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Corporate Organizational Chart Example

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Corporate Organizational Chart Example document sample

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									                                                                     NC DHHS
   Reviewer:
                                                                  DMH/DD/SAS
   Date Reviewed:                                 Community Support (MH/SA)- Children/ Adolescents
                                                          Conditional                        Full
                       DESCRIPTION                        Endorsement                    Endorsement
           COMMUNITY SUPPORT (MH/SA) -                    Evidence of       NOT          Evidence of               NOT
             CHILDREN/ADOLESCENTS                          Compliance MET   MET   NA      Compliance         MET   MET   NA   COMMENTS
   Provider Requirements
a. **1) Must be delivered by practitioners employed
  by a mhsa provider organization which meets
  standards established by the Division of                   Provider
                                                                                           Provider
  MHDDSAS. These standards set forth the                    application
                                                                                        application with
  administrative, financial, clinical, quality                with all
                                                                                          all required
  improvement, and information services                      required
                                                                                          supporting
  infrastructure necessary to provider services.            supporting
                                                                                        documentation
   2) Organizations must demonstrate that they meet       documentation
                                                                                         completed as
  these standards by being certified by the LME. Within 3 completed as
                                                                                          required in
  years of enrollment, must have national accreditation     required in
                                                                                           provider
                                                             provider
                                                                                          application;
  ** 3) The organization must be established as a          application;
                                                                                           Program
  legally recognized entity in the US and registered         Program
                                                                                          description;
  to do business as a corporate entity in the State of     description;
                                                                                           Policy &
  N.C.                                                       Policy &
                                                                                          Procedure
  4) CS providers must have the ability to deliver          Procedure
                                                                                             Manual
  services in various environments, such as homes,            Manual
  schools, detention centers & jails (state funds only)
  homeless shelters, street locations, etc.
b There is evidence of fidelity to EBP                     training plan                training records
   Staffing Requirements
a **1) Persons who meet the requirements specified                                      Personnel files;
   for Qualified Professional or Associate                                                 Supervision
   Professional status according to 10A NCAC                                                plans and
   27.G.0104, within the requirements specified in the                                   documentation
                                                            Program
   above rule. 2) Supervision is provided according to                                   that education,
                                                          description;
   supervision requirements specified in 10A NCAC                                         experience &
                                                           Personnel
   27.G.0104 & according to licensure or certification                                  training for staff
                                                          Manual; Job
   requirements of the appropriate discipline.                                            are consistent
                                                          descriptions
                                                                                               with
                                                                                          requirements
                                                                                               and
                                                                                         responsibilities.




                                                                              1 of 12                                         7ba39734-c7dd-4944-b30c-cc014cce8960.xls
                                                                         NC DHHS
    Reviewer:
                                                                      DMH/DD/SAS
    Date Reviewed:                                    Community Support (MH/SA)- Children/ Adolescents
                                                                Conditional                        Full
                         DESCRIPTION                            Endorsement                    Endorsement
          COMMUNITY SUPPORT (MH/SA) -                           Evidence of       NOT          Evidence of              NOT
              CHILDREN/ADOLESCENTS                               Compliance MET   MET   NA      Compliance        MET   MET   NA   COMMENTS
  Staffing Requirements (continued)
b **1) Paraprofessional level providers who meet the
  requirements specified for paraprofessional status
  according to 10A NCAC 27.G.0104 N.C. may
  deliver CS services within the requirements of the                                          Personnel files;
  staff definition specific in the above role. **2)               Program                        Supervision
  When a paraprofessional provides CS services                  description;                      plans and
  they must be under the supervision of a QP.                    Personnel                     documentation
  Supervision shall be carried out according to 10A             Manual; Job                   that supervision
  NCAC 27.G.0104.                                               descriptions                    requirements
   **2) When a paraprofessional provides CS                                                    are being met.
  services they must be under the supervision of a
  QP. Supervision shall be carried out according to
  10A NCAC 27.G.0104.
c QP, CCS, CCAS can perform the following activities:             Program                     Personnel files
  Coordination & oversight of initial & ongoing                 description;                   and consumer
  assessment activities; initial development & ongoing           Personnel                     charts to show
  revision of PCP; monitoring of implementation of PCP.         Manual; Job                     QP actions re
                                                                descriptions                          PCP
d AP and paraprofessional can perform the following               Program                     Personnel files
    activities: various skill building activities of daily &    description;                   and consumer
    community living skills; socialization skills, adaptation    Personnel                     charts to show
    skills; symptom management skills, wellness education;      Manual; Job                     AP and Para-
    education substance abuse; behavior & anger                 descriptions                    prof activities
    management techniques.                                                                          with/for
                                                                                                  consuumer.
e    Staff providing CS services to children & families must      Program                     Personnel files
    complete a twenty hours of training specific to CS          description;                    showing that
    including crisis response within the first 90 days of        Personnel                       staff have at
    employment.                                                 Manual; Job                    least minimum
                                                                descriptions                  experience and
                                                                                              documentation
                                                                                              of completion of
                                                                                                    training
                                                                                                requirements.




