such situations in an expedient manner.


                  d. The funds aggregated and used to finance an individual budget may be
          controlled by more than one funding source. Flexibility in the use of these funds is
          therefore constrained by the specific limitations of funding sources (e.g., Home Help,
          Vocational Rehabilitation, etc.) Consumers must be informed when some of the
          resources associated with accomplishing their plan of services and supports involve
          commitments from funding sources other than Northpointe, and will be assisted to
          work within constraints that accompany them. All expenses covered by Medicaid
          capitated dollars must be reflected in the individual plan of service, and must directly
          relate to approved mental health specialty services and supports as defined in Chapter
          III. Generally, purchases of assets are not allowed, unless considered necessary
          adaptive equipment.

      5. Either party - Northpointe or the consumer - may terminate a self-determination
      agreement. Prior to Northpointe terminating an agreement, unless it is not feasible,
      Northpointe shall inform the consumer of the reasons that have led to the discontinuation
      or alteration of the self-determination arrangement, in writing. An opportunity for
      problem resolution will be offered whenever possible. Typically changes such as this
      would be conducted using the person-centered planning process, with termination being
      the option of choice if other mutually agreeable solutions cannot be found. In any
      instance of Northpointe discontinuation of a self-determination arrangement, the local
      process for dispute resolution may be used to address and resolve these issues.

      6. Discontinuation of a self-determination arrangement shall not, by itself, change the
      consumer’s plan of services, nor eliminate the obligation of Northpointe to assure
      specialty mental health services and supports included in the plan are continued.

      7. As long as the mental health specialty services and supports are not reduced,
      suspended, or terminated, the Medicaid Fair Hearing Process does not apply to the
      termination of the self-determination agreement.

VI . Provider Access

   A. A consumer shall be able to access any willing and qualified provider entity that is
       available, qualified, and competent to provide needed specialty mental health services
       and supports.

   B. A consumer utilizing the self-determination process shall be able to access alternative
      methods to choose, control and direct the personnel necessary to provide the services


                                                                                                44
         and supports in the individual’s plan. These may include, upon the consumer’s request
         and in line with their preferences:
                1) Access to a provider entity that can serve as employer of record for personnel
                     selected by the consumer.
                2) Northpointe contractual language with provider entities that assures
                     consumer control over the selection and retention of personnel who provide
                     the specialty services and supports consistent with the individual plan of
                     service.
                3) Northpointe is the employer of record for personnel that the consumer
                     chooses to deliver specialty services and supports. Northpointe shall assure
                     that the consumer is fully involved in the selection of personnel, and the
                     removal or reassignment of personnel who fail to meet consumer
                     preferences.
                4) Northpointe or contractual provider entity shall perform all employment
                     functions associated with the hiring of selected personnel, including, but not
                     limited to, assuring that required paperwork is completed, providing training,
                     criminal background checks, monitoring of consultant and contract
                     agreements, payroll agent functions, etc.

     C. Consumers, in collaboration with Northpointe, shall assure that written agreements that
        specify the type of service or support, the rate to be paid, and the requirements
        incumbent upon the provider are developed with each provider entity or individual.
        Copies of all agreements shall be kept current and available for review.
            1) All individuals selected by the consumer shall meet applicable provider
                requirements for direct support staff personnel, or other requirements pertinent
                to the particular professional services offered by the provider.
            2) Services/supports provided by a consumer-selected provider with whom the
                consumer executes a direct purchase-of-services agreement is not an available
                option at this time. A consumer shall not be required to select and direct needed
                provider entities or his/her direct support personnel if she or he does not desire
                to do so.

     D. Consumers using the self-determination process function as an employer in terms of the
        selection, training, retention, scheduling and in determining the rates of pay for support
        personnel. However, consistent with CMS standards, Medicaid funds may not be given
        directly to a consumer, and consumers may not function as the formal employer of
        record with respect to fulfilling the legal responsibilities as the employer and payroll
        agent for selected personnel.

    E. Documentation requirements and financial reporting requirements shall be delineated in
       the written self-determination arrangements between the consumer and Northpointe and
       shall be agreed upon by both parties. This includes determination of what documentation
       will be required of those providing specialty services and supports and how/when this
       information will be provided to Northpointe as well as establishing the format for
       financial reporting, assuring that there is timely service activity and cost reporting to
       Northpointe, and that the consumer receives regular, current information on the status of
       the budget.

VII. Northpointe shall assist a consumer participating in self-determination to select and
direct his/her support personnel, and to select and retain chosen qualified contract provider
entities via Northpointe.


                                                                                                45
      A. Consistent with MDCH Technical Advisory instructions and within the IRS,
          Department of Treasury and federal and state employment guidelines, Northpointe may
          choose to make available reasonable access to other possible alternative methods for
          directing and managing support personnel. This may include the use of a qualified
          third party entity to function as a fiscal intermediary to perform the employer agent
          functions that would otherwise be the responsibility of Northpointe or alternative
          provider entity. The consumer and Northpointe must assure that the retention of a
          fiscal intermediary does not add excessive administrative charges over and above the
          administrative costs that would typically be associated with a Northpointe or other
          provider entity performing the functions of employer agent. If chosen as an option, a
          fiscal intermediary shall be under contract with Northpointe. Such a contract shall
          clearly delineate the specific employer agent functions to be accomplished by the fiscal
          intermediary. These may include:

           1. Disbursement of funds to provider entities for services provided in accord with the
              consumer’s plan of service.
           2. Provision of periodic (not less than monthly) financial status reports to both
              Northpointe and consumer.
           3. Provision of an accounting to Northpointe for the funds transferred to it and used
              to finance the costs of authorized individual budgets under its management
           4. Assuring timely invoicing, service activity, and cost reporting to Northpointe for
              the specialty mental health services and supports provided to the consumer in
              accord with the authorized budget and individual plan of service.
           5. Other supportive services, as denoted in the contract with Northpointe that
              strengthens the consumer’s role in the direction and management of personnel that
              provide their services and supports.

        B. Northpointe shall exercise due diligence in establishing the qualifications,
           characteristics and capabilities of the entity to be selected as a fiscal intermediary,
           and shall manage the use of fiscal intermediaries consistent with MDCH Technical
           Assistance Advisories addressing fiscal intermediary arrangements. Northpointe is
           obligated to assure that the entities selected to perform intermediary functions are
           capable of meeting and maintaining compliance with the applicable requirements
           associated with their stated functions.

        C. Northpointe shall be the decision maker in determining whether any optional
           alternative methods abide by state and federal regulations and whether Northpointe
           will offer such options Northpointe shall attempt to provide any other supportive
           services that strengthen the role of the consumer as an employer, and will assist with
           the use of other agreements directly involving the consumer in the process of
           securing needed services.

        D. Northpointe shall have policies and procedures addressing potential conflict of interest
           scenarios involving consumers and their services and supports providers.

VIII. Assurances and Indicators of Person-Centered Planning Implementation and that the
Self Determination Option was offered.
       It is the responsibility of the Northpointe to assure that the Individual Plan of Service is
developed utilizing a person-centered planning process including the option of self-determination.



                                                                                                 46
Below are examples of systemic and individual level indicators that would demonstrate that
person-centered planning and/or self-determination has occurred. The methods of gathering
information or evidence may vary, and include the review of administrative documents, clinical
policy and guidelines, case record review, satisfaction surveys, and interviews/focus groups with
individuals and their families.
 A. Systemic indicators would include, but not be limited to:
    1. Northpointe has a policy or practice guideline that delineates how person-centered
       planning will be implemented.
    2. Evidence that Northpointe informs individuals of their right to person-centered planning,
       the self-determination process and associated appeal mechanism, investigates complaints
       in this area, and documents outcomes.
    3. Evidence that Northpointe’s quality improvement system actively seeks feedback from
       individuals receiving services, support and/or treatment regarding their satisfaction,
       providing opportunities to express needs and preferences and the ability to make choices.
       Information is collected and changes are made in response to the individual’s feedback.
    4. Northpointe’s staff development plan includes efforts to ensure that executive team,
       professional employees, direct care staff, board members, consumers, families and other
       stakeholders are trained in the philosophy, methods, and implementation activities of
       person-centered and self-determination processes.
    5. Northpointe collects information and makes changes when necessary on processes to
       develop natural supports. Information collected examines the development, initiation,
       and maintenance of community connections and friendships through the person-centered
       process.
    6. Northpointe has developed and implemented, in partnership with individuals with
       disabilities, a plan for independent facilitation including but not limited to training
       requirements, performance expectations, satisfaction surveys, retention of skilled
       facilitators, and ongoing training with support.

B. Individual indicators could include, but not be limited to:


    1. Evidence the individual was provided with information of his/her right to person-centered
       planning and self determination.
    2. Evidence that the individual chose topics he/she would like to talk about in the meeting,
       topics he/she does not want discussed at the meeting, whether or not other persons should
       be involved, and those identified were involved in the planning process and in the
       implementation of the Individual Plan of Service.
    3. Evidence that the individual chose the places and times to meet, convenient to the
       individual and to the persons he/she wanted present.
    4. Evidence that the individual had choice in the selection of who will facilitate the plan,
       and treatment or support services provided including staff that will assist in carrying out
       the activities in the plan.
    5. Evidence that the individual’s preferences and choices were considered or a description
       of the dispute/appeal process and the resulting outcome.
    6. Evidence that the progress made toward the valued outcomes identified by the individual
       was reviewed and discussed for the purpose of modifying the strategies and techniques
       employed to achieve these outcomes.
    7. Evidence that a budget was developed and agreed upon by all parties.




                                                                                               47
IX. Dispute Resolution/Appeal Mechanisms
     All consumers have the right to a fair and efficient process for resolving complaints
     regarding their services and supports managed and/or delivered by Prepaid Inpatient
     Health Plans (PIHPs), their affiliate Community Mental Health Services Programs
     (CMHSPs) and their provider networks. A recipient of or applicant for public mental
     health services may access several options to pursue the resolution of complaints. These
     options are defined through the Recipient Rights requirements referenced in the Michigan
     Mental Health Code for all recipients of public mental health services, federal law for
     Medicaid recipients, and the MDCH/PHP or CMHSP contract. It is important to note that
     an individual receiving mental health services and supports may pursue their complaint
     within multiple options simultaneously.

     Chapters 7, 7a, 4 and 4a of the Mental Health Code describe the broad set of rights and
     protections for recipients of public mental health services as well as the procedures for the
     investigation and resolution of recipient rights complaints. Processes for complaints related
     to the denial, reduction, suspension or termination of services and supports are specified in
     the Grievance and Appeal Technical Requirement, Attachment 6.3.2.1 of the Department
     of Community Health Contract for Mental Health Services and Supports.

     This requirement is based upon the premise that all recipients of, or applicants for, public
     mental health services will receive notice of their rights and an explanation of the grievance
     and appeal processes. This requirement in no way requires the exhaustion of grievance or
     alternative dispute resolution processes prior to the filing of a recipient rights complaint
     pursuant to Chapter 7 and 7a of the Code.

X. Advanced Directive and Crisis Planning are addressed in the IPOS




                                                                                                 48
NBHS CARE MANAGEMENT                                                                                  Section 7

Provider Network Manual


                   Recipient Rights, Grievance and Appeal

                             Policies and Procedures Manual
Policy Title:                                                                                      Adm. Review Date

Change in Type of Treatment ...................................................................................05/01/09
Communication, Telephone & Visiting Rights ........................................................05/01/09
Complaint and Appeals Process ...............................................................................05/01/09
Complaint Investigation and Resolution ........................................................11/12/09
Comprehensive Examination .........................................................................05/01/09
Confidentiality/Disclosure .............................................................................05/01/09
Confidentiality and Disclosure Training ........................................................05/01/09
Consumer Bill of Rights and Responsibilities ...............................................05/01/09
Consumer Grievance and Appeal Process .....................................................05/01/09
Dignity and Respect .......................................................................................05/01/09
Freedom of Movement ...................................................................................05/01/09
Harassment or Retaliation ..............................................................................05/01/09
Informed Consent...........................................................................................11/12/09
Labor ..............................................................................................................05/01/09
Least Restrictive Setting ................................................................................05/01/09
Notification of Rights ....................................................................................05/01/09
Personal Property and Funds .........................................................................05/01/09
Protection of Consumers from Abuse and Neglect........................................11/12/09
Recipient Rights Committee ..........................................................................05/01/09
Recipient Rights System ................................................................................05/01/09
Residents’ Right to Access the Media ...........................................................05/01/09
Seclusion and Physical Restraint/Crisis Response ........................................11/12/09
Services Suited to Condition ..........................................................................11/12/09
Sterilization, Abortion, Contraception & Family Planning ...........................05/01/09
Treatment by Spiritual Means ........................................................................05/01/09




Last Revised: 11/12/09




                                                                                                                               49
POLICY TITLE: Substance Abuse 42 C.F.R., Part 2
POLICY:

It is the policy of Northpointe Behavioral Healthcare System to protect information that may
identify the consumer as someone who has received alcohol or drug treatment services.

PURPOSE:

To establish policy regarding confidentiality of substance abuse records and disclosure of
information according to applicable laws. For the purpose of this policy, reference can be made
to the 2006 Edition of Confidentiality and Communication, A Guide to the Federal Drug and
Alcohol Confidentiality Law and HIPAA by the Legal Action Center. The information below
contains excerpts from this manual. More detail is available in the manual.

APPLICATION:

This policy applies to all Northpointe employees, volunteers, student interns, Peer Support
specialists and persons under contract with Northpointe.

DEFINITIIONS:

Both HIPAA and 42 CFR. Part 2 protect consumer identifying information. Under 42 CFR, Part
2 this is information that would identify them as someone who has received alcohol or drug
treatment services, either directly or indirectly. This includes any information, whether oral or
written that would directly or indirectly reveal a person’s status as a current or former consumer.
Records protected from unauthorized disclosure include any information acquired about a
consumer– including identity, address, medical or treatment information, and all communications
made to program staff – whether it is in writing or is recorded in some other form.

42 CFR, Part 2 protects “consumers” who have applied for, participated in, or received an
interview, counseling, or any other service from a federally assisted or drug abuse program,
including someone who, after arrest on a criminal charge, is identified as an alcohol or drug
patient during an evaluation of eligibility for treatment.

HIPAA protects any health information that identifies an individual, while 42 CFR, Part 2 only
protect information that identifies an individual as being a patient in a drug or alcohol abuse
program or as having a drug or alcohol problem. It is possible for some information, i.e. that
which does not include drug/alcohol info, to only be protected by HIPAA and not by 42 CFR,
Part 2.
HIV – Human Immunodeficiency Virus

ARC – Aids Related Complex

AIDS – Acquired Immunodeficiency Syndrome



STANDARDS:




                                                                                                  50
  1. Internal Confidentiality. Internal access to confidential information shall be limited to
      those staff that has a need to know that specific information to perform their assigned job
      duties. Access shall ordinarily be limited to staff providing services to the consumer, or
      staff performing approved peer review, professional consultation, investigation,
      supervisory, or clinical records functions.
  2. Consumers receiving substance abuse services must have Release of Information form(s)
      completed which is 42 CFR compliant. All previous releases are no longer valid.
  3. Most disclosures are permissible if a patient has signed a valid 42 CFR, Part 2 consent
      form which has not expired or been revoked by the consumer. If authorized by consent, a
      disclosure is allowed even if it may not be in the consumer’s best interests.
  4. The consumer may revoke consent at any time. 42 CFR, Part 2 is silent on the issue of
      whether the revocation can be oral or must be in writing. As a result, drug and alcohol
      programs honor oral revocation.
  5. Under 42 CFR, Part 2, 1) the program must always obtain the minor’s consent for
      disclosures, and cannot rely on the parent’s signature instead; and 2) parental consent for
      disclosure to a third party is required in addition to the minor’s only if the program is
      required by state law to obtain parental permission before providing treatment to a minor.
      In other words, if parental consent was not required to treat the minor, then parental
      consent is not required to make disclosures. If it is required, the consent of both the
      minor consumer and the parent or guardian is required to make disclosures.
  6. Adolescents (14-18 years old): Typically, parents consent to treatment for their child to
      receive mental health services. This is not the case for adolescents receiving substance
      abuse treatment. It is recommended that at the onset of mental health services, the
      adolescent sign releases and consents that are 42 CFR compliant. Otherwise, if the child
      becomes a participant in co-occurring treatment, the parental consent and releases will no
      longer be effective.
  7. Any disclosure made with written consumer consent must be accompanied by a written
      statement that the information is protected by federal law and that the recipient cannot
      make any further disclosure unless permitted by regulations. Redisclosure is not allowed
      unless the consumer requests it and signs a valid authorization.
  8. Disclosures may be permitted when a consumer has a medical condition that poses an
      immediate threat to the health of an individual or requires immediate medical
      intervention. In this situation, information may only be disclosed to medical personnel,
      not family members or “emergency contacts”.
  9. Under 42 CFR, Part 2, a subpoena, search warrant or arrest warrant, even when it is
      signed by a judge and labeled a court order, is not sufficient, when standing alone, to
      require or even permit a program to make a disclosure. If confronted with a subpoena or
      court order directing the program to produce patient records or testimony about a
      consumer, it is best to seek the advice of legal counsel.
  10. Michigan has a duty to warn. This can be done without violation by either obtaining a
      court order, anonymously or a non-patient identifying report (and must not implicate
      substance abuse treatment).
  11. If there is suspected Child Abuse and Neglect, the program may comply with State
      mandatory reporting laws per the following:
           a. Make an initial report to the state’s child abuse hotline
           b. Provide written confirmation, if required
           c. Provide nothing more in follow-up investigation, unless provided with patient’s
               written consent or a valid court order.


PROCEDURES:


                                                                                              51
    1. A simple screening tool will be used to determine substance abuse/co-occurring status.
       This tool will be implemented within the assessment, both at intake and ongoing in case
       substance abuse is discovered during the course of treatment.
    2. A Substance Abuse Disability Designation field (17.03) will be included on the forms so
       that medical records staff can complete data entry for State reporting. These assessments
       will have an “HH” modifier attached to it for billing/reporting purposes. If a SA
       Disability Designation field is indicated, Medical Records staff will do an administrative
       revocation with date and signature of staff and all existing/prior releases would be
       revoked. Clinical staff will complete new 42 CFR releases with the consumer.
    3. Medical Records staff will mark the chart with a colored sticker.(inside front cover of
       chart)
    4. A regional Release of Information Form was developed and will be implemented along
       with this policy.
    5. A consumer has the right to revoke consent (written/oral). Med Records staff will:
            a. Draw a line through the consent form
            b. Stamp“Revoked by Consumer” (a stamp will be available at each service site);
               staff member will initial and date.
            c. Provide copy to consumer, if indicated
            d. Place revoked consent in the consumer’s file
            e. Inform appropriate staff
    6. At Intake, clinical staff will address guidelines for 14-17 year old minors:
            a. Consent for services and releases signed by both minor and parent
            b. Minor signs releases to parents
            c. Minor’s right to revoke releases: Explain to the parents that at some point in the
               future, if there is not a release from the child, CMH may not be able to
               communicate with them anymore about the child’s treatment.

 CROSS REFERENCES:
 42 CRF, Part 2
 Confidentiality and Communication: A Guide to the Federal Drug & Alcohol Confidentiality
   Law and HIPAA, 6th Ed, New York, NY: Legal Action Center, 2006
 cl.116sa -Authorization for Release of Information, 42, CFR, Part 2
 17.03 Substance Abuse Disorder/SUD – Disability Designation




POLICY TITLE: Change in Type of Treatment
POLICY:
It is the policy of the Northpointe Board that the recipient or applicable parent or guardian shall be
informed when the recipient is ready for a change in type of treatment or has received maximum benefit
from the current program.

PURPOSE:
To establish a procedure to effect a change of treatment for a consumer.

APPLICATION:
  A. A recipient’s written plan of service shall include a specific date or dates when the overall plan,



                                                                                               52
         and any of its subcomponents, will be formally reviewed for possible modification or revision.

    B. Changes shall be made a part of the person-centered planning process. A recipient shall be
       informed when staff determine he or she is ready for change, release, discharge, or has received
       the maximum benefit from current treatment. Required written notice about the change and how
       to request a review of this change shall be provided according to Agency procedures.

    C. If the recipient, parent, or guardian is not satisfied with a proposed change in type of treatment or
       discharge, he or she may ask the primary clinician or the Office of Recipient Rights, verbally or
       in writing, for a review at any time. The review will be conducted according to the Agency’s
       process for a local appeal/second opinion. The review shall be completed within 30 days.

DEFINITIONS:
Primary Clinician - The staff member in charge of implementing the recipient’s plan of service.

PROCEDURES:
The primary clinician will:

    1.   Verbally inform the recipient, parent, or guardian about:
         a. The proposed change, release, or discharge, or that the recipient has received the maximum
            benefit from current treatment;
         b. The justification for such change or discharge;
         c. The process for requesting a review of this determination;

    2. Provide required written notice, according to Agency procedures, about review options within
         Northpointe and the Department of Community Health.

CROSS REFERENCES:
Act 258 of the Public Acts of 1974, as amended (Mental Health Code) Section 712
Department of Community Health Administrative rule 7199
Department of Community Health Master Contract BPG 4.5.1.




POLICY TITLE:                  Communication, Telephone and Visiting
Rights
PURPOSE:
To establish policies and procedures for residents to communicate by mail, telephone and/or
visits.

APPLICATION:
All residential mental health facilities operated by or under contract with Northpointe Healthcare
Systems.

DEFINITIONS:




                                                                                                 53
Controlled Condition: At least two staff members are present when opening mail.

House Rules: Rules applying to all residents of a home, which are established to assure the safety
and comfort of recipients and the orderly functioning of the home.

Incoming Mail: Resident's mail (including parcels and packages); and Agency/facility mail
(includes mail in the form of government check addressed to agency/facility as representative
payee for the resident).

Legal Inquiry: Any matter including civil, criminal, or administrative law.

Limitation: A limit placed on the resident's right to receive mail as written and documented in the
resident's Individual Plan of Service.

Private: Secret, not intended to be made known publicly, confidential.

Reasonable Time: Meeting the criteria of not seriously taxing the effective functioning of the
agency.

Restriction: An exclusion of a particular item as stated in the written policies of NBHS and
applies to all residents.

Uncensored: Without rebuke, reproach or disapproval; free from criticism; not judged or
condemned.

Unimpeded: Without hindrance, barricade or other obstacles.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:

1.    A resident is entitled to unimpeded, private and uncensored communication with others by
mail and telephone and is also entitled to meet face-to-face with persons of his/her choice. This
right shall not be further limited except as authorized in the resident’s person-centered plan.
Reasons limitations may be included in the plan are:
             a. To prevent the resident from violating a law;

            b. To prevent substantial and serious physical or emotional harm;

            c. There is good reason to believe that the resident's mail contains items which are
               not allowed in the facility;

            d. There is good reason to believe that the resident's mail contains items which are
               limited in the resident's Individual Plan of Service;

            e. The resident, guardian, or the parent of a minor child has consented in writing
               that an article of mail be opened or destroyed by a designated person; and

            f. If another person accuses a resident of harassment and; future telephone
               harassment can reasonably be expected, the frequency of past harassing phone
               calls is established or the person requesting the limitation has done so in writing.



                                                                                                 54
2. Residents shall be given the right to appeal any communication limitation imposed.

3. Each facility shall make telephones accessible; ensure that correspondence can be
   conveniently received and mailed; and make space available for residents to visit with others.

4. Telephone usage funds, and postage shall be provided to residents who are financially unable
   to access such items based on a financial determination made by the resident's Responsible
   Care Manager and/or Home Operator/Manager.

5. Non-letterhead stationary, envelopes, and pens or pencils shall be given to the residents, upon
   request.

6. Each facility shall have a postal box or daily pickup and deposit for resident's mail.

7. Sealed mail, telephone calls to or from residents, and visitations from the resident's private
   physician, mental health professional, court representative, attorney and/or others when it
   involves matters which are or may be the subject of legal inquiry, shall not be limited except
   non-emergency visits from the resident's private physician or mental health counselor if it
   infringes on the effective functioning of the facility.

PROCEDURES:
1. During the person-centered planning process the following will be reviewed, discussed, and
agreed upon:
    a) Rationale to justify the limitation.
    b) Documented evidence to support the expected mental or physical harm, violation of law
        and/or harassment.
    c) Documented evidence to justify the extent of the limitation as being the minimal amount.
    d) Determine an expiration date for the imposed limitation. The imposed limitation shall be
         reviewed every 30 days even if the expiration date is beyond 30 days.

2. Residents whose communication through mail, telephone and/or visits are limited per his/her
Person-Centered Plan shall have each instance of limitation and justification for its application
documented in the residential facility on a program with data being taken by the staff. This
information shall be reviewed every 30 days by the Treatment Team and BMRC to discuss the
resident's progress or lack of progress and determine if the limitation still needs to be imposed.
This information shall be documented utilizing the BMRC form.

3. The Responsible Care Manager shall immediately inform the resident when a limitation
regarding mail, telephone calls and/or visits has been imposed along with the intended purpose of
the limitation.

4. If the resident appeals the communication limitation, he/she shall submit a verbal or written
statement to the Responsible Care Manager. A resident may contest the justification, extent or
duration of a limitation. The Responsible Care Manager shall place the original statement in the
resident's clinical file and submit a copy to his/her supervisor.

            A. The Responsible Care Manager's supervisor shall review the appeal within five
               (5) working days and determine if the imposed limitation is justified or not.

            B. If the resident does not agree with the decision made by the Responsible Care


                                                                                                55
                 Manager's supervisor, he/she may appeal to the responsible Site Supervisor. The
                 Site Supervisor shall review the appeal within five (5) working days and
                 determine if the imposed
                 limitation is justified or not.

            C. The resident shall be informed that he/she can file a complaint with the Recipient
               Rights Officer if he/she feel that his/her right to communicate is being violated.

  5. Sealed mail, calls from or to, and visits from a resident's private physician, or a mental
health professional, a court, a resident's attorney, or other person when communication involves
matters which are or may be the subject of legal inquiry shall not be limited, except that non-
emergency visits of a private physician or a mental health professional may be limited to
reasonable times. A time is reasonable if a visit does not seriously tax the effective functioning of
the facility. "Legal inquiry" includes any matter concerning civil, criminal, or administrative law.

   6. Incoming and outgoing mail for a resident shall not be opened unless a resident, guardian,
or a parent of a minor child has consented that an article of mail be opened by a designated
person. Each instance of opening or destruction of mail shall be done with two staff members
present and documented in the resident's record.

   7. Each facility shall establish a reasonable limit on the amount of funds that shall be available
to those residents who are financially unable to access such items as writing materials, postage
and telephone usage

  8.   Mail shall be distributed to residents on a daily basis.

   9. The times incoming and outgoing telephone calls are permitted shall be posted in the house
rules.

  10. The group home shall have regular visiting hours as long as it does not disrupt normal
treatment activities. Visiting hours shall be posted in waiting rooms, guest areas, resident
quarters and on the resident bulletin board which are documented in the house rules and posted in
the home.



POLICY TITLE:                   Complaint and Appeals Process
POLICY:
It is the policy of the Northpointe Board that the Recipient Rights Advisory Committee, be
designated to also serve as the Recipient Rights Complaint Appeals Committee. This committee
shall meet the composition required in Section 774 of the Mental Health Code.

PURPOSE:
Chapter 7A of the Michigan Mental Health Code, P.A. 258 of 1974, as amended, establishes the
right of public mental health service recipients, or someone acting on their behalf, to file
complaints alleging a violation of rights guaranteed by Chapter 7 of the Code. Chapter 7A also
assures that an appeal can be taken regarding the findings, remedial action, or timeliness of the
complaint investigation. The purpose of this procedure is to establish the process for handling
these appeals to assure all recipients and those acting on their behalf due process including its



                                                                                                   56
essential elements of notice and an opportunity to be heard by a fair and impartial decision-making
entity.

APPLICATION: All programs operated by or under contact with Northpointe Behavioral
Healthcare Systems.

DEFINITIONS:
Appeals Committee - A committee designated by the Northpointe Board under Section 774 of the
Mental Health Code to hear recipient rights complaint appeals brought by, or on behalf of, a
recipient of Northpointe.

Appellant - The recipient, complainant, parent, or legal guardian who appeals recipient rights
finding or respondent’s action to an appeals committee.

Complainant - An individual who files a recipient rights complaint.

DCH - Department of Community Health.

Legal Guardian - A judicially appointed guardian.

Respondent - The service provider that had responsibility, at the time of an alleged rights
violation, for the services with respect to which a rights complaint has been filed.

PROCEDURES:
  A. Training for Appeals Committee
     The Office of Recipient Rights shall ensure that initial and ongoing training and
     education is provided to the Appeals Committee. Topics may include:
  1. Categories of rights violations;
  2. Complaint investigation process;
  3. Types and weighing of evidence;
  4. Preponderance of evidence standard;
  5. Statutory definition of “appropriate remedial action”;
  6. Disciplinary guidelines for Northpointe and its contract providers;
  7. Northpointe Recipient Rights Complaint Appeals Procedure and functions of the Appeals
     Committee.

B. Notification of Appeal Rights
   Every complainant (recipient if different than the complainant), recipient’s legal guardian, and
   parent of a minor recipient shall be informed in the Summary Report issued by the Chief
   Executive Officer of the right to appeal to the Northpointe Appeals Committee. Notice shall
   include information on the grounds for appeal, advocacy organizations that may assist with
   filing the written appeal, and an offer of assistance by the Office of Recipient rights in the
   absence of assistance from an advocacy organization.

C. Requesting an Appeal
    Not later than 45 calendar days after receipt of the Summary Report, the appellant may file a
    written appeal with the Northpointe Appeals Committee. The request for an appeal should
    include the reason for the appeal. The appeal shall be mailed to:
                         Recipient Rights Appeals Committee Chair
                         c/o Office of Recipient Rights
                         Northpointe Behavioral Healthcare Systems


                                                                                                 57
                          715 Pyle Drive
                          Kingsford, MI 49802

D. Grounds for appeal to the Northpointe Appeals Committee shall be as follows:
     1. The investigative findings of the Office of Recipient Rights are not consistent with the
        facts or with law, rules, policies, or guidelines;
     2. The action taken or plan of action proposed by the respondent, does not provide an
        adequate remedy;
     3. An investigation was not initiated or completed on a timely basis.

E. Reviewing Request for Appeal
   1. Within five business days of receipt of the appeal, a member of the Appeals Committee
          shall:
              a) Review the appeal to determine if it meets the criteria stated above. This review
                 may be conducted by the Chair, Vice-Chair, or other available Committee
                 member.
              b) Provide written notice to the appellant that the appeal has been accepted or not
                 accepted.
              c) If the appeal has been accepted, shall provide a copy of the appeal to the
                 respondent, the Chief Executive Officer, and the Office of Recipient rights.

     2.   The Chief Executive Officer and the Office of Recipient rights may provide copies of the
          appeal to staff as they deem appropriate.

F.   Conducting an Appeal Meeting
     1. Within 30 calendar days after receipt of an accepted appeal, the Appeals Committee shall
        meet in closed session and review the facts as stated in all complaint investigation
        documents.

     2.   The Office of Recipient rights shall ensure that:
          a. Copies of complaint investigation documents are provided to the Appeals Committee;
          b. A date and time is scheduled for the appeal meeting;
          c. A room is scheduled for the appeal meeting;
          d. All appropriate individuals are notified of the appeal meeting;
          e. Establish and maintain a written record of the appeal including:
             1) The appeal and any supporting documentation;
              2) Complaint investigation documents utilized by the Appeals Committee;
              3) Any other documentation utilized by the Appeals Committee;
              4) Notification sent to the appellant.
          f. Maintain a log of all appeals received and the disposition of each.

     3. Clerical support staff shall:
        Prepare the Committee’s response to the appeal and have it reviewed by the Committee
        members. The response shall include:
                      1) The members and other individuals present;
                      2) The Committee’s decision;
                      3) The rationale for the decision.

     4.   Any member of the Appeals Committee who has a personal or professional relationship
          with an individual involved in the appeal, who has been contacted personally with
          information about the appeal, or who has any conflict of interest shall abstain from


                                                                                                   58
        participating in that appeal.

   5.   The Committee shall not consider additional allegations that were not part of the original
        complaint at issue on appeal but shall inform the appellant of his/her right to file a new
        complaint with the Office of Recipient Rights.

   6.   The Committee may, at its discretion, request additional supporting documentation from
        any party involved in the appeal. If the documentation is not provided to the Committee
        in a timely manner, the appeal will proceed and the decision will be made without the
        documentation.

   7.   The Committee may, at its discretion, request technical assistance only.

   8.   At the appeal meeting, the Appeals Committee shall do one of the following:
        a. Uphold the investigative findings of the Office of Recipient Rights and the action
            taken or plan of action proposed by the respondent;
        b. Return the investigation to the Office of Recipient Rights and direct that it be
            reopened or reinvestigated with specific information about what needs to be reopened
            or reinvestigated and the reason;
        c. Uphold the investigative findings of the Office of Recipient Rights but direct that the
            respondent take additional or different action to remedy the violation;
        d. If the Committee confirms that the investigation was not initiated or completed in a
            timely manner, recommend that Northpointe’s Chief Executive Officer take
            appropriate supervisory action with the investigating rights staff or take other
            appropriate action;
        e. Recommend that the Northpointe Board request an external investigation by the Department
            of Community Health—Office of Recipient Rights.

