Policy



The following policies are required to be submitted to the Regional Office.Accounting for Personal FundsAdvocacyCrisis Intervention PolicyComplaint Resolution Emergency/Urgent CareFire, Sanitation and Emergency PrecautionsHealth Care Needs (ISP) – HIPAAIncident ManagementProtection of RightsQuality assessment, assurance, and improvementRecords ManagementRespect to Persons SupportedTitle VI Transportation to People supported Use of Positive ApproachesWell Trained StaffFor all of the above there are “critical element” review sheets which detail what should be included.17 -Personnel Policies that at least address:Hiring Procedures, Process and Minimum QualificationsProgressive DisciplinesEmployee Grievance ProcedureEmployee Driving Own Vehicle Employment ScreeningPolicyPolicy ReferenceCritical ElementsCompleteYes NoAccounting for Personal Funds*If the provider manages or assists in management of personal funds.DIDD Personal Funds Policy #80.4.3QA Organizational Checklist: Domain 10 (10.B.1.)TCA §33-1-302 and 303; §4-3-2708Executive orders of the State of Tennessee #9, 10, 21, and 34DIDD Provider Manual1. The person participates in their own finances to the extent of their capabilities.2. How personal funds will be maintained securely and safeguarded including limitations on staff access to personal funds.3. Limitations on staff access to personal funds.4. A separation of duties concerning personal funds (Personal allowance and petty cash in the home).5. The staff positions authorized to approve disbursements.6. The staff positions authorized to sign checks drawn on personal accounts.7. A statement of the agency's liability in the case of loss of personal funds due to staff negligence or theft. The statement needs to include the staff positions covered in the agency's fiduciary bond.8. Ensure records are kept for each person served.9. Which fees and costs the individual is responsible for paying and the extent the agency will financially assist the individual in paying these costs, if necessary.10. The procedure or basis used to determine a person's rent or room and board charges.11. Personal funds are kept separate from agency funds.12. Personal funds are not used to supplement agency funds.13. Staff does not borrow money nor accept personal benefits from people.14. How direct support and other designated staff are trained on agency policies and procedures15. Agency’s oversight of the accumulation of personal funds to prevent loss of benefits (SSI, Medicaid eligibility)16. Advancement of funds on behalf of persons supported if the agency chooses to advance ments:Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoAdvocacyPersonal outcome measures: CQL-Factor 3QA Organizational Checklist: Domain 4 DIDD Provider ManualAdvocate for the person supported and arrange for external advocacy services as needed.Delineates activities the agency may engage in to assist in advocacy efforts (e.g., participation on work groups, committees, task forces related to advocacy efforts; efforts at encouraging and supporting participation by individuals in advocacy groups).Opportunities available for staff to express their ideas, concerns or complaints which affect people they support (e.g., at regular staff meetings, meetings with supervisors of the agency, meeting with members of the board of directors) without fear of retribution and which ensure such issues will be seriously considered and addressed.Accessing Natural Supports and assisting the person’s supported to build a Natural Support Network. Natural supports are family members and close (constant, stable, steady, long-lasting, and established) friends of the person using services. A natural support can be someone who is relatively new in the life of the person using services.Providers are required to supply information and skills training as necessary to provide safe and effective natural supports. The information and training may be based on the time they are spending together with the person. Consent must be obtained from the person served or their legal representative in writing before any personal information is ments: CQL Factor 3: Natural Support Networks?3a Policies and practices facilitate continuity of natural support systems.?3b The organization recognizes emerging support networks.?3c Communication occurs among people, their support staff and their families.?3d The organization facilitates each person’s desire for natural supports.Reviewer(s): Date:PolicyPolicy ReferenceCritical ElementsCompleteYes NoComplaint ResolutionProvider ManualPerformance MeasuresComplaint resolution procedures for persons supported, family members, and legal plaint Resolution plaint data is utilized to monitor compliance with the federally mandated health and welfare assurance and related CMS-approved performance measures.Providers are required to establish a complaint resolution process to address complaints submitted by persons using services and families.Providers are also required to have an identified complaints contact person and to maintain documentation of all complaints plaint procedures and pertaining to alleged Title VI violations for persons ments:Reviewer(s): Date:PolicyPolicy ReferenceCritical ElementsCompleteYes NoCrisis Intervention PolicyDIDD Provider Manual CQL Factor 1a, 1b, 1c, 1d, 1e CQL Factor 3c CQL Factor 5f CQL Factor 6a, 6c CQL, Factor 8a, 8c,8d, 8e QA Organizational Checklist: Domain 41. Instructions for use of PRN psychotropic medications and behavioral safety interventions as applicable. 