                                                                                    2 of 12                                        7ba39734-c7dd-4944-b30c-cc014cce8960.xls
                                                                          NC DHHS
   Reviewer:
                                                                       DMH/DD/SAS
   Date Reviewed:                                      Community Support (MH/SA)- Children/ Adolescents
                                                               Conditional                        Full
                         DESCRIPTION                           Endorsement                    Endorsement
           COMMUNITY SUPPORT (MH/SA) -                         Evidence of       NOT          Evidence of            NOT
             CHILDREN/ADOLESCENTS                               Compliance MET   MET   NA      Compliance      MET   MET   NA   COMMENTS
  Service Type / Setting
a CS is a direct & indirect periodic service where the CS
   worker provides direct intervention & also arrange,                                       Program
   coordinates, & monitors services on behalf of the           Program                       description,
   recipient. Service is provided in any location and may      description                   PCP, service
   be provided to an individual or a group of individuals.                                   notes

b 1) For persons residing in higher-level residential          Program                       Program
   program (e.g., PRTF, residential levels II-IV), CS          description                   description,
   services are limited to individuals transitioning from or                                 PCP, service
   to these residential programs.                                                            notes, Medicaid
                                                                                             RA forms

c 1) CS also includes telephone time with the recipient & Program                            PCP, service
   collateral contact with persons who assist the recipient    description                   notes, Medicaid
   in meeting his/her rehabilitation goals.                                                  RA statements

   Program/Clinical Requirements
a All youth receiving CS must receive a minimum of two         program                       PCP, service
  (2) contacts per month with one (1) contact occurring        description                   notes, billing
  face-to-face with the recipient.                                                           tracking forms
b Contact benchmarks shall be measured on an annual            program                       Annual
  basis substantiating sixty per cent (60%) or more of CS      description                   aggregate
  services are delivered face-to-face with recipients &                                      provider report
  sixty per cent (60%) or more of staff time must be spent
  working outside of the agency's facility, with or on
  behalf of the consumers.
c 1) Caseload size may not exceed 1:15 (one QP worker          program                       staff caseload
  per fifteen (15) clients. 2) Groups size may not exceed      description                   assignment,
  eight (8) individuals.                                                                     group
                                                                                             attendance
                                                                                             roster




                                                                                   3 of 12                                      7ba39734-c7dd-4944-b30c-cc014cce8960.xls
                                                                   NC DHHS
   Reviewer:
                                                                DMH/DD/SAS
   Date Reviewed:                               Community Support (MH/SA)- Children/ Adolescents
                                                        Conditional                        Full
                       DESCRIPTION                      Endorsement                    Endorsement
         COMMUNITY SUPPORT (MH/SA) -                    Evidence of       NOT          Evidence of              NOT
            CHILDREN/ADOLESCENTS                         Compliance MET   MET   NA      Compliance        MET   MET   NA   COMMENTS
  Program/Clinical Requirements (continued)
d **The development, monitoring, revising and           Policies and                  Policies and
  updating of the recipient's person centered plan is   Procedures in                 Procedures in
  the responsibility of the qualified professional      place for PCP                 place for PCP
                                                        development                   development.
                                                        that includes                 PCP in chart.
                                                        crisis planning               Documentation
                                                        and procedure                 of C&F Team
                                                        for                           meetings, with
                                                        involvement of                membership,
                                                        child and                     roles,
                                                        family team.                  responsibilities.
                                                                                      Documentation
                                                                                      of family
                                                                                      involvement.