   9.   The Appeals Committee shall document its decision in writing within 10 business days
        following the decision and shall provide copies to the appellant (recipient if different than
        the appellant), recipient’s legal guardian, parent of a minor recipient, the Chief Executive
        Officer of Northpointe, and the Office of Recipient Rights. Documentation shall include
        justification for the decision made by the Committee and inform the appellant of their
        right to appeal to the Department of Community Health within 45 days of receipt of this
        notice.

G. Reopening or Reinvestigating a Complaint
   1.  If the Appeals Committee directs that the Office of Recipient Rights reopen or
      reinvestigate the complaint, the Office shall submit another Investigative Report in
      compliance with Section 778(5) of the Mental Health Code within 45 calendar days of
      receipt of the written decision of the Committee. The 45-day time frame may be extended
      at the discretion of the Appeals Committee upon a showing of good cause by the Office.
      At no time shall the time frame exceed 90 calendar days.
   2. Within 10 business days of receipt of the Investigative Report, the Chief Executive Officer
      shall issue another Summary Report in compliance with Section 782 of the Mental Health
      Code. The Summary Report shall be submitted to the appellant (recipient if different than
      the appellant), parent of a minor recipient, the Office of Recipient Rights, and the Appeals
      Committee. The Summary Report shall contain information regarding the appellant’s right
      to further appeal, the time frame for the appeal, and the grounds for appeal. The Summary
      Report shall also inform the appellant of advocacy organizations that may assist in filing
      the written appeal or offer the assistance of the Office of Recipient Rights in the absence


                                                                                                  59
          of assistance from an advocacy organization.
     3.   If the investigative findings of the Office remain the same as those appealed, the appellant
          may file a further appeal to the Department of Community health. The written appeal shall
          be mailed to:
                            Department of Community Health
                            Administrative Tribunal
                            P.O. Box 30195
                            Lansing, MI 48909

     4. If the investigative findings result in the substantiation of a previously unsubstantiated
        rights violation but the appellant disagrees with the adequacy of the action taken or the
        plan of action proposed by the respondent, the appellant may file an appeal to
        Northpointe’s Appeals Committee. The written appeal shall be mailed to:
                          Recipient Rights Appeals Committee Chair
                          c/o Office of Recipient Rights
                          Northpointe Behavioral Healthcare Systems
                          715 Pyle Drive
                          Kingsford, MI 49802

H. Taking Additional or Different Action
     1. If the Appeals Committee upholds the findings of the Office and directs that the
        respondent take additional or different action, that direction shall be based on the fact that
        appropriate remedial action has not been taken in compliance with Section 780 of the
        Mental Health Code. The Appeals Committee shall base its determination upon any or all
        of the following:
              a. Action taken or proposed did not correct or remedy the rights violation;
              b. Action taken or proposed was/will not be taken in a timely manner;
              c. Action taken or proposed did not/will not prevent a future recurrence of the violation.
     2. Written notice of this direction for additional or different action to be taken by the
        respondent shall also be provided to Northpointe’s Chief Executive Officer (if different
        than the respondent), and the Office of Recipient Rights.
     3. Within 30 calendar days of receipt of the determination from the Appeals Committee, the
        respondent shall provide written notice to the Appeals Committee that the action has been
        taken or justification as to why it was not taken. The written notice shall also be sent to the
        appellant (recipient if different than the appellant), recipient’s legal guardian, parent of a
        minor recipient, the Chief Executive Officer (if different than the respondent), and the
        Office of Recipient Rights.
     4. If the action taken by the respondent is determined by the Appeals Committee and/or the
        appellant still to be inadequate to remedy the violation, the appellant shall be informed
        by the Appeals Committee of his/her right to file a recipient rights complaint against the
        Chief Executive Officer for a violation of Section 755(3)(b) of the Mental Health Code.


I.   Appeal to the Department of Community Health
     1. An appeal to the Department of Community Health (DCH) may be taken only upon the
        ground that the investigative findings of the Office of Recipient rights were inconsistent
        with the fact, or with law, rules, policies, or guidelines and only after a decision on an
        appeal has been made by the Northpointe Appeals Committee.
     2. Within 45 calendar days after receiving written notice of the decision of the Appeals
        Committee, the appellant may file a written appeal with DCH. The written appeal shall be
        mailed to:


                                                                                                     60
                          Department of Community Health
                          Administrative Tribunal
                          P.O. Box 30195
                          Lansing, MI 48909
   3.   Upon receipt of the appeal, DCH shall give written notice of the receipt to the respondent,
        Northpointe Office of Recipient Rights, and the Chief Executive Officer. The respondent,
        Office of Recipient Rights, and Chief Executive Officer shall ensure that DCH has access
        to all necessary documentation and other evidence cited in the complaint and local appeal.
   4.   DCH shall review the record generated by the local appeal. It shall not consider
        additional evidence or information that was not available during the local appeal.
   5.   Within 30 calendar days after receiving the appeal, DCH shall review the appeal and do
        one of the following:
              a. Uphold the findings of the Office Recipient Rights;
              b. Affirm the decision of the Northpointe Appeal Committee;
              c. Return the matter to the Chief Executive Officer of Northpointe with instruction
                  for additional investigation or consideration.
   6.   DCH shall provide copies of its action to the respondent, the appellant (recipient if
        different than the appellant), recipient’s legal guardian, parent of a minor recipient, the
        Northpointe Board, and the Northpointe Office of Recipient Rights. If DCH upholds the
        findings of the Office of Recipient Rights, notice shall be provided to the appellant of
        his/her legal right to seek redress through the circuit court.
   7.   If DCH instructs that additional investigation be conducted, the Chief Executive Officer
        shall assure that such investigation is completed in a fair and impartial manner within 45
        calendar days of receipt of the written notice from DCH. The 45-day time frame may be
        extended at the Department’s discretion upon a showing of good cause by the Chief
        Executive Officer. At no time shall the time frame exceed 90 calendar days.
   8.   Within 10 business days of the receipt of the Investigative Report, the Chief Executive
        Officer shall issue a Summary Report in compliance with Section 782 of the Mental
        Health Code to the Department, appellant (recipient if different than the appellant), parent
        of a minor recipient.
   9.   If the findings of the additional investigation remain the same as those appealed, the
        Department shall inform the appellant (recipient if different than the appellant),
        recipient’s legal guardian, parent of a minor recipient in writing of the right to seek
        redress through the circuit court. Copies of this notice will be provided to the Director of
        the DCH Quality Management and Service Innovation.

   10. If the additional investigation results in the substantiation of a previously unsubstantiated
        violation but the appellant (recipient if different than the appellant), recipient’s legal
        guardian, or parent of a minor recipient disagrees with the adequacy of the action taken or
        plan of action proposed to remedy the violation, the Department shall inform the
        individual(s) of the right to appeal this to Northpointe’s Appeals Committee.

CROSS REFERENCES:
  A. Act 258 of the Public Acts of 1974, as amended (Mental Health Code), Sections 772,
     774, 776, 778, 780, 782, 784, 786
  B. Department of Community Health Technical Advisory – Recipient Rights Appeal Process, Dated
     December 16, 1998

EXHIBITS:
Flow Chart for the Appeals Process produced by the DCH Office of Recipient Rights



                                                                                                  61
POLICY TITLE:                   Complaint Investigation and Resolution
PURPOSE:
To develop a policy to assure code mandated complaint investigation and resolution.

APPLICATION:
All programs operated by or under contract with Northpointe Behavioral Healthcare Systems.

POLICY:
It is Northpointe’s policy that:
A. A mechanism shall be provided for prompt reporting, review, investigation, and resolution of
      apparent or suspected rights violations, which includes an appeals process and a mediation
      option.
B. Firm and fair disciplinary action and adequate remedial action shall be taken in the event of a
      violation.

DEFINITIONS:
Mediation
A private, informal dispute resolution process in which an impartial, neutral individual, in a
confidential setting, assists parties in reaching their own settlement of issues in a dispute and has
no authoritative decision-making power.

Preponderance of evidence
A standard of proof which is met when, based upon all available evidence, it is more likely that
something is true than untrue; greater weight of evidence, not as to quantity (number of witnesses),
but as to quality (believability and greater weight of important facts); more than 50 percent.

Reasonable Cause
A suspicion founded upon circumstances sufficiently strong to warrant a reasonable person to
believe that the suspicion is true.

Respondent
The service provider that had responsibility at the time of an alleged rights violation for the
services with respect to which a rights complaint has been filed.

Rights Complaint
A written or oral statement filed by a recipient, or another individual on behalf of a recipient, with
the Office of Recipient Rights, alleging a violation of the Mental Health Code or Administrative
rules, and which contains the following information:
A.       A statement of the allegations that give rise to the dispute;
B.       A Statement of the right or rights that may have been violated;
C.       The outcome that the complainant is seeking as a resolution to the complaint.

PROCEDURES:
A. Reporting Rights Violations

    1. Northpointe and respondents shall ensure that:




                                                                                                   62
        a. Appropriate administrative action is taken for failure to report suspected rights
        violations;
        b. Action is taken to protect the recipient during the investigation;
        c. The Office of Recipient Rights (Office) has unimpeded access to all of the following:
             1) All programs and services;
             2) All employees, volunteers, trainees, and recipients;
             3) All evidence that the Office determines is necessary to conduct a thorough
        investigation or to fulfill its monitoring of remedial action;
        d. Employees, volunteers, and trainees who may have knowledge pertinent to the
        investigation, cooperate fully with the Office and other authorized investigative bodies,
        respond to questions put forth, verbally or in writing, provide written statements when
        requested, and provide accurate and honest information. Appropriate disciplinary action
        shall be taken for any failure to cooperate;
        e. All employees, volunteers, trainees, recipients, and others who file a complaint or
        cooperate in an investigation are protected from discrimination, harassment, or retaliation
        in accordance with applicable laws and Agency policies/procedures, and appropriate
        disciplinary action is taken if this does occur;
        f. The recipient’s record and other documentary or physical evidence is immediately
        secured as necessary and protected from tampering, erasures, deletions, or any other type
        of falsification;
        g. Copies of documentation requested by the Office are provided in a timely manner.

2. The Office of Recipient Rights shall assure that recipients, parents, guardians, and others have
ready access to complaint forms.

3. All employees, volunteers, and trainees who witness, discover, or have reasonable cause to
suspect recipient rights violations shall report, verbally or in writing, to a designated supervisor
and/or the Office of Recipient Rights within 24 hours.

4. Any supervisor who receives an allegation of a suspected rights violation shall contact the
Office within 24 hours.

5. Individuals who orally report a suspected violation, or individuals who file an Incident Report
which contains a possible violation, will be asked if they wish to be considered the complainant.

        a. If the individual assents, she/he will be informed of the availability of assistance with
        the complaint process, and a complaint form will be provided.

        b. If the individual declines, she/he will be informed that the Office of Recipient Rights
        will act as complainant, and the individual will not receive a copy of the report or have
        access to the complaint appeal process.

B. Filing Rights Complaints
    1. The Office of Recipient rights shall:
       a. Date, number, and record each rights complaint when it is received and send an
           acknowledgement, along with a copy of the complaint, to the complainant within five
           business days. If the Office determines that no investigation of the rights complaint is
           warranted, it shall notify the complainant within five business days;

        b. Assist the recipient or other individual with the complaint process as necessary;



                                                                                                       63
        c. Advise the recipient or other individual that there are advocacy organizations such as
           Michigan Protection and Advocacy Services available to assist in preparation of a
           written rights complaint and offer to refer the recipient or other individual to those
           organizations. In the absence of assistance from an advocacy organization, the Office
           shall assist in preparing a written rights complaint that includes a statement of the
           allegation, the right allegedly violated, and the outcome desired by the complainant;

        d. Inform the recipient or other individual of the option of mediation and under what
           circumstances and when it may be exercised;

        e. Accept complaints that are filed anonymously and protect any information that may
           lead to identification of the anonymous complainant;

        f.   Route complaints involving alleged abuse, neglect, serious injury, or death to the
             Chief Executive Officer.

    2. When the Office determines that no investigation of the rights complaint is warranted, it
    may:
       a. Recommend remedial action for obvious rights violations;
       b. Inform the complainant of other agencies he or she may contact for complaints
       outside the Agency’s jurisdiction and assist if requested by the complainant.

    3. An employee who is aware that a recipient, or other individual, wants to file a rights
    complaint shall either assist that person or refer him/her to the Office. Complaints shall be sent
    to the Office within 24 hours.

C. Investigation
   1. All employees, volunteers, and trainees shall cooperate fully with investigators from the
   Office of Recipient Rights and other Authorized investigative bodies, respond to questions put
   forth, verbally or in writing, and provide accurate and honest information.

    2. The Office of Recipient rights shall:
       a. Initiate investigation of apparent or suspected rights violations in a timely and efficient
           manner. Investigation shall be initiated immediately in cases involving alleged abuse,
           neglect, serious injury, or the death of a recipient that involves an apparent or
           suspected rights violation;

        b. Conduct investigations in a manner that does not violate employee rights;

        c. Complete the investigation not later than 90 days after receiving the rights complaint;
        subject to delays involving pending action by external agencies including law
        enforcement, protective services, or licensing entities

        d. Include the following when pertinent to the investigation:
            1) An interview with the complainant when circumstances allow, preferably face to
                face;
            2) An interview with the recipient if other than complainant when circumstances
                allow, preferably face to face;
            3) Interviews with all witnesses and others who may provide relevant information,
                preferably face to face;
            4) Interviews with employees, volunteers, and trainees who are alleged to have


                                                                                                  64
                 violated a right, preferably face to face;
              5) Written statements from employees, volunteers, trainees, recipients, and relevant
                 others when such a statement is necessary to support oral interview, to obtain
                 additional information, or to provide findings relevant to the investigation;
              6) Review of recipient records and appropriate other documentation;
              7) Review of investigations into the same allegation conducted by law enforcement,
                 licensing entities, or others when available;
              8) Visit to the site of the alleged violation;
              9) Review of pertinent laws, rules, policies and procedures.

         e. Maintain accurate records of investigative activities and findings;

         f.   Store all investigative documents and evidence in a secure manner in a locked cabinet
              in the Office, separate from clinical or personnel records and within the constraints of
              confidentiality and privileged communications in Section 748 and 750 of the Mental
              Health Code;

         g. Determine whether a right was violated by using a preponderance of evidence as the
            standard of proof;

         h. Monitor progress toward remediation of all substantiated violations of rights.

    3. The Office may:
       a. File additional rights complaints when it becomes apparent that other rights may have
          been violated;
       b. Consult with the respondent to determine appropriate remedial action.

    4.   If a rights complaint has been filed regarding the conduct of the Chief Executive Officer,
         the rights investigation shall be conducted by the office of another community mental
         health services program or by the state office of recipient rights as decided by the
         Northpointe Board.

D. Status Report
   The Office of Recipient Rights shall:
   1. Issue a written Status Report every 30 calendar days during the course of the investigation.
       The report shall be submitted to the complainant, the respondent, and Northpointe;
    2. Include all of the following in the Status Report:
       a) Statement of the allegations;
       b) Statement of the issues involved;
       c) Citations to relevant provisions of the Mental Health Code, Administrative Rules,
           guidelines, and Northpointe policies and procedures;
       d) Investigative progress to date;
       e) Expected date for completion of the investigation.

E. Investigative Report
    The Office of recipient Rights shall:
   1. Submit a written Investigative Report to the respondent and the Northpointe CEO upon
      completion of the investigation. Issuance of the written Investigative Report may be
      delayed pending completion of investigations that involve external agencies, including law
      enforcement, protective services, or licensing entities;



                                                                                                   65
     2. Include all of the following in the Investigative Report:
             a) Statement of the allegations;
             b) Statement of the issues involved;
             c) Citations to relevant provisions of the Mental Health Code, Administrative Rules,
                 guidelines, and Northpointe policies and procedures;
             d) Investigative findings;
             e) Conclusions;
             f) Recommendations, if any.

     The Office may reopen or reinvestigate a complaint if there is new evidence that was not
     presented at the time of the original investigation.

F.       Remedial Action
         If it has been determined through investigation that a right has been violated, or if an
         intervention determines that remedial action is necessary:

         The respondent shall:
         1. Take appropriate remedial action that meets all of the following requirements:
             a. Corrects or provides a remedy for the rights violation;
             b. Is implemented in a timely manner;
             c. Attempts to prevent a recurrence of the rights violation;

         2. Provide the Office with written documentation of the remedial action for its record.

         Northpointe and respondents shall:
         1. Ensure that appropriate disciplinary action is taken against those who have engaged in
            abuse or neglect;
         2. Apply remedial action for a specific complaint to all recipients in similar situations,
            when applicable.

G.      Summary Report
        The Chief Executive Officer shall:
           A. Submit a written Summary Report to the complainant and recipient, if different
              than the complainant, the recipient’s guardian (if one has been appointed), the
              parent of a minor, and the Office within 10 business days after receiving a copy of
              the Office’s Investigative Report;
           B. Include all of the following in the Summary Report:
                1) Statement of the allegations;
                2) Statement of the issues involved;
                3) Citations to relevant provisions of the Mental Health Code, Administrative
                    Rules, guidelines, and Northpointe policies and procedures;
                4) Summary of investigative findings;
                5) Conclusions;
                6) Recommendations made by the Office;
                7) Action taken, or plan of action proposed, by the respondent;
                8) Statement describing the option of mediation and the right to appeal that
                    includes the following:
                   a) The complainant may file a written appeal with Northpointe’s Appeals
                        Committee not later than 45 days after receipt of the Summary Report;
                   b) The appeal shall be based on one of the following grounds:
                        I. The investigative findings of the Office are not consistent with the


                                                                                                    66
                             facts or with law, rules, policies, or guidelines;
                         II. The action taken or plan of action proposed by the respondent does
                             not provide an adequate remedy;
                        III. An investigation was not initiated or completed on a timely basis;

                     c) An offer from the Office of Recipient Rights to either refer the
                        complainant to an advocacy organization for assistance in preparing the
                        written appeal or assist the complainant in preparing the written appeal.
                     d) Provide information in the Summary Report in a manner that does not
                        violate the rights of any employee.
                     e) Provide information in the Summary Report within the constraints of the
                        confidentiality/privileged communications sections of the Mental Health
                        Code

         C. The Chief Executive Officer may designate the Office to prepare a draft of the
            Summary Report for review and approval by the CEO.

H. Appeals
      See the Recipient rights Complainant Appeals Procedure.

I. Mediation
    1. At any time after the Office completes the Investigative Report, the parties may agree to
       mediate the dispute. A mediator shall be jointly selected to facilitate a mutually acceptable
       settlement between the parties. The mediator shall be an individual who has received
       training in mediation and who is not involved in any manner with the dispute or with the
       provision of services to the recipient.

    2.   If the parties agree to mediation and reach agreement through the mediation process, the
         mediator shall prepare a report summarizing the agreement, which shall be signed by the
         parties. The signed agreement shall be binding on both parties. Notice that an agreement
         has been reached shall be sent to the Office.

    3.   If the parties fail to reach agreement through the mediation process, the mediator shall
         document that fact in writing and provide a copy of the documentation to both parties and
         the Office within 10 days after the end of the mediation process.

    4.   If the parties engage in mediation, all appeal and response times are suspended during the
         period of time the mediation process is taking place. The suspension of time periods
         begins on the day the parties agree to mediate and expires five days after the day the
         mediator provides the written documentation to the parties and the Office that mediation
         was not successful.

CROSS REFERENCES:
A. Act 258 of the Public Acts of 1974, as amended (Mental Health Code), Sections 100a, 146,
   722, 755, 772, 774, 776, 778, 780, 782, 784, 786, 788
B. Department of Community Health Administrative Rule 7035

EXHIBITS:
A. Flow Chart for the Complaint Process
B. Flow Chart for the Appeal Process




                                                                                                  67
POLICY TITLE: Comprehensive Examination
POLICY
It is the policy of Northpointe that a resident shall receive an initial comprehensive physical,
mental and social examination.

PURPOSE
To establish a procedure for service planning for comprehensive assessments to aid in
development of an initial plan of care as well as the individualized plan of service.

APPLICATION: Northpointe Residential Programs.

REQUIRED BY
Department of Mental Health Administrative Rules - Rule 7181

PROCEDURE
1.       This examination shall serve as the basis for development of a resident's individualized
plan of service. The comprehensive examination shall be thorough and consistent with
professional standards. For residents admitted as mentally retarded, the mental examination shall
include psychological and educational evaluations and an assessment of adaptive behavior level.
For residents admitted as mentally ill, the mental examination shall include a history,
psychological evaluation and a mental status assessment. The results shall be recorded in the
resident's clinical record. An examination shall be conducted whenever possible prior to
admission.

2.      A report of any initial comprehensive examination shall include diagnosis of physical and
mental conditions and a prescribed program for initial care, treatment and rehabilitation of the
diagnosed conditions pending completion of a total individual plan of service.

The CSM will coordinate the initial plan of care and individualized plan of service to assure the
following assessments are completed by the appropriate disciplines.

        a)     Physical examination will be completed by a physician.
        b)     Nursing assessments will be completed by the agency R.N.
        c)     Mental assessments will be completed by the agency psychologist.
Social assessments will be completed by the CSM.

3.      Examinations subsequent to admission shall be completed within 3 working days after an
informal or formal voluntary admission or temporary admission and within 2 working days after a
preliminary hearing which results in continued residence for those involuntarily admitted.

4.      Re-examination shall be a part of the required periodic review. It shall include diagnosis
of a    resident's physical and mental condition. Additional content shall be provided as
required by a policy or procedure, and an evaluation of the current plan of service.

5.       Clinical results of examinations and re-examinations shall be kept in the same record as a
resident's written plan of service.




                                                                                                   68
POLICY TITLE: Confidentiality & Disclosure Policy/Procedure
POLICY:
It is the policy of the Northpointe Board that information in the record of a recipient, and other
information acquired in the course of providing mental health services to a recipient, shall be kept
confidential and shall not be open to public inspection. The information may be disclosed only in
the circumstances and under the conditions set forth in P.A. 258 of 1974, as amended. There are
additional protections to those receiving substance abuse treatment. Refer to policy on Substance
Abuse 42 CFR Part 2.

PURPOSE:
To establish policy regarding confidentiality and disclosure of consumer information according to
applicable laws.

APPLICATION:
Applies to all Northpointe employees, volunteers, student interns, and persons under contract.

DEFINITIONS:
Closest Relative
The surviving spouse, or if there is no surviving spouse, the individual or individuals most closely
related to the deceased recipient within the third degree on consanguinity as defined in civil law.

Confidential Information
A. All information in the record of a recipient including, but not limited to:
   1. Information acquired in diagnostic interviews or examinations;
   2. Results and interpretations of tests ordered by a mental health professional or given by a facility;
   3. Entries and progress notes by mental health professionals and supporting personnel;
B. All other information acquired in the course of providing mental health services to a recipient.

Disclosure
Releasing confidential information outside Northpointe and its contract agencies.

Holder of the Record
The Chief Executive Officer of Northpointe or other staff designated to perform job
responsibilities related to disclosing confidential information.

Primary Clinician
The staff member in charge of implementing the resident’s plan of service.

Staff
Employees, volunteers, trainees, and contract employees.

STANDARDS:
A. Internal Confidentiality
   Internal access to confidential information shall be limited to those staff who have a need to
   know that specific information to perform their assigned job duties. Access shall ordinarily be
   limited to staff providing services to the recipient, or staff performing approved peer review,
   professional consultation, investigation, supervisory, or clinical records functions. No consent
   is required for internal access by authorized staff.


                                                                                                 69
B. Disclosures – General Information
   1. All disclosures shall be consistent with Sections 748 and 750 of the Mental Health Code
      and with Agency standards.
   2. Requests for confidential information shall be directed to clinical records staff, or to the
      authorized supports coordinators in residential programs that maintain clinical records,
      for processing and documentation.
   3. A request for information about a staff who has applied for, or is receiving, services shall
      be handled in accordance with Section 748 and Agency standards.

C. Disclosures – Mandatory
   1. When requested, confidential information shall be disclosed only under one or more of the
        following circumstances:
        a. Pursuant to valid orders or subpoenas of a court of record, or subpoenas of the
            legislature, unless the information is make privileged by law;
        b. To a prosecuting attorney as necessary to the prosecuting attorney to participate in a
            proceeding governed by the Mental Health Code if it is either:

            1) Non-privileged information or;
            2) Privileged information disclosed pursuant to Section 750(2), including:
               a) Names of witnesses to acts which support the criteria for involuntary admission;
               b) Information relevant to alternatives to admission to a hospital or facility;
               c) Other information designated in Northpointe policies.

        c. To an attorney for the recipient, with the consent of the recipient, the recipient’s
           guardian with authority to consent, or the parent with legal and physical custody of a
           minor recipient;
        d. If necessary in order to comply with another provision of law;
        e. To the Department of Community Health if the information is necessary in order for
           the Department to discharge a responsibility placed upon it by law;
        f. To the office of the auditor general if the information is necessary for that office to
           discharge its constitutional responsibility;
        g. To a surviving spouse, or if none, closest relative of the recipient in order to apply for
           and receive benefits, but only if spouse or closest relative has been designated the
           personal representative or has a court order;
        h. To an adult recipient if all of the following apply;
           1) A request has been received from the recipient;
           2) The recipient does not have a guardian and has not been adjudicated legally
                incompetent;
           3) The case entry was made after March 28, 1996.

   2.   The holder of the record shall not deny or delay releasing information which is:
        a. A mandatory disclosure listed above;
        b. A request from the recipient’s attorney even if the legally empowered guardian or the
           parent of a minor recipient has requested a delay;
        c. A case record entry made after March 28, 1996, which is being disclosed to an adult
           recipient, upon the recipient’s request, if the recipient does not have a guardian and
           has not been adjudicated legally incompetent.

D. Disclosures – Discretionary


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    1.   If informed consent is obtained from the recipient, the recipient’s guardian with authority
         to consent, the parent with legal custody of a minor recipient, or the court-appointed
         personal representative or executor of the estate of a deceased recipient, confidential
         information may be disclosed to all of the following:

         a. Providers of mental health services to the recipient;
         b. The recipient or his or her guardian or the parent of a minor recipient or any other
            individual or agency unless in the written judgment of the holder the disclosure would
            be detrimental to the recipient or others.

    2. To enhance treatment, recipients may be requested to authorize disclosure of information to
       family members, significant others, or other agencies providing services to the recipient. Such
       consent is voluntary.
    3. To encourage opportunities for positive community integration, recipients in residential
       or day treatment programs may be requested to authorize disclosure of generic
       information. Such consent is voluntary and all such disclosures shall respect the privacy
       and dignity of the recipient.
    4. When information is disclosed for clinical purposes and with appropriate consent, the holder of
       the record shall release a copy of the entire medical and clinical record to the provider of mental
       health services.
    5. Information may be disclosed in the discretion of the holder of the record without recipient
       consent:
       a. As necessary in order for the recipient to apply for or receive benefits without the
           consent of the recipient or legally authorized representative only if the benefits shall
           accrue to the provider or shall be subject to collection for liability for mental health
           service;
       b. As necessary for the purpose of outside research, evaluation, accreditation, or
           statistical compilation, provided that the individual who is the subject of the
           information can be identified only if such identification is essential in order to
           achieve the purpose for which the information was sought or if preventing such
           identification would clearly be impractical, but in no event if the subject of the
           information is likely to be harmed by the identification;
       c. To providers of mental or other health services or a public agency, if there is a
           compelling need for disclosure based upon a substantial probability of harm to the
           recipient or other individuals.

E. Disclosures – Detrimental Information
   1. For case record entries made subsequent to March 28, 1996, information made
       confidential by Sec. 748 of the Mental Health Code shall be disclosed to an adult
       recipient, upon the recipient’s request, if the recipient does not have a guardian and has
       not been adjudicated legally incompetent. The information shall be disclosed as
       expeditiously as possible but in no event later than the earlier of 30 days after receipt of
       the request or, if the recipient is receiving treatment, before the recipient is released from
       treatment. This information may not be withheld even if the holder of the record judges it
       would be detrimental to the recipient or others.
   2. Unless the above applies to a request for information, the holder of the record may make
       a determination that disclosure of information may be detrimental to the recipient or
       others, decline to disclose the information, and determine whether part of the information
       may be released without detriment. A determination of detriment shall not be made if the
       benefit of disclosing the information to the recipient outweighs the detriment. The holder
       of the record shall make a determination of detriment within three business days if the


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          record is onsite and within ten business days if the record is offsite. The primary clinician
          will be consulted in making any determination of detriment. The holder of the record
          shall provide written notification of the determination of detriment and justification for
          the determination to the person who requested the information, including notification that
          the individual may appeal the decision to the Chief Executive Officer or file a rights
          complaint.

     3.   If an individual does not receive requested information because of a determination of
          detriment or any other reason, he or she may file a recipient rights complaint.

     4.   Review for Detriment Process - If a review of detriment is appropriate then the authorized
          clinician in conjunction with his or her clinical supervisor will perform such review under
          the following guidelines.
          a. Authorized clinician has determined in the exercise of professional judgment that the
              access requested is reasonably likely to endanger the life or physical safety of the
              individual or another person.
          b. The Protected Health Information (PHI) makes reference to another person and the
              authorized clinician has determined in the exercised professional judgment that the
              access requested is reasonably likely to cause substantial harm to such other person.
          c. Request for access is made by the individual’s personal representative and the
              authorized clinician in the exercise of professional judgment has determined that the
              provision of access to such personal representative is reasonably likely to cause
              substantial harm to the individual or another person.
          d. In all cases a determination of detriment shall not be made if the benefit to the
              recipient from the disclosure outweighs the detriment.

     5. Authorization by the Executive Director.
        The authorized clinician will send a written statement to the Executive Director outlining
        what information is to be withheld and why. The Executive Director will make the final
        determination within 3 business days if record is on site or 10 business days if record is
        off site, whether the disclosure would be detrimental to the recipient of others.

     6. Implementation and Process for Denial of Access - If Northpointe denies access in whole
        or in part, Northpointe must, to the extent possible, give the individual access to any other
        PHI requested after excluding the PHI which has been denied.

     7. Request for Review of Denial of Access.
        a. All requests for review of denial of access shall be forwarded to the rights
           office/privacy officer.
        b. The rights office/privacy officer will ensure that a licensed health care professional
           who is not directly involved in the denial shall promptly provide a second opinion of
           the denial of access.
        c. The licensed health care professional must determine within a reasonable period of
           time, not to exceed 10 business days, whether or not to uphold the denial of access.
           The licensed health care professional shall promptly inform the recipient of the
           decision in writing.
        d. If the recipient is not satisfied with the final determination he or she can file a
           complaint with the office of the recipient rights.

F.   Disclosures – Protection and Advocacy
     An identified representative of Michigan Protection and Advocacy Services shall be granted


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   access to records in accordance with Public Law 94-103, 89 Stat. 486, Public Law 99-319,
   100 Stat. 478, and Act 258 of the Public Acts of 1974, as amended. This includes:
   A recipient, if the recipient, the recipient’s guardian with authority to consent, or a minor
   recipient’s parent with legal and physical custody of the recipient has consented to the access;
   1. A recipient, including a recipient who has died or whose whereabouts are unknown, if all of the
       following apply:
       a. Because of mental or physical condition, the recipient is unable to consent to the access;
       b. The recipient does not have a guardian or other legal representative, or the recipient’s
           guardian is the state;
       c. Michigan Protection and Advocacy has received a complaint on behalf of the recipient
           or has probable cause to believe based on monitoring or other evidence that the
           recipient has been subject to abuse or neglect.
   2. A recipient who has a guardian or other legal guardian if all of the following apply:
       a. A complaint has been received by Michigan Protection and Advocacy or there is
           probable cause to believe the health or safety of the recipient is in serious and
           immediate jeopardy;
       b. Upon receipt of the name and address of the recipient’s legal representative,
           Michigan Protection and Advocacy has contacted the representative and offered
           assistance in resolving the situation;
       c. The representative has failed or refused to act on behalf of the recipient.

G. Disclosures – Protective Services
   1. Staff shall report suspected abuse or neglect to Protective Services in accordance with Act
   238 of the Public Acts of 1975 and Act 519 of the Public Acts of 1982.
   2. Per Senate Bill No. 1225 Sec. 748a:
      A) If there is a compelling need for mental health records or information to determine
   whether child abuse or child neglect has occurred or to take action to protect a minor where
   there may be a substantial risk of harm, a Department of Human services case worker or
   administrator directly involved in the child abuse or neglect investigation shall notify a
   mental health professional that a child abuse or neglect investigation has been initiated
   involving a person who has received services from the mental health professional and shall
   request in writing mental health records and information that are pertinent to that
   investigation. Upon receipt of this notification and request, the mental health professional
   shall review all mental health records and information in the mental health professional’s
   possession to determine if there are mental health records or information that is pertinent to
   that investigation. Within 14 days after receipt of a request made under this subsection, the
   mental health professional shall release those pertinent mental health records and information
   to the case worker or administrator directly involved in the child abuse or neglect
   investigation. The recipient must be promptly informed that such a report has been or will be
   made, except if:
                        Northpointe, in the exercise of professional judgment, believes
                           informing the recipient would place the recipient at risk of serious
                           harm or;
                        Northpointe would be informing a personal representative, and
                           Northpointe reasonably believes the personal representative is
                           responsible for the abuse, neglect, or other injury, and that informing
                           such person would not be in the best interest of the individual as
                           determined by Northpointe in the exercise of professional judgment.
      B) The following privileges do not apply to mental health records or information to which
         access is given under the section:


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                  (1) The physician-patient privilege created in section 2157 of the revised
                  judicature act of 1961. 1961 PA 236. MCL600.2157.
                  (2) The dentist-patient privilege created in section 16648 of the public health code.
                  1978 PA 368. MCL 333.16648.
                  (3) The licensed professional counselor-client and limited licensed counselor-
                  client privilege created in section 18117 of the public health code. 1978 PA 368
                  MCL 333.18117.
                  (4) The psychologist-patient privilege created in section 18237 of the public health
                  code. 1978 PA 368. MCL 333.18237.
                  (5) Any other health professional-patient privilege created or recognized by law.
     C) To the extent not protected by the immunity conferred by 1964 PA 170.MCL691.1401 to
     691.1415, an individual who in good faith gives access to mental health records or
     information under this section is immune from civil or administrative liability arising from
     that conduct, unless the conduct was gross negligence or willful and wanton misconduct.
     D) A duty under this act relating to child abuse or neglect does not alter a duty imposed under
     another statute, including the child protection law. 1975 PA 238 MCL 722.621 to 722.638,
     regarding the reporting or investigation of child abuse or neglect.