2. Assurance that procedures are only used in response to behaviors which present risk of harm.3. Assurance that procedures is in alignment with DIDD procedural definitions. 4. References to de-escalation and redirection techniques which are used prior to behavioral safety interventions. 5. Assurance that behavioral safety interventions are only used when they are in the safest most appropriate response. 6. Safeguards to prevent misuse of behavioral safety interventions.7. Mechanisms for recording the agency’s use of behavioral safety interventions.8 Mechanisms for reviewing the agency’s use of behavioral safety interventions.9. Mechanisms for ensuring a behavior assessment is requested when a person has 3 uses of behavioral safety intervention of PRN medication within a 6 month period.10. General procedures for managing crisis situations involving outside entities including staff monitoring of a person’s status until it is clear the person has been admitted to a facility. 11. Policy is approved by HRC. Comments:CQL Factor 1: Rights Protection and Promotion: Indicators 1a, 1b, 1c, 1d, 1e1a The Organization implements policies and procedures that promote people’s rights.1b The organization supports people to exercise their rights and responsibilities 1c Staff recognizes and honors people’s rights. 1d The organization upholds due process requirements, 1e Decision-making supports are provided to people as needed. CQL Factor 3: Natural Support Networks: Indicator 3cCommunication occurs among people, their support staff and their families. CQL Factor 5: Best Possible Health: Indicator 5f5f Staff immediately recognizes and responds to medical emergencies. CQL Factor 6: Safe Environments: Indicators 6a, 6c6a The organization provides individualized safety supports. 6c The organization has individualized emergency plans. CQL Factor 8: Positive Services and Supports: Indicators: 8a, 8c, 8d, 8e8a People’s individual plans lead to person-centered and person-directed services and supports. 8c The organization provides positive behavioral supports to people. 8d The organization treats people with psychoactive medications for mental health needs consistent with national care standards of care. 8e People are free from unnecessary, intrusive interventions. Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoEmergency/Urgent Care Personal Outcome Measures: CQL, Factor 5-Best Possible Health.QA Organizational Checklist: Domain 5 The nature and the involvement of the support coordinator and provider. 2. Notification requirements3. Documentation requirements4. Instructions on what an emergency looks like, as well as, what to do and who to contact in an emergency for people identified as having high medical and/or behavioral or mental health needs.5. Instructs staff 911 calls must not be delayed.6. Indicates information regarding initiation of emergency first aid procedures.7. Indicates requirements for provision of information to emergency medical staff.8. Indicates requirements for notification of designated provider supervisory staff.Addresses first aid kits to include the following: accessibilitylocationscontentssecurityperiodic review and restockingComments:CQL Factor 5-Best Possible Health?5a People have supports to manage their own health care.?5b People access quality health care.?5c Data and documentation support evaluation of health care objectives and promote continuity of services and supports.?5d Acute health needs are addressed in a timely manner.?5e People receive medications and treatments safely and effectively.?5f Staff immediately recognize and respond to medical emergencies.Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoFire, Sanitation and Emergency PrecautionsDIDD Licensure Rules, Chapter 0940-5-5.02, General environmental requirements for all facilities. Personal Outcome Measures: CQL, Factor 6-Safe EnvironmentsQA Organizational Checklist: Domain 3 (3.A.3.; 3.A.5.; 3.A.6.; 3.A.7.; 3.B.2.)1. Agencies have emergency plan in effect in the event of fire, severe weather, or health crisis (includes an evacuation plan and documented regular drills).2. Agencies have approved compliance record from fire, health and environmental safety authorities.3. Persons served are not put at risk for safety hazards (i.e.; people serving more than one person in a wheelchair have adequate staff for evacuation procedures.4. Homes/facilities must be maintained in a safe manner and continuing effort made to eliminate potential hazards.5. Homes/facilities must be maintained in a sanitary and clean condition, free from all accumulation of dirt and rubbish, well ventilated, and free from foul, stale, or musty odors.6. Homes/facilities must be kept free of mice, rats, and other rodents.7. Housekeeping practices and standards must be maintained which will ensure the eradication of flies, roaches, and other ments:CQL Factor 6 Safe Environments?6a The organization provides individuals safety supports.?6b The physical environment promotes people’s health, safety and independence.?6c The organization has individualized emergency plans.?6d Routine inspections ensure that environments are sanitary and hazard free.Reviewers: Date:PolicyPolicy ReferenceCritical ElementsCompleteYes NoHealth Care NeedsPersonal Outcome Measures: CQL, Factor 5-Best Possible HealthProvider ManualQA Organizational Checklist: Domain 5T.C.A. §33-3-103HIIPAA standards1. Name of current MCO/BHO and ID# are in the person’s file. (include additional insurances).2. Name of contact people and their phone numbers are in the person’s file. 3. Current names of PCP including phone numbers are in the person’s file. 4. All medical specialists and their phone numbers are listed in the person’s file. 5. Description of individual’s overall health and specific issues or conditions is listed in the person’s file as specified in the individual transition plan (ITP) or ISP6. Name and contact information or specific requirements:a). For medical specialists, dentist, therapies, home health services, medical supplies, transportation, outpatient services, diagnostic/labs, hospitalizations, and emergencies.b). Information regarding medicationsc). Individual medical historyd). Information regarding equipment (assistive, durable medical, durable supplies, and communication devices)e). Information regarding any special medical condition and the treatment required.7. Includes compliance with confidentiality requirements (HIPAA Standards)Comments:CQL Factor 5-Best Possible Health?5a People have supports to manage their own health care.?5b People access quality health care.?5c Data and documentation support evaluation of health care objectives and promote continuity of services and supports.?5d Acute health needs are addressed in a timely manner.?5e People receive medications and treatments safely and effectively.?5f Staff immediately recognizes and responds to medical emergencies.Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoIncident ManagementDIDD Provider ManualPersonal Outcome Measures: CQL, Factor 4-Protection from Abuse, Neglect, Mistreatment and ExploitationTCA §37-1-403, §37-1-605, §71-6-103 (b) (1) & §71-6-103 (2) (c)Quality Assurance Checklist, Domain 3 (3.C.4., 3.C.5., 3.C.7., 3.C.10. and 3.C.12.)1. Incidents that are defined as Reportable Incidents which must be reported to the DIDD Central Office.2. Reportable Incidents which must be reported immediately (within four hours) to the DIDD Investigation Hotline.3. Review, follow-up and closure of Reportable Incidents.4. Requirements for notification of entities external to the provider organization and DIDD of the occurrence of Reportable Incidents and of pending DIDD investigations.5. Timely response to Reportable Incidents and DIDD investigations.6. Trend studies of Reportable Incidents and substantiated reports of abuse, neglect, and exploitation.7. Risk assessments/reviews of persons supported, community homes/programs or other situations/circumstances which trend studies identify as presenting high protection and safety risks.8. Immediate response to Safety and Health risks associated with Reportable Incidents.9. Policy addresses 15 types of incidents: death, abuse, neglect, exploitation, injuries, accidents, elopement, choking/aspiration, seizures, swallowing inedible/harmful matter, non-consensual sexual activity, medication error, physical aggression, self-injurious behavior, and behavioral interventions.10. All Reportable Incident Forms (RIF) must be accurately completed.11. An Incident Management Coordinator (IMC) is designated.12. IMC produces an annual written analysis of the trends and patterns related to Reportable Incidents, including substantiated reports of abuse, neglect and exploitation.13. Incident Review Committee (IRC) is established.14. IRC meets bi-weekly to review individual RIFs.15. IMC documents recommendations, actions implemented, and effects of actions taken to reduce and prevent