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TABLE OF CONTENTSSECTION B: POLICIES AND PROCEDURESCONTENTS:PAGEEstablishing and Reviewing Policy1New Policy and Procedures Review Form2Manual Revisions3Manual Distribution Table4Non-Discriminatory Policy5Admission and Discharge Procedures6-9Guardianship: Need, Appointment, Continuity (Policy Attachment)10The Individual Habilitation Plan11Table of IHP Process Time Frames12“In-Charge Person:” Twenty Four Hour Basis13Twenty Four Hour Accountability14Building Procedures: Keystone Residential15Personal Rights16DDD Personal Rights17-18Personal Rights Acknowledgement 19Human Rights Committee20-25Human Rights Committee Members25House Rules26Grievance Procedure27Abuse/Neglect & Exploitation28-29Abuse/Neglect & Exploitation Staff Responsibilities29Unusual Incidents and Reporting Method30-32Unusual Incident Report Instructions33-34Unusual Incident Report (154 Front St.)35-36Unusual Incident Report (GH’s, SLP, Supervised Apt, Voc)37-38Procedures for Daily Written Communication39-40Staff Meetings41Procedures In Case Of Missing Person42Procedures In Case Of Death43Volunteering At Keystone44Management of Client Funds45-53Personal Financial Record54Cash on Hand55Special Activities Expense Form56Authorization for Assistance in Financial Management57Safeguarding Procedures58Leisure Programming59Leisure Assessment for G.H.; S.A.; & S.L. Programs60Leisure Time Assessment Form61Telephone Use62Long Distance Consent Form for Keystone Living63Food Storage for Keystone Residential Program64Food Service Operation/Food Shopping Policy65Fire Safety66Location and Use of the Fire Alarm System at 154 Front St.67Fire Prevention67Fire Evacuation Procedures67-73Fire Evacuation for Overnight Shift at 154 Front St.68Special Needs and Home Specific Addendum68-71Fire Safety Equipment Check71Fire Evacuation Procedures for Weekday Mornings72-73Severe Weather Procedures74Emergency Evacuation and Temporary Relocation75Keystone’s Continuous Quality Improvement Plan76-84Maintenance of Physical Environment85Procedures for Safeguarding Equipment86Criminal Background Checks87-89Background Check and Release of Information90-91Employee Injuries Procedure 92-93First Report of Injury94-96Concentra Medical Center Employee Injury Form97Return to Work Program98-99 Physicians Evaluation100Smoking Policy101Mobile Technology in the Workplace102Emergency Call and On-Site Treatment103EMS Sign Off