H. Peer Review
     The records, data, and knowledge collected for or by individuals or committees assigned a
     peer review function, including reviewing the quality and appropriateness of services, shall be
     used only for peer review, are not public records, and are not subject to court subpoena.

I.   Statement Correcting or Amending Information
     A recipient, guardian, or parent of a minor recipient, after having gained access to treatment
     records in accordance with Agency procedures, may challenge the accuracy, completeness,
     timeliness, or relevance of factual information in the recipient’s record and shall be allowed
     to insert a statement into the record correcting or amending the information at issue without
     changing the original documentation. That statement shall become part of the record.

J.   Providing Information to Attorneys, Other than Prosecuting Attorneys
     1. An attorney who is retained or appointed by a court to represent a recipient and who
        presents identification and a valid consent or release executed by the recipient, by a
        legally empowered guardian, or by the parents of a minor shall be permitted to review, at
        Northpointe, the recipient’s record. An attorney who has been retained or appointed to
        represent a minor pursuant to an objection to hospitalization of a minor shall be allowed
        to review the minor’s record;
     2. If there is not a valid consent or release, an attorney who does not represent a recipient
        shall not be allowed to review records, unless the attorney presents a certified copy of a
        court order directing disclosure of information concerning the recipient to the attorney;
     3. An attorney shall be refused written or telephoned requests for information, unless the
        request is accompanied or preceded by a certified copy of an order from a court ordering
        disclosure of information to that attorney or unless a valid consent or release has been
        appropriately executed. The attorney shall be advised of the procedures for reviewing and
        obtaining copies of recipient records.

K. Providing Information to Private Physicians or Psychologists Appointed or Retained to
     Testify in Civil, Criminal, or Administrative Proceedings
     1. a physician or psychologist who presents identification and a certified true copy of a
        court order appointing the physician or psychologist to examine a recipient for the



                                                                                                   74
       purpose of diagnosing the recipient’s present condition shall be permitted to review, at
       Northpointe, a record containing information concerning the recipient. Physicians or
       psychologists shall be notified before the review of records when the records contain
       privileged communication which cannot be disclosed in court under Section 750;
    2. The court or other entity that issues a subpoena or order and the attorney general’s office,
       when involved, shall be informed if subpoenaed or ordered information is privileged
       under a provision of law. Privileged information shall not be disclosed unless disclosure
       is permitted because of an express waiver or privilege or because of other conditions
       which, by law, permit or require disclosure.


L. Providing Information to a Prosecuting Attorney
    A prosecutor may be given non-privileged information or privileged information which may
    be disclosed pursuant to Section 750 of the Mental Health Code if it contains:
    1. Information relating to the names of witnesses to acts which support the criteria for involuntary
        admission;
    2. Information relevant to alternatives to admission to a hospital or facility;
    3. Other information designated in Northpointe policies.

PROCEDURES:
A. Summary of Section 748
   Clinical records staff shall file a summary of Section 748 of the Mental Health Code in each
   recipient record when it is opened.
B. Disclosures
   1. Clinical records staff/authorized supports coordinators who disclose clinical record
       information shall ensure that the identity of the individual and any other information is not
       disclosed unless it is essential to the purpose.
   2. Clinical records staff/authorized supports coordinators will keep a record of all
       disclosures which includes:
       a. Information released;
       b. To whom it is released;
       c. The purpose stated by the person requesting the information;
       d. A statement indicating how the disclosed information is germane to the stated purpose;
       e. The subsection of Section 748 of the Mental Health Code, or other applicable law,
            under which a disclosure was made;
       f. A statement stamped on the information that the individual receiving confidential
            information shall disclose the information to others only to the extent consistent with
            the authorized purpose for which the information was obtained and in accordance with
            Section 748.
   When information is to be disclosed without identifying the name of the recipient, clinical
       records staff/ authorized supports coordinators will block out the recipient’s name.
   Clinical records staff/authorized supports coordinators will safeguard confidential
       information against unwarranted identification, including inspecting or sampling of
       information.
   When disclosure is appropriate, clinical records staff/authorized supports coordinators will
       provide copies to authorized receivers stamped with the non-disclosure information.
   When information is being requested for outside research, evaluation, accreditation, or
       statistical compilation, the primary clinician will determine whether such disclosure is
       appropriate for that recipient and will determine whether the recipient’s identity may be
       disclosed.
   The primary clinician will determine when identification would be harmful to a recipient.


                                                                                                75
POLICY TITLE: Confidentiality and Disclosure Training Policy
PURPOSE:
To ensure all employees, volunteers, agents, and contract providers are trained and can
demonstrate competence in Northpointe’s Confidentiality and Disclosure Policies and
Procedures .
APPLICATION:        All Northpointe employees, volunteers, agents, and contract providers.

POLICY:
It is the policy of Northpointe to comply with, the Health Insurance Portability and
Accountability Act (HIPAA), the Center for Medicare and Medicaid Services (CMS) Security
and Privacy Regulations, the Michigan Mental Health Code, Code of Federal Regulations (CFR),
Title 42 Part 2, and other applicable accreditation standards, regarding the training of staff.

DEFINITIONS: Please see HIPAA Definitions filed online with the Administrative Policy/Procedures.

PROCEDURES:
1. All employees will be trained and demonstrate competence in the Northpointe’s
   Confidentiality and Disclosure Policies and Procedures.
2. All new staff will be trained and demonstrate competence in the Northpointe Confidentiality
   and Disclosure Policy and Procedure no later than thirty (30) days after date of hire.
3. All staff will receive annual update training in Northpointe’s Confidentiality and Disclosure
   Policy and Procedure.
4. All staff will sign a Nondisclosure Agreement after the completion of their orientation
   training and their annual evaluation thereafter.
5. All staff will abide by policies and procedures restricting designated access to confidential
   records area.
6. The Northpointe’s Privacy, Security and Compliance Officers are responsible for developing,
   presenting and training in the following subjects:
        a. Requirements of HIPAA and the CMS Privacy and Security Regulations.
        b. Requirements of 42 CFR Part 2
        c. Requirements of other federal and state laws regulating health information.
        d. Northpointe’s Confidentiality and Disclosure Policy and Procedures and all other
            HIPAA policies.
        e. Procedures for reporting breaches of security and confidentiality.
7. Northpointe’s Clinical Directors, the clinical records supervisor and the Northpointe Privacy,
   Security, and Compliance Officers shall be responsible for developing, presenting and
   documenting supplemental training as necessary for the particular needs of each clinical and
   administrative section.

LEGAL AUTHORITY:
 Act 258 of the Public Acts of 1974, as amended (Michigan Mental Health Code) Sections
  748, 748 (a), and 750.
 45 CFR Part 164, Section 530 (b) (2).
 42 CFR Part 2




                                                                                              76
POLICY TITLE: Consumer Bill of Rights and Responsibilities
PREAMBLE
Based upon the public mental health system's obligation under the Michigan Mental Health Code to
assure that your rights and responsibilities as a resident of the United States, of the State of
Michigan, and a consumer of public health services are protected and supported, the following
Consumer Bill of Rights and Responsibilities is established by the Northpointe Behavioral
Healthcare Systems Board. These rights apply to you, your parent if you are a minor, and your
guardian if you have a guardian.

This Consumer Bill of Rights was developed with input from the Northpointe Behavioral
Healthcare Systems Recipient Rights Committee. This committee is comprised of 50% consumers
receiving services from Northpointe.

NOTIFICATION OF RIGHTS
You have the right:

    To be informed and receive a copy of your rights as a consumer of public mental health
       services in a manner and frequency you understand.
    To be informed of the name, telephone number, and mailing address of the recipient rights
       staff.

TREATMENT
You have the right:

    To have a written treatment plan that is appropriate to meet your individual needs. You and
       significant others, if you give your consent, have the right to be part of the treatment
       planning process and the periodic reviews. Your treatment plan will be explained to you in
       a manner you understand. You may review this plan, ask questions about the plan, or ask
       for it to be changed if you think it is not appropriate to your needs. You may ask for a copy
       of your treatment plan.
      To be told how much you will be charged for your treatment based on your ability to pay.
       You may appeal of you disagree with the amount.
      To receive services suited to your condition in a safe, sanitary, and humane treatment
       environment and in the least restrictive setting that is appropriate and available.
      To be treated with dignity and respect.
      To have assistance in locating and obtaining additional available community resources in
       meeting the following everyday needs of life if you have such needs and want assistance:
       shelter; food; clothing; medical care; legal assistance; education and recreational
       opportunities; inpatient services for children, adolescents and adults; residential,
       psychiatric, dental, rehabilitative, vocational, and transportation services; case management
       to provide access to needed services; and other necessities of life.
      To stop treatment with the agency any time, unless your treatment is court ordered. You
       also have the right to consult with staff about the option of stopping treatment before you
       make that decision.

RIGHT TO CONSENT
You have the right:

    Once you know all the facts, to make your own decision regarding your treatment, release


                                                                                                 77
      of any information concerning you or your treatment, and to consent to any changes in your
      treatment.
     To change your mind when you believe anything you have agreed to concerning your
      treatment is no longer in your best interest.

CONFIDENTIALITY
You have the right:

     To have information about you and your treatment kept private within the requirements of
        the law
     To give your written permission to have information about you released to others.

Exceptions to Confidentiality
There are times when agency staff are required to release confidential information. These include
suspicion of abuse or neglect, threats to harm yourself or someone else, court orders, and other
laws.

ACCESS TO RECORDS
You have the right:

     To personally review information in your record. If part of the information would be
        harmful to you or to others, that information may be withheld and you will be told this has
        been done. You can appeal this decision.

ABUSE AND NEGLECT
You have the right:

     To be safe from abuse and neglect. This includes physical, sexual, or verbal abuse.

CIVIL RIGHTS
You have the right:

     To not be discriminated against in receiving services at this agency. You have the right to
        all of the protection of the Americans with Disabilities Act, Federal Fair Housing Act,
        Michigan Handicappers Civil Rights Act, and Section 504 of the Rehabilitation Act.

RIGHT TO COMPLAIN
You have the right:

     To complain to the person in the Rights Office, in writing or verbally, if you think that
      something is wrong with your treatment or if you think any of your other rights may have
      been violated. You have the right to ask staff for the address and telephone number of the
      Rights Officer without being questioned.
     To ask the Rights Office for clarification or advice about your rights.

RESIDENTIAL RIGHTS
If you are receiving residential services you have the right:

     To get and send mail without anyone else opening it unless there is reason to believe the
        mail contains something that could result in breaking the law or is harmful to you or others.



                                                                                                  78
     To talk on the telephone in private. This right may be limited based on your plan of service
        or agency policy.
       To see visitors you want to see during regular visiting hours and to see your own doctor or
        spiritual counselor at any time.
       To contact your lawyer any time regarding your legal matters.
       To practice your religion or faith. You will not be forced to be involved in a religious
        event.
       To go to the polls to vote if you are registered. If you are not registered, you may arrange
        to become registered.
       To stay in a place that is clean, has good light, enough heat, fresh air, hot and cold water, a
        bathroom with privacy, and personal storage space.
       To wear your own clothes and keep your own belongings, unless restricted by law, policy,
        or written plan of service. You shall have the right to sufficient clothing that is appropriate
        to size, season and is in good repair.
       To be free from unreasonable searches, to watch if a search does occur, to have the reason
        for the search explained to you written in your record.
       To be paid for work you agree to do if you are offered work. You will not be paid for
        personal housekeeping chores such as making your own bed.
       To go anywhere you want unless limited by law, policy, or your written plan of service.

RESPONSIBILITIES
Rights and responsibilities go together. People cannot always exercise rights when the results
would burden others or interfere with their rights. The importance of rights does not diminish
people's responsibilities for their own lives. A sense of fairness depends on the responsibility shown
by each of us. As a consumer of public mental health services, you have the responsibility:

 To be fully responsible for your own actions, and for the consequences of those actions.
  Freedom to choose carries with it the responsibility for your choices.
 To be an active participation in your treatment, and if dissatisfied, to complain to the
  appropriate persons.
 To do as much as possible to identify and meet your own needs. To respect the rights, privacy,
  and beliefs of others by showing courtesy and consideration.
 To be responsible for the cost of treatment based on your ability to pay. To keep appointment
  times as scheduled, or telephone in advance to cancel.
 To respect the environment and property of others, as well as your own.
 To share with staff your experience with the Agency's services, what they do well, and what
  they could do better.

OTHER RIGHTS
If you are receiving services from public agencies such as the Department of Social Services,
Michigan Rehabilitation Services, or Department of Education, you may have additional rights
specific to those agencies. Each school aged foster child shall be enrolled in an appropriate school
program. You are encouraged to contact these agencies regarding those rights.




                                                                                                    79
POLICY TITLE:                 Consumer Grievance and Appeal Process
POLICY:
It is the policy of NBHS that all consumers have the right to a fair and efficient process for
resolving disagreements regarding their services and supports. A consumer of, or applicant for,
public mental health services may access several options to pursue the resolution of
disagreements. Consumers will be informed of these rights from the time of the initial application
for services and throughout their care. Consumers will be educated as to the basic information
about their appeal and grievance rights; how to initiate the processes; and will be provided
assistance in completing forms and in taking procedural steps if requested and/or needed. This
includes but is not limited to providing interpreter services and toll free numbers that have
adequate TTY/TTD and interpreter capability. Consumers will be informed that Northpointe will
not retaliate against a person who wishes to file a grievance or appeal, nor will they impose
barriers to services received.
**Note – a recipient identified as co-occurring/42 CFR Part 2 must file a Recipient Rights
complaint themselves – no other person. i.e. guardian/parent/advocate can file such a
complaint on their behalf.

PURPOSE:
The purpose of this policy is to outline the grievance and appeals processes for consumers of
services provided by Northpointe Behavioral Healthcare Systems (NBHS). This is a three
layered system with consumer rights protected by local, state and federal laws and regulations.
The resolution of consumer concerns and the goal of improving quality of care are key aspects of
these processes.

DEFINITIONS:
Action:
        A. The denial or limited authorization of a requested Medicaid or non-Medicaid
           service, including the type or level of service;
        B. The reduction, suspension, or termination of a previously authorized Medicaid or
           non-Medicaid covered service;
        C. Denial in whole, or in part, of payment for a Medicaid or non-Medicaid service;
        D. The failure of NBHS to make an authorization decision and provide notice about
           the decision within the standard time frames;
        E. Failure to provide Medicaid or non-Medicaid services within the standard time
           frame;
        F. In regard to Medicaid covered services, failure of NBHS to act within the time
           frame required for the disposition of grievances and appeals;
        G. The denial of a Medicaid consumer’s request to exercise his or her right to obtain
           services outside the NBHS Provider Network.
           1. Failure to permit the consumer to choose from at least two physicians OR two
             care managers;
           2. Failure to allow the consumer to obtain services under any of the following
                circumstances:
                 a. The service or type of provider (in terms of training, experience, or
                      specialization) is not available within the NBHS Network;
                 b. The provider is not part of the NBHS Network, but is the main source of
                      a service to the consumer if:
                       The provider is given the opportunity to become a participating
                          provider under the same requirements for participation in the NBHS



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                            Network as other providers of that type;
                           If the provider does not join the NBHS Network, or does not meet
                            the necessary qualifications to join, the consumer will be transitioned
                            to a participating provider within 60 days (after being given an
                            opportunity to select a provider who participates);
                     c. The only plan or provider available to the consumer does not, because of
                        moral or religious objections, provide the service the consumer seeks;
                     d. The consumer’s primary care provider or other provider determines that
                        the consumer requires related services that would subject the consumer
                        to unnecessary risk if received separately and not all of the related
                        services are available in the NBHS Network;
                     e. The State of Michigan determines that other circumstances warrant out-
                        of-network treatment.

Action/Adequate Notice: A written notice mailed or directly provided to a consumer or his/her
guardian or legal representative at the same time an action takes effect or at the time of signing of
the Individual Plan of Service (IPOS).
Action/Advance Notice: A written notice that is provided to the consumer or his/her guardian or
legal representative at least twelve (12) calendar days before the date of action involving a
termination, suspension or reduction of a service currently being received.
Alternative Services: Services offered under authority of Section 1915(a)(1)(A), Michigan’s
1915(b) Specialty Services Waiver and the services covered under the 1915(c) Habilitation
Supports Waiver. These services may be offered by NBHS to allow a wider, more flexible and
mutually negotiated set of supports and services than possible with the State Plan Services. The
list of Alternative Services is in the MDCH master contract with NBHS and will become part of
Michigan Medicaid Manual, Chapter III.
Appeal: A request for a review of an action (as defined above) relative to a Medicaid covered
service or non-Medicaid covered service.
Authorized Representative: The person the consumer selects to represent them during the
Grievance and Appeal process.
Chief Executive Officer (CEO): CEO of NBHS, or the CEO’s designee, NBHS’s CFO/COO.
Hearing Coordinator: Person or his/her designee appointed by the CEO to coordinate the
Administrative Hearing process.
Grievance: An expression of dissatisfaction about any matter other than an action as defined
above, or a rights complaint as defined in the Mental Health Code.
Michigan Department of Community Health (MDCH) Administrative Hearing: An
evidentiary hearing conducted by an Administrative Law Judge with the MDCH Administrative
Tribunal regarding a decision by NBHS to deny, terminate, reduce or suspend a Medicaid
covered service or a Habilitation Supports Waiver Service.
Michigan Department of Community Health (MDCH) Alternative Dispute Resolution
Process: An impartial review, conducted by a MDCH representative, regarding a decision by
NBHS to deny, terminate, reduce or suspend a non-Medicaid covered service.

Resolution Notice: Notice to the consumer that is required within established time frames
relative to the disposition of grievances and resolution of appeals.
Rights Complaint: A written or verbal statement by a recipient or anyone acting on behalf of a
recipient alleging a violation of a code protected right cited in Chapter 7, which is resolved
through the processes established in Chapter 7A.




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State Plan Services: Services that NBHS is required to offer according to the Michigan
Medicaid Manual Chapter III, The Coverage and Limitations of the Prepaid Inpatient Health
Plans (PIHP), Mental Health, Substance Abuse and Children's Waiver, date: 10-01-03.
Utilization Review: A process, in addition to the IPOS, in which established criteria are used to
recommend or evaluate services provided in terms of cost-effectiveness, necessity and effective
use of resources.

PROCEDURES
A Medicaid consumer has the right to file a Local Appeal and/or a Fair hearing request whenever
a Medicaid covered service is denied. A non-Medicaid consumer may file a Local Appeal then a
request for MDCH Alternative Dispute Resolution following the Local Appeal.
I.      NOTICE REQUIREMENTS
        A. An Action Notice is given whenever a Medicaid State Plan, waiver, or alternative
             service is denied, reduced, suspended or terminated. This notice must be in writing
             and must be provided in the language format needed by the individual to
             understand the content (i.e., the format meets the needs of those with limited
             English proficiency, and/or limited reading proficiency.)


 Action                                   Type of Action Notices         Time Frame for Notice
Denial of service request                  Adequate/Denial of service    at the time of decision

Plan of Service developed                  Adequate                      at the time of plan
development

Increase in benefits                       Adequate                      at the time of the action

Reduction, suspension or                   Advance                       12 days before action
termination of service currently
being received

Standard authorization decision            Adequate                      within 14 days of
request* that denies or limits services
requested

Expedited authorization decision           Adequate                      within 3 working days
of that denies or limits services                                        request*
requested


        *Time frame may be extended up to another 14 days at the request of the consumer or the
             provider
         Note: If a consumer’s physician makes a determination that a particular Medicaid State
             Plan or Waiver service is not medically necessary, no adverse action occurred and
             an advance notice is not required.

        B.    The written notice (as defined above) must contain the following:
              1. The action NBHS or its contractor has taken or intends to take.
              2. The reasons for the action.
              3. The date of the intended action.




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     4.   If access to services or hospitalization is denied, the right to request a second
          opinion and an explanation of the process.
     5.   The consumer's right to file an appeal and/or rights complaint (the latter is
          relative only to the suspension, reduction or termination of a service or the
          denial of hospitalization) and the time frames for doing so.
     6.   In regard to Medicaid covered services, the consumer's right to request a
          MDCH Fair Hearing and the timeframes for doing so.
     7.   The procedures for exercising the resolution options.
     8.   The circumstances under which expedited resolution is available and how to
          request it.
     9.   In regard to Medicaid covered services, the consumer's right to have benefits
          continue pending resolution of the appeal or MDCH Fair Hearing decision,
          how to request that benefits be continued, and the circumstances under which
          the consumer may be required to pay the costs of these services.

C.   Action/Adequate Notice (Applies to all consumers)

     1.   During the person-centered planning process adequate notice will be provided
          at the time the individual plan of service, developed or modified through a
          person-centered planning process, is finalized with the consumer or his/her
          guardian or authorized representative.
     2.   Denial of Service outside the PCP Process (Applies to all individuals.)
          When an individual is denied initial access to services, or denied access to
          inpatient psychiatric hospitalization, the individual will be informed of this
          denial with an adequate notice, Denial of Service form. The form may be
          presented directly or mailed to the individual or his/her guardian or authorized
          representative at the time of denial. A Medicaid consumer has the right to file
          a fair hearing request whenever a Medicaid covered services is denied. A
          non-Medicaid consumer may file an appeal using the local appeal procedure
          described below.
     3.   A copy of the Denial of Service should be forwarded to the Recipient Rights
          Office for tracking purposes.


D.   Action/Advance Notice (Applies to all consumers)
     Whenever Medicaid State Plan or Waiver services are denied, suspended, reduced,
     or terminated as a result of a Utilization Review or authorization function or that
     occurs in addition to the person-centered planning process by NBHS or their
     contracting agencies, NBHS will issue an Advance Notice of Adverse Action to the
     consumer.

     An Action/Advance Notice will be mailed at least twelve (12) calendar days before
     the date of action.
     Exceptions to the Action/Advance Notice:
     1.NBHS will mail an Action/Advance notice no later than the date of action if:
          a. It has factual information confirming the death of the consumer;

          b.   NBHS receives a clear written statement signed by the consumer or
               his/her legal representative that:
                    He/she no longer wishes services; or
                    Gives information that requires termination or reduction of


                                                                                         83
                              services and
                              indicates that he/she understands that this must be the result of
                              supplying the information.

                 c.   The consumer has been admitted to an institution where he/she is
                      ineligible under Medicaid for further services;

                 d.   The consumer’s whereabouts are unknown and the post office returns
                      NBHS mail directed to him/her indicating no forwarding address;

                 e.   A change in the level of medical care is prescribed by the consumer’s
                      physician.

                 f.   NBHS may shorten the period of advance notice to five (5) days before
                      the date of action if it has knowledge indicating that the action should be
                      taken because of probable fraud and these facts have been verified, if
                      possible through secondary sources. If possible, this knowledge should
                      be verified through secondary sources.

II.   GRIEVANCE AND APPEAL RESOLUTION PROCESSES (SEE ATTACHMENT
      1 –SUMMARY OF RESOLUTION PROCESSES)
      An individual receiving mental health specialty services and supports may pursue appeals
      or grievances using multiple options simultaneously. Medicaid consumers are not
      required to exhaust local processes before they request a Medicaid Fair Hearing.
      A. Denial of Hospitalization
             1. Request for second opinion
                  a. If a preadmission screening unit or children’s diagnostic and treatment
                      service of NBHS denies hospitalization, the individual, his/her guardian
                      or his/her parent in the case of a minor child, may request a second
                      opinion from the CEO of NBHS.
                  b. The CEO shall arrange for an additional evaluation by a psychiatrist,
                      other physician, or licensed psychologist to be performed within three
                      (3) days, excluding Sundays and legal holidays, after the CEO receives
                      the request. If the determination of the second opinion is different from
                      the determination of the preadmission screening unit, the CEO, in
                      conjunction with the Medical Director, shall make a decision based on all
                      clinical information available within one (1) business day.
                  c. The CEO’s decision shall be confirmed in writing to the individual who
                      requested the second opinion, and the confirming document shall include
                      the signatures of the CEO and Medical Director or verification that the
                      decision was made in conjunction with the Medical Director.
                  d. If an individual is assessed and found not to be clinically suitable for
                      hospitalization, the preadmission screening unit shall provide appropriate
                      referral services.
             2. Rights Complaint
                  a. If the request for a second opinion is denied, the individual or someone
                      on his/her behalf may file a recipient rights complaint with the Recipient
                      Rights Office of NBHS.
                  b. If the initial request for inpatient admission is denied and the individual
                      is a current consumer of other NBHS services, the individual or someone
                      on his/her behalf is informed that they may file a Recipient Rights


                                                                                                  84
             Complaint with the Recipient Rights Office alleging a violation of
             his/her right to treatment suited to condition.
         c. If the second opinion determines the individual is not clinically suited for
             Hospitalization and the individual is a current consumer of other NBHS
             services, and a recipient rights complaint has not been filed previously on
             behalf of the individual, the individual or someone on his/her behalf may
             file a complaint with the Recipient Rights Office of NBHS.
     3. Appeal
         a. See Local Appeal Resolution Process section.
     4. MDCH level
         a. If the consumer is a Medicaid consumer see Medicaid Consumer Rights
             to Administrative Hearing section.
         b. If the consumer is not a Medicaid consumer see MDCH Alternative
             Dispute Resolution Process section.

B.   Denial of Access to Community Mental Health Program Services
     If an initial applicant for NBHS services is denied such services, an appropriate
     referral may be provided.
     1. Request for second opinion
           a. If an initial applicant for NBHS services is denied such services, the
                 applicant or his/her guardian, or the applicant’s parent in the case of a
                 minor, must be informed of their right to request a second opinion of the
                 Northcare Access Department. The request shall be processed in
                 compliance with Section 705 of the Michigan Mental Health Code and
                 must be resolved within five (5) business days.
           b. Northpointe CEO or designee shall secure the second opinion from a
                 Licensed Bachelor’s level social worker, Limited Licensed Bachelor’s
                 level social worker or Mental Health Professional to include Master’s
                 level social worker, Physician, Registered professional nurse, or
                 Master’s level psychologist.
           c. If the individual providing the second opinion determines that the
                 applicant has a serious mental illness, serious emotional disturbance, or a
                 developmental disability, or is experiencing an emergency situation or
                 urgent situation, the community mental health services program shall
                 direct services to the applicant.
           d. A copy of the Request for Second Opinion should be forwarded to the
                 Recipient Rights Office for tracking purposes.
     2. Rights Complaint
           a. The applicant or his/her guardian may not file a recipient rights
                 complaint for denial of services suited to condition, as he/she does not
                 have standing as a consumer of mental health services. The applicant or
                 his/her guardian may, however, file a rights complaint if the request for a
                 second opinion is denied.
     3. Appeal
           a. See Local Appeal Resolution Process section.
     4. MDCH level
           a. If the consumer is a Medicaid consumer see Medicaid Consumer Rights
                 to Administrative Hearing section.




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          b.   If the consumer is not a Medicaid consumer see MDCH Alternative
               Dispute Resolution Process section.


C.   Denial through the service authorization process of the request for Medicaid state
     plan, waiver, or alternative service OR denial of the requested amount, scope or
     duration of a service that was identified and agreed upon by the consumer during
     person-centered planning
     1. Appeal --See Local Appeal Resolution Process section.
     2. Rights Complaint
          a. The consumer or his/her guardian may file a rights complaint for
               treatment suited to condition.
     3. MDCH level
          a. Medicaid Consumer Rights to Administrative Hearing.
          b. MDCH Alternative Dispute Resolution for non-Medicaid covered
          services

D.   Unreasonable delay of a Medicaid state plan, waiver or alternative service beyond
     the start date agreed upon during the person-centered planning process and as
     authorized by NBHS. Unreasonable delay is defined as 14 or more calendar days.
     1. Appeal ---See Local Appeal Resolution Process section.
     2. Rights Complaint
           a. The consumer or his/her guardian may file a rights complaint for
                treatment suited to condition.

E.   Denial or Termination of Family Support Subsidy
     1.   Pursuant to Section 159(3) of the Code: “If an application for a family
          support subsidy is denied or a family support subsidy is terminated by
          NBHS, the parent or legal guardian of the affected eligible minor may
          demand, in writing, a hearing by NBHS. The hearing shall be conducted in
          the same manner as provided for contested case hearings under Chapter 4 of
          the Administrative Procedures Act of 1969, Act No. 306 of the Public Acts
          of 1969, and being Sections 24.271 to 24.287 of the Michigan Compiled
          Laws.”

     2.    Pursuant to the Administrative Rules: Copies of blank application forms, parent
           report forms, the forms for changed family circumstances, and appeal forms shall be
           available from NBHS. (R330.1616 Availability of Forms) (NOTE: It is acceptable
           to ask families to write a letter to NBHS requesting an appeals hearing in lieu of a
           standardized form.)

     3.    NBHS shall review an application and promptly approve or deny the application and
           shall provide written notice to the applicant of its action and of the opportunity to
           administratively appeal the decision if the decision is to deny the application. If the
           denial is due to the insufficiency of the information on the application form or the
           required attachments, NBHS shall identify the insufficiency. (Rule R330.1641
           Application Review)

     4.    If an application is denied or the subsidy terminated, a parent or legal guardian may
           file an appeal. The appeal shall be in writing and be presented to NBHS within two
           (2) months of the notice of denial or termination. (R330.1643 Appeal)


                                                                                        86
                                           Department of Community Health
                             Division of Program Development, Consultation and Contracts
                                     Bureau of Community Mental Health Services
                                  ATTN: Request for DCH Level Dispute Resolution
                                            Lewis Cass Building – 6th Floor
                                                 Lansing, MI 48913

             5.    If the DCH representative, using a “reasonable person” standard, believes that the
                   denial or termination of the subsidy will pose an immediate and adverse impact upon
                   the consumer’s health and safety, the issue is to be referred within one business day
                   to the Bureau of Community Mental Health Services for contractual action consistent
                   with applicable provisions of the MDCH/CMHSP contract.


III.   DISPUTE RESOLUTION DURING THE PCP PROCESS
       A. If an individual requests inpatient treatment, or a specific mental health support or
           service for which appropriate alternatives for the individual exist that are of equal
           or greater effectiveness and equal or lower cost, the staff should:
           1.    Identify and discuss the underlying reasons for the request/preference;
           2.    Identify and discuss alternatives with the individual; and
           3.    Negotiate toward a mutually acceptable support, service and/or treatment.

       B.    In the event that a mutually acceptable alternative cannot be reached, the staff
             should:
             1. Document the individual’s preference, the support, service and/or treatment
                    offered and the reason for not accepting that preference.
             2.     Inform the individual of their right to file a grievance or local appeal. This
                    would include:
                    a. His/her right to contact the Recipient Rights office/Customer Service
                        Office and file a grievance for investigation, consultation, mediation or
                        intervention in response to their request for a specific mental health
                        support or service.
                    b. His/her right to request a second opinion as referenced in the Mental
                        Health Code, if requesting inpatient treatment and his/her right to a Fair
                        Hearing, if a consumer with Medicaid coverage.


       C.    If in the judgment of staff, an individual’s choice or preference for the inclusion or
             exclusion of a planning participant, meeting location, or specific provider poses an
             issue of health or safety or exceeds reasonable expectations of resource allocation,
             staff should discuss and identify the individual’s underlying reason for that specific
             choice or preference. Then, negotiate toward a mutually acceptable alternative that
             meets the outcomes intended.

       D.    If an individual is not satisfied with his/her Individual Plan of Service, the
             Michigan Mental Health Code allows the individual to make a request for review to
             the designated individual in charge of implementing the plan. The review shall be
             completed within thirty (30) calendar days.

       E.    If the individual believes that the opportunity for person-centered planning is not


                                                                                                   87
            provided as specified in the manner above, it is the responsibility of NBHS to
            inform the individual of his/her right to file a complaint with the Recipient Rights
            Office/Customer Service Office at NBHS.

      F.    When there is a disagreement between an individual and the legal guardian or
            responsible parent, staff should attempt to mediate between the two parties in order
            to provide an outcome that is acceptable to both parties.