incidents.16. Procedures are in place for accepting abuse allegations.17. Results of falsification of incident reports and misleading or withholding information during an investigation.18. Responsibilities of all staff in regard to reporting incidents timely and accurately.Must specifically state: “Any person subject to this policy who retaliates against another person for his or her involvement as a reports, witness or in any other capacity related to incident management and/or investigations of abuse, neglect and exploitation shall be subject to disciplinary action, including possible termination. Such actions may also result in legal or other administrative measures as appropriate.”20. How administrative staffing actions are handled with regard to investigations.Ensures confidentiality of the following:DIDD reportable incident form Incident follow-up and review documentationDIDD investigation reportsComments:CQL Factor 4-Protection from Abuse, Neglect, Mistreatment and Exploitation4a The organization implements policies and procedures that define, prohibit and prevent abuse, neglect, mistreatment and exploitation. 4b People are free from abuse, neglect, mistreatment and exploitation.4c The organization implements systems for reviewing and analyzing trends, potential risks and sentinel events including allegations of abuse, neglect, mistreatment and exploitation, and injuries of unknown origin and deaths.4e The organization ensures objective, prompt and thorough investigations of each allegation of abuse, neglect, mistreatment and exploitation, and of each injury, particularly injuries of unknown origin.4f The organization ensure thorough, appropriate and prompt responses to substantiated cases of abuse, neglect, mistreatment and exploitation, and to other associated issues identified in the investigation.Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoProtection of RightsQA Organization Checklist: Domain 4 (4C2, 4C3, 4C7, 4D2, 4D3, 4D4, DIDD Provider ManualPersonal Outcome Measures: CQL, Factor 1-Rights Protection and Promotion HCBS Settings RuleAre provider policies outlining rights of people supported made available to the people the agency supports?Are the policies regularly reassessed for compliance and effectiveness and amended as necessary? 3. People served will be entitled to their rights and must be assisted in understanding the responsibilities associated with certain rights. Any restrictions must be reviewed by the Human Rights Committee.4. The agency will have the Behavior Analyst take BSPs inclusive of restrictive interventions through an approved Human Rights Committee for review.5. A local Human Rights Committee will be constituted according to DIDD requirements.6. The agency Incident Management Coordinator will, within established time frames, review all serious incidents that involve emergency use of restrictive procedures.7. If there is any rights restriction, restricted intervention or psychotropic medication being used by the person, the person and his/her family and/or legal representative have received information about risks, benefits, side effects and alternatives, and have given voluntary, informed, documented consent for the use of the intervention or ments:CQL Factor 1- Rights Protection and Promotion?1a The organization implements policies and procedures that promote people’s rights.?1b The organization supports people to exercise their rights and responsibilities.?1c Staff recognizes and honor people’s rights.?1e Decision-making supports are provided to people as neededReviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoQuality Assessment, Assurance and ImprovementDIDD Provider ManualProviders must have a process for conducting self-assessments. Self-assessment is the process by which the provider identifies issues affecting the quality of services provided, as well as areas of operation resulting in non-compliance.Providers must react to self-assessment findings by determining the causative factors and taking action to improve quality or complianceComments:Reviewer(s): Date:PolicyPolicy ReferenceCritical ElementsCompleteYes NoRecords ManagementDIDD Provider ManualHealth Insurance Portability and Accountability Act (HIPAA)Health Information Technology for Economic and Clinical Health Act (HITECH)Provider agreementT.C.A. § 33-3-103Providers shall create an individual record for each person supported that contains documentation of services providedAll records and information obtained and/or created by the provider, regardless of whether the information is kept and/or shared as a paper document, as an electronic record, as a verbal report or by any other means shall be kept confidential in accordance with applicable state and federal laws, rules, regulations, policy and ethical standards.3. Providers shall honor