                                                                            4 of 12                                        7ba39734-c7dd-4944-b30c-cc014cce8960.xls
                                                                       NC DHHS
    Reviewer:
                                                                    DMH/DD/SAS
    Date Reviewed:                                  Community Support (MH/SA)- Children/ Adolescents
                                                           Conditional                           Full
                         DESCRIPTION                      Endorsement                      Endorsement
            COMMUNITY SUPPORT (MH/SA) -                    Evidence of       NOT           Evidence of       NOT
                CHILDREN/ADOLESCENTS                       Compliance MET    MET   NA       Compliance MET   MET   NA   COMMENTS
e   **The Community Support must have policies and       Policies and                    Policies and
    capacity to carry out "first responder"              procedutes in                   procedures in
    responsibilities for their recipients on a face to   place for crisis                place for crisis
    face basis and also telephonically at all times      response                        response.
    (24/7/365), with capacity for face-to-face emergency implementation                  Crisis Plans in
    response within 2 hours.                              including on                   charts.
                                                         call                            Proactive Plan
                                                         scheduling                      with triggers and
                                                         process;                        Reactive Plane
                                                         process for                     with contacts
                                                         the on call                     and phone
                                                         person to                       numbers;
                                                         have access                     Service notes
                                                         to consumer's                   document
                                                         crisis plan that                implementation
                                                         includes                        of crisis plan
                                                         proactive plan                  when needed.
                                                         with triggers                   On call rotation
                                                         and reactive                    schedule. On
                                                         plan with                       call person has
                                                         contacts &                      access to and
                                                         phone                           follows
                                                         numbers and                     consumer's
                                                         procedures to                   crisis plan.
                                                         ensure that
                                                         crisis plan is
                                                         followed by
                                                         provider.


    Documentation Requirements
    Minimum standard is a daily full service note that      Service                      PCP; service
    includes: 1) the purpose of contact, 2) describes the   record; Policy               notes document
    provider's interventions, 3) effectiveness of the       & Procedure                  these items.
    intervention, 4) the time spent performing the          Manual
    intervention, and 5) signature (degree/credentials or
    position) of person providing service



                                                                               5 of 12                                  7ba39734-c7dd-4944-b30c-cc014cce8960.xls
Reviewer:                                                        NC DHHS                                                   Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                                 Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                               NOT       60-day review
                  Psychosocial Rehabilittion (PSR)                         Evidence of Compliance                         Evidence of
                                                                                                            MET MET NA    Compliance      COMMENTS
      Provider Requirements
  a   1) Agency has current, valid business verification.                  NEA from another LME or
                                                                            Business Verification
                                                                              completed locally
      Staffing Requirements
  a   Each PSR site must be staffed by the following:

      • At least one (1) full time program director per site who meets
      the requirements specified for a Qualified Professional and
      has a minimum of two years experience in adult mental health
      treatment services who must be actively involved in program
      development, implementation, and service delivery;
      AND
      • At least one (1) FTE Qualified Professional or Associate
      Professional                                                       Organizational Chart for PSR;
      AND                                                                  Program description; Job
      • At least one (1) additional FTE (Qualified Professional,          description consistent with
      Associate Professional, Paraprofessional, or Certified Peer         Provider Agency Policy for
      Support Specialist)                                                    PSR service definition;
                                                                         Personnel files per core rules
                                                                         checklist; License/certification
                                                                           (if applicable); experience
                                                                           verification; staff schedule;
                                                                         Organizational Chart for PSR;
  b                                                                        Program description; Job
                                                                          description consistent with
      Persons who meet the requirements specified for QP or AP            Provider Agency Policy for
      status according to 10A NCAC 27G. 0104 and a minimum of               PSR service definition;
      1 year of documented experience with the adult MH                  Personnel files per core rules
      population may deliver PSR                                         checklist; License/certification




PSR 9-28-09...... DRAFT                                                      Page 6                                                      NC DMH/DD/SAS
Reviewer:                                                         NC DHHS                                                  Provider:_________________
Date Reviewed:                                                  DMH/DD/SAS                                                Site:______________________

                                                  Psychosocial Rehabilitation (PSR-MH Adults)
                              DESCRIPTION
                                                                                                               NOT       60-day review
                 Psychosocial Rehabilittion (PSR)                          Evidence of Compliance                         Evidence of
                                                                                                            MET MET NA    Compliance      COMMENTS
  c A Paraprofessional level staff may provide PSR services.
     They must meet the requirements specified for                       Organizational Chart for PSR;
     paraprofessional status according to 10A NCAC 27.G.0104                Program description; Job
     and have a minimum of 1 year of documented experience                 description consistent with
     with the adult MH population and may deliver PSR services             Provider Agency Policy for
     within the requirements of the staff definition specific in the          PSR service definition;
     above role.                                                         Personnel files per core rules
                                                                         checklist; License/certification
                                                                            (if applicable); experience
                                                                           verification; Individualized
                                                                          Supervision Plan/Contract;
                                                                               staff schedule; Clinical
                                                                                      Interviews
  d A NC Certified Peer Support Specialist staff may deliver PSR         Organizational Chart for PSR;
     services within the requirements of the staff definition specific      Program description; Job
     in the above role. A NC Certified Peer Support Specialist is          description consistent with
     not required to demonstrate 1 year of documented experience           Provider Agency Policy for
     in working with the adult MH population, as his or her                   PSR service definition;
     personal experience in MH services fulfills that requirement.       Personnel files per core rules
                                                                          checklist; NC Certified Peer
                                                                          Support Specialist certificate
                                                                            issued by BHRP verifying
                                                                           certified status, experience
                                                                           verification; Individualized
                                                                          Supervision Plan/Contract;
                                                                                    staff schedule;