      G.    During the person-centered planning process Action Notice (applies to all
            consumers) will be provided at the time the Individual Plan of Service is finalized
            with the consumer and/or his/her guardian or authorized representative. Notice will
            include:
            1.    Basic information as to appeal rights and what options exist to resolve
                  service delivery disputes;
            2.    Information regarding how to access services, obtain help with problems, and
                  how to inquire about benefits.

IV.   GRIEVANCE PROCEDURE (APPLIES TO ALL INDIVIDUALS)
      A. At any time, a consumer or his/her legal representative may express their
          dissatisfaction by filing a grievance. The grievance process would be utilized when
          a concern is not addressed either through a formal “Action” process or through a
          “rights complaint” as outlined in the Michigan Mental Health Code. A consumer
          may file a grievance either in writing or orally with NBHS Recipient Rights Office
          and/or the Customer Service Office. Upon receipt of a grievance, the Recipient
          Rights Office/Customer Service Office shall:
          1.     Determine whether the grievance is more appropriately a recipient rights
                 complaint, and if so, refer the grievance, with the consumer’s permission, to
                 the Office of Recipient Rights;
          2.     Log receipt in the NBHS Recipient Rights Complaint and Appeals/Customer
                 Service Database;
          3.     Send an acknowledgment letter within ten (10) business days of receipt;
          4.     Submit the grievance to the appropriate staff including an NBHS
                 administrator with the authority to require corrective action, none of whom
                 shall have been involved in the initial determination. Facilitate resolution of
                 the grievance within thirty (30) calendar days of receipt of the grievance;
          5.     Within five (5) calendar days of a decision by NBHS regarding the
                 grievance, notification of the outcome of the process is provided to the
                 consumer, guardian, or parent of a minor child.

V.    LOCAL APPEAL PROCEDURE FOR CONSUMERS WITH MEDICAID
      A. Appeal Process:
         Within forty-five (45) calendar days of the Notice of Action (either Advance or
         Adequate), the consumer or his/her legal representative, may file a Local Appeal
         either orally or in writing with NBHS Recipient Rights Office. Unless the
         consumer is requesting an expedited appeal, the consumer must confirm an oral
         appeal request with a written signed request.
         1.     The office of Recipient Rights shall then:
                a. Log receipt of the Local Appeal request in the NBHS Recipient Rights
                    Appeal Database and send an acknowledgement letter within ten (10)
                    business days of receipt of the Local Appeal request.



                                                                                               88
                  b. Advise the individual, guardian, or in the case of a minor, the parent, that
                      he/she may file a request for a MDCH administrative hearing in lieu of
                      or in addition to the Local Appeal. This information provided to the
                      individual shall include the process for filing the request for a hearing, an
                      offer of assistance in filing the request, and an explanation of time
                      frames and circumstances under which services will be continued
                      pending the hearing decision.
                  c. Submit the Local Appeal to the appropriate staff with the authority to
                      require corrective action; none of whom may have been involved in the
                      initial determination to deny, suspend, terminate, or reduce the service.
           2.     NBHS will provide the appellant a reasonable opportunity to present
                  evidence and allegations of fact or law in person as well as in writing. If the
                  appellant has requested an expedited resolution, staff shall inform the
                  appellant of the limited time available to present evidence.
           3.     Provide the appellant or his/her representative opportunity, before and during
                  the appeals process, to examine the appellant’s case file including medical
                  records, and any other documents and records considered during the appeals
                  process.
           4.     Facilitate resolution of the appeal within ten (10) calendar days of receipt;
                  assure an expedited review of a local appeal involving an emergent situation
                  where the standard ten (10) day time frame would seriously jeopardize the
                  health or life of the individual. Such a review shall be completed within 24
                  hours of receiving all necessary information by relevant NBHS services staff
                  involved in the local appeal process.
      B.   Resolution of the Appeal: NBHS designated staff have 10) calendar days to
           provide the individual, guardian, or parent of a minor child or his/her legal
           representative, written notification of the resolution in regard to the regular Local
           Appeal, or 24 hours to provide notification when an expedited appeal is requested.
      C.   For an expedited appeal NBHS must make reasonable efforts to provide oral notice
           and follow-up with written notice. The written notice shall include:
           1. The results of the appeal and the date completed;
           2. An explanation of the right to request an MDCH Administrative Hearing and
                 an offer of assistance in filing the request;
           3. The right to receive benefits while a requested hearing is pending and that the
                 consumer may be held liable for the cost of those benefits if the hearing
                 decision upholds the decision of NBHS’s action;
           4. For appeals resolved not wholly in favor of a consumer who is disputing action
               that impacts a non-Medicaid covered service, information on how to file for a
               MDCH Alternative Dispute Resolution and an offer of assistance;
           5. For appeals resolved locally to the satisfaction of the consumer: an explanation
               and offer of assistance in the process for withdrawing a Fair Hearing request;
           6. Information on the right to file a Recipient Rights complaint with the
                  Recipients Rights Office alleging a violation of the consumer’s rights to
                  treatment suited to his/her condition.
           7. NBHS may extend timeframes for a local appeal by up to fourteen days if:
                    a. The consumer requests the extension;
                    b. NBHS must document there is a need for additional information and
                       how it is in the consumer’s best interest. This documentation must be
                       made to MDCH upon request.

VI.   LOCAL APPEAL PROCEDURE FOR PERSONS WITHOUT MEDICAID


                                                                                                89
       A.   Appeal Process:
            Within forty-five (45) calendar days of the Notice of Action (either Advance or
            Adequate), the consumer or his/her legal representative, may file a Local Appeal
            either orally or in writing with NBHS Recipient Rights Office. Unless the
            consumer is requesting an expedited appeal, the consumer must confirm an oral
            appeal request with a written signed request.

            1.     The Recipient Rights Office shall then:
                   a. Log receipt of the local appeal request in the NBHS Recipient Rights
                       Appeals Database and send an acknowledgement letter to the appellant
                       within ten (10) business days of receipt of the request.
                   b. Submit the Local Appeal to the appropriate staff with the authority to
                       require corrective action; none of whom shall have been involved in the
                       initial determination.

            2.    NBHS will provide the appellant a reasonable opportunity to present
                  evidence and allegations of fact or law in person as well as in writing. If the
                  appellant has requested an expedited resolution, staff shall inform the
                  appellant of the limited time available to present evidence.

            3.    Provide the appellant or his/her representative opportunity, before and during
                  the appeals process, to examine the appellant’s case file including medical
                  records, and any other documents and records considered during the appeals
                  process.

            4.    Facilitate resolution of the appeal within ten (10) calendar days of receipt.

            5.    Assure an expedited review of the appeal involving an emergent situation
                  where the standard ten (10) day time frame would seriously jeopardize the
                  individual’s health or safety. Such a review shall be completed within 24
                  hours of receipt of all necessary information by relevant NBHS Services
                  staff involved in the local appeal process.

       B.   Resolution of the Appeal: NBHS designated staff have 10) calendar days to
            provide the individual, guardian, or parent of a minor child or his/her legal
            representative, written notification of the resolution in regard to the regular Local
            Appeal, or 24 hours to provide notification when an expedited appeal is requested.
            For an expedited appeal NBHS must make reasonable efforts to provide oral
            notice. The written notice shall also include:
            1. The results of the appeal and the date completed.
            2.    Information regarding the individual, guardian, or parent of a minor child’s
                  right to access the MDCH Alternative Dispute Resolution Process and an
                  offer of assistance in doing this;
            3.     Information on the individual, guardian, or parent of a minor child or his/her
                   legal representative’s right to file a recipient rights complaint with the
                   Recipient Rights Office alleging a violation of the consumer’s rights to
                   treatment suited to his/her condition.

VII.    MDCH ALTERNATIVE DISPUTE RESOLUTION PROCESS FOR CONSUMERS
                                     WITHOUT MEDICAID
       A. Within five (5) business days after receiving Notice of the decision reached during


                                                                                               90
            the local appeal process, the consumer or his/her authorized representative may
            request access to the MDCH Alternative Dispute Resolution process. Access to
            this process does not require agreement by NBHS and may be initiated solely by
            the consumer.
        B. Requests may be received in any written form, but must include the following
            information:
            1.     Name of NBHS consumer;
            2.     Name of the guardian legally empowered to make treatment decisions or a
                   parent of a minor child;
            3.     Daytime phone number where the consumer, legal guardian, or parent of a
                   minor child may be reached;
            4.     Name of the NBHS where services have been denied, suspended, reduced or
                   terminated;
            5.     Description of the service being denied, suspended, reduced, or terminated;
            6.     Description of the adverse impact on the consumer caused by the denial,
                   suspension, reduction or termination of service.
            7.     The request should be directed to:

                       Michigan Department of Community Health
                            Division of Community Services
                  ATTN: Request for MDCH Alternative Dispute Resolution
                                   Lewis Cass Building
                                   Lansing, MI 48913

        C.   NBHS communications to consumers regarding this Alternative Dispute
             Resolution Process shall include the information contained in item B above.
        D.   If the MDCH representative, using a “reasonable person” standard, believes that
             the denial, suspension, termination or reduction of the services and/or supports will
             pose an immediate and adverse impact upon the consumer’s health and safety, the
             issue is to be referred within one (1) business day to the Bureau of Community
             Mental Health Services for contractual action consistent with applicable provisions
             of the MDCH/CMHSP contract. In all other cases, MDCH shall complete its
             review of the dispute within fifteen (15) business days of receipt. Written Notice
             of the resolution shall be submitted to the consumer, his/her guardian or parent of a
             minor consumer.

        E.   The Office of Recipient Rights will:
             1. Provide information about the process for filing;
             2. Offer to assist the individual with filing;
             3. On the day the request for Alternative Dispute Resolution is received:
                    a. Date stamp the request
                    b. Fax the request to MDCH
                    c. Mail the request to MDCH
                    d. Log the request in the NBHS Database
                    e. Forward a copy of the request to the Hearings Coordinator

VIII.   MEDICAID CONSUMER RIGHTS TO ADMINISTRATIVE HEARING
        A. All Medicaid consumers are told of their right to an Administrative Hearing if they
           are dissatisfied at any point with the Medicaid State Plan Services, Alternative
           Services and the Habilitation and Supports Waiver for persons with developmental
           disabilities and the Children’s Waiver that they are receiving or have requested.


                                                                                               91
B.   MDCH Administrative Hearing

     1. Within ninety (90) calendar days after receiving notice that Medicaid State
           Plan, Alternative Services or Waiver services have been denied, suspended,
           reduced, or terminated, a Medicaid consumer or his/her authorized
           representative may:
           a.      Request an Administrative Hearing directly with the MDCH;
           b.      Request a local Appeal;
           c.      File a rights complaint with NBHS Recipient Rights Office for
                   failure to provide treatment suited to condition;
           d.      Simultaneously file a request for a local appeal with the NBHS
                   Recipient Rights Office, and file a request an Administrative Fair
                   Hearing with MDCH and file a rights complaint

     2.    The Office of Recipient Rights will:
           a. Provide information about the process for filing, the time frames, the
               circumstances when services will be continued until a hearing decision
               is
               rendered, and the process for withdrawing a hearing request;
           b. Offer to assist the individual with filing a hearing request;
           c. On the day the hearing request is received:
                   Date stamp the request;
                   Fax the request to MDCH;
                   Mail the request to MDCH;
                   Forward a copy of the request to be logged;
                   Log the Request in the NBHS Recipient Rights Appeal Database.
           d. Receive notice of hearing requests from MDCH;
           e. Maintain an accurate, secure record system for requests for
               Administrative Hearings (NBHS Recipient Rights Appeals Database);
           f. If the hearing request is received before the date of action, notify the
               appropriate supervisor that services must be continued until a hearing
               decision has been rendered;
           g. Schedule a room and appropriate equipment for the hearing.

     3.   The Hearings Coordinator will:
          a. Offer a pre-hearing conference to the consumer to see if the issues can
               be resolved;
          b. Prepare a Hearing Summary and documents to be used as evidence
               during the hearing and submit this to MDCH. If the Hearings
               Coordinator is not the staff responsible for presenting the case at the
               hearing, the Hearings Coordinator will assist the staff in preparing for
               the hearing;
          c. Present the agency’s case at the hearing unless a different staff is
               assigned this responsibility.

C.   Maintaining Medicaid covered services and supports.
     1.   If NBHS mails the advance notice of adverse action impacting Medicaid
          covered services as required and the consumer or his/her authorized
          representative requests a MDCH hearing before the date of action in lieu of,



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                  or in addition to, filing an appeal, NBHS may not terminate or reduce
                  services until a decision is rendered unless:
                    a. It is determined at the hearing that the sole issue is one of Federal or
                        State law; AND
                    b. NBHS promptly (i.e., in the advance notice) informs the consumer that
                        services are to be terminated or reduced pending the MDCH hearing
                        decision.
            2.    If NBHS’s action is sustained by the Fair Hearing decision, NBHS may seek
                  reimbursement from the consumer for the cost of any services provided the
                  consumer during this period of time, up to the individual’s ability to pay as
                  determined by the Code.

      D.    Reinstatement of Medicaid covered services

            1.   NBHS must reinstate Medicaid covered services if a consumer or his/her
                 authorized representative requests a MDCH Fair Hearing not more than
                 twelve (12) calendar days after the date of action.
            2.   The reinstated Medicaid covered services must continue until the hearing
                 decision unless, at the hearing, it is determined that the sole issue is one of
                 Federal or State law or policy.
            3.   NBHS must reinstate and continue Medicaid covered services until a hearing
                 decision, if:
                    a. Action was taken without the required Advance Notice; AND
                    b. The consumer or his/her authorized representative requests a hearing
                       within twelve (12) calendar days of the mailing of the notice of action;
                       AND
                    c. NBHS determines that the action resulted from factors other than the
                       application of Federal or State law or policy.
            4.   If a consumer’s whereabouts are unknown, as indicated by return of mail that
                 could not be forwarded, any discontinued Medicaid State Plan, Alternative
                 services or Waiver services must be reinstated if his/her whereabouts become
                 known during the time he/she is eligible for services.

IX.   RECORDKEEPING AND REPORTING REQUIREMENTS.
      NBHS must maintain a record of appeals and grievances and their disposition that is
      available for review by state officials. Aggregate reports following the HIPAA privacy
      regulations shall be available to the applicable committee chairpersons.

X.    REFERENCES

      42 CFR Chapter IV, Subpart E, sections 431.200 et seq
      42 CFR Chapter IV, Subpart F, Sections 438.402 to 424
      Michigan Mental Health Code, Act 258 of the Public Acts of 1974 as Amended

      Michigan PA 516 of 1996
      Michigan Medicaid Manual , Revised Chapter III, 10-1-03
      MDCH-MSA Policy Bulletin: Medicaid Eligibility Manual – Consumer Hearings
      MDCH-MSA Policy Bulletin: Hourly Home Care – Criteria for Determining Number of
      Hours (Children’s Waiver)




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POLICY TITLE: Dignity and Respect
POLICY:
It is Northpointe’s policy that all consumers and their family members will be treated with dignity
and respect.

PURPOSE:
To establish a policy to ensure that Board recipients as well as their family members are treated
with dignity and respect.

APPLICATION:
All mental health programs by or under contract with Northpointe Behavioral Healthcare
Systems.

DEFINITIONS:
Dignity - To be treated with esteem, honor, politeness, or honesty; to be addressed in a manner
that is not patronizing, condescending, or demeaning; to be treated as an equal; to be treated the
way the individual wants to be treated.

Respect - To show deferential regard for; to be treated with esteem, concern, consideration, or
appreciation; to protect the individual's privacy; to be sensitive to cultural differences; to allow
the individual to make choices.
Dignity and respect shall be further clarified by the recipient or family member and considered in
light of the specific incident, treatment goals, safety concerns, laws and standards, and what a
reasonable person would expect under similar circumstances.

Examples of dignity and respect include, but are not limited to: Calling a person by his or her
preferred name; knocking on a closed door, using positive language, encouraging the individual
to make choices instead of making assumptions about what he or she wants, taking the
individual's opinion seriously, including the individual in conversations, allowing the individual
to do things independently or to try new things.

PROCEDURE:
A.   The following shall be construed to protect and promote the dignity and respect
     to which recipients and their family members are entitled:

            1.   NBHS polices and procedures;
            2.   Mental Health services provided and the manner in which they are provided;
            3.   Employee interactions with recipients and their family members.

B.      All employees shall treat recipients and their family members with dignity and
        respect, being sensitive to conduct that is offensive to the other person.

C.      In addition to the above, showing respect for family members shall include:

            1. Giving family members an opportunity to provide information to
               the treating professionals;
            2. Providing family members an opportunity to request and receive
               educational information about the nature of disorders,
               medications and their side effects, available support services,



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                advocacy and support groups, financial assistance, and coping
                strategies.

D.      Information shall be received from or provided to family members within the
        confidentiality constraints of Section 748 of the Mental Health Code and 42 CFR
        Part 2.

E.      The Office of Recipient Rights shall ensure that all employees receive training
        related to dignity and respect before or within 30 days after being employed.




POLICY TITLE:                 Freedom of Movement
PURPOSE:
To establish policies and procedures to ensure freedom of movement to service recipients.

APPLICATION:
All Northpointe programs operated by or under contract with Northpointe Behavioral Healthcare
Systems.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:

            1. Recipients shall receive treatment in the least restrictive setting.
            2. The freedom of movement of a recipient shall not be restricted more than is
               necessary to provide mental health services to him or her, to prevent injury to
               him or her or to others, or to prevent substantial property damage, except that
               security precautions appropriate to the condition and circumstances of an
               individual admitted by order of a criminal court or transferred as a sentence-
               serving convict from a penal institution.
            3. Service recipients freedom of movement shall not be restricted more than what
               is clinically justified and shall be on a time limited basis.
            4. All restrictions of freedom of movement must be approved by the Behavior
               Management Review Committee.
            5. Service recipients shall be informed of their rights related to freedom of
               movement.
            6. Service recipients shall be given the right to appeal restrictions regarding
               freedom of
               movement.
            7. Recipients shall have the freedom to move about in public areas such as the
               waiting room and restroom of NBHS.
            8. Recipients shall have the right to freedom to access areas suited for vocational,
               social and recreational activities.

PROCEDURES:

                1.       Service recipients whose freedom of movement is restricted per
                his/her Individual Plan of Service shall have each instance of limitation


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     justified and time limited. This shall be documented in his/her progress
     notes. This information shall be reviewed by the Responsible Care Manager
     and other involved staff members on a weekly basis to discuss the service
     recipient's progress or lack of progress and determine if the freedom of
     movement restriction still needs to be imposed. The Responsible Care
     Manager/Clinician shall document the above information in the recipient's
     clinical record.

     2.      Any restriction on freedom of movement of a
     recipient is removed when the circumstance that justified its
     adoption ceases to exist.

     3.      Service recipients whose freedom of movement is restricted in an
     emergency situation shall be reviewed by the Responsible Care
     Manager/Clinician and other involved staff members within 72 hours and
     weekly thereafter to discuss the service recipient's progress or lack of
     progress and determine if the freedom of movement restriction still needs to
     be imposed. The above information shall be documented according to the
     procedures in number one (1) of this policy.

      4.      A service recipient shall not be transferred to a more restrictive
     setting unless evidence exists that the recipient presents a substantial danger
     to others. The justification shall be documented by the Responsible Care
     Manager/Clinician in the recipient's clinical record.

      5.     If a service recipient's freedom of movement is restricted the
     Responsible Care Manager/Clinician shall inform the recipient's guardian,
     parent of a minor child or Probate Court during the hearing process, if
     applicable.

     6.     Service Recipient's Appeal Process:

     a. If the service recipient appeals the freedom of movement limitation,
     he/she shall submit a verbal or written statement to the Responsible Care
     Manager/Clinician. The Responsible Care Manager/ Clinician shall place
     the original statement in the service recipient's clinical file and submit a
     copy to his/her supervisor.

     b. The Responsible Care Manager/Clinician's supervisor shall review the
     appeal within five (5) working days and determine if the imposed limitation
     is justified or not.

     c. If the service recipient does not agree with the decision made by the
     Responsible Care Manager's supervisor, he/she may appeal to the
     appropriate Site Supervisor. The appropriate Site Supervisor shall review
     the appeal within five (5) working days and determine if the imposed
     limitation is justified or not.

7.   Service Recipient's Appeal Process for Denial of Leave Request:




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                 a. If the service recipient appeals the denial of leave request, he/she shall
                 submit a verbal or written statement to the Responsible Care
                 Manager/Clinician. The Responsible Care Manager/Clinician shall place
                 the original statement in the service recipient's clinical file and submit a
                 copy to his/her supervisor.

                 b. The Responsible Care Manager/Clinician's supervisor shall review that
                 appeal within 48 hours and determine if the imposed limitation is justified or
                 not.

                 c. If the service recipient does not agree with the decision made by the
                 Responsible Care Manager's supervisor, he/she may appeal to the
                 appropriate Site Supervisor. The Site Supervisor shall review the appeal
                 within 48 hours and determine if the imposed limitation is justified or not.

         8. The service recipient shall be informed that he/she can file a complaint with the
        Recipient Rights Officer if he/she feels that his/her right to freedom of movement
        has been violated.




POLICY TITLE:                   Informed Consent
POLICY:
It is the policy of the Northpointe Board that informed consent shall be obtained from the recipient,
or applicable parent or guardian for participation in mental health services including medication,
surgery, electro convulsive therapy, photographing, videotaping, audio taping, fingerprinting,
viewing through a 1-way glass, for services rendered via video teleconferencing, or disclosing
confidential information which required consent. There are additional protections for persons
receiving Substance Abuse treatment. See policy on Substance Abuse 42 CFR Part 2.

PURPOSE:
To develop a policy to assure informed consent is obtained for services.

APPLICATION:
All services provided by Northpointe Behavioral Healthcare Systems.

DEFINITIONS:
Competency – The quality or state of being mentally competent, the quality or state of
being legally qualified or adequate.

Comprehension – An individual must be able to understand what the personal implications
of providing consent will be based upon the information that has been provided.

Informed Consent – A written agreement executed by a recipient, a minor recipient’s
parent, or a recipient’s legal representative with authority to execute a consent, or a verbal
agreement of a recipient that is witnessed and documented by an individual other than the
individual providing treatment, that assumes competency, knowledge, comprehension, and
voluntariness.



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Knowledge – To consent, a recipient or legal representative must have basic information
bout the procedure, risks, other related consequences, and other relevant information. The
standard governing required disclosure by a doctor is what a reasonable patient needs to
know in order to make an informed decision. Other relevant information includes all of the
following:
          a. The purpose of the procedures.
          b. A description of the attendant discomforts, risks, and benefits that can
              reasonable be expected.
          c. A disclosure of appropriate alternatives advantageous to the recipient.
          d. An offer to answer further inquiries.

Legal Competency – An individual shall be presumed to be legally competent. This
presumption may be rebutted only by a court appointment of a guardian or exercise by a
court of guardianship powers and only to the extent of the scope and duration of the
guardianship. An individual shall be presumed legally competent regarding matters that are
not within the scope and authority of the guardianship.

Other relevant Information – Includes the purpose of the procedures, a description of attendant
discomforts, risks, and benefits reasonably to be expected, a disclosure of appropriate alternatives
advantageous to the recipient, and an offer to answer further inquires.

Primary Clinician – The staff member in charge of implementing the recipient’s person-centered
plan.

Voluntariness – Free power of choice without the intervention of an element of force, fraud, deceit,
duress, overreaching or other ulterior form of constraint or coercion, including promises or
assurances of privileges or freedom. There shall be an instruction that an individual is free to
withdraw consent and to discontinue participation or activity at any time without prejudice to the
recipient or the individual signing the consent.

STANDARDS:
1. An agreement in writing documenting an informed consent shall not include an exculpatory
   language through which the recipient, or a person consenting on the recipient’s behalf, waives or
   appears to waive, legal right, including releasing the agency or its contract agencies from liability
   for negligence. The agreement shall include all the basic elements of informed consent for this
   particular situation.
2. The individual signing the consent form shall be given adequate opportunity to read the
   document an ask questions before signing it.
3. When essential to the individual’s understanding, or when otherwise deemed advisable, the
   document shall be read, or an oral explanation shall be provided in a language the individual
   understands. A note of the explanation and who made it shall be filed in the recipient’s record
   along with the consent form.
4. A consent is executed when it is signed by the appropriate individual.

PROCEDURES:
A. Obtaining Informed Consent
   1. The primary clinician shall:
      a. Obtain informed consent prior to the recipient receiving any assessment or mental
           health treatment, including medication, surgery, or electro convulsive therapy, but not
           including necessary emergency services;
      b. Obtain informed consent prior to photographing, audio taping, or fingerprinting, or


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           using a 1-way glass, or video teleconferencing;
        c. Obtain informed consent prior to any release to the media;
        d. Obtain informed consent prior to disclosing confidential information which requires
           consent
        e. Verify that the individual signing the consent is one of the following:
           1) The recipient if he/she is 18 years of age or over and does not have a guardian
               empowered to consent for this specific purpose;
           2) The guardian of the recipient if the guardian is legally empowered to execute such
               a consent;
           3) The parent with legal custody of the recipient if the recipient is less than 18 years
               of age;
           4) Other individuals specified in Section 716 of 717 of the Mental Health Code.
        f. Assure that the informed consent;
            1) Is filed in the recipient’s record;
            2) Specifies the date it will expire;
            3) Shall not remain in effect for longer than 12-months;
            4) Automatically expires when the purpose for which it was obtained has been
               achieved. If the purpose has not been achieved by the expiration date, consent must
               be re-obtained or the purpose discontinued;
            5) Is re-obtained if changes in circumstances substantially change the risks, other
               consequences, or benefits that were previously expected.

       g.    Inform the individual signing the consent of the:
             1) Procedure, attendant discomforts, risks, benefits, and other consequences that can
                 be reasonable expected;
             2) Appropriate alternatives which could be advantageous to the recipient;
             3) Other relevant information that the individual needs to make a decision.
             4) Offer to answer further inquiries;
             5) Instruct the individual signing the consent that he/she is free to withdraw consent
                 and to discontinue participation or activity at any time without prejudice to the
                 recipient or the individual consenting;
             6) Use the initial and annual assessment process to evaluate whether the recipient is
                 competent to give informed consent, and report to his/her supervisor if there is a
                 need to file a petition for guardianship;
             7) Evaluate the recipient’s ability prior to any guardianship proceeding and report the
                 findings to his/her supervisor.

    2. The primary clinician’s supervisor shall review the evaluation of competency and determine
       whether there is a need to file a petition for guardianship.

B. Consent for Treatment
           1. The primary clinician shall ensure that the individual signing the consent has
                received an explanation of the following during the person-centered planning
                process:
           2. The goals, objectives, and time frames for the proposed treatment plan;
           3. The methods or interventions used to achieve the goals and objectives;
           4. Possible adverse or uncomfortable effects of the plan;
           5. Possible alternatives to the plan.

C. Consent for Treating a Minor Aged 14 or Older



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            1. A minor 14 years of age or older may request and receive mental health services,
               and a mental health professional may provide mental health services on an
               outpatient basis, excluding pregnancy termination referral services and the use of
               psychotropic drugs, without the consent or knowledge of the minor’s parent/,
               guardian, or person in loco parentis.
            2. The minor’s parent, guardian, or person in loco parentis shall not be informed of
               the services without the consent of the minor unless the mental health
               professional treating the minor determines that there is a compelling need for
               disclosure based on a substantial probability of harm to the minor or to another
               individual, and if the minor is notified of the mental health professional’s intent
               to inform the minor’s parent, guardian, or person in loco parentis.
            3. Services provided to a minor under this section shall be limited to not more than
               12 sessions or 4 months per request for services. After the 12th session or 4th
               month of services the mental health professional shall terminate the services or,
               with the consent of the minor, notify the parent, guardian, or person in loco
               parentis to obtain consent to provide further outpatient services.

D.   Consent for Medication
     The primary clinician or designated medical staff shall ensure that consent is obtained and
     information is provided according to agency policy and procedures.
E.   Consent for Surgery
     The primary clinician, or involved medical or emergency staff shall ensure that consent is
     obtained according to Section 716 of the Mental Health Code.
F.   Consent for Electro convulsive Therapy
     The primary clinician, or involved medical or emergency staff, shall ensure that consent is
     obtained according to Section 717 of the Mental Health Code.

G. Consent for Photographs, Audiotapes, fingerprints, and Use of 1-way Glass


             1. Prior to photographing, videotaping, audio taping, and/or using one-way vision
                mirrors the primary provider shall have the service recipient, his/her guardian or
                a parent of a minor child sign a Consent form. The primary provider shall
                explain to the service recipient that he/she has the right to keep his/her identity
                confidential.

             2. Photographing, videotaping, audio taping, and/or using one-way vision mirrors
                may be used under the following conditions:
                      a. To provide education and training which includes:
                                 Reviewing the effectiveness of the clinical treatment.
                                 Providing an objective self-critique of the service
                                    recipient's demeanor to be used in teaching ADL skills,
                                    interviewing skills, etc.
                                 Providing public awareness of mental health services.
                      b. For informational or purely personal or social purposes. In these
                      circumstances a service recipient's refusal will be respected.




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           3. Photographs taken of the service recipient in order to assist in identifying the
           service recipient shall also become a part of his/her clinical record. If a copy of a
           photograph is given to others to assist in determining the name/identity of a service
           recipient (e.g. law enforcement) the photograph shall be returned to the primary
           provider and kept a part of the recipient's clinical record. In addition, the primary
           provider shall inform the outside      party that the copy of the photograph is to be
           returned to NBHS once the name/identity of the service recipient is made.
                     The primary provider shall document in the service recipients' progress notes the
                        need for making a copy of the service recipient's photograph. The primary
                        provider shall also document in the service recipient's progress notes the date the
                        photograph was given to the outside party and the date the copy of the
                        photograph was returned to Northpointe Behavioral Healthcare Systems.

                   Video and audio tapes will be stored in a secured area with the clinical record.
           4. The primary provider shall review the need to keep photographs and/or videotapes
                  of the service recipient at the time of the quarterly review. This information
                  shall be documented in the Quarterly Status Report. The primary provider shall
                  determine if the photographs and/or Videotapes are to be destroyed or given to
                  the service recipient.

           5. Photographs and/or videotapes of the service recipient shall be given to him/her
              when they are no longer essential for treatment or destroyed upon discharge from
              Northpointe Behavioral Healthcare Systems, whichever comes first.


H.   Consent for Services Rendered via Video Teleconferencing
           1. The primary clinician shall review the process with and assure that
              consumer/parent of a minor/guardian is informed that receiving services via
              video teleconferencing is optional and any refusals shall be respected.
           2. The primary clinician shall ensure that consent is obtained prior to any video
              conferencing sessions.
           3. The consumer will be told who is present at the remote site at the time of the
              videoconference session.
           4. The consumer will be told that in the event of technical difficulties that technical
              staff may be called to assist.
           5. The consumer will be told that his/her confidentiality shall be safeguarded as if
              receiving ay other service from Northpointe.
           6. A videoconference session will only be taped if the consumer/parent of a
              minor/guardian agrees and signs a consent indicating approval. All videotapes of
              session will be stored in a secure location within the clinical record room. All
              videotapes will be destroyed after one year or anytime at the request of the
              consumer.
           7. The consumer/parent of a minor/guardian may withdraw consent for receiving
              services via videoconferencing and/or taping of videoconference services at any
              time.

I.   Consent for Media Release




                                                                                               101
     The primary clinician shall ensure that consent is obtained prior to releasing any recipient
     photographs, names, or recipient information to the media.

All these forms must be thoroughly completed and witnessed.
At times, it may be necessary to obtain consent/release verbally. If this is the case, it MUST be
witnessed by a second individual and the WRITTEN SIGNATURE be obtained within two (2)
weeks. In rare instances (i.e. due to severe physical impairment), where a written signature can
never be obtained, please document on the form that this is the case.

REFERENCES AND LEGAL AUTHORITY:
Act 258 of the Public Acts of 1974, as amended (Mental Health Code) Sections 100a, 716, 717, 724.
Department of Community Health Administrative Rule 7003, as amended.
NBHS Policy/Procedure – Informed Consent for Medication Treatment
42 CFR Part 2




POLICY TITLE:                  Harassment or Retaliation
POLICY:
It is the policy of Northpointe that any consumer, complainant, staff of the Office of Recipient Rights or
any staff acting on behalf of a recipient shall be protected from harassment or retaliation resulting from
recipient rights activities.

PURPOSE:
To develop a policy to protect persons, from harassment or retaliation, when involved in recipient rights
activities.

APPLICATION:
Applies to all Northpointe staff, consumers, and complainants.

DEFINITIONS:
Harassment – Words, gestures, or actions which threaten an individual; unreasonably interfere with an
individual’s performance; or create an intimidating, hostile, or offensive work or treatment environment.

Retaliation – Unjustified negative actions taken against an individual. Examples include, but are not
limited to: changes in treatment; discharge for just cause; deterioration in performance evaluations,
compensation, benefits.

PROCEDURES:
1. An individual who is not a Northpointe employee and who believes he or she is the subject of
   harassment or retaliation resulting from recipient rights activities should inform the Office of
   Recipient Rights.

2. Any employee who believes he or she has been the subject of any harassment shall complete an
   Employee Harassment Complaint Form, within three (3) days of the occurrence, and submit the form
   to his or her immediate supervisor. The employee may keep a copy of the completed Form. A
   complaint may be filed by an employee who was not the target of harassment or retaliation.



                                                                                                102
   NOTE:      The employee may give verbal notification to his or her immediate
               supervisor, if appropriate; however, in all cases, an Employee
               Harassment Complaint Form must be completed within the three
               (3) day time frame.

3. The immediate supervisor shall make provisions to ensure the safety of the identified
   employee, if necessary or appropriate.

4. The immediate supervisor shall investigate the complaint and prepare a written report
   of the investigation. The supervisor will give the employee a written response to the
   complaint with three (3) working days. A copy of the report will be given to the
   Director of Human Resources. All complaints and actions taken to resolve such
   complaints will be treated confidentially and will be disclosed only when necessary
   to the investigation and the resolution of the matter.

5. Where the immediate supervisor was: (1) a participant in the prohibited activity; (2)
   condoned the activity; (3) failed to respond in writing within three days without good
   cause; or (4) the response is unsatisfactory, the employee may, at his or her own
   choosing, bypass the immediate supervisor and submit a written complaint directly to
   the Director of Human Resources or other such person designated by the employer to
   handle the complaint.

6. In those situations where a violation has been shown to have occurred, immediate
   action will be taken to remedy the situation. Further steps will be taken to discourage
   or prevent future reoccurrences.

7. The original Complaint Form will be forwarded to the Director of Human Resources
   and will be filed in a separate file.

8. Appropriate disciplinary action shall be taken in accordance with agency Corrective Action policy
and procedure if there is evidence of harassment or retaliation.

NON-RETALIATION POLICY:
The above policy not only strictly prohibits harassment but also prohibits any act of retaliation
against an employee who, in good faith, has filed a complaint pursuant to this policy. Any
supervisor, agent, or employee of the employer who is found to have taken actions determined to
be retaliatory in nature against a complainant shall be subjected to immediate discipline up to and
including immediate discharge. Any person who believes they were retaliated against for
exercising his or her rights under this policy should immediately file a complaint.

REFERENCES AND LEGAL AUTHORITY:
Act 258 of the Public Acts of 1974, as amended (Mental Health Code) Section 755
Act 469 of the Public Acts of 1980 (Whistleblowers Protection Act)
Northpointe Personnel Policy Manual




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POLICY TITLE:                   Labor
PURPOSE:
To establish policies and procedures that protects the rights of recipients who work for Northpointe.

APPLICATION:
All recipients of mental health services.

POLICY:
A. Residents of a mental health facility operated by or under contract with Northpointe:

     1. May perform labor which contributes to the operation and maintenance of the facility for
     which the facility would otherwise employ someone only if:

                a. The resident voluntarily agrees to perform the labor;

                b. Engaging in the labor would not be inconsistent with the resident's individual
                   plan of service, or interfere with other ongoing treatment; and is approved by
                   the person in charge of the plan; and

                c. The resident is employed appropriately and in accordance with applicable
                   federal and state labor laws, including minimum wage and minimum wage
                   reduction provisions.

                d. That discharge from the facility or privileges shall in no event be a condition
                   of performing the labor.

                e. That the resident's right to compensation shall be protected by the
                   facility when performing labor, which results in an economic benefit to
                   another person or agency other than the facility.

     2. May be required to perform personal housekeeping tasks without compensation.

B. A recipient may perform volunteer activities on behalf of the organization in the volunteer program.

PROCEDURES:

        1.      Northpointe’s primary responsibility to the recipient is that of treatment
                services and that treatment must not be compromised by using recipients to
                perform physical labor. Therefore any work being done by recipients beyond
                the scope of the residential guidelines shall be justified in the Individual Plan
                of Service or House Rules.

        2.      Residents performing labor shall have prior approval by the Treatment
                Team and reviewed at Treatment Team meetings to discuss the resident's
                progress or lack of progress.

        3.      If the Treatment Team members do not all agree with the resident
                performing labor, the reason why shall be documented on a progress note by
                the responsible Care Manager and placed in the clinical record. In addition,



                                                                                                    104
                the impasse of the resident performing/or not performing labor may be
                referred to a Review Committee for a final decision, as follows:

             a. Each discipline involved in the Treatment Team has ten working days to
                submit documentation of assessment information, which is related to the
                resident performing labor, to the responsible Care Manager.
             b. The responsible Care Manager shall submit the assessment information to
                the appropriate supervisor
             c. The appropriate supervisor shall form a Review Committee of three
                privileged staff members who are familiar with the program/population
                being served but not directly involved with the case.
             d. The Review Committee shall review the case within five working days
                from receipt of the assessment information.
             e. The Review Committee shall review the assessment information and make
                a final decision.
             f. A member of the Review Committee shall meet with the Treatment Team
                to inform them of the decision regarding the impasse.

        4.      Resident labor shall not consume more than six hours a day, unless
                approved by the appropriate Site Supervisor.

        5.      NBHS shall maintain a record of payments made to the resident.

        6.      One half of any compensation paid to a resident shall be exempt from
                collection for payment of mental health services provided.




POLICY TITLE:                  Least Restrictive Setting
PURPOSE:
To develop a policy to ensure that NBHS recipients are being served in the least restrictive
setting.

APPLICATION:
All Northpointe Behavioral Healthcare services.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that services shall be provided in
the least restrictive setting that is appropriate and available.

PROCEDURE:
A review of the least restrictive setting will be conducted, at a minimum, as part of the annual
person-centered planning meeting.




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POLICY TITLE:                  Notification of Rights
POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that all applicants, recipients, and
applicable parents and guardians are notified of their rights.

PURPOSE:
To develop a procedure to provide notification of rights as defined in the Michigan Mental Health
Code.

DEFINITIONS:
Accurate Summary of Rights - A written summary of Chapters 7 and 7a of the Michigan
Mental Health Code which includes the name, address, and telephone number of a staff of the
Office of Recipient Rights.

Applicant - An individual or his/her legal representative who makes a request for mental health
services.

Guardian - A person appointed by the court to exercise specific powers over an individual who
is a minor, legally incapacitated, or developmentally disabled.

Recipient - An individual who receives mental health services from NBHS or from a provider
that is under contract with NBHS.

PROCEDURES:
A.   All recipients, upon acceptance for service (each potential recipient and parent(s)
     or guardian) receive an accurate written summary of rights along with the name,
     location, and function of the Recipient Rights Officer/Advisor. This service shall
     be documented in the recipient's clinical record and the rights complaint
     procedure shall be verbally explained to the recipient. Special explanation of the
     rights summary shall be given and documented if the recipient is:

        1)      Illiterate
        2)      Retarded
        3)      Non-English speaking (the verbal explanation shall be in a language that the
                recipient understands and may be delayed until a translator is available).
        4)      Emotionally upset (the verbal explanation may be delayed until a more
                clinically suitable time if the recipient is unable to comprehend the explanation
                at the time of admission)
        5)      Deaf (explanation shall be communicated by a means that is understandable to
                the recipient and may be delayed until a qualified translator is available)
        6)      Blind
        7)      A minor (the verbal explanation should be simplified in accordance with the
                minor's ability to comprehend; parent/guardian shall also be given explanation).

B.      Notification of rights is given at the time of admission for all recipients of mental
        health services from Northpointe BHS and annually thereafter. Recipients are
        also given a Rights Booklet, which includes the Department of Community
        Health Office of Recipient Rights address where they may obtain further



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         information/consultation regarding their rights.

C.       If a minor 14 years of age or older is receiving mental health services without the
         consent or knowledge of the minor's parent, guardian, or person in loco parentis,
         only the recipient will be notified of recipient rights.

     D. The Office of Recipient Rights shall:

         1.      Ensure that the telephone number and address of the Office of Recipient
                 Rights and the names of Rights Officers are conspicuously posted in all
                 service sites.

         2.      Ensure that each service site is visited with the frequency necessary for
                 protection of rights but in no case less than annually.

         3.      Promote freedom from retaliation for persons served who make
                 complaints or grievances.

     E. Visit each program of the agency regularly to be available to recipients and staff
        concerning rights, issues and appropriate notification.

     F. Ensure education is available for consumers regarding program rules to the
        person served that identifies events, behaviors, or attitudes that may lead to the
        loss of rights or privileges and the means by which the person served may regain
        rights or privileges that have been restricted.

     G. When a person is discharged from a program for aggressive/assaultive behavior,
        documented follow up occurs to ensure linkage to appropriate care within 72
        hours post discharge.


POLICY TITLE: Personal Property and Funds

PURPOSE:
To establish policies and procedures governing the control and protection of consumers personal
property and funds.

APPLICATION:
All programs operated or contracted by Northpointe Behavioral Healthcare Systems.

DEFINITIONS:

Exclusion: Restriction of specific personal property items from a consumer, which includes:
           a.       Weapons such as firearms, knives, other sharp objects and explosives.
           b.       Drugs, whether prescribed or not, unless possession of the drug is
                    specifically authorized by the attending physician.
           c.       Alcoholic Beverages.




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House Rules: Rules applying to all consumers of a community housing facility, which are
established to assure the safety and comfort of consumers and the orderly functioning of the
facility.

Limitation: A time limited restriction placed on a consumer.

Personal Property: Any possessions belonging to the consumer.

Consumer Funds: The consumer's money, legal tender, note, draft, certificate of deposit, stock,
bond, check, or credit card.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:
          1. Consumers whose property and funds are supervised by a NBHS program or contract
          agency shall have their personal property inventoried. Any additional property obtained
          or disposed of while a consumer is in community housing care, or as stated per his/her
          individual plan of service, shall also be inventoried.

        2. A consumer in community housing shall be provided a reasonable amount of storage
        area for his/her clothing and personal property.

        3. Consumers of service should assume responsibility for their own funds, unless there is
        a legal determination to the contrary or the consumer chooses to do otherwise.

        4. Restrictions shall not be placed upon the consumer's handling or expenditure of
        personal funds, unless there is a specific written plan developed by the Treatment Team.

        5. Personal allowance funds shall not be used for personal care items that are basic to the
        provision of room, board and supervision and are included in the per diem provided for
        room, board and supervision required by licensing standards (e.g. shampoo, toothpaste,
        soap, food).

        6. A consumer may appeal the limitation or the length of time his/her property and/or
        funds have been restricted.

PROCEDURES:

1. Consumer's personal property:

        a. If a facility has particular kinds of personal property that are excluded, the home
        operator/manager shall list the specific items in the house rules and notify the consumer
        of these exclusions at the time of admission. The house rules shall be posted in a
        conspicuous place within the residential facility.

        b. Staff members shall inventory the consumer's personal property in his/her
           presence and place list of inventoried items in the consumer's record. If
           personal property is taken from the consumer and/or stored by the facility, a
           receipt shall be given to them or an individual he/she designates. A resident
           is permitted to inspect personal property at reasonable times. The personal
           property shall be returned to the consumer to whom it belongs upon
           discharge from the facility/program.


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c. The CMHSP may limit property in order to prevent theft, loss or destruction
   of the property, unless a waiver is signed by the resident.

d. The facility/program shall have prior consent from the consumer, guardian or
   parent of a minor when disposing of personal property. This form shall be
   placed in the consumer's clinical record.

e. If there is reason to believe that the consumer has hidden an item that places
   the consumer or others in eminent danger, the home manager may conduct a
   search in the presence of the consumer and a witness. If there is reason to
   believe that the consumer has hidden an item that is illegal, the Recipient
   Rights Officer/Advisor shall be contacted. The police shall then be contacted
   to conduct a search. All searches of the consumer's personal property shall
   be justified and documented in the consumer's progress notes. The Rights
   Office will ensure that no constitutional rights are violated during this
   process.

f.   The Interdisciplinary Team shall have the authority to limit a consumer's
     right to receive, possess and use personal property under the following
     conditions:
              1. To prevent the consumer from physically harming him/herself or
                  others;
              2. To prevent theft, loss or destruction of property;

g. Consumers whose personal property is limited shall have each instance of limitation
and justification for its application documented in the progress notes. The imposed
limitation shall also be incorporated into the consumer's Individual Plan of Service and
reviewed at least every 90 days by the Interdisciplinary Team. The Interdisciplinary
Team shall discuss the consumer's progress or lack of progress and determine if the
limitation still need to be imposed.


2. Consumer's Funds:

A. The consumer's choice to handle his/her funds shall be documented in his/her
initial/annual assessment. If the consumer is unable to exercise choice and provider
management is requested, the guardian must consent in writing.

B. Consumer funds that are submitted to the facility/program for safekeeping shall be
handled in the following manner:

     1. The provider shall both maintain the funds and account for their disbursements
        separate from funds received for reimbursement for care and programs. Funds shall
        be used at the discretion of the consumer, consumer advocate, representative payee
        or guardian.

     2. The money shall be accounted for in the name of the consumer

     3. The money shall be locked at the facility/program site and/or deposited into the
        consumer's savings/checking account. No more than $200.00 per consumer may


                                                                                       109
        be kept in any facility for the consumer. All funds will be locked in a safe located
        in the facility.

     4. Any time an account is opened or closed, you must notify the Contract Manager
        using the Resident Funds Account Change form (res.162). If an account is closed,
        a cashier’s check for the funds must be written to the consumer and/or guardian. A
        copy of the check and the bank statement must be attached to a copy to the
        Resident Funds Account Change Form and forwarded to the Contract Manager.

     5. When an account is opened on behalf of a consumer, the Home Manager and the
        Assistant Home Manager will also have their name added to the account for
        managing purposes as a Representative of Northpointe. If there is a separation of
        employment of that Northpointe Representative listed on the account, the finance
        department of Northpointe will notify the bank and the employee will be
        immediately removed from the account and another representative will be added.
        The representatives will be identified on the Resident Funds Part 1 and a new
        Resident Funds Part 1 form will be filled out when any change occurs.

     6. For purchases in access of $100.00 or more, a written consent from the guardian is
        needed, and a copy will be attached to the Resident Funds Account Change form
        and then sent to the Contract Manager for review.

     7. Each time money is given to the consumer, it shall be documented on the Resident
        Funds Part II (Res.152) and the consumer shall write his/her initials on the form to
        indicate that he/she received the money. If the individual is not capable of
        handling his/her own money without assistance, a staff member different from the
        staff disbursing the money shall initial the Resident funds Part II

     8. Facility Manager and/or the Assistant Manager (or a designated representative);
        shall count the consumer's money periodically to ensure that the money on hand
        and in any savings accounts, is the same as what is recorded on the Resident Funds
        Part II form. At the end of each quarter, another designated manager will
        randomly request the records of a minimum of 50% consumers and compare the
        Resident Funds Part II with the bank statement and receipts, for accuracy. A
        Quarterly Accounting form (res.170) will be sent to the Contract Manager for
        review and filing purposes.

     9. The consumer's financial record/money shall be made available on request to
        his/her legal guardian if the guardian has such authority; and a Quarterly
        Accounting form(res.170) will be sent out to the guardian following each quarter
        with a copy of the consumers Resident Funds Part II forms.

     10. The consumer shall be entitled to easy access to his/her money and to use as he/she
         chooses, except as provided in Section 2.1. Each program shall determine what
         time of day consumers can have access to their money and inform the consumers
         of the times.

3.       Consumer's appeal process:
     A. If the consumer appeals the personal property limitation, he/she shall submit a
     verbal or written statement to the responsible care manager. The responsible care
     manager shall place the original statement in the consumer's clinical file and submit a


                                                                                         110
             copy to his/her supervisor.

             B. The responsible care manager's supervisor shall review the appeal within five (5)
             days and determine if the imposed limitation is justified or not.

             C. If the consumer does not agree with the decision made by the responsible care
             manager's supervisor, he/she may appeal to the appropriate Site Supervisor. The Site
             Supervisor shall review the appeal within five (5) days and determine if the imposed
             limitation is justified or not.

             D. The consumer shall be informed that he/she can file a complaint with the
             Recipient Rights Officer if he/she feels that his/her right to personal property has
             been violated.

        4.       Disposal of resident personal property and funds:

             A. In the event of death of a consumer:
                   1. Every effort shall be made by Northpointe Behavioral Healthcare Systems
                       to divest itself from the consumer's personal property and monies if they
                       consist of only wearing apparel and up to $100 in cash. Divestments shall
                       be made to the legal representative of the deceased. The legal
                       representative shall furnish identification and an affidavit of such
                       relationship, and evidence that an estate of the deceased is not pending.

                      If such legal representative does not exist, and only if the personal property
                      consists of more than $100, the disposition shall be handled according to
                      State Law (see paragraph C).

                   2. The responsible care manager shall send a list of personal property and
                      money by registered mail to the legal representative of the deceased. The
                      notice shall also call attention to statutes that provide for disposition.

                   3. If there are questions as to rival claims to personal property and money, it
                      may be held by Northpointe until the claims are determined in a probate
                      court.

                   4. If the legal representative cannot be contacted, the responsible care
                      manager shall send a list of the personal property and money, by registered
                      mail, to the person or entity that paid for the funeral expenses.


                   5. If there are no claims to personal property or money of a deceased
                      consumer, the property and money shall be considered to be unclaimed
                      (see paragraph C).

            B. If the consumer does not return from an authorized leave, and if the consumer’s
property and money are not claimed by the consumer or consumer's relatives, heirs, or personal or
legal representative, the responsible care manager shall retain custody of the same and handle the
matter as unclaimed property. (see paragraph C ).




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           C. If personal property or money of a consumer is unclaimed and has been held for
two (2) years, the property or money shall be disposed of pursuant to Act No.63 of the Public
Acts of 1949, as amended, being 567.20 et seq. of the Michigan Compiled Laws. Delivery of
property and a report to the state boards of escheat shall be on or before the thirtieth day of June
each year. The report shall list the property possessed as of the preceding first day of June.
Appropriate property may be disposed of before the end of the two (2) year period pursuant to
Act. No. 238 of the Public Acts of 1957, being 434.151 et seq. of the Michigan Compiled Laws.



POLICY TITLE: Protection of Consumers from Abuse and Neglect
POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:

1.      Recipients shall not be subjected to abuse or neglect.
2.      Any suspected abuse or neglect is promptly reported.
3.      Appropriate disciplinary action is taken for substantiated allegations of abuse or
        neglect.

PURPOSE:
To establish policy and procedures to protect Northpointe Behavioral Healthcare
Systems service recipients from being abused and neglected.

APPLICATION:
All programs operated by or under contract with Northpointe Behavioral Healthcare Systems.

DEFINITIONS:
Abuse:
Non-accidental physical or emotional harm to a recipient, or sexual contact with or sexual
penetration of a recipient as those terms are defined in section 520a of the Michigan penal code,
1931 PA 328, MCL 750.520a, that is committed by an employee or volunteer of the department, a
community mental health services program, or a licensed hospital or by an employee or volunteer
of a service provider under contract with the department, community mental health services
program, or licensed hospital.

Abuse Class I:
A non-accidental act, or provocation of another to act, by an employee, volunteer, or
trainee which caused, or contributed to, death, serious physical harm, or sexual abuse of
a recipient.

Abuse Class II:
A)     A non-accidental act, or provocation of another to act, by an employee, trainee,
       or volunteer, which caused or contributed non-serious physical harm to a
       recipient; or
B)     The use of unreasonable force on a recipient by an employee, trainee, or
       volunteer, with or without apparent harm; or,
C)     Any action, or provocation of another to act, by an employee, trainee, or
       volunteer which causes, or contributes to, emotional harm to a recipient; or,




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D)      An action taken on behalf of a recipient, by assuming incompetence, although a
        guardian has not been appointed or sought, which results in substantial economic,
        material, or emotional harm to the recipient.
E)      Exploitation of a recipient by an employee, volunteer, or agent of a provider.

Abuse Class III:
Verbal abuse

Abuse (DHS):
The harm or threatened harm to a child or vulnerable adult's health or welfare caused by another
person, including non-accidental physical or mental injury, sexual abuse, or maltreatment.
Examples of abuse can be found in training materials.

Bodily Function
The usual action of any region or organ of the body.
Chief Executive Officer/Designee
The individual appointed to direct the agency, or his/her designee, or a supervisor who normally
receives Incident Reports.
Criminal Abuse
One or more of the following:
a)     An assault that is a violation or an attempt or conspiracy to commit a violation of
       Sections 81 to 90 of the Michigan Penal Code, Act. No 328 of the Public Acts of
       1931, being Sections 750.81 to 750.90 of the Michigan Compiled Laws.
       Criminal abuse does not include an assault or an assault and battery that is a
       violation of Section 81 of Act. No. 328 of the Public Acts of 1939, being Section
       750.81 of the Michigan Compiled Laws that is committed by a recipient against
       another recipient unless it results in serious physical injury;
b)     A criminal homicide that is a violation or an attempt or conspiracy to commit a
       violation of Section 316, 317, or 321 of Act No. 328 of the Public Acts of 1931,
       being Sections 750.316, 750.317, and 750.321 of the Michigan Compiled Laws;
c)     Criminal sexual conduct that is a violation or an attempt or conspiracy to commit
       a violation of Sections 520b to 520e or 520g of Act No. 328 of the Public Acts of
       1931, being Sections 750.520b to 750.520e and 750.520g of the Michigan
       Compiled Laws;
d)     Vulnerable adult abuse that is a violation or an attempt or conspiracy to commit a
       violation of Sections 145n of the Michigan Penal Code, Act No. 328 of the
       Public Acts of 1931, being Section 750.145n of the Michigan Compiled Laws;
e)     Child abuse that is a violation or an attempt or conspiracy to commit a violation
       of Section 136b of Act No. 328 of the Public Acts of 1931, being Section
       750.136n of the Michigan Compiled Laws.
Emotional Harm - Impaired psychological functioning, growth, or development of a
significant nature as evidenced by observable, physical symptomatology and, as determined
by a psychiatrist or fully/limited licensed psychologist or social worker.
Employee - An individual who works for NBHS or under contract with NBHS and
receives compensation for that work.
Endangerment, Family Independence Agency Protective Services - A life threatening
situation caused by the inability of the person whose life is threatened to respond.



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Exploitation
An action by an employee, volunteer, or agent of a provider that involves the misappropriation or
misuse of a recipient’s property or funds for the benefit of an individual or individuals other than
the recipient.
Exploitation, Family Independence Agency Protective Services - An action which involves the
misuse of funds, property, or personal dignity by another person.

Neglect:
An act or failure to act committed by an employee or volunteer of the department, a community
mental health services program, or a licensed hospital; a service provider under contract with the
department, community mental health services program, or licensed hospital, that denies a
recipient the standard of care or treatment to which he or she is entitled under this act.
Neglect Class I
a)      Acts of commission or omission by an employee, volunteer, or agent of a
        provider which result from noncompliance with a standard of care or treatment
        required by law, rules, policies, procedures, guidelines, written directives,
        training, or individual plan of service and which cause, or contribute to, serious
        physical harm to or sexual abuse of a recipient; or,

b)      Failure to report apparent or suspected abuse Class I or neglect Class I of a
        recipient.
Neglect Class II
a)      Acts of commission or omission by an employee, volunteer, or agent of a
        provider which result from noncompliance with a standard of care or treatment
        required by law, rules, policies, procedures, guidelines, written directives, or
        individual plan of service and which cause, or contribute to, non-serious physical
        harm, or emotional harm to a recipient; or,
b)      Failure to report apparent or suspected abuse Class II or neglect Class II of a
        recipient.
Neglect Class III
a)      Acts of commission or omission by an employee, volunteer, or agent of a
        provider which result from noncompliance with a standard of care or treatment
        required by law, rules, policies, procedures, guidelines, written directives, or
        individual plan of service which either placed or could have placed a recipient at
        risk of physical harm or sexual abuse; or,
b)      The failure to report apparent or suspected abuse Class III or neglect Class III of
        a recipient.

Neglect, Dept. of Human Services
Harm to a child or vulnerable adult's health or welfare caused by the conduct of a person
responsible for their health or welfare, including the failure to provide adequate food, clothing,
shelter or medical care. Examples of neglect can be found in training materials.

Non-Serious Physical Harm
Physical damage or what could reasonably be construed as pain suffered by a recipient, which a
physician or registered nurse determines could not have caused or contributed to the death of a


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recipient, the permanent disfigurement of a recipient, or an impairment of his/her bodily
functions.
Physical Management
A technique used by staff to restrict the movement of a recipient by direct physical contact in
order to prevent the recipient from harming himself, herself, or others or from causing substantial
property damage.
Reasonable Cause
A suspicion founded upon circumstances sufficiently strong to warrant a reasonable person to
believe that the suspicion is true.

Reporting Person
The employee, volunteer, or trainee who has reasonable cause to suspect the criminal abuse of a
recipient, or the abuse, neglect, endangerment, or exploitation of a recipient who is a child or a
vulnerable adult.

Serious Physical Harm
Physical damage suffered by a recipient, which a physician or a registered nurse determines
caused or could have caused the death of a recipient, or caused the impairment of his/her bodily
function(s), or caused the permanent disfigurement of a recipient.

Sexual Abuse
       a) Criminal sexual conduct as defined by section 520b to 520e or 1931 PA 318, being
           MCL 750.520b to MCL 750.520e involving an employee, volunteer, or agent of a
           provider and a recipient
       b) Any sexual conduct involving an employee, volunteer, or agent of a department
           operated hospital or center, a facility licensed by the department under section 137 of
           the act or an adult foster care facility and a recipient.
       c) Any sexual contact between an employee, volunteer, or agent of a provider and a
           recipient for whom the employee, volunteer, or agent provides direct services.

Sexual Contact
The intentional touching of the recipient’s or employee’s intimate parts or the touching of the
clothing covering the immediate area of the recipient’s or employee’s intimate parts, if that
intentional touching can reasonably be construed as being for the purpose of sexual arousal or
gratification, done for a sexual purpose, or in a sexual manner for:
           a) Revenge
           b) To inflict humiliation
           c) Out of anger
Sexual Harassment
Sexual advances toward a recipient, requests for sexual favors from a recipient, or other
conduct or communication of a sexual nature toward a recipient.

Unreasonable Force
Physical management or force that is applied by an employee, volunteer, or agent of a provider to
a recipient in one or more of the following circumstances:
    1. There is no imminent risk of serious or non-serious physical harm to the recipient,
         staff or others
    2. The physical management used is not in compliance with techniques approved by the



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        provider and the responsible mental health agency.
     3. the physical management used is not in compliance with the emergency interventions
        authorized in the recipient’s individual plan of service.
     4. the physical management or force is used when other less restrictive measures were
        possible but not attempted immediately before the use of physical management or
        force.

Verbal Abuse
The use of language or other means of communication by an employee, volunteer, or
agent of a provider to degrade, threaten or sexually harass a recipient.

PROCEDURES:
A.   Prevention and Protection
1.   All employees, volunteers, and trainees shall safeguard recipients from abuse and neglect, obtain
     treatment for observed injuries, and act to prevent additional harm.
2.   The Office of Recipient Rights shall provide training on the definitions of abuse
     and neglect, and the mandated reporting requirements.
3.   There are special reporting requirements for persons receiving Substance Abuse
     treatment. See policy on 42 CFR Part 2.

B.      Reporting
        1.      All employees and volunteers shall:
                a.     Immediately make an oral report to the RRO in
                       the Office of Recipient Rights when they
                       witness, discover, or have reasonable cause to
                       suspect abuse or neglect of a recipient, and
                       follow-up with a written Incident Report within
                       24 hours;
                b.     Write an Incident Report within 24 hours when
                       they witness, discover, or otherwise become
                       aware of an assault by one recipient against
                       another if it results in serious physical harm;
                c.     Report to the designated law enforcement
                       agency as required by law. The reporting person
                       shall immediately make or cause to be made, by
                       telephone or otherwise, an oral report of
                       suspected criminal abuse to the law enforcement
                       agency. Within 72 hours after making the oral
                       report, the reporting person shall file a written
                       report with the law enforcement agency, and the
                       Office of Recipient Rights in accordance with
                       applicable laws and procedures;
                d.     Report to the Dept. of Human Services
                       according to their definitions of abuse,
                       endangerment, exploitation or neglect, as
                       required by law. The reporting person shall
                       make an oral report immediately, by telephone
                       or otherwise and may file a written report;
                e.     Report to the Department of Consumer and
                       Industry Services Bureau of Regulatory Services
                       as required by law.


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                f.       Any suspicion of child abuse shall be reported
                         within 24 hours to licensing authority and
                         guardian.

        2.      An employee, volunteer, or trainee who fails to make required
                report shall be subject to disciplinary action, and legal penalties
                and liabilities.
        3.      The employee in charge of implementing the recipient's plan of
                service shall notify the guardian or parent of a minor of any
                suspected abuse or neglect of that recipient.

C.      Investigation
        The Office of Recipient Rights shall conduct timely investigations of alleged abuse or
neglect in accordance with the agency's investigation procedure.



POLICY TITLE: Recipient Rights Committee
PURPOSE:
To establish a Recipient Rights Committee.

APPLICATION:
Northpointe Behavioral Healthcare Systems.

REQUIRED BY:
Rule 7037 of the Dept. of Mental Health Administrative Rules.

POLICY:
In order to support the stated mission of Northpointe Behavioral Healthcare Systems and the
principles established to affect that end, the Board recognizes the responsibility to protect the
Office of Recipient Rights from pressure which could interfere with impartial, even handed and
thorough performance of its duties.

MEMBERSHIP:
The Recipient Rights Committee shall be composed of one Northpointe Board member and 11
members selected from Dickinson, Iron and Menominee counties. The Board member shall be
the liaison between the Recipient Rights Committee and the Board.

Membership shall consist of public mental health consumers, their families or guardians,
consumer interest groups, government officials, attorneys, or individuals from the general
community who have an interest in mental health issues.

All members shall have full membership privileges including the right to be heard on all matters
affecting the Rights Committee, to vote, to hold office, to participate on a committee, and to chair
a committee.

Members shall be appointed by the Northpointe Board based upon recommendations from the
Rights Committee and shall serve a term of three (3) years. Staggered terms shall assure that no




                                                                                                117
more than one-third (1/3) of the membership expires in any one (1) year. Vacancies shall be
filled in the same manner as new appointments.

Membership shall be terminated by a two-thirds (2/3) vote of the Rights Committee with
concurrent approval by the Northpointe Board for lack of attendance or participation.

Northpointe CEO and/or designee, Recipient Rights Officer, shall serve as ex-officio
members of the Rights Committee.

OFFICERS:
The officers of the Rights Committee shall be the Chairperson, Vice-Chairperson and the
committee members. These officers shall comprise the Recipient Rights Committee.

The Chairperson and Vice-Chairperson shall be elected on an annual basis. No person shall
hold office if he/she is not a member and no member shall hold more than one (1) office at a
time.

The Chairperson and Vice-Chairperson shall be elected by simple majority of written ballots
cast by members in attendance at the annual meeting. The term of office shall begin upon
adjournment of the annual meeting.

DUTIES OF OFFICERS:

Section 1: Chairperson
The Chairperson shall be the official representative of the Rights Committee and shall:

        a.      Preside at all regular or special meetings of the Rights Committee;
        b.      Be a non-voting member of all standing and special committees;
        c.      Appoint special ad-hoc committees as necessary to deal with specific issues;
        d.      Ensure that an annual report is submitted to the Northpointe Board and the
                Dept. of Mental Health.

Section 2: Vice-Chairperson
The Vice-Chairperson shall:

        a.      Preside in the absence of the Chairperson at any Rights
                Committee activities;
        b.      Fulfill the duties of the Chairperson in the event the office becomes vacant;
        c.      Perform such duties as the Chairperson may delegate.

MEETINGS:
Section 1.
The Rights Committee shall hold regular meetings once each quarter. Meeting dates and
times shall be set at the annual meeting.

Section 2.
The regular meeting held during the second quarter of the agency's fiscal year shall be
known as the annual meeting and shall be for the purpose of electing officers, reviewing the
Rights Committee's goals and objectives, reviewing the operation of the Office of Recipient
Rights, presenting an annual report on the activities of the Rights Committee during the



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previous year, establishing meeting dates for the coming year, and conducting any other
business that may arise.

Section 3.
Special meetings may be called by the Chairperson or by a quorum of the members voting
on a request for a special meeting.

Section 4.
At any regular, special, or committee meeting one-third (1/3) of the total membership shall
constitute a quorum for the transaction of business. Unless otherwise required, a simple
majority of members present shall be sufficient to adopt a motion.

Section 5.
The Recipient Rights Committee shall:

a.      Protect the Office of Recipient Rights from pressures which could interfere with
        impartial, even-handed and thorough performance of its duties;

b.      Recommend to the CEO candidates to head the Office of Recipient Rights when a
        vacancy occurs. Consult with the CEO prior to the replacement or dismissal of the
        Rights Officer and prior to any substantial changes to the rights system. Substantial
        changes include alterations to levels of funding, staffing or to functions required to
        the Office of Recipient Rights. Inform the Board of the Committee's position when
        there is disagreement between the Rights Committee and the CEO.

c.      Advise the Rights Officer on rights issues, but shall not review actual incident
        reports, complaints and rights investigations as a way of maintaining confidentiality.

d.      Review the Office of Recipient Rights annually and submit a written report to the
        Northpointe Board and the Dept. of Mental Health.

e.      Develop an intermediate complaint appeal process with Northpointe to assure
        greater due process for recipients of services.

f.      Meet at least quarterly or more often if necessary.

APPEAL PROCEDURE:
The Rights Committee shall serve as the Appeals Committee. At the time of an appeal the
responsibilities of the appeals committee shall be to:

1)      Review the appeal at the second level and through this review determine
        whether or not they will uphold the decision made by the rights officer or
        overrule this decision.

2)      Their decision shall be documented in writing to the CEO, and the
        complainant along with the rationale for their decision.

3)      The complainant’s right to appeal this decision to the Dept. of Community
        Health, Administrative Tribunal, ATTN: Step 2 Appeal, Lewis Cass
        Building, Lansing, MI 48913 shall be included in the response back to the
        complainant.


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DUTIES OF CEO:
The CEO shall provide technical consultation to the Rights Committee at regular meetings
and as otherwise requested.

DUTIES OF RECIPIENT RIGHTS OFFICER:
The Recipient Rights Officer shall serve as chief coordinator for the Rights Committee activities.




POLICY TITLE:             Recipient Rights System
PURPOSE:
To protect and promote the rights of recipients in accordance with P.A. 258 of 1974, as amended
(the Mental Health Code); that an Office of Recipient Rights shall be established which is
subordinate only to the Chief Executive Officer, which is protected from pressures that could
interfere with the impartial, even-handed, and thorough performance of its duties, and whose staff
have the education, training, and experience to fulfill the responsibilities of the Office.

APPLICATION:
All programs operated by or under contract with Northpointe Behavioral Healthcare Systems.

POLICY:
A. The Chief Executive Officer (CEO) shall ensure that:
    1. The Recipient Rights Officer and Recipient Rights staff do not have direct service
       responsibilities and that any duties in addition to recipient rights are not in conflict with
       the basic purpose of the Office of Recipient Rights (Office);

      2. The process for funding the Office of Recipient Rights includes an annual review of the
         funding by the Recipient Rights Advisory Committee;

      3. The Office will have unimpeded access to all of the following:
         a.    All programs and services operated by or under contract with the Agency;
         b.    All staff employed by or under contract with the Agency;
         c.    All evidence necessary to conduct a thorough investigation or to fulfill its
         monitoring function.

     4. Employees and recipients have unimpeded access to the Office;

     5. Each contract between the Agency requires all of the following:
         a.     That the provider and all individuals employed by the provider receive recipient
         rights training before or within 30 days after being employed;
         b.     That recipients will be protected from rights violations while they are receiving
         services under the contract.

     6. Complainants, staff of the Office, and any staff acting on behalf of a recipient will be
        protected from harassment or retaliation resulting from recipient rights activities in
        accordance with Agency policies and procedures, and that appropriate disciplinary action
        will be taken if there is evidence of harassment or retaliation;



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     7. Education and training in recipient rights’ policies and procedures are provided to its
        Recipient Rights Advisory Committee and its Recipient Rights Complaint Appeals
        Committee;

     8. Staff of the Office receive training each year in recipient rights protection;

     9. Staff of the Office have access to the Agency’s personnel grievance process in the event of
        disciplinary action or discharge;

     10. Appropriate remedial action is taken to resolve violations of rights;

     11.Notice is provided to complainants of substantiated violations in a manner that does not
        Violate employee rights.

B. The Office of Recipient Rights shall ensure that:

       1. Recipients, parents of minor recipients, and guardians or other legal representatives
          have access to summaries of the rights guaranteed by Chapters 7 and 7a of the Mental
          Health Code and are notified of those rights in an understandable manner, both at the
          time services are requested and/or initiated, and annually during the time services are
          provided to the recipient;

        2. A complete copy of Chapters 7 and 7a of the Mental Health Code is readily available
           for review by applicants and recipients;

        3. The telephone number and address of the Office and the names of rights staff are
           conspicuously posted in all service sites;

        4. All individuals employed by the Agency, or a contract agency, receive training related
           to recipient rights protection before or within 30 days after being employed.

        5. Each service site:
           a. Is visited with the frequency necessary for protection of rights but in no case less
           than annually;
           b. Has an adequate supply of all of the following:
               1) Recipient rights booklets;
               2) Complaint forms’
               3) Incident Report forms;
               4) DCH-ORR Summary of Abuse and Neglect Reporting Requirements chart;
               5) Summary of the Whistleblowers’ Protection Act;
               6) Poster with the name, address, and telephone number of rights staff.

C. The Recipient Rights Officer shall possess the education, training, and experience necessary to
    fulfill the responsibilities of the position as documented in the position description on file in
    the Personnel Office.

DEFINITIONS:




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Complaint: A written or oral statement filed by a recipient, or another individual on behalf of a
recipient, with the Office of Recipient Rights, alleging a violation of the Mental Health Code or
Administrative Rules, and which contains the following information:
                    A. A statement of the allegations that give rise to the dispute;
                    B. A statement of the right or rights that may have been violated;
                    C. The outcome that the complainant is seeking as a resolution to the
                     complaint.



PROCEDURES:
A. General Responsibilities
   The Office shall:
   1. Provide or coordinate the protection of recipient rights for all directly operated or
      contracted services;

    2.   Participate in the development of policies and procedures pertinent to the rights of
         recipients;

    3.   Review the recipient rights policies and the rights system of each provider of mental
         health services under contract with the Agency to determine that the rights protection
         system of each provider is in compliance with the Mental Health Code and is of a
         uniformly high standard;

    4.   Serve as consultant to the CEO, staff, and recipients of the Agency in matters related to
         recipient rights;

    5.   Semi-annually provide summary complaint data consistent with the annual report required
         in Section 755 of the Mental Health Code, together with a summary of remedial action
         taken on substantiated complaints by category, to the Department of Community Health
         and to the Agency’s Recipient Rights Advisory Committee;

    6.   Attend meetings when rights-related matters are to be discussed, i.e., Behavior
         Management Committee, Quality Improvement Committees and Ad Hoc Committees,
         Supervisors, Board, and individual case meetings;

    7.   Follow the Agency’s procedure for local appeals, administrative hearings, and dispute
         resolution for applicants and Medicaid/non-Medicaid recipients.

B. Staffing
   1. The CEO shall
         a. Select a director of the Office, known as the Recipient Rights Officer, who has the
            education, training, and experience to fulfill the responsibilities of the Office;
         b. Consult with the Recipient Rights Advisory Committee prior to selecting, replacing,
            or dismissing the Recipient Rights Officer and prior to any substantial changes to the
            rights system.

    2.    In the absence of a Recipient Rights Officer or other Recipient Rights staff the CEO or
         the Agency’s emergency services staff shall be available to attempt to contact a rights staff
         and to provide necessary rights services and shall inform the Office of any services
         requested.


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C. Funding
     The CEO shall consult with the Recipient Rights Advisory Committee prior to any alterations
     to levels of funding for the Office.

D. Investigation
     The Office shall:
     1. Maintain a record system for all reports of apparent or suspected rights violations received
        by the Office, including a mechanism for logging all complaints and a mechanism for
        secure storage of all investigative documents and evidence;

     2.   Investigate all reports of apparent or suspected violations of rights within the Agency in
          accordance with Section 778 of the Mental Health Code and record those that do not
          warrant investigation;

     3.   Respond to complaints concerning Section 504 of the Rehabilitation Act of 1973;

     4.   For grievances related to the Americans with Disabilities Act of 1990, refer the individual
          to the Agency’s ADA compliance officer.

E. Annual Report
      1. The CEO shall submit to the Agency’s Recipient Rights Advisory Committee, the Board,
      and the Department of Community Health an annual report prepared by the Office on the
      current status of recipient rights in the Agency and a review of the operations of the Office.
      The report shall be submitted not later than December 30 of each year for the preceding
      fiscal year or period specified in the contract with the Department.

      2. The Recipient Rights Advisory Committee shall review and provide comments on the
      report.

      3. The annual report shall include, at a minimum, all of the following:
         a. Summary data by category regarding the rights of recipients receiving services from
            the Agency including complaints received, the number of reports filed, and the
            number of reports investigated by the Office;
         b. The number of substantiated rights violations by category and provider;
         c. The remedial actions taken on substantiated rights violations by category and
            provider;
         d. Training received by staff of the Office;
         e. Training provided by the Office to employees and contract providers;
         f. Desired outcomes established for the Office and progress toward these outcomes;
         g. Recommendations to the Board.

F.   Recipient rights Advisory Committee
     1. The Board shall appoint a Recipient Rights Advisory Committee as a subcommittee of the
        Board. The membership of the Rights Advisory Committee shall be broadly based so as to
        best represent the varied perspectives of the Agency’s geographic area. The Recipient
        Rights Advisory Committee shall be comprised of a minimum of six (6) members. At
        least 1/3 of the membership shall be primary consumers or family members, and of that
        1/3, at least ½ shall be primary consumers.

     2. The Recipient Rights Advisory Committee shall:


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         a. Meet at least quarterly or as necessary to carry out its responsibilities;
         b. Maintain a current list of members’ names to be made available to individuals upon
            request;
         c. Maintain a current list of categories represented to be made available to individuals
            upon request. The identity of specific consumers may not be disclosed without
            informed consent for such disclosure;
         d. Protect the Office from pressures that could interfere with the impartial, even-handed,
            and thorough performance of its functions;
         e. Recommend candidates for Recipient Rights Officer to the CEO, and consult with the
            CEO regarding any proposed dismissal or replacement of the Officer and prior to any
            substantial changes to the rights system;
         f. Serve in an advisory capacity to the CEO and the Officer;
         g. Inform the Board of the Committee’s position when there is disagreement between the
            Committee and the CEO;
         h. Review the semi-annual summary of complaint data prepared by the Office;
         i. Review and provide comments on the annual report submitted by the CEO to the
            Board under Section 755 of the Mental Health Code;
         j. Serve as the Board’s designated Recipient Rights Complaint Appeals Committee.

    3.   Meetings of the Recipient Rights Advisory Committee are subject to the open meetings
         act, Act No. 267 of the Public Acts of 1976. Minutes shall be maintained and made
         available to individuals upon request.

CROSS REFERENCES:
Act 258 of the Public Acts of 1974, as amended (Mental Health Code) Sections 100a, 100b, 100c,
722, 755, 772, 776.




POLICY TITLE: Resident’s Right to Access the Media
PURPOSE:
To establish policy and procedures regarding service recipient’s right to access the media.

APPLICATION:
All residential mental health facilities operated or under contract with Northpointe Healthcare
Systems.

DEFINITIONS:

House Rules: The rules applying to all residents of a home, which are established to assure the
safety and comfort of the recipients and the orderly functioning of the home.

POLICY:
It is the policy of Northpointe Healthcare Systems that:

         1.      A resident shall not be prevented from acquiring, at his/her expense, or from
                 reading written or printed material or from viewing or listening to television,
                 radio, recordings, or movies available at a facility for reasons of, or similar to,




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         censorship.

    2.   Restrictions or limitations may be imposed if indicated in the resident's
         Individual Plan of Service. This restriction limitation shall be reviewed every 30
         days by the BTC (Behavior Treatment Committee) and shall be removed when it
         is no longer essential.

    3.   The right of access shall not entitle a minor resident to obtain and keep written or
         printed material, or to view television programs or movies, over objection of a
         minor's parent or guardian or if prohibited by state law. In the event a minor’s
         parent or guardian does not approve of material, not prohibited by law, this
         should be noted in the Individual Plan of Service. The CSM is permitted to
         attempt to persuade a parent or guardian of a minor to withdraw objection to
         material, not prohibited by law, if desired by the minor.

    4.   The right of a resident to access the media shall not infringe on the rights of other
         residents.

PROCEDURES:

    1.   At the time of admission into a residential facility, the staff member responsible
         for completing the necessary paperwork with the resident shall ask him/her what
         kinds of interest he/she has in regard to accessing information from the media.
         This information shall be documented in the resident's record.

    2.   Residents whose access to the media is restricted or limited per his/her Individual
         Plan of Service shall have each instance of restriction or limitation and
         justification for its application documented in the residential progress notes by
         the staff member who imposed the restriction or limitation. This information
         shall be reviewed every 90 days or more frequently if necessary by the
         Responsible Care Manager and other involved staff members to discuss the
         resident's progress or lack of progress and determine if the restriction/limitation
         still needs to be imposed. If it is determined that the restriction/limitation is no
         longer essential it shall be removed.

    3.   The Responsible Care Manager shall immediately inform the resident when a
         limitation regarding accessing the media has been imposed along with the
         intended purpose of the limitation.

    4.   If the resident appeals the media limitation, he/she shall submit a verbal or
         written statement to the Responsible Care Manager. The Responsible Care
         Manager shall place the original statement in the resident's clinical file and
         submit a copy to his/her supervisor.

         a.      The Responsible Care Manager's supervisor shall review the appeal
                 within five (5) working days and determine if the imposed limitation is
                 justified or not.

         b.      If the resident does not agree with the decision made by the Responsible
                 Care Manager's supervisor, he/she may appeal to the appropriate Site



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                         Supervisor. The Site Supervisor shall review the appeal within five
                         working days and determine if the imposed limitation is justified or not.

                c.       The resident shall be informed that he/she can file a complaint with the
                         Recipient Rights Officer if he/she feels that his/her right to access the
                         media is being violated.

        5.      The Home Operator/Manager of a residential facility shall make provisions for
                the residents to have access to a daily newspaper.



POLICY TITLE: Seclusion and Physical Restraint/Crises Response
PURPOSE:
To establish policy and procedures addressing interventions, de-escalation techniques and
restricting the use of seclusion and physical restraint in the provision of services to NBHS service
recipients. Northpointe wants to provide direction/assistance to staff when presented with
consumers exhibiting physically threatening, aggressive behavior, suicidal ideation/threat, and/or
an unmanageable situation.

APPLICATION:
This policy applies to all programs operated by or contracted with Northpointe Behavioral
Systems.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that NBHS employees and contract
employees shall be trained in appropriate interventions including de-escalation. Physical restraint
and seclusion are prohibited by NBHS, except where allowed by law, to manage a service
recipient's behavior. NBHS Rights Office shall review the emergency interventions, physical
restraint and seclusion policies of contracted providers. Physical holds may be used as an
emergency procedure.

Northpointe recognizes the need to provide for the safety and security of all employees, residents,
and visitors. Consumers with known challenging behaviors will have a Person Centered
Individual Treatment Plan specifying interventions that are approved by the Behavior Treatment
Committee. Threats, physical attacks, property damage, and suicidal ideation/threat will be
treated in an immediate and serious manner.

DEFINITIONS:
Consumer: Person receiving services and/or participating in activities of NBHS.

Seclusion: Temporary placement of a service recipient in a room alone where egress is prevented
by any means.

Physical Restraint: The use of mechanical or material appliances to restrict activity from a
service recipient. These devices are not used for the primary purpose of providing anatomical
support. This does not include steel or metal when required by conditions of criminal arrest.




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       Physical Intervention: Physical intervention used must comply with Crisis Prevention Institute
       (CPI) guidelines, may only be used as a last resort.

       Time Out: a voluntary response to the therapeutic suggestion to a recipient to remove himself of
       herself from a stressful situation in order to prevent a potentially hazardous outcome.

       Threat: Is the expression of intent to cause physical or mental harm. An expression constitutes a
       threat without regard as to whether the party communicating the threat has the present ability to
       carry it out and without regard as to whether the expression is contingent, conditional or future.

       Physical Attack: Is unwanted or hostile physical contacts such as hitting, fighting, pushing
       shoving biting, spitting, and throwing objects.

       Property Damage: Is intentional damage to property which includes property owned by
       Northpointe, employees, visitors or vendors.

       Suicidal Ideation/Threat: recurrent thoughts of death (not just fear of dying), recurrent suicidal
       ideation w/o specific plan, or a suicidal attempt or a specific plan to commit suicide.

       Therapeutic de-escalation: means an intervention, the implementation of which is incorporated in
       the individualized written plan of service, wherein the recipient is placed in an area or room,
       accompanied by staff who shall therapeutically engage the recipient in behavioral de-escalation
       techniques and debriefing as to the cause and future prevention of the target behavior.

       PROCEDURE:

       I.        Consumer behaviors are to be evaluated periodically by the team members to
                 determine the appropriate treatment (i.e., reinforcement, restrictions,
                 interventions, etc.) of all behavior concerns. This is to be done on an as-needed
                 basis and annually in the Person-Centered Plan (PCP). All consumers with
                 behavior plans that include any type of restriction and/or emergency physical
                 management must have their plans approved by the Behavior Treatment Review
                 Committee (BTRC), the treatment team, and the consumer/guardian.

       II.       Only behaviors that have a negative impact on the consumer and/or their environment are
                 to be considered for behavior intervention and/or plans. Those behaviors will be defined
                 as: 1) aggressive behavior is of such magnitude that the consumer presents a danger to
                 self or others and/or 2) property damage: a) throwing objects that could harm another
                 (i.e., furniture, lamps, etc.) and b) engaging in acts of destruction that could harm the
                 consumer (i.e., breaking windows, head banging, etc.).

III.         The consumer's person-centered plan shall address these behaviors and the methods of
             intervening when they occur. Socially appropriate coping and behaviors shall be modeled for
             consumers at all times and positive programming implemented including redirection and de-
             escalation, unless more intrusive/restrictive methods are approved by the team and the BTRC.
             Under no circumstances may physical discipline be inflicted, including group discipline for
             the misdeeds of an individual, denial of services, denial of meals, denial of visits or
             communication with family, denial of eight hours sleep within a 24-hour period, denial of
             shelter, clothing or essential personal needs, verbal abuse, ridicule or humiliation, excessive
             chemical, mechanical, or physical restraints. Consumers are not permitted to discipline other
             consumers.


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IV.      Special attention needs to be paid to the environment, safety, access, proximity to others,
noise, and stimulation. The staff need to have completed all the training modules and receive
special training as needed (i.e., CPI, stress management, empathy, child management techniques,
development needs of children, etc.). The staff may also work a modified shift to prevent
targeting, burnout, etc.

V.      When a consumer engages in a behavior that is addressed in their PCP, Northpointe staff
are required to follow the PCP behavior plan.

VI.      Northpointe employees working with consumers who exhibit physically/threatening,
suicidal behavior shall be provided training as specified in their job description, required by
licensing and outlined in the individual treatment plans.

VII. Approved physical holds are outlined in the Crisis Prevention Institute, Inc. Program Manual.
     They are as follows:

        1. The Crisis Prevention Institute interventions are:
               A. Approved Physical Intervention Techniques For Adults:
                    1. Team Control Position is used to manage individuals who have become
                        dangerous to themselves or others. Two staff members hold the
                        individual as the auxiliary team member(s) continually assess the safety
                        of all involved and assist if needed.

                     2. Transport Position will assist staff in safely moving an individual who is
                        beginning to regain control.

                     3. Interim Control Position is a temporary control position that allows staff
                        to maintain control of both the individual’s arms, if necessary, for a
                        short time.

                B. Approved Physical Intervention Techniques For Persons with Special Needs:
                    1. Persons with special needs shall have individualized interventions
                       outlined in their IPOS.

                C. Approved Physical Intervention Techniques For Children:
                    1. Children’s Control Position is the only position that is approved for use
                       with children. This hold should also be used for an individual
                       considerably smaller than the person using the hold.

VIII. If the behavior escalates and the consumer presents a danger to self or others and /or is
engaged in significant property damage, the following steps shall be taken:

        A. All other consumers in the vicinity of the incident shall be moved to a safe area.

        B. Non-violent physical crisis intervention may be utilized by trained, competent staff, if
            all other attempts to de-escalate the situation fail.

        C. If the staff determine they are unable to safely de-escalate the situation, additional
            staff, supervisors or law enforcement shall be notified to assist.



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        D. This shall be done by calling the main switchboard (774-0522) during normal office
             hours or using the emergency beeper (222- 3118) during non office hours. When
             using the emergency beeper, punch in the homes phone number after the tone. The
             emergency worker will automatically respond by going immediately to the home or
             finding another worker(s) to send to the home.

        E. The emergency response personnel will asses the situation, determine if the person is
             a suicide risk, in need of hospitalization or placed on “suicide watch” within a
             residential facility.

        F.   Any consumer placed on “suicide watch” within a home will have EYES ON 24
             hour supervision with 15 minute documentation. This will continue until the care
             manager determines the watch is no longer needed.

        G.   Appropriate medical care and comfort measures shall be provided to any consumer
             or employee who may be injured during an incident.

REPORTING:
1. Each incident of threatening, violent behavior, suicidal threat committed by a consumer must
   be reported to the Director of Environmental Resources and your supervisor.

2. An Unusual Incident Report must be completed.

3. The appropriate licensing consultant and guardians must be notified.

4. If a traumatic event occurs, then a debriefing will be offered by trained personnel.

CROSS REFERENCE:
Crisis Prevention Institute, Inc.(CPI) - Nonviolent Crisis Intervention Training Program Booklet
Quick Reference to the Diagnostic Criteria from DSM-IV, American Psychiatric Association, pg.
163 (9)
NBHS Policy: Grievance and Appeals
NBHS Policy: BTC Review Guidelines
NBHS Form Envsa.100
NBHS Form RR.100




POLICY TITLE: Services Suited To Condition
PURPOSE:
To develop a policy regarding recipient services suited to condition.

APPLICATION:
All Northpointe Behavioral Healthcare Systems services.

DEFINITIONS:
Applicant – An individual or his/her legal representative who makes a request for mental health
services.




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POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems (NBHS) Board that:

A.      Services shall promote the best interests of the individual receiving services and shall be
designed to increase independence, improve quality of life, and support community integration
and inclusion;|
B.      Services for children and families will be designed to strengthen and preserve the family
unit if appropriate.

C.      Services for each recipient shall be suited to his/her condition and be developed using a
person- centered planning process. These services will be provided in a safe, sanitary and
humane living environment.

D.      Services shall be offered in the least restriction setting that is appropriate and available.

E.       A recipient shall be given a choice of physician or other mental health professional within
the limits of available staff and appropriate as determined by the clinical team.

F.      The IPOS will identify any restrictions or limitations of the recipient rights and will
include documentation describing attempts to avoid such restrictions as well as what action will
be taken as part of the plan to ameliorate or eliminate the need for the restrictions in the future.

G.     Justification for the exclusion of individuals chosen by the recipient to participate
in the IPOS process shall be documented in the case record.



POLICY TITLE: Sterilization, Abortion, Contraception and
Family Planning
POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:

        1. Upon request from the consumer, staff members will provide education, information
        on family planning, and/or referral; however, mental health services are not contingent
        upon receiving family planning services. Consumers are made aware of this via the
        Health Assessment form completed upon entry to services and annually thereafter.

         2. NBHS employees are only permitted to provide education and information regarding
            sterilization, abortion and contraception.

PURPOSE:
To establish policies and procedures concerning situations which involve sterilization, abortion
and contraception rights of service recipients.

APPLICATION:
All programs operated by or under contract with Northpointe Behavioral Healthcare Systems.

REQUIRED BY:



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Department of Mental Health Administrative Rule 330.7029

DEFINITIONS:

 Abortion: The termination of pregnancy before the stage of viability, induced or performed
purposely, as by a surgeon.

Contraception: The prevention of conception by chemical or mechanical means, not to include
surgical sterilization.

Emergency: Demands immediate action as determined by a physician.

Non-Therapeutic: An elective procedure not having medicinal or healing properties.

Service Recipient: A person who receives mental health services from Northpointe Behavioral
                   Healthcare Systems.

Sterilization: Surgical removal of testes or ovaries, or inactivation by irradiation, or by tying of
or removal of a portion of the reproductive ducts.

Therapeutic: Having medicinal or healing properties. A governing body shall not consider
mental illness, mental retardation, or other developmental disability as an illness or injury for
which a therapeutic procedure is deemed necessary.

PROCEDURES:

        1. Responsible Care Managers/Clinicians may provide, upon request, the service
           recipient or his/her guardian orally or in writing information pertaining to:

                 a. Family planning service agencies;

                 b. Agencies offering non-therapeutic abortions;

                 c. Agencies offering sterilization procedures; and

                 d. Obtaining contraception.

        2. The above information shall be documented in the progress note section of the
        clinical record. The service recipient shall be informed that receiving mental health
        services does not mean in any way that a service recipient must request or not request
        family planning services or health information services. This shall be documented in the
        progress note section of the clinical record.

3. If other staff members receive requests for such information, they should refer the service
   recipient to the Responsible Care Manager/Clinician.




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POLICY TITLE: Treatment by Spiritual Means
PURPOSE:
To establish policy and procedures to ensure recipients the right to treatment by spiritual means.

APPLICATION:
All recipients of services provided by Northpointe Behavioral Healthcare Systems.

DEFINITIONS:

Facility - a residential setting for the treatment of mentally ill or developmentally disabled
individuals.

Recipient - a mentally ill or developmentally disabled person living in a residential facility
operated under contract with Northpointe Behavioral Healthcare Systems.

Responsible Care Manager - an employee of Northpointe Behavioral Healthcare Systems
who is primarily responsible for the coordination and delivery of services to a recipient.

Treatment by Spiritual Means -- encompasses a spiritual discipline or school of thought
upon which a recipient wishes to rely to aid physical or mental recovery and includes easy
access, at the recipient's expense, both to printed, recorded, or visual material essential or
related to treatment by spiritual means and to a symbolic object of similar significance.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that:

1.      A recipient shall be permitted to receive treatment by spiritual means at his/her
        request or at the request of his/her guardian, parent of a minor, with the recipient's
        consent.

2.      The opportunity for contact with agencies or individuals providing treatment by
        spiritual means shall be provided in the same manner as recipients are permitted to
        see private physicians and attorneys.

3.      The "right to treatment by spiritual means" includes the right of recipients, guardians, or
        parents of a minor child to refuse medication or other treatment due to spiritual beliefs
        that predicate the current instance of mental illness or disability. The "right to treatment
        by spiritual means" does not extend to circumstances where either:

        3.1 A guardian or Northpointe has been empowered by a court to consent to or provide
        treatment, and has done so; or

        3.2 A recipient is presently dangerous to self or others and treatment is essential to prevent
        physical injury.

4.      The "right to treatment by spiritual means" does not include the right:

        4.1 To use mechanical devices or chemical or organic compounds which are physically
        harmful;



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     4.2 To engage in an activity prohibited by law;

     4.3 To engage in an activity which physically harms the recipient or others; or

     4.4 To engage in an activity which is inconsistent with a court-order custody, or a voluntary
     placement made by a person other than the recipient.

5.   Recourse to court proceedings shall be available where there is refusal of
     medication or other treatment for a minor.

6.   Notice shall be given to the person requesting treatment by spiritual means if such
     treatment is denied along with the reasons for such denial.

7.   The person requesting the treatment by spiritual means shall have the option of
     appealing if the request is denied.

PROCEDURES:

1.   Request for treatment by spiritual means:

     1.1 A request for treatment by spiritual means shall be communicated to the primary
         provider.

     1.2 This request shall be documented and filed in the recipient's clinical record.

     1.3 When there is a request for treatment by spiritual means being made by another person
     or guardian on the recipient's behalf, the primary provider shall ask the recipient if he/she
     assents to the treatment by spiritual means that is being requested by another person or
     his/her guardian.

2.   Approval of the request:

     2.1 The recipient's primary provider shall be responsible for reviewing and approving the
     request for treatment by spiritual means.

     2.2 Approval shall only be denied according to agency policies.

     2.3 Approval shall be given in writing to the recipient and to the person requesting
         treatment, if different than the recipient. A copy of the approval shall be placed in the
         recipient's clinical record.

     2.4 The primary provider shall write the specific request for treatment by spiritual means
         into the recipient's record.

3.   Denial of the request:

     3.1 The recipient's primary provider shall be responsible for the decision when denying the
     request for treatment by spiritual means.

     3.2 Denial shall only be made after examining the request in accordance with agency


                                                                                                133
        policies.

        3.3 Denial shall be made in writing explaining the grounds for the denial to the recipient and
        the person requesting treatment, if different than the recipient. A copy shall be placed in the
        recipient's clinical record and another copy forwarded to the primary provider.

4. Appeal process:

        4.1 The primary provider’s supervisor shall immediately review the decision for denying
        treatment by spiritual means upon receiving the copy from the primary provider.

        4.2 The primary provider’s supervisor shall be the first level in the appeal process. An
        appeal be made orally; however, the recipient or person acting on the recipient's behalf
        should be assisted in putting it in writing. The primary provider’s supervisor shall make
        written response regarding the appeal within 14- working days from receipt of the notice of
        the appeal. This information shall be placed in the recipient's clinical record.

        4.3 If the recipient or person acting in the recipient's behalf does not agree with the decision
made by the primary provider’s supervisor, an appeal shall be made to the CEO. The CEO shall
make written response to the appeal within five (5) working days from receipt of the notice of appeal.
This information shall be placed in the recipient's clinical record.

          4.4 The recipient or the person acting on his/her behalf shall also be reminded of his/her
right to file a Recipient Rights Complaint.




                                                                                                       134
NBHS CARE MANAGEMENT                                                   Section 8

Provider Network Manual


                           Unusual Incident
                                    Reporting
PURPOSE:
To establish policies and procedures regarding reporting unusual incidents.
APPLICATION:
All Northpointe personnel, agents, volunteers, contract and subcontractors of
Northpointe.
POLICY:
It is the policy of Northpointe that all unusual incidents both involving recipients and not
involving recipients that occur shall be documented by employees on the Unusual
Incident Report Form, reviewed and if necessary, investigated.
DEFINITIONS:
Unusual Incident - An out of the ordinary occurrence that disrupts or adversely affects the
course of treatment or care of a recipient or an occurrence that has the potential or does
place an employee, recipient or visitor at risk.
Recipient - An individual who receives mental health services from the department, a
community mental health services program or from a provider that is under contract with
the department or a community mental health services program.
Visitor – Any individual who is not an open consumer with Northpointe, or employee,
but was on Northpointe premises.
GUIDELINES:
Recipient Related Incident Report Guideline:
Serious incidents include but are not limited to:
1. Death of a recipient.
2. Suspected abuse (physical, verbal, emotional or sexual) or neglect of a recipient.
3. Instances of destruction of property.
4. Any accident or injury of a recipient that requires hospitalization.
5. Significant injuries of unknown origin.
6. Criminal offenses (per AFC guidelines)
7. Attempts at self-inflicted harm or harm to others.
8. Displays of serious hostility.


                                                                                         135
9. Resident is absent without notice.
10. When the removal of, or attempted removal of, a foster child occurs by any person
    who is not authorized by Northpointe.
11. When a foster child is involved with law enforcement authorities.

All serious incidents must be immediately reported to the Rights Office, the immediate
supervisor, designated representative/guardian in accordance with NBHS policy and
procedure entitled Guardianship Notification.

All cases of suspected abuse or neglect shall be handled in accordance with NBHS Policy
and Procedure entitled Reporting Abuse and Neglect.

The immediate supervisor shall forward copies of required incident reports to licensing as
outlined in the Child Placing Agency Rule R400.12415 and AFC Licensing Rule 311(1):
A licensee shall make a reasonable attempt to contact the resident’s designated
representative and responsible agency by telephone and shall follow the attempt with a
written report to the resident’s designated representative, responsible agency, and the
adult foster care licensing division within 48 hours of any of the following:
    1  The death of a resident.
    2  Any accident or illness that requires hospitalization
    3  Incidents that involve any of the following:
        a. Displays of serious hostility
        b. Hospitalization
        c. Attempts at self-inflicted harm or harm to others
        d. Instances of destruction to property
    4. Incidents that involve the arrest or conviction of a resident as required pursuant
       to the provisions of section of Act No. 322 of the Public Acts of 1988.
    5. A resident is absent without notice.
Other recipient related issues requiring documentation on an Unusual Incident Report but
are not limited to:
     1. Any serious or non-serious physical injury or illness which requires the
         services of a nurse or physician or which is unusual in nature or degree.
     2. Behaviors that are unusual for that recipient and are not addressed in the
         recipient's plan of service.
     3. Threats toward self or others if substantial probability of harm exists.
     4. Disruption in treatment or residential facility.
     5. Unusual or first time medically related occurrences such as seizures, etc.
     6. Category III Medication errors, abuse, or omission. (See Reporting
         Medication Incident Policy Procedure).
     7. Use of physical intervention
     8. Inappropriate sexual activity of recipients.
     9. Involvement of other agencies (police, jail, hospital, fire, Protective
         Services).
     10. Recipient medical equipment broken or unavailable.



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Non-Recipient Related Incidents
Reportable incidents include but are not limited to:
    1. Unusual behavior of staff that may be indicative of a risk in the
        workplace.
    2. Unsafe work practices that may cause undo risk.
    3. Unsafe equipment that may place client or staff at risk.
    4. Threat of violence by a staff member.
    5. Potential building, vehicle, or equipment security problems
    6. Missing, stolen or lost property.
    7. Lost or stolen consumer service records.
    8. Misplaced or stolen medications.
    9. Staff damaging or destroying Northpointe property.
    10. Staff having personal property damaged or destroyed at work.
    11. Any alleged breach of personal confidentiality.
    12. When a staff person allegedly fails to follow NBHS code of ethical
        practice.