individual rights as specified in HIPAA and in accordance with the following: -Allow persons to see their records - Provide copies of personal records to persons upon request. Additionally, providers are expected to educate people using services about their record and its contents. - Provide information to persons about how information is used and shared. - Respond to requests from persons to restrict the use and/or disclosure of personal information. - Respond to requests from persons to change incorrect information in records. - Provide persons with a list of people or entities who have obtained information from their records. - Honor requests from persons that certain health information not be shared. - Honor requests to rescind consents to share information.Provide appropriate information and individual records to the POA/conservator in a timely manner when required or requested. 5. Requirements applicable to all providers maintaining persons’ records include: -Providers must implement written policies pertaining to records maintenance, including the location of required components and staff responsible for records maintenance.-Records must be stored in a manner that maintains the confidentiality of the information.- Records must be maintained for a period of ten (10) years from date of death or discharge.-Professional support services licensure rules require maintenance of records for people with developmental disabilities for ten (10) plus one (1) years from date of death or discharge.-Records maintained in the home of the person supported must be regularly purged to ensure usability of the record and to protect the confidentiality of the records.-Providers must maintain original (e.g., paper or electronic) documents for the services provided by their employed staff. See Section A of the Provider Agreement for additional details.-Providers must maintain copies of required documentation obtained from contracted staff and other providers.-Records must be maintained in a manner that ensures that the records are accessible and retrievable within two (2) ments:Reviewer(s): Date:PolicyPolicy ReferenceCritical ElementsCompleteYes NoRespect To Persons SupportedPersonal Outcome Measures: CQL, Factor 2-Dignity and RespectQA Organizational Checklist: Domains 4, 7 and 8 HCBS Settings RuleDIDD Provider Manual1. Agency staff is informed and practice the First Amendment Rights that are most important to persons supported/served.2. Level of satisfaction is obtained from persons served concerning services received and personal life situations.3. Persons served participate in meaningful employment and activities, privacy and advocacy.4. Agency policy and procedures reflect people first language.5. Reflects dignity and respect through positive interaction, refraining from activities that draw undue attention to a person's disability or differences, enhancement of self-esteem, and non-intrusive non-demeaning services and supports.6. Reflects how agency will facilitate and support natural support systems.Do people supported in residential settings have full access to their home? Is the setting physically accessible and there are no obstructions limiting their mobility in the setting? IF present are there environmental adaptations put in place to ameliorate the obstruction?Is assistance provided in private as appropriate when needed?Do people have privacy in their sleeping or living space?Can the person close and lock the bedroom and bathroom door?Does staff only use a key to enter a living area of privacy space under limited circumstances agreed upon with the person?Do people have full access to typical facilities in a home such as a kitchen with cooking facilities, dining area, laundry, and comfortable seating in shared areas?Are people moving about inside and outside the setting as opposed to sitting by the front door?Is the setting free from gates, Velcro strips, locked doors, or other barriers preventing people’s entrance to or exit from certain areas of the setting?Does the provider provide options for community integration and utilization of community services in lieu of onsite services?Are people able to regularly access the community and are they able to describe how they access the community, who assists in facilitating the activity and where he or she goes?Are people aware of or have access to materials to become aware of activities occurring outside the setting?Do people shop, attend religious services, schedule appointments, have lunch with family and friends, etc., in the community as they choose?Are people able to come and go at any time?Comments:CQL Factor 2 Dignity and Respect?2a People are treated as people first.?2b The organization respects people’s concerns and responds accordingly.?2c People have privacy.?2d Supports and services enhance dignity and respect.?2e People have meaningful work and activity choices.Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoTitle VIProvider Agreement D.5.Civil Rights Act of 1964C. Title 33Provider ManualHCBS Waiver Personal Outcome Measures: CQL, Factor 1-Rights Protection and PromotionQA Organizational Checklist: Domain 4 Ensures the person receives equal treatment, equal access, equal rights and equal opportunities without regard to race, color, national origin or Limited English Proficiency (LEP).Agency has a designated Title VI Local Coordinator.Addresses a system to ensure people know who the Local Coordinator is and how to contact him/her.Addresses employee training to ensure Title VI compliance during service provision, recognition of and appropriate response to Title VI violations, complaint procedures and appeal rights pertaining to violations and governing response to employees who do not maintain Title VI compliance in interacting with people.Arranges language assistance to persons of limited English proficiency (interpreters and/or language appropriate written materials).Provides meaningful access to services for people with limited English proficiency.Discusses how people supported are informed of Title VI.Describes a mechanism for advising people of their options for filing a Title VI complaint.Title VI materials are displayed in conspicuous places accessible to all.Residential providers must ensure room assignments and transfers are made without regard to race, color, or national origin.Employees are oriented to their Title VI responsibilities and the penalties for noncompliance within the first sixty (60) days of employment with documentation placed in personnel files.Annual Title VI in-service training is completed and documented in personnel file. 13. All providers must ensure that vendors, subcontractors and other contracted entities are clearly informed of Title VI responsibilities and are required to maintain Title VI compliance.All providers must complete and submit an annual Title VI self-ments:Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoTransportation to People SupportedDIDD Provider ManualProvider Agreement1. Policy addresses how the agency will agency will safely transport people supported in personal or agency vehicles.2. Vehicles in which people are transported in have operable seat belts and used in the proper manner based on the person’s needs.3. Any mobility support needs applicable to the person’s transportation must be met in accordance with the ISP or staff instructions.4. Policy addresses how the agency will document the vehicle being used to transport people are safe and it meets all the transportation service requirements whether the vehicle is owned by the provider or by provider staff.5. Maintain a copy of the vehicle liability insurance certificate for vehicles used to transport people whether the vehicles are owned by the provider or by provider staff.First aid supplies are maintained in the vehicle.Providers may not charge people supported or their families for the cost of routine maintenance or the cost of cleaning the vehicle owned by the provider or provider’s staff.Providers may not charge people or their families for the cost of providing a cellular phone intended for the use of staff involved in transporting people, unless specifically requested by the person supported or legal ments:Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoUse of Positive ApproachesDIDD Provider ManualPersonal Outcome Measures: CQL, Factor 8-Positive Services and SupportsQA Organizational Checklist: Domain 4 1. The policy must classify behavior interventions as unrestricted or restricted in accordance with the DIDD provider manual.2. The policy must outline interventions which are allowed and which are prohibited by the agency.3. The policy must provide for the development of support teams which meet to regularly evaluate behavioral data and solve problems of quality of life for persons.4. The policy must state that restrictive interventions may only be used after less restricted interventions have been tried except when the person’s behavior poses a risk of injury to self or others.Are cameras present inside the setting only utilized in direct relation to the person-centered plan of care?Comments:CQL Factor 1: Rights Protection and Promotion1d The organization upholds due process requirements.CQL Factor 8: Positive Services and Supports8a People’s individual plans lead to person-centered and person-directed services and supports.8b The organization provides continuous and consistent services and supports for each person.8c The organization provides positive behavioral supports to people.8d The organization treats people with psychoactive medications for mental health needs consistent with national standards of care.8e People are free from unnecessary, intrusive interventions.Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoWell Trained Staff (Paid and unpaid)DIDD Provider Manual Personal outcome measures: CQL, Factor 7-Staff Resources and SupportsQA Organizational Checklist: Domain 9Provider Agreement A.15Performance MeasuresAn effective training system for ensuring pre-service and core training courses are successfully completed within the DIDD required timeframes. An identified employee coordinates, monitors, assigns, and trains, as applicable, to ensure all employee training is completed and current. 3. Compliance with DIDD employee training requirements found deficit by any DIDD affiliated reviewer. 4. Provide appropriate information and skills training to volunteers as necessary to protect the health and safety of the person served and the volunteer. Information and Training Specific to the Person. Under no circumstance will a volunteer be left alone with a person served or assigned responsibility to perform the duties of trained and paid staff. Consents must be obtained from the person served or their legal representative before any personal information is shared.5. Do paid and unpaid staff receive new hire training and continuing education related to the rights of people receiving services and their experience as outlined in HCBS rules?Comments:CQL: Factor 4 Protection from Abuse, Neglect, Mistreatment and Exploitation?4d Support staff knows how to prevent, detect, and report allegations of abuse, neglect, mistreatment and exploitation.CQL: Factor 7 Staff Resources and Supports?7b The organization implements an ongoing staff development program.?7d The organization implements systems that promote continuity and consistency of direct support professionals.?7e The organization treats its employees with dignity, respect and fairness.Reviewer(s): Date: PolicyPolicy ReferenceCritical ElementsCompleteYes NoPersonnel PolicesDIDD Provider Manual ProviderAgreement A.13 Title VI Compliance HIPAA Compliance-Provider Agreement D.17Drug Free Workplace-TCA Section 50-9-101, Provider Agreement A.10.eF. Personal Outcome Measures: CQL-Factor 8-Staff Resources and SupportsQA Organization Checklist: Domain 3 (3.C.6.) Domain 9 (9.B.3.)1. Procedures for hiring staff including minimum qualifications for each staff position.2. Development and communication of job descriptions of each staff position.3. Procedures for initiating and resolving employee complaints.4. Requirements pertaining to utilization of employee-owned vehicles to transport persons receiving services, if applicable.5. Procedures for initiating employee progressive disciplinary actions, including, but not limited to, those related to Title VI non-compliance, drug-free workplace violations, and substantiation of abuse, neglect, and/or exploitation of people receiving services.6. Procedures for staff termination, suspension, or placement on the Department of Health’s Tennessee Abuse Registry.7. Procedures for tuberculosis testing in accordance with current Department of Health Policy.8. Procedures pertaining to drug-free workplace requirements.EmploymentScreeningA. DIDD Provider ManualB. Senate Bill 913.C. Personal outcome measures: CQL-Factor 7D. QA Organizational Checklist: Domain 3 (3.C.6.)E. Performance MeasuresF. Provider Agreement1. Criminal background checks will be conducted on persons employed to work with or having contact with persons with developmental disabilities.2. The agency will retain on file any reports of a criminal background check for all employees stating whether the employee met criteria for employment.3. All applicants for employment must be informed of the fingerprint sample and/or the criminal background check requirement.4. Employment applications must require that applicants list any and all prior convictions, or if they have been required to register as a sexual offender.5. Maintain personnel records for staff and sub-contractors, including evidence of timely completion of required checks: background checks, DOH’s Tennessee Elderly and Vulnerable Abuse Registry, the Sexual Offender Registry and the Office of Inspector General’s List of Excluded Individuals/Entities (LEIE)6. Maintain personnel records for staff and sub-contractors, including evidence of timely completion of required checks: background checks, DOH’s Tennessee Elderly and Vulnerable Abuse Registry, the Sexual Offender Registry and the Office of Inspector General’s List of Excluded Individuals/Entities (LEIE)Comments:CQL factor 7: Staff Resources and Supports7a The organization implements a system for staff recruitment and retention.7c The support needs of individuals shape the hiring, training and assignment of all staff.Reviewer(s): Date: ................
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