PSR 9-28-09...... DRAFT                                                      Page 7                                                      NC DMH/DD/SAS
Reviewer:                                                        NC DHHS                                                  Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                                Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                              DESCRIPTION
                                                                                                           NOT        60-day review
                 Psychosocial Rehabilittion (PSR)                      Evidence of Compliance                          Evidence of
                                                                                                        MET MET NA     Compliance        COMMENTS
  e Individualized Supervision is provided according to
     supervision requirements specified in 10 A NAC27.G.0104 &       Organizational Chart for PSR;
     .0203.                                                            Program description; Job
                                                                      description consistent with
                                                                      Provider Agency Policy for
                                                                         PSR service definition;
                                                                     Personnel files per core rules
                                                                     checklist; License/certification
                                                                       (if applicable); experience
                                                                       verification; Individualized
                                                                      Supervision Plan/Contract;
                                                                          staff schedule; Clinical
                                                                                 Interviews
  f PSR staff ratios must be as follows:
     • At least one (1) staff member on site for each (8) eight or
     fewer recipients in average daily attendance shall be
     maintained.                                                         Program description;
                                                                     Personnel Manual; Policy and
     • One Qualified Professional must be on staff for every 24        Procedure manuals, Job
     recipients, based on average daily attendance. The PSR           description consistent with
     Program Director may serve as this Qualified Professional.       Provider Agency Policy for
                                                                      PSR service definition, staff
     • One of the staff (other than the program director) must be              schedule                              caseload list;
     designated to address the vocational needs of the recipients.                                                   billing/tracking
                                                                                                                     forms; service
                                                                                                                     notes




PSR 9-28-09...... DRAFT                                                  Page 8                                                         NC DMH/DD/SAS
Reviewer:                                                        NC DHHS                                                    Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                                  Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                             NOT        60-day review
                  Psychosocial Rehabilittion (PSR)                        Evidence of Compliance                         Evidence of
                                                                                                          MET MET NA     Compliance         COMMENTS
  g All PSR staff must complete a minimum of 20 hours of                   Program description;
      training specific to the required components of the PSR
                                                                          Personnel Manual; Job
      service definition, including crisis response and person-
                                                                       descriptions. Personnel files
      centered thinking, within the first 90 days of each staff
                                                                      and/or other documentation of
      member’s delivery of this service. Qualified Professional staff
                                                                         required experience and
      responsible for Person Centered Plan development shall also
                                                                           completion of training
      participate in “PCP Instructional Elements” training within the
                                                                       requirements per core rules
      same time frame. All pre-requisites for training have been met
                                                                      checklist; training certificates.
      per 10A NCAC 27G .0202 & .0203.
                                                                         Agency staff training plan

      Service Type/Setting
  a   PSR is a day/night service provided in a licensed facility
      meeting the requirements of 10A NCAC 27G.1200. PSR shall         Program description; job
      be available at least five hours a day. The PSR program must     descriptions; policy and
      include off site service activities related to transferring      procedure manuals;agency
      rehabilitative skills to the community for the purpose of        license, staff schedule,                        PCP, service
      achieving the goals outlined in the Person Centered Plan.        interview with PSR staff.                       notes, Medicaid
                                                                                                                       RA forms
      Program / Clinical Requirements
  a PSR services must be available five or more hours per day, at Program description; job
      least five days per week, and may be provided on weekends        descriptions; policy and
      or in the evening. The number of hours that a recipient          procedure manuals;                              PCP; service
      receives PSR services are to be specified in his/her Person      supervision plans; Team                         notes; billing
      Centered Plan.                                                   Meeting Minutes, Clinical                       tracking forms;
                                                                       Interviews                                      client interviews
  b                                                                    Program description; job
                                                                       descriptions; policy and
      Each PSR facility shall provide transitional or supported
                                                                       procedure manuals;
      employment services to facilitate the recipient’s entry into     supervision plans; Team                         Service Notes;
      competitive employment in accordance with 10A NCAC               Meeting Minutes Clinical                        PCP; Team
      27G.1203.                                                        Interviews                                      meeting minutes.