    PROCEDURES:
    For All Incidents Involving Recipients:
    1. All unusual incidents shall be documented by employees on an Unusual
        Incident Report Form immediately following an incident or no later than
        the end of the workday. Employees must utilize the Online Unusual
        Incident Report Form whenever possible.
    2. Upon completion of the UIR Form, the employee shall email or fax this
        report to his/her supervisor, NBHS-Recipient Rights and NBHS Quality
        Improvement Manager.
    3. The supervisor shall review the UIR Form and complete the corrective
        measures section of this form and develop a plan for remedial action to
        correct and/or prevent recurrence.
    4. If the incident report indicates a possible rights violation the immediate
        supervisor shall immediately confer with the Rights Officer/Advisor.
    5. The Rights Officer/Advisor shall then make a determination of whether
        or not a rights investigation is warranted or if supervisory follow-up
        would be adequate.
    6. This decision will be communicated to the immediate supervisor by the
        Rights Officer/Advisor.
    7. All incident reports naming a recipient shall be forwarded by the
        immediate supervisor to the RN for review and signature when they are
        medically related.
    8. Reports that are not medically related shall be forwarded to the recipient's
        case manager for review and initials.
    9. The Case Manager shall forward the Incident Report to the Rights Office.
    10. The Rights Office shall:
           a. Review all incident reports and monitor whether or not
              adequate remedial action was taken to prevent recurrence of
              such an incident. If remedial action is deemed inadequate by


                                                                                      137
               the Rights Office, the Rights Officer/Advisor shall make
               recommendations to appropriate supervisory personnel.
           b. Open rights investigations on incident reports as deemed
               necessary.
           c. Ensure that all recipient related incident reports are entered
               into the Incident Report database and the original incident
               report is filed.
           d. Route a copy of the completed Unusual Incident Report to
               the service site that the report originated.
     11. The Quality Improvement Manager shall:
            a. Review all incident reports and determine if the incident is a
Sentinel Event.
            b. If the incident is determined to be a Sentinel Event, the QI
Manager shall start investigative proceedings for a Root Cause Analysis
within 2 business days of the event and follow procedures set forth in the
Northpointe Sentinel Event Policy.

For all Non-Recipient Related Incidents:
     1. All unusual incidents shall be documented by employees on an Unusual
         Incident Report Form immediately following an incident or no later than
         the end of the work day. Employees must utilize the Online Unusual
         Incident Report Form whenever possible.
     2. Upon completion of the UIR the employee shall email or fax this report
         to his/her supervisor and NBHS Quality Improvement Manager.
     3. The supervisor shall review the UIR and complete the correction
         measures section of the form and develop a plan for remedial action to
         correct this issue and/or to prevent recurrence.
     4. If an investigation is warranted, it shall be completed by the immediate
         supervisor or the appropriate NBHS personnel.
     5. The immediate supervisor shall route a copy of the completed report to
         the service site that the report originated and to the Quality Improvement
         Manager
     6. The Director of Quality Management shall:
        a. Review all incident reports and monitor whether or not
            adequate remedial action was taken to prevent recurrence of
            such an incident. If remedial action is deemed inadequate,
            make recommendations to appropriate supervisory personnel.
        b. Keep a file of all non-recipient Unusual Incident Reports.




                                                                                      138
NBHS CARE MANAGEMENT                                                             Section 9

Provider Network Manual


                     Access to Continuum of Services

                                             Adults
                                                &
                                            Children

Adult
PURPOSE:
Northpointe’s policy is to ensure timely access to appropriate and necessary specialty mental health
services and developmental disability supports for all eligible individuals, and are supported in
exercising choice as to the provider of services, to the extent possible and appropriate.

APPLICATION: This policy applies to all eligible individuals seeking services.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems to make services available to all
individuals of Dickinson, Iron, and Menominee Counties and specified contractual consumers
without discrimination as to physical or mental disability, race, color, religion, nation origin, sex
(within the limitations of the homes to accommodate residents of different sexes), age, marital
status, ability or inability to pay, sexual orientation, political affiliation, cultural background or
those with limited English proficiency.

All residents of Dickinson, Iron, and Menominee Counties and specified contractual consumers are
offered equal access to appropriate and necessary behavioral health services via 24 hour crisis
support and referral. Northpointe Behavioral Healthcare Systems' goal is to guarantee individuals
accessibility to an appropriate integrated system of care, honoring the individual’s choices,
including service providers, and preferences as negotiated in the person-centered planning and self-
determination process.

Northpointe Behavioral Healthcare Systems maintains standards for access to services in
accordance with Michigan Department of Community Health (MDCH) and NorthCare guidelines
and consistent with accreditation standards. Standards have been developed for emergent and
routine accessibility of services and to meet medical necessity criteria. Northpointe Behavioral
Healthcare Systems' leaders consider the needs of the populations served, available resource,
strategies, and settings for delivery of service when making care available to those who need it,



                                                                                                     139
providing the care in a continuous manner and using care settings appropriate to individual needs
and requests. There are channels of communication among the service providers in order to
facilitate the stability, continuity, and comprehensiveness of services to an individual, and are
monitored via review of Performance Indicators There is ongoing supervision of direct service
personnel that addresses issues of ethics, legal aspects of clinical practices, professional standards,
clinical documentation, and cultural competency issues.

DEFINITIONS:
Denying or Limiting Services – In the processing of requests for initial and continuing
authorizations of services, any decision to deny a service authorization or to authorize a service in
an amount, duration, or scope that is less than requested, must be made by a healthcare professional
who has appropriate clinical expertise in treating the enrollee’s condition or disease. Reference 42
CFR 434 Subpart D 438.210(b) (3).

Health Care Professional – The staff who are eligible to provide Medicaid services are listed in the
Michigan Department of Community Health Medicaid Provider Manual, Chapter for Mental
Health/Substance Abuse, Section 2.4.

Service Authorization Request – Means a managed care enrollee/guardian’s request for the
provision of a service. Reference 42 CFR 431.201.

Limited English Proficiency (LEP): A consumer with limited English proficiency will be provided
assistance in an alternative language format. This could include oral language translation; sign
language; and other types of assistance necessary to fully understand how to access and utilize
services.

PROCEDURES:
All consumers requesting services from Northpointe during normal business hours will be
connected to the Northcare Centralized Access and Eligibility department for determination of
eligibility for Specialty Mental Health Services
Any consumer or individual acting on behalf of a consumer may call Northpointe after hours for
emergent and urgent care via local crisis support and referral systems.
All providers have the responsibility to assess the need for Limited English Proficiency assistance
at the time of access.

NBHS defines two acuity levels and access standards for each level:
   Emergent Situations: Those clinical presentations which involve real and imminent
      danger to self or others and which require immediate diagnosis and treatment.
      Assessment and disposition to be completed within 3 hours.
   Routine: Those situations in which the consumer presents as relatively stable and able to
      function in their current environment, but may require services to improve functioning in
      one or more settings and/or to alleviate emotional distress, and/or to address significant
      behavioral disturbances. Assessment to be provided within 14 days of initial request.

Initial Request for Services: When a consumer, legal guardian, or responsible party acting on
behalf of a consumer initiates a request for services, consumers are asked to identify whether or
not they are calling regarding a crisis or urgent matter, and if identified as an emergent situation,
are immediately diverted to a crisis support staff consumer. If the call is identified as a routine
request for services, the initial telephone screening completed by Northcare, identifies client
demographics, referral information (including whether or not the consumer is referred by a
primary EPSDT screener) and potential funding sources. The consumer who is eligible for


                                                                                                    140
Specialty Mental Health services is then scheduled for a psychosocial assessment (i.e. intake) at
the appropriate Northpointe office

The clinical information gathered at the time of initial assessment (either when scheduled face-to-
face or when screened by clinical staff) includes an assessment of clinical condition(s) and/or
presence of a developmental disability or substance abuse concern, addresses degree of functional
impairment across settings, determines degree of risk, assesses the consumer strengths and
supports, and determines intensity of service needs. When either case management or supports
coordination services are indicated, the provider shall inform consumers of all available options
in their area and allow them to choose their provider to the extent possible and appropriate. If the
assessment including appropriate Level of Functioning tools indicates that ongoing services are
appropriate, an initial treatment plan is developed, the consumer is then scheduled with the
appropriate service provider to begin treatment (within 14 days of the initial assessment if
services are indicated) and to develop an individual plan of service within 30 days of the initial
assessment. These assessments and service assignments, when indicated, are made according to
the MDCH eligibility criteria and service selection guidelines. These criteria help to ensure
consistent application across the region in eligibility determinations for all behavioral health, case
management, and supports coordination services, using NorthCare’s Clinical Management
Criteria outlined in the Utilization Management Plan. Once a level of care is determined for the
consumer, the NorthCare Benefit Plan is used to guide the selection of medically necessary
services.

If the individual resides within one CMHSP’s area (the Home Board) but is requesting routine
services from another CMHSP, the consumer needs to have a clinical assessment by the home
Board. If an assessment determines the consumer is eligible for outpatient specialty services or
supports, it is the responsibility of the two providers to manage the authorization and payment
issues in a manner that

ensure timely access to services. If the initial assessment indicates a consumer is in need of
intensive services beyond typical outpatient care, the consumer will be referred back to their
Home Board for the completion of their person-centered plan.

Referrals to other community resources in lieu of specialty health services and supports are
documented. If the consumer is denied services, an appropriate referral and an Action notice is
provided to the consumer, which includes specific contact information and instructions on
consumer's rights to appeal or to request a second opinion. Staffs who are denying services must
meet the criteria given in the definition section above. Action Notices are tracked for regional
trending and patterns.

Consumers seeking outpatient substance abuse services will be encouraged to initiate access
directly at the outpatient Medicaid provider of their choice within the NorthCare provider network.
The providers are listed in the NorthCare Customer Handbook. Co-occurring services will be
available to consumers who meet the criteria for Specialty Mental Health services.

When appropriate, an on-site visit to Northpointe programs may be provided to the person to be
served/legal guardian.

Exclusion Criteria: Northpointe maintains access to services in accordance with MDCH (Michigan
Dept. of Community Health), NorthCare and accreditation standards. Consumers from out of state;
consumers who request services we do not provide; and consumers (except Hab Waiver) who are
rated as mild to moderate in severity of mental illness are referred to other appropriate community


                                                                                                 141
resources. Consumers must meet medical necessity and are transitioned to meet independent status
as clinically indicated.
Medicaid consumers from NorthCare service regions may obtain office based services at any CMH
in the NorthCare Network.

Children
PURPOSE:
Northpointe’s policy is to ensure timely access to appropriate and necessary specialty mental health
services and developmental disability supports for all eligible individuals, and are supported in
exercising choice as to the provider of services, to the extent possible and appropriate.

APPLICATION: This policy applies to all eligible children, age 17 and under, seeking services.

POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems to make services available to all
individuals of Dickinson, Iron, and Menominee Counties and specified contractual consumers
without discrimination as to physical or mental disability, race, color, religion, nation origin, sex
(within the limitations of the homes to accommodate residents of different sexes), age, marital
status, ability or inability to pay, sexual orientation, political affiliation, cultural background or
those with limited English proficiency.

All residents of Dickinson, Iron, and Menominee Counties and specified contractual consumers are
offered equal access to appropriate and necessary behavioral health services via 24 hour crisis
support and referral. Northpointe Behavioral Healthcare Systems' goal is to guarantee individuals
accessibility to an appropriate integrated system of care, honoring the individual’s choices,
including service providers, and preferences as negotiated in the person-centered planning and self-
determination process.

Northpointe Behavioral Healthcare Systems maintains standards for access to services in
accordance with Michigan Department of Community Health (MDCH) and NorthCare guidelines
and consistent with accreditation standards. Standards have been developed for emergent and
routine accessibility of services and to meet medical necessity criteria. Northpointe Behavioral
Healthcare Systems' leaders consider the needs of the populations served, available resource,
strategies, and settings for delivery of service when making care available to those who need it,
providing the care in a continuous manner and using care settings appropriate to individual needs
and requests. There are channels of communication among the service providers in order to
facilitate the stability, continuity, and comprehensiveness of services to an individual, and are
monitored via review of Performance Indicators. There is ongoing supervision of direct service
personnel that addresses issues of ethics, legal aspects of clinical practices, professional standards,
clinical documentation, and cultural competency issues.

DEFINITIONS:
Denying or Limiting Services – In the processing of requests for initial and continuing
authorizations of services, any decision to deny a service authorization or to authorize a service in
an amount, duration, or scope that is less than requested, must be made by a healthcare professional
who has appropriate clinical expertise in treating the enrollee’s condition or disease. Reference 42
CFR 434 Subpart D 438.210(b) (3).




                                                                                                     142
Health Care Professional – The staff who are eligible to provide Medicaid services are listed in the
Michigan Department of Community Health Medicaid Provider Manual, Chapter for Mental
Health/Substance Abuse, Section 2.4.

Service Authorization Request – Means a managed care enrollee/guardian’s request for the
provision of a service. Reference 42 CFR 431.201.

Limited English Proficiency (LEP): A consumer with limited English proficiency will be provided
assistance in an alternative language format. This could include oral language translation; sign
language; and other types of assistance necessary to fully understand how to access and utilize
services.

PROCEDURES:
All consumers requesting services from Northpointe during normal business hours will be
connected to the Northcare Centralized Access and Eligibility department for determination of
eligibility for Specialty Mental Health Services
Any consumer or individual acting on behalf of a consumer may call Northpointe after hours for
emergent and urgent care via local crisis support and referral systems.
All providers have the responsibility to assess the need for Limited English Proficiency assistance
at the time of access.

NBHS defines two acuity levels and access standards for each level:
   Emergent Situations: Those clinical presentations which involve real and imminent
      danger to self or others and which require immediate diagnosis and treatment.
      Assessment and disposition to be completed within 3 hours.
   Routine: Those situations in which the member presents as relatively stable and able to
      function in their current environment, but may require services to improve functioning in
      one or more settings and/or to alleviate emotional distress, and/or to address significant
      behavioral disturbances. Assessment to be provided within 14 days of initial request.

Initial Request for Services: When a parent, legal guardian, or responsible party acting on
behalf of a child, initiates a request for services, responsible parties are asked to identify whether
or not they are calling regarding a crisis or urgent matter, and if identified as an emergent
situation, are immediately diverted to a crisis support staff member who is trained in Children’s
services. If the call is identified as a routine request for services, the initial telephone screening
completed by Northcare, identifies client demographics, referral information (including whether
or not the consumer is referred by a primary EPSDT screener) and potential funding sources. The
consumer who is eligible for Specialty Mental Health services is then scheduled for a
psychosocial assessment (i.e. intake) at the appropriate Northpointe office
The consumer is then either scheduled for a clinical assessment or is asked to come in to the
Northpointe office to receive a face to face triage assessment with a senior clinician who makes a
determination regarding clinical eligibility for services based on clinical triage assessment for
children, which will include the results from CAFAS, PECAFAS, or DD Level of Functioning, as
appropriate results, and meeting medical necessity criteria.

The clinical information gathered at the time of initial assessment (either when scheduled face-to-
face or when screened by clinical staff) includes an assessment of clinical condition(s) and/or
presence of a developmental disability or substance abuse concern, addresses degree of functional
impairment across settings, determines degree of risk, assesses the consumer strengths and
supports, and determines intensity of service needs. When either case management or supports
coordination services are indicated, the provider shall inform consumers of all available options


                                                                                                 143
in their area and allow them to choose their provider to the extent possible and appropriate. If the
assessment including the appropriate Level of Functioning tool indicates that ongoing services are
appropriate, an initial treatment plan is developed, the member is then scheduled with the
appropriate service provider to begin treatment (within 14 days of the initial assessment if
services are indicated) and to develop an individual plan of service within 30
days of the initial assessment. These assessments and service assignments, when indicated, are
made according to the MDCH eligibility criteria and service selection guidelines. These criteria
help to ensure consistent application across the region in eligibility determinations for all
behavioral health, case management, and supports coordination services, using NorthCare’s
Clinical Management Criteria outlined in the Utilization Management Plan. Once a level of care
is determined for the consumer, the NorthCare Benefit Plan is used to guide the selection of
medically necessary services.

If the individual resides within one CMHSP’s area (the Home Board) but is requesting routine
services from another CMHSP, the consumer needs to have a clinical assessment by the home
Board. If an assessment determines the consumer is eligible for outpatient specialty services or
supports, it is the responsibility of the two providers to manage the authorization and payment
issues in a manner that ensure timely access to services. If the initial assessment indicates a
consumer is in need of intensive services beyond typical outpatient care, the consumer will be
referred back to their Home Board for the completion of their person-centered plan.

Referrals to other community resources in lieu of specialty health services and supports are
documented. If the consumer is denied services, an appropriate referral and an Action notice is
provided to the consumer, which includes specific contact information and instructions on
consumer's rights to appeal or to request a second opinion. Staff who are denying services must
meet the criteria given in the definition section above. Action Notices are tracked for regional
trending and patterns   .
Consumers seeking outpatient substance abuse services will be encouraged to initiate access
directly at the outpatient Medicaid provider of their choice within the NorthCare provider network.
The providers are listed in the NorthCare Customer Handbook. Co-occurring services will be
available to consumers who meet the criteria for Specialty Mental Health services.

When appropriate, an on-site visit to Northpointe programs may be provided to the person to be
served/legal guardian.

Exclusion Criteria: Northpointe maintains access to services in accordance with MDCH (Michigan
Dept. of Community Health), NorthCare and accreditation standards. Consumers from out of state;
consumers who request services we do not provide; and consumers (except MI Child or Hab
Waiver) who are rated as mild to moderate in severity of mental illness are referred to other
appropriate community resources. Consumers must meet medical necessity and are transitioned to
meet independent status as clinically indicated.
Medicaid consumers from NorthCare service regions may obtain office based services at any CMH
in the NorthCare Network.




                                                                                                 144
NBHS CARE MANAGEMENT                                                          Section 10

Provider Network Manual


                              Usage of Northpointe
                              Information Systems


POLICY TITLE: Network Security End User Policy
PURPOSE:
Northpointe Behavioral Healthcare Systems’ (NBHS) Information Network offers the NBHS
community increasingly rich and valuable tools and information. However, as this “information
asset” grows in value, it becomes increasingly important for each participant to protect the
integrity and security of the network environment.

APPLICATION:
This policy applies to everyone who receives access to NBHS’s information network; for ease of
reference, the term “NBHS’s staff” or “staff” is used to include employees, volunteers,
contractors, physicians, as well as others obtaining Internet access through NBHS’s facilities.

POLICY:
Each user of the NBHS Information Network is required to protect the integrity and security of
the information contained with or accessed via in accordance with the procedure outlined below.

Unauthorized or inappropriate use of the NBHS’s Information Network may result in disciplinary
action up to and including termination per NBHS’s Human Resources Policy and Procedure
Manual, Section 9.0.
PROCEDURES:

1.      Security

        You must safeguard your password at all times to protect your applications and those of
        all other network users. To this end, the system will automatically force you to change
        your password regularly (every 30-90 days). Additionally, you should observe the
        following guidelines to maintain our network’s security:
        A.      Never share your password with another person.
        B.      Never record your password in writing or in any system file (e.g., taping it in
                front of your terminal or e-mailing it to a friend).




                                                                                                  145
        C.      Do not use easily guessed personal references as your password (e.g., your dog’s
                name, your birthday, your logon-id, your last name, etc.).
        D.      Avoid words in the dictionary for your password; passwords that include
                numbers, special characters, and letters with a mix of upper and lower case are
                the most secure.
        E.      Do not leave yourself logged-on when you are no longer present at the
                workstation.
2.      Confidentiality

        The confidentiality of information stored in NBHS’s information system must be
        preserved. Information stored on any workstation is subject to disclosure restrictions
        based on the data type (personal/employee data, consumer data, research data, NBHS’s
        proprietary data). Employees or persons granted access to the NBHS’s network are not
        to release, transmit, copy on removable disks, or print out any of the above data unless
        they follow the following NBHS’s policies/ guidelines:
        A.      Human Resources (HR) is responsible for safeguarding personal/employee data
                subject to the Privacy Act and for establishing the procedures for release of that
                data.
        B.      Consumer data may not be disclosed, transmitted, or taken offsite without the
                appropriate consent and must follow NBHS’s guidelines as outlined in the
                NBHS’s Recipient Rights Policy and Procedure Manual.
        C.      Data pertaining to NBHS’s business practices, intellectual property, or other
                NBHS’s proprietary data should only be disclosed with the approval of the
                appropriate department manager. Check with your department manager if you
                are unsure of the proprietary nature of an application or business practice.
Unattended print-outs of system reports or workstations that are signed-on to the network are
extremely susceptible to breaches in confidentiality. Once on the network, anyone who has even
a modest understanding of PCs and networks can read your e-mail, personal documents, or
consumer information. Moreover, the same conditions and constraints apply equally to using e-
mail and U.S. mail with specific consumer information. E-mail is “discoverable” in a legal sense;
it is the same as a written memo or policy. Refer to the Policy on the Use of Internet and E-mail
for standards of conduct using Web technologies.


3.      Network Integrity/Standardization
        As soon as you connect to the network, your PC becomes an interpersonal computer.
        Only enterprise-approved and properly tested software and hardware can be connected.
        No unlicensed or non-approved software may be loaded on an employee workstation. No
        changes to hardware or the operating system configuration can be made without the
        assistance of designated Information Services support staff.




                                                                                                146
POLICY TITLE: Use of Electronic Mail
PURPOSE:
Northpointe Behavioral Healthcare Systems’ (NBHS) Information Network offers the NBHS
community increasingly rich and valuable tools and information. However, as this “information
asset” grows in value, it becomes increasingly important for each participant to protect the
integrity and security of the network environment.

APPLICATION:
This policy applies to everyone who receives access to NBHS’s information network; for ease of
reference, the term “NBHS’s staff” or “staff” is used to include employees, volunteers,
contractors, physicians, as well as others obtaining Internet access through NBHS’s facilities.

POLICY:
Each user of the NBHS Information Network is required to protect the integrity and security of
the information contained with or accessed via in accordance with the procedure outlined below.

Unauthorized or inappropriate use of the NBHS’s Information Network may result in disciplinary
action up to and including termination per NBHS’s Human Resources Policy and Procedure
Manual, Section 9.0.

PROCEDURES:

1.      Security

        You must safeguard your password at all times to protect your applications and those of
        all other network users. To this end, the system will automatically force you to change
        your password regularly (every 30-90 days). Additionally, you should observe the
        following guidelines to maintain our network’s security:
        A.      Never share your password with another person.
        B.      Never record your password in writing or in any system file (e.g., taping it in
                front of your terminal or e-mailing it to a friend).
        D.      Do not use easily guessed personal references as your password (e.g., your dog’s
                name, your birthday, your logon-id, your last name, etc.).
        D.      Avoid words in the dictionary for your password; passwords that include
                numbers, special characters, and letters with a mix of upper and lower case are
                the most secure.
        E.      Do not leave yourself logged-on when you are no longer present at the
                workstation.
     2. Confidentiality

        The confidentiality of information stored in NBHS’s information system must be
        preserved. Information stored on any workstation is subject to disclosure restrictions
        based on the data type (personal/employee data, consumer data, research data, NBHS’s
        proprietary data). Employees or persons granted access to the NBHS’s network are not



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        to release, transmit, copy on removable disks, or print out any of the above data unless
        they follow the following NBHS’s policies/ guidelines:
        A.      Human Resources (HR) is responsible for safeguarding personal/employee data
                subject to the Privacy Act and for establishing the procedures for release of that
                data.
        B.      Consumer data may not be disclosed, transmitted, or taken offsite without the
                appropriate consent and must follow NBHS’s guidelines as outlined in the
                NBHS’s Recipient Rights Policy and Procedure Manual.
        C.      Data pertaining to NBHS’s business practices, intellectual property, or other
                NBHS’s proprietary data should only be disclosed with the approval of the
                appropriate department manager. Check with your department manager if you
                are unsure of the proprietary nature of an application or business practice.
Unattended print-outs of system reports or workstations that are signed-on to the network are
extremely susceptible to breaches in confidentiality. Once on the network, anyone who has even
a modest understanding of PCs and networks can read your e-mail, personal documents, or
consumer information. Moreover, the same conditions and constraints apply equally to using e-
mail and U.S. mail with specific consumer information. E-mail is “discoverable” in a legal sense;
it is the same as a written memo or policy. Refer to the Policy on the Use of Internet and E-mail
for standards of conduct using Web technologies.
3.      Network Integrity/Standardization
        As soon as you connect to the network, your PC becomes an interpersonal computer.
        Only enterprise-approved and properly tested software and hardware can be connected.
        No unlicensed or non-approved software may be loaded on an employee workstation. No
        changes to hardware or the operating system configuration can be made without the
        assistance of designated Information Services support staff.




POLICY TITLE: Use of the Internet
PURPOSE:
Northpointe provides access to the Internet and publishes materials on its Internet Web Site to
promote its mission of excellence in the management and delivery of behavioral health care
services. Staff with access to the Internet must use it responsibly and consistent with their job
duties and Northpointe’s mission. Materials may be published on the web site only as provided
in this policy.
POLICY:
Workstation and user accounts with Internet access will have full access to the resources it
provides. All employees must sign the User Acknowledgement Form (IS.103), which includes a
statement regarding Internet use.

Any violation of this policy may be grounds for disciplinary action including termination as
defined in the Northpointe sanctions policy

PROCEDURES:
1.   Northpointe Presence on the Internet (the web site)



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     A.      Northpointe has established an Internet web server for publications of materials
             appropriate to its mission. These materials are accessible to the public through
             the Internet.
     B.      Northpointe has established a Web Site Steering Committee, which is responsible
             for developing a uniform “look and feel” to all publications on the Northpointe
             web server.
     C.      The Web Site Steering Committee has final authority to decide whether to allow
             publication of materials on the Northpointe web server. Materials may be
             published for Northpointe’s internal use only or for both internal (Northpointe)
             and external use. If materials are published for external use, they become
             available to anyone with Internet access.
     D.      The responsibility for preparing materials for publication on the Northpointe
             WWW server rests with the relevant department, division, service, unit, or other
             organization within Northpointe. The preparer of the materials is responsible for
             assuring that they are accurate, current, complete, relevant to, and consistent with
             Northpointe’s mission. Final approval of content must take place at the
             department, division, or other relevant unit level, and the department supervisor
             or designee, or their equivalent for the unit preparing the materials, must indicate
             her or his approval. On request, the Information Services department can provide
             technical assistance to prepare materials.
     E.      All materials published on the Northpointe web server must include the
             Northpointe disclaimer notice.
     F.      No materials to be published on the Northpointe web server should contain any
             figures, graphs, pictures, illustrations, text, tables, or other portions from another
            publication unless permission has been granted for the inclusion.

2.   Use of the Internet by Northpointe Staff

     A. Northpointe’s staff is encouraged to use the Internet to its fullest potential to further
        the mission and values of Northpointe, to provide service of the highest quality to our
        consumers, families, providers, and others we serve, to discover new ways to use
        resources to enhance service, and to promote staff development.

     B. Northpointe’s staff may use the Internet on personal time at work where possible.
        Personal time includes breaks, lunchtime, and the time before and after work. Where
        staff shares equipment or resources for Internet access, staff using the resources to
        fulfill job responsibilities has priority over those desiring access for personal use.

     C. Staff use of the Internet is a privilege, not a right, and may be revoked at any time for
        inappropriate conduct. All staff with access to the Internet through Northpointe’s
        facilities is responsible for complying with the policies, guidelines, and standards of
        conduct contained in this policy. Violations may result in revocation of Internet
        access privileges and any other appropriate disciplinary sanction. Examples of
        inappropriate conduct include:

             a.   Use of the Internet for unlawful activities.
             b.   Use of the Internet for private gain.
             c.   Use of the Internet to access illicit and pornographic sites.
             d.   Use of abusive or objectionable language in public or private messages.


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                e.   Misrepresentation of oneself or Northpointe.
                f.   Lobbying elected officials.
                g.   Sending chain letters.
                h.   Using Northpointe’s email system to distribute personal information.
                i.   Other activities that could cause congestion and disruption of networks and
                     systems.
                j.   Staff must respect intellectual property rights at all times when using the
                     Internet.

        D.      The World Wide Web is not a secure means of communication. Be very cautious
                about providing personal information, such as credit card numbers, over the Web.




POLICY TITLE:                  Password Policy
PURPOSE:
NBHS provides users with "electronic tools", which help to improve the effectiveness and
efficiency of NBHS' employees. Employees who have access to these "electronic tools" must use
them responsibly and within NBHS' policy and procedures as to not open NBHS to security risks.

APPLICATION:
This policy applies to everyone who receives access to "electronic tools" throughout NBHS; for
ease of reference, the terms, "user", NBHS' staff, and "staff" are used to include employees,
volunteers, contractors, physicians, as well as others who have access to the "electronic tools"
made available throughout NBHS' facilities.

POLICY:

1. Types of Passwords:

        a.      Administrator assigned passwords- New employees will be given an initial
                password to access system functions after the employee's status has been
                confirmed with their supervisor. Users will be responsible for changing initial
                password to a new password that adheres to the Password Policy. Additional
                passwords may be assigned depending on job functions. The staff person's
                supervisor and the CIO or his/her designee must approve changes in access
                privileges.

        b.      Self assigned passwords- Passwords that the user will assign to him/herself.

        c.      Temporary assigned passwords- If an incident shall occur where an
                administrator must delete a user's password, the administrator will assign a new
                temporary password. After doing so the administrator will clearly write the
                password on a sheet of paper and seal it in a secure envelope entitled the user's
                name and clearly marked "Confidential". The user will login using the temporary
                assigned password. The user will then be responsible for changing the temporary
                password to a new password that adheres to the Password Policy.

2. Password Definition:


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        a.      The password must contain eight (8) characters consisting of a combination of
                both letters and numerals (i.e. Abcd1234). At no time will the name of the user
                or department be part of the password. No whole words that may be found in the
                dictionary will be used as the password.

3. Changing Passwords:

        a.      All users will change their passwords every ninety-(90) days. Instructions for
                changing user passwords is defined in the User Acknowledgement Form signed
                by all NBHS' employees at time of hire at NBHS. All users who have difficulty
                changing their passwords will direct their questions to the helpdesk in the IS
                Department.

        b.      All network system passwords, as designated in the password logbook located in
                the information systems server room, will be changed by an administrator every
                ninety-(90) days.

DEFINITIONS:
"Electronic Tools"- The term "electronic tools" is defined as all computer equipment including
desktop, laptop and palmtop systems; all software; all other electronic equipment which requires
a password for accessibility.

PROCEDURES:

1.      Appropriate use of Passwords

All employees who have access to "electronic tools" should follow the guidelines below:

        a.      New employees will be given an initial password to access system functions after
                the employee's status has been confirmed with their supervisor. Users will be
                responsible for changing initial password to a new password that adheres to the
                Password Policy. Additionally, users should observe the following guidelines to
                maintain our network's security:
                        i.       Never share your password with another person.
                        ii.      Never record your password in writing or in any system file (i.e.,
                                 taping it in front of your terminal or e-mailing it to a friend).
                        iii.     Do not use easily guessed personal references as your password.
                                 (i.e., your dog's name, your birthday, your logon-id, your last
                                 name, etc…)
                        iv.      Avoid words in the dictionary for your password; passwords that
                                 include numbers, special characters, and letters with a mix of
                                 upper and lower case are the most secure.
                        v.       Do not leave yourself logged-on when you are no longer present
                                 at the workstation.

        b.      You must safeguard your password at all ties to protect your applications and
                most of all other network users. Users will be required to change passwords
                every ninety-(90) days. Instructions for changing user passwords is defined in the
                User Acknowledgement Form signed by all NBHS' employees at time of hire at
                NBHS. All users who have difficulty changing their passwords will direct their


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                questions to the helpdesk in the IS Department.

        c.      As all work done on agency equipment shall be work related, signing on to a
                system with someone else's logon name and password is prohibited unless the
                CIO gives specific authorization. Such authorization shall be on an individual
                basis. The staff person must provide the CIO or his/her designee with the
                password, and the CIO or his/her designee must be notified of the existence of
                the password-protected file(s).

        d.      All network systems shall have the passwords changed every ninety-(90) days by
                a designated administrator. This is to include all software & hardware on the
                network and as stated in the password logbook located in the Information
                Systems Server Room.




POLICY TITLE: Master HIPPA Security Policy
PURPOSE:
Northpointe shall ensure the confidentiality, integrity and availability of its information systems
containing ePHI by implementing appropriate and reasonable policies, procedures and controls to
prevent, detect, contain, and correct security violations.
POLICY:
This policy reflects Northpointe compliance with 45 CFR 164 - HIPAA Security Standards.


PROCEDURE:
1. Security Management
Security Management reflects Northpointe commitment to implement a risk analysis, risk
management and information security review process to prevent, detect, contain and correct
security violations.
Reference: IS Security Management Procedure

2. Assigned Security Responsibility
Information Security Officer will be the responsible function for the implementations of ePHI
security at Northpointe.
The purpose of the Northpointe Information Security Office is to protect the confidentiality,
integrity, and availability of Northpointe information systems and ePHI. Northpointe’s
Information Security Officer is responsible for the development and implementation of all
policies and procedures necessary to appropriately protect the confidentiality, integrity, and
availability of Northpointe information systems and ePHI. This function includes the
responsibility of investigating all alleged violations of Northpointe security policies and includes
appropriate action to mitigate the infraction and recommend sanctions as warranted.

3. Security Awareness and Training
Northpointe shall develop, implement, and regularly review a formal, documented program for
providing appropriate security training and awareness to its workforce members. All new
Northpointe employees must receive appropriate security training before being provided with



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access or accounts on Northpointe information systems. All non-Northpointe employees must be
made aware of the security policies, procedures and must have a confidentiality agreement on
file.
Reference: IS Security Training Procedure

4. Security Incidents Handling
Northpointe shall have a formal, documented process for quickly and effectively detecting and
responding to security incidents that may impact the confidentiality, integrity, or availability of
Northpointe information systems. The process, as detailed in the Security Incident Response
Procedure involves among others the creation of the incident response team (SIRT), an awareness
program through regular training and the means for the organization employees to effectively
report any potential incidents.
Reference: IS Security Incident Response Procedure

5. Contingency
Northpointe shall prepare for and be able to effectively respond to emergencies or disasters in
order to protect the confidentiality, integrity and availability of its information systems.
Reference: IS Contingency Preparedness and Recovery Procedure

6. Business Associates Contracts
Northpointe may permit a business associate to create, receive, maintain, or transmit ePHI on its
behalf. This agreement provides assurance that the business associate will appropriately
safeguard the information.
Reference: Business Associate Agreement Policy

7. Facility Access Controls
Northpointe must appropriately limit physical access to the information systems contained within
its facilities while ensuring that only properly authorized workforce members can physically
access such systems.
Reference: IS Facility Access Controls Procedure

8. Workstation Use & Security
Northpointe workstations and media shall be used only for authorized purposes to support the
research, education, clinical, administrative, and other functions of Northpointe. Workforce
members shall not use Northpointe workstations to engage in any activity that is either illegal or
is in violation of other Northpointe policies. Access to Northpointe workstations with ePHI shall
be controlled and authenticated. Northpointe shall regularly conduct a formal, documented
process that ensures accountability of all electronic media and information systems containing
ePHI.
Reference:        Internet Use Policy
                  Email Use Policy
                  Workstation Use and Security Policy
                  Device and Media Control Policy

9. Information System Access Controls
Northpointe shall develop and implement a formal documented process for authorizing and
granting appropriate access to information systems containing ePHI.
Reference:      IS Systems Access Controls Procedure
                Password Policy
                Network Security End User Policy



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10. Audit Controls
Northpointe will record and examine significant activity, as defined by the risk analysis, on its
information systems that contain or use ePHI. Audit record shall include user identifications,
date/time and description of the event.
Northpointe will conduct a technical and non-technical evaluation on annual basis of its security
controls and processes to document its compliance with its security policies and the HIPAA
Security Rule. The evaluation will be carried out by the Information Security Officer or a third-
party organization that has appropriate skills and experience. The evaluation will be documented
and recorded to in support of organization’s compliance with HIPAA ePHI standards.

11. Data Integrity
Northpointe must appropriately protect the integrity of all ePHI contained on its information
systems. Methods used to protect the integrity of ePHI contained on Northpointe information
systems must ensure that the value and state of the ePHI is maintained and protected from
unauthorized modification and destruction.

12. Transmission Security
Northpointe must provide an appropriate protection for confidentiality, integrity and availability
of all data it transmits over electronic communications networks. Appropriate protection should
include, but not limited to, data encryption as determined by relevant risk analysis. Highly
sensitive Northpointe data such as authentication must always use encryption and integrity
controls. Northpointe Information Security Officer must approve all encryption and integrity
controls prior to their use.

When applying risk analysis, consider the following factors when determining whether or not
encryption or integrity controls must be used:
     The sensitivity of the data
     The risks to the data if they are not encrypted
     The expected impact functionality and work flow if the data are encrypted
     Alternative methods available to protect the confidentiality, integrity and availability of
        the data
     The ability of the recipient of the data to decrypt and/or check the integrity of the data
        received

Scope/Applicability:
This policy is applicable to all workforce members.

This policy’s scope includes all electronic protected health information, as described in HIPAA
Security Cross Reference.

Responsible Department:
Information Systems / Technology

Policy Authority/ Enforcement:
Northpointe’s Security Officers are responsible for monitoring and enforcement of this policy, in
accordance with related policies and procedures.

Related Policies / Procedures:
As referred to in the Policy section above.



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Renewal/Review:
This policy and all supporting documents are to be reviewed annually to determine if the policy
complies with current HIPAA Security regulations. In the event that significant related
regulatory changes occur, the policy will be reviewed and updated as needed.

Scope of Legislative Reference:
This policy is also intended to act in accordance with the security and privacy safeguards of the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), other federal and state
laws protecting confidentiality of health information, accreditation requirements and professional
ethics. This policy will reference only HIPAA standards directly. All other Federal, State or
accreditation requirements are adhered to but not referenced in this policy.

HIPAA Security
Rule Language:
“Implement policies and procedures to prevent, detect, contain, and correct security violations.”




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NBHS CARE MANAGEMENT                                                             Section 11
Provider Network Manual

Billing Information
     A. All payments are made on the mutual assumption that the parties’ relationship is
        that of an independent contractor.

     B. Northpointe shall reimburse the Provider only for those clients and services as
        approved by Northpointe’s Chief Executive Officer or his/her designee.

     C. Northpointe reserves the right to withhold payment for services, which are not
        correctly documented per client services manager’s instructions.

     D. The Provider agrees to provide a billing statement (using a format acceptable to
        Northpointe) for each month in which contractual services are completed pursuant to
        this Agreement. Facility Providers shall submit each billing statement by the third of
        the next month to Northpointe. Professional service/Individual Provider’s (i.e.: OT,
        PT, SLP, Psych, Dietary, etc) need to submit a bill for the first half of the month (days
        1-15) by the 18th and for the later half (days 16-31) by the third of the following
        month. Submission of a billing statement to Northpointe for any contractual service
        fees constitutes the Provider’s verification that the services have been completed, as
        authorized. Statements arriving after the third of the month will result in delayed
        payment to the Provider.

     E.   Northpointe shall process billings for client fees (i.e., service payments made directly
          by such Clients to Northpointe) and reimbursements from Medicaid, Medicare,
          managed care organizations, self-insured employers, third party administrators, Blue
          Cross/Blue Shield of Michigan and/or insurance carriers, etc., for the Provider ‘s
          services to the Clients and only Northpointe shall receive and retain, rightfully, all
          said fees and reimbursements for the services provided by the Provider under this
          Agreement.

     F.   Each party shall retain all billing and payment records for a total of seven (7) years
          after the date of generation and shall permit access to such payments upon the
          request of the other or any authorized representative of a third-party payer as
          identified in the preceding paragraph. This provision shall survive termination of
          this Agreement.

     G. All questions regarding appropriate billing forms may be directed to the Contract
        Manager at 1.906.779.0644.

     H. All billing information must be forwarded to:
                         Northpointe Behavioral Healthcare systems
                            715 Pyle Drive, Kingsford, MI 49802
                                  Attn: Accounts Payable
                                        906.779.0525




                                                                                              156
NBHS CARE MANAGEMENT               Section 12

Provider Network Manual




            Provider Application




                                                157
                                   Provider Application
                    Northpointe Behavioral Healthcare Systems Network


A.       PERSONAL INFORMATION (For Group Providers please begin with Section B)


Last Name                                                     First                                M.I.


Home Address                          City                             State             Zip                 Phone #

SS #        /       /         DOB          /      /           County/State of Birthplace:

Highest Degree:                          Discipline:                               Licensed as:

     Male        Female    U.S. Citizen?          Yes        No If no, status of Visa at the present time:

List all languages in which you are proficient (including American Sign Language):


B.       PRACTICE LOCATION / BILLING INFORMATION
Sole Provider           Group Provider            Group / Business Name:

Tax ID:                               Group ID                 Individual ID          DEA Number:
If a group provider, are you accredited?                     Yes      No                JCAHO             CARF
NCQA         COA

Contact Person:                          Title:                         Phone #:

Primary Office Address:


Street Address                                                City                                 State / Zip


County                      Phone #                           Fax #                                E-mail Address

Mailing / Billing Address (if different from primary office address):


Street Address                                                City                                 State / Zip


County                      Phone #                           Fax #                                E-mail Address

Billing / Accounts Manager:                                                      Phone #:

Are you a Medicaid Provider?                   Yes          No Medicaid Number:

Are you a Champus Provider?                           Yes      No      Provider Number:

Do you accept Medicare Assignment?                    Yes      No      UPIN Number:


                                                                                                                 158
Do you file claims electronically?            Yes     No

Provider Application Secondary Office Address: (Any additional addresses may be listed on a
separate sheet and attached to application)


Street Address                                       City                              State / Zip


County                     Phone #                   Fax #                             E-mail Address

Professional Liability Information: (Please list carriers for the past 5 years)

Current Carrier:                                                       Policy #:

Address:                              City:                   State:                    Zip:

Coverage Limits: $                    /$              Date coverage began:         /    /
Expiration:     /         /
                       (occurrence)           (aggregate)

Previous Carrier:                                                      Policy #:

Address:                              City:                   State:                    Zip:

Coverage Limits: $                    /$              Date coverage began:         /    /
Expiration:     /         /
                       (occurrence)           (aggregate)

C.       PRACTICE INFORMATION

Office Hours (Specific to each location, attachments acceptable for additional locations)
    Monday        Tuesday         Wednesday       Thursday       Friday Saturday Sunday
        ___             ___             ____           ___                 ______

Are you able to schedule clients for an initial appointment within 7 days of their first contact
with your agency?       Yes       No

Do you provide 24-hour coverage?    Yes                No
Night/Beeper, Answering Service Number:

Do you have 24-hour access to a licensed psychiatrist or doctoral level psychologist?
      Yes       No
If yes, give name, address and phone number of doctor:



Client Population you serve (Check the age ranges for which you offer services and provide the
percentage of your current practice represented by each):
Treat Percentage                               Treat Percentage


                                                                                                     159
                Adult (19-64 years)                             Adult (65 years and older)

                Adolescent (13-18 years)

                Child (6-12 years)                              Child (0-5 years)

Cultural Competency/Special Needs Population you serve (if applicable):

    Blind / Visually Impaired        Developmentally Disabled       Mentally Ill
    Deaf / Hearing Impaired          Physically Impaired            Veterans
    Geriatric                        American Indian
    Other (please specify):


Can you communicate with patients via TDD (Telecommunications Device for the Deaf)?
      Yes          No
Are your office locations wheelchair/handicap accessible?
      Yes          No
Is your office located within one block of public transportation carrier stop?
      Yes          No

Treatment Modalities (Indicate modalities you currently employ in your practice):

  Biofeedback             Behavior Modification            Hypnotherapy            EMDR
  Psychotherapy           Individual                       Conjoint / Couple       Family
  ECT                     Pharmacotherapy                  Group (Please specify type):
   Inpt.     Outpt.            EAP
       Other (please specify):




Clinical Services for Specific Disorders: (Under Training, check those disorders for which you
have had post-graduate or post-residency training and/or experience. Under Service Population,
check the age group you currently treat for specific disorders).
Training                     Service Population: Children                Adolescents     Adults
        Geriatrics
    ADHD
    Anxiety Disorders
    Adj / Re-Adj Disorder
    Mood Disorders
    Psychotic Disorders
    Personality Disorders
    Psychosomatic / Somatoform
    Addictions
    Trauma / Crisis
    Grief / Bereavement
    Head Injury Patients
    Chronic Pain / Illness
    HIV Positive Patients


                                                                                             160
    Sexual Disorders
    Eating Disorders
    EMDR
    Post Traumatic Stress Disorder
    Other:

Hospital Privileges (Please list the hospitals at which you currently have privileges):


Hospital Name             City    Type of Privilege                                      Department


Hospital Name             City    Type of Privilege                                      Department


Hospital Name             City    Type of Privilege                                      Department

Professional Society Memberships and/or Fellowships: (List all professional fellowships,
memberships, and societies, past and present. List additional information on a separate sheet):


Name of Organization                                                           Inclusive Dates

Complete Street Address                              City                      State             Zip



Name of Organization                                                   Inclusive Dates

               ___________________________________________________________
Complete Street Address                  City                State        Zip


LICENSURE AND OTHER REGISTRATION
List all active licenses and licenses held in the last five (5) years. A copy of all current licenses
must accompany this application (along with a copy of your DEA certificate if applicable).

State:           License #:                ______ Type:              Expiration Date:_____________

State:           License #:                ______ Type:              Expiration Date:_____________

DEA #:                                                           Issue Date:
Expiration Date:

Specialty Board Certification

Are you certified by a specialty board?        Yes          No         If yes, specialty:


Date Certified:                     Certification #:
Expiration Date:


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Have you ever been re-certified?        Yes        No
If yes, date:

Are you certified by more than one specialty board?          Yes        No
If yes, specialty:

Date Certified:                    Certification #:
Expiration Date:

Have you ever been re-certified?        Yes        No         If yes, date:

Have you applied for a board examination?          Yes             No     If yes, which board:


Are you scheduled for examination by any specialty board?           Yes         No If yes, which
board:

If you have been accepted into the examination process, give year when acceptance will
terminate:

D.      EDUCATION / EXPERIENCE (Group Providers may omit this Section if nationally
accredited)
Attach vita/resume to provide information on employment experience, education, internship,
residency, or equivalent positions in chronological order. Employment history must include all
the positions held for the last five (5) years. Please provide explanation for any gaps in history.


College / University                      Degree                              Graduation Date


Street Address                            City                                State              Zip

If degree obtained outside of the United States, please submit copy of Educational Commission
for Foreign Medical Graduates or other applicable educational board Certificate verifying
satisfactory examination in the United States.


College / University                      Degree                              Graduation Date


Street Address                            City                                State              Zip

Previous Practice Locations and Dates:


Practice Name                                      Address                                       Dates

Practice Name                                      Address                                       Dates

Practice Name                                      Address                                       Dates


                                                                                                       162
Continuing Medical Education
Physicians must provide proof that they have met the continuing medical education requirements
set by the recognition award of the AMA, AOA, or other continuing medical education required
by state law, if greater. Please attach a list of continuing medical education activities you have
participated in during the past 24 months.

Voluntary Information
Not only do customers often express preferences for therapists of a particular ethic background or
gender, but also employers may wish to determine if our network reflects the ethnic/gender
profile of their employees. If you volunteer to provide the following information, it will be held
in the strictest confidence. It will be used only when a customer indicates such information is
important when selecting a provider or in the aggregate profile of our network.

Ethnic Background:           American Indian / Alaskan Native               Asian / Pacific Islander
           Black             Caucasian        Hispanic                  Other:

Disclosure Questions
Please provide a complete, signed and dated explanation on a separate sheet if any of the
following questions are answered in the affirmative.

Yes      No        1. Have you ever been named in any malpractice action? (This would include
pending claims or lawsuits, dismissed or dropped claims/lawsuits, settlements and final
judgments).
Yes      No        2. Has your professional liability carrier ever cancelled your insurance or refused
renewal?
Yes      No        3. Has your professional license or registration (including DEA if applicable)
ever been terminated, suspended, voluntarily relinquished, refused or not renewed by any
licensing board of any health related agency, or is there a review pending?
Yes      No        4. Has your membership, participation, clinical privileges or employment ever
been denied, terminated, restricted, refused, revoked, or not renewed by any peer review
organization, third party payer, medical staff, or any health-related agency, or is there a review
pending?
Yes      No        5. Has your certificate or participation in any private, federal (i.e. Medicare,
Medicaid, etc.) or state health insurance program ever been revoked or otherwise limited or
restricted, or is any investigation with respect to any such action presently underway?
Yes      No        6. Are there any charges pending or are you currently charged with or have you
ever been indicted or found guilty of a felony, misdemeanor (other than a traffic violation), or
other offense involving fraud, misrepresentation, dishonesty or deceit?
Yes      No        7. Have you ever been found liable, guilty or responsible for sexual impropriety,
misconduct or sexual harassment?
Yes      No        8. Are you currently using illegal drugs?
Yes      No        9. Do you have a condition that would affect your ability, with or without
reasonable accommodation, to perform the essential functions of a practitioner in your area of
practice without posing significant health or safety risk to your clients?

Acknowledgements and Attestation

I wish to participate in Northpointe Behavioral Healthcare Systems Provider Network. I hereby
certify that all information in this application is complete, true and accurate. I further understand
that information entered into this Application which is subsequently found to be false could result
in a change of my status as a provider and/or the cancellation of any contract or employment


                                                                                                 163
agreement I may have entered into with Northpointe. If any material changes occur affecting my
professional status, I understand it is my obligation to notify the Human Resource Director
(employees) or the Network Manager (contract providers).


Signature:                                                                  Date:


Name:
             (Please print or type name)


Professional References
    We require the submission of the name/title, organization and address of three (3)
        individuals personally acquainted with the applicant’s professional, clinical and ethical
        performance in other settings. One reference must be the individual with the most recent
        organizational responsibility for your performance. If possible, references should
        originate from more than one practice location. We will contact the references listed.

Consent to Release information

I hereby grant permission and consent for Northpointe Behavioral Healthcare Systems and/or its
designee, to contact the references here listed, and to obtain and/or verify the information
contained in this application. I consent to the release of all information that may be reasonably
relevant to an evaluation of my professional competence, ability to render clinical services in a
cost-effective manner, and moral character and ethical qualifications by any person, organization
or other entity. I agree to hold harmless any such person, organization, or other entity from any
cause of action based on the release of such information to Northpointe Behavioral Healthcare
Systems and/or its designee. I understand that my participation as a provider for Northpointe
Behavioral Healthcare Systems is dependent upon review of this application and completion of
the credentialing and privileging processes.


Signature:                                                  Date:


Please submit application and related materials to:
Attn: Contract Manager, Northpointe Behavioral Healthcare Systems, 715 Pyle Drive,
Kingsford, MI 49802.

Attach:
    1)        Current resume/vitae to include documentation of relevant training or experience.
    2)        Copy of transcripts and diploma.
    3)        Copies of current licenses, certifications and accreditation if applicable.
    4)        A copy of your Professional Liability Insurance Certificate sent directly to
              Northpointe by your liability carrier.

When submitting a group application, each provider must fill out an application. Duplicate form
as needed.

Note: You must receive written confirmation of your clinical approval and contractual providers


                                                                                              164
must have a signed executed contract from Northpointe Behavioral Healthcare Systems prior to
seeing any NBHS clients.

---------------------------------------------------------------------------------------------------------------------

For Office Use Only

Credentialing Date:

Notes:




This information is confidential and the proprietary information of NBHS.




                                                                                                                 165
NBHS CARE MANAGEMENT                                                           Section 13

Provider Network Manual


                        Regional Provider Network Offices

Information regarding the location of all offices and other providers in included in this section.


Northpointe Kingsford Office:

        Northpointe Crises Center                          1-800-750-0522
        (24-hours-a-day/7-days-a-week assistance)

        715 Pyle Drive, Kingsford, MI 49802                1-906-774-0522
                                                           1-800-750-0522

        Fax – Clinical Services                            1-906-779-1306
        Fax – Administrative Services                      1-906-774-1570

Prevention Services                                        1-906-779-0637

Older Adult Services                                       1-906-779-0542

Phoenix Center                                             1-906-779-2131
405 Carpenter Ave., Iron Mountain MI 49801



Northpointe Iron River Office:

Northpointe Crises Center                                  1-800-750-0522
(24-hours-a-day/7-days-a-week assistance)

703 2nd Ave., Iron River, MI 49935                         1-906-265-5128

        Fax – Clinical Services                            1-906-265-5878



Northpointe Menominee Office:

Northpointe Crises Center                                  1-800-750-0522
(24-hours-a-day/7-days-a-week assistance)




                                                                                                 166
401 Tenth Ave., Menominee, MI 49855                         1-906-863-7841
                                                            1-800-273-7143

         Fax – Clinical Services                            1-906-863-6280


Other:

Office of Recipient Rights                                  1-906-863-1519
                                                            1-800-750-0522

Director of Developmental Disability Services               1-906-265-5126


Billing Questions                                           1-906-774-0522
                                                            1-800-750-0522


TDD – Michigan Relay Center                                 1-800-649-3777




     Northpointe Behavioral
       Healthcare Systems
 Provider Network
             2010

             Name                         Address             Phone Number            Services
PSYCHIATRIC
HOSPITALS
Alpena General Hospital            1501 West Chisholm St        989.356.7390   Psychiatric Inpatient
                                   Alpena, MI 49707                            Services - Adults

Bellin Psychiatric Center          301 East St. Joseph          920.433.3629   Psychiatric Inpatient
                                   Street, PO Box 23725                        Services - Children,
                                   Green Bay, WI 54305                         Adolescents & Adults
                                                                               ECT Available


Marquette General                  420 W. Magnetic Street       906.228.9440   Psychiatric Inpatient
                                   Marquette, MI 49855                         Services - Children,
                                                                               Adolescents & Adults
                                                                               ECT Available




                                                                                              167
Northern Michigan Hospital    416 Connable Ave.        231.487.4000   Psychiatric Inpatient
                              Petoskey, MI 49770                      Services - Adults Only
                                                                      ECT Available
St. Mary's Hospital           1044 Kable               715.369.6428   Psychiatric Inpatient
                              Rhinelander, WI 54501                   Services - Adolescents
                                                                      and Adults

War Memorial                  500 Osborn Blvd          906.635.4456   Psychiatric Inpatient
                              Sault Ste Marie, MI                     Services - Adults
                              49783

Specialized Residential
Beacon Services (formerly KRF) 56838 48th Avenue       616.674.7616   Licensed AFC, Serves
                               Lawrence, MI 49864                     Male and Female in 4
                                                                      home complex. Case
                                                                      Management &
                                                                      Psychiatric services
                                                                      available
Birchwood AFC                 646 Lake Street          906.774.9571   Licensed AFC,
                              Quinnesec, MI 49876                     Services Adult Female
                                                                      - Capacity - 6
Erickson’s AFC                W637 US 2 & 41           906.466.5317   Licensed AFC, Serves
                              Harris, MI 49845                        Male and Female,
                                                                      Capacity 4


Ihander AFC                   N9910 Holmesbrook Rd.    906.753.4572   Licensed AFC, Serves
                              Daggett, MI 49821                       Male and Female,
                                                                      Capacity - 5
Kutha AFC North               W9835 Co. Rd. 352        906.753.4880   Licensed AFC, Serves
                              Rt. 1 Box 220                           Male and Female
                              Stephenson, MI 49887                    Capacity - 11
Lane St AFC                   340 Lane St              906.828.1605   Licensed AFC, Serves
                              Kingsford, MI 49802                     Male and Female,
                                                                      Capacity -6
Lighthouse                    1336 Riverview           906.774.7663   Licensed CFC, Serves
                              Kingsford, MI 49802                     Male or Female
                                                                      Capacity - 4
Newlin AFC                    W5338 No 14 Rd           906.788.4873   Licensed AFC, Serves
                              Wallace, MI 49893                       Male and Female,
                                                                      Capacity - 3
Schlaud AFC                   W8677 Co. Rd. 356        906.753.4092   Licensed AFC, Serves
                              Rt. 1 Box 142                           Male and Female
                              Stephenson, MI 49887                    Capacity - 12
Teaching Family Homes         1009 West Ridge Street   906.228.7997   Licensed Child Caring
Regional Treatment Center     Marquette, MI 49855                     Institution, Serves MI &
                                                                      DD Children,
                                                                      Capacity - 6




                                                                                     168
Wakeham Children's Home        214 Wyandotte             906.482.7188   Licensed Child Caring
                               Atlantic Mine, MI 49905                  Institution, Serves MI &
                                                                        DD Children,
                                                                        Capacity - 6

Vocational Services
Goodwill Industries            1428 Main Street          715.732.0563   Vocational Services for
                               Marinette, WI 54143                      Dickinson &
                                                                        Menominee Counties
                                                                        including OES, CES, &
                                                                        Personal, Social,
                                                                        Community .
Powers Activity Center         N16068 Pinecrest Drive    906.497.5666   Prevocational and Skill
                               Powers, MI 49874                         Building services
Trico, Inc.                    137 N. Hooper St.   PO    906.774.5718   Vocational Services in
                               Box 2610                                 Dickinson & Iron
                               Kingsford, MI 49802                      Counties includes OES
                                                                        & CES, and Maint.




    Individual Providers
Johnson, Neal, NLJ PT Center   901 Pyle Drive            906.774.3779   Physical Therapy
                               Kingsford, MI 49802

Schmeisser, Dale, PhD          Route 1, Box 70A          906.852.3547   Dietician
                               Trout Creek, MI 49967
Zigman, Carrie, SLP            1001 Pierce Ave.          715.251.1598   Speech Therapy
                               Niagara, WI 54151
          Physicians
Carlson, Vernette, MD          Daggett Clinic            906.753.2155   residential physician for
                               PO Box 37 School Rd                      Men. Co
                               Daggett, MI 49821
Kearney, Terrance, DO          1500 W. Ice Lake Rd.      906.265.5378   residential physician for
                               Iron River, MI 49935                     Iron Co.

Ziemba, Dennis, MD             145 Roseland Street       906.774.1944   residential physician for
                               Kingsford, MI 49802                      Dick. Co.




                                                                                       169
NBHS CARE MANAGEMENT                                                    Section 14
Provider Network Manual


Network Design
The development and management of the Northpointe Provider Network is under the
direction of the Financial Department of the Administrative Services division of
Northpointe Behavioral Healthcare Systems. As such, it is your primary resource within
the organization.
       Chief Financial Officer                      906.779.0525
       Reimbursements                               906.779.2342
       Billing Information                          906.779.0539
       Contract Management                          906.779.0644

However, as a provider of clinical services, several departments within Northpointe are
available resources for you. The functions of these areas as they pertain to you are
discussed below.
   A. Recipient Rights Department – 906.863-1519 or 906.774.0555
      Northpointe is bound by federal and state confidentiality requirements with
      respect to all written and verbal communication about consumer clinical history,
      treatment plans, etc. The Provider must demonstrate their ability to meet these
      standards.
   B. Customer Service/Access Department – 906.779.0527
      The Customer Service/Access Department can provide general information on
      Northpointe programs and operations as well as direct your call to the
      appropriate department for further information or follow-up. The Access
      Department may also complete an initial consumer screening, entering
      consumers into our service delivery system
   C. Utilization Management Department – 906.779.0537
      This department has staff available 24 hours per day/7days per week for:
              Preauthorization of inpatient services
              Authorization of additional services
              Utilization Review
              Consultation for case specific issues

   D. Clinical Services – Call the appropriate Department Manager
      This department will assist you with case specific information. Please consult
      with the appropriate director.
              Dickinson County Director of Behavioral Services – 906.779.0528


                                                                                       170
       Menominee County Director of Behavioral Services – 906.863.1525
       Iron County Director of Behavioral Services – 906.265.5126
       Director of Older Adult Services – 906.779.0542
       Director of DD Services – 906.265.5126
E. Medical Director – 906.774.0522
   This Department will assist you with case specific information.
F. Older Adult Services – 906.779.0532
   This Department offers consultation to Nursing Homes, completes OBRA
   assessment and assists families in caring for their elderly loved ones.
G. Director of Human Resources – 906.779.0529
   This Department will assist you with the credentialing process and any
   personnel related issues.
H. Director of Environmental Safety – 906.779.0547
   This Department will assist you in maintaining a safe working environment.
   Any and all concerns regarding facility structure and/or vehicle safety need to
   be directed to this department.
I.   Director of Developmental Disabilities Services – 906.265.5126
     This Department will assist you in specific services for developmentally disabled
     individuals including residential and vocational services.




                                                                                  171
NBHS CARE MANAGEMENT                                                       Section 15

Provider Network Manual


                             Sentinel Event Policy
POLICY:
It is the policy of Northpointe Behavioral Healthcare (NBHS) to report, review, investigate, and
act upon sentinel events for persons living in 24-hour specialized settings; those living in their
own homes receiving ongoing and continued assistance with activities of daily living; Assertive
Community Treatment (ACT), Home Based services, Wraparound services, children enrolled in
the Children’s Waiver Program or the Children’s SED Waiver, and those persons receiving
Targeted Case Management or Habilitation Supports Waiver Coordination services. When an
unusual incident occurs, an employee must complete the Unusual Incident Report (rr.100) and
email the report immediately to the Recipient Rights officers, the Quality Improvement Manger
and their immediate supervisor.

PURPOSE:
To ensure a process is in place to report and review all sentinel events.

APPLICATION:           All incidents meeting definitions described in this policy.

DEFINITIONS:
Incident is any of the following, which shall be reviewed by the Recipient Rights Officer
and the Quality Improvement Manger to determine whether it meets the criteria for
sentinel event per the “Sentinel Event Definition” listed below.
         death of recipient
         serious illness requiring admission to hospital
         alleged case of abuse or neglect
         injury from accident or abuse to the recipient requiring emergency room visit
            or admission to hospital serious challenging behavior
         arrest and/or conviction
         medication error (Category III only)

Sentinel Event is defined as an “unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof. Serious injury specifically includes
loss of limb or function. The phrase, “or the risk thereof” includes any process
variation for which a reoccurrence would carry a significant chance of a serious adverse
outcome.” (JCAHO 1998)

24-hour Specialized Settings means residential home certified by Michigan Department
of Human Services to serve persons with mental illness or developmental disabilities.



                                                                                               172
Own Home for purposes of sentinel event reporting means supported independence
program for person with mental illness or developmental disabilities regardless of who
holds the deed, lease, or rental agreement; as well as own home or apartment for which
the consumer has a deed, lease, or rental agreement in his/her own name. Own home
does not mean a family’s home in which the child or adult is living.
Ongoing and continuous in-home assistance means assistance with activities of daily living
provided in the person’s own home at least once a week, and 6 months or longer.

Death: that which does not occur as a natural outcome to a chronic condition (e.g., terminal
illness) or old age.

Injuries occurring as a result of accidents or abuse which required visits to emergency rooms,
medi-centers and urgent care clinics/centers and/or admissions to hospitals should be included in
reporting. In many communities where hospitals do not exist, medi-centers and urgent care
clinics/centers are used in place of hospital emergency rooms.


Physical illness resulting in admission to a hospital does not include planned surgeries, whether
inpatient or outpatient. It also does not include admissions directly related to the natural course
of the person’s chronic illness, or underlying condition. For example, hospitalization of an
individual who has a known terminal illness in order to treat the conditions associated with the
terminal illness is not a sentinel event.

Serious challenging behaviors are those not already addressed in a treatment plan and
include significant (in excess of $100) property damage, attempts a t self-inflicted harm
or harm to others, or unauthorized leaves of absence. Serious physical harm is defined by
the administrative rules for mental health (330.7001) as “physical damage suffered by a
recipient that a physician or registered nurse determines caused or could have caused the
death of a recipient, caused the impairment of his or her bodily functions, or caused the
permanent disfigurement of a recipient.”

Arrests and Convictions are any arrest or conviction that occurs with an individual who is
in the reportable population at the time the arrest or conviction takes place.

Medication Errors mean a) wrong medication; b) wrong dosage; c) double dosage; d)
missed dosage that resulted in death or serious injury or the risk thereof. It does not
include instances in which consumers have refused medication.

APPLICATION
With the exception of arrests/convictions and serious challenging behaviors, all incidents
involving the population described above should be reviewed to determine if the
incidents meet the criteria and definitions for sentinel event, and are related to practice of
care. The outcome of this review is a classification of incidents as either a) sentinel
events, or b) non-sentinel events.

PROCEDURE:




                                                                                                173
1. Review to Determine If Incidents Are Sentinel Events: The Office of Recipient
   Rights and the Quality Improvement Manager will review all Unusual Incident
   Reports to determine if they meet criteria and definitions for sentinel events and if
   they are related to practice of care. The outcome of this review will be a
   classification for incidents as either sentinel events or non-sentinel events.

2. Root Cause Analysis: A thorough and credible root cause analysis or investigation
   will be conducted within 2 business days of the sentinel event. This will be a
   “process for identifying the basic or causal factors that underlie variation in
   performance, including the occurrence or possible occurrence of a sentinel event. A
   root cause analysis focuses primarily on systems and processes, rather than individual
   performance.” (JCAHO, 1998)
   This Root cause analysis will be conducted by a review team consisting of the
   Deputy/Clinical Director, Utilization Manager, Medical Director or designated
   medical staff, QI Manager, and the appropriate supervisor(s) and staff and the
   analysis will begin within 2 days of the event.

3. Plan of Action/Rationale for Not Intervening: Following the root cause analysis,
   Northpointe will implement either a plan of action to prevent further occurrence of
   the sentinel event or presentation of a rationale for not pursuing an intervention. A
   plan of action or intervention must identify what actions are to be implemented, who
   will implement, when and how implementation will be monitored or evaluated.
   Documentation must also include whether or not policy and procedure was
   appropriately followed.

CREDENTIALS FOR PERSONS INVOLVED IN REVIEWS
Sentinel events are reviewed and acted on as appropriate by individuals possessing the
appropriate credentials to review the scope of care. Participation by a physician or nurse
will be required in any instance that involves a serious medical condition or death.
NorthCare's Medical Director is available for consultation purposes and to review
sentinel events as deemed necessary

REPORTING:

Data Submission to MDCH and NorthCare.
Northpointe will submit a copy of Root Cause Analysis completed on each sentinel event
to NorthCare via confidential website on Quickplace. The sentinel event statistical data
for consumers on Children’s Medicaid Waiver and Children’s SED Waiver will be
reported directly to MDCH quarterly on a template provided by MDCH. Plans of action
or interventions will be available upon request by MDCH and/or NorthCare. Some
exceptions to the root cause analysis rule may be arrests, convictions, and repeat offenses
for which the issues have already been analyzed.
Statistical data of Sentinel events on all other Medicaid consumers in the reportable
populations will be reported to Nothcare semi-annually on the template provided by
MDCH for reporting purposes.




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