PSR 9-28-09...... DRAFT                                                     Page 9                                                         NC DMH/DD/SAS
Reviewer:                                                       NC DHHS                                             Provider:_________________
Date Reviewed:                                                DMH/DD/SAS                                           Site:______________________

                                                Psychosocial Rehabilitation (PSR-MH Adults)
                              DESCRIPTION
                                                                                                      NOT        60-day review
                 Psychosocial Rehabilittion (PSR)                        Evidence of Compliance                   Evidence of
    This is a service that provides structured rehabilitative                                      MET MET NA     Compliance        COMMENTS
  c interventions designed to:
    • assist the recipient in achieving recovery goals identified in
    the Person Centered Plan;
    • promote healthy lifestyles that reduce psychiatric
    symptoms;
    • promote symptom stability and wellness management, such
    as self-management of medication, psychoeducation, relapse
    prevention training, and coping skills training; restore
    personal, social, and community living skills necessary for
    independent self-management;
    • assist individuals in gaining access to necessary services in    Program description; job
    all life domains (emotional, social, safety, housing, medical      descriptions; policy and
    and health, educational, vocational, and legal);                   procedure manuals;
    • provide psychoeducational information to the recipients,         supervision plans, Team
    families, and/or other individuals involved with the               Meeting Minutes, Clinical
    recipient’s care about the recipient’s diagnosis, condition,       Interviews
    and treatment to support recovery and encourage problem
    solving strategies;
    • establish or restore prevocational skills that focus on the
    development of positive work habits and abilities, talents,
    and skills that increase the individual’s self worth, purpose
    and confidence; these activities are not to be job-specific
    training; increase the ability to access financial entitlement,
    housing, work, and social opportunities in the community;                                                   Service Notes;
    • provide or make provision for transitional or supported                                                   PCP; Team
    employment services                                                                                         meeting minutes.




PSR 9-28-09...... DRAFT                                                   Page 10                                                  NC DMH/DD/SAS
Reviewer:                                                        NC DHHS                                               Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                             Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                         NOT        60-day review
                   Psychosocial Rehabilittion (PSR)                      Evidence of Compliance                      Evidence of
                                                                                                      MET MET NA     Compliance        COMMENTS
  d
       Expected rehabilitative outcomes include but are not limited
       to the following:
       • achieved recovery goals identified in the Person Centered
       Plan;
       • reduced psychiatric symptoms;
                                                                       Policies and Procedures in
       • increased symptom stability and management;                   place for PCP development. ;
       • improved personal, social, and community living skills;       Team Meeting Minutes;
       • increased access to necessary services in all life domains;   Program description; job
       • improved problem solving strategies;                          descriptions; supervision
       • improved use of appropriate coping skills;                    plans, Clinical Interviews
       • improved functioning in community roles;
       • established or restored prevocational skills; and
       • increased ability to access financial entitlement, housing,
       work, and social opportunities in the community.                                                            Service Notes;
       .                                                                                                           PCP; Team
                                                                                                                   meeting minutes.
  e.                                                                                                               PCP; service
       Signed Order based on individualized assessment.                                                            notes;
       Documentation Requirements




PSR 9-28-09...... DRAFT                                                   Page 11                                                     NC DMH/DD/SAS
Reviewer:                                                      NC DHHS                                                 Provider:_________________
Date Reviewed:                                               DMH/DD/SAS                                               Site:______________________

                                               Psychosocial Rehabilitation (PSR-MH Adults)
                             DESCRIPTION
                                                                                                         NOT        60-day review
                 Psychosocial Rehabilittion (PSR)                      Evidence of Compliance                        Evidence of
                                                                                                      MET MET NA     Compliance      COMMENTS
     Full service note for each contact or intervention (such as
     individual counseling, case management, crisis response), for
     each date of service, written and signed by the person(s) who
     provided the service, that includes the following:
     • Recipient’s name
     • Medicaid identification number
     • Service provided (for example, CST)
     • Date of service
     • Place of service                                               Program Description; Policy &
     • Type of contact (face-to-face, telephone call, collateral)     Procedure Manual, job
     • Purpose of the contact                                         descriptions.
     • Description of the provider’s interventions
     • Amount of time spent performing the interventions
     • Description of the effectiveness of the interventions
     • Signature and credentials of the staff member(s) providing
     the service (for paraprofessionals, position is required in lieu
     of credentials with staff signature)
                                                                                                                   PCP; service
                                                                                                                   notes




PSR 9-28-09...... DRAFT                                                 Page 12                                                     NC DMH/DD/SAS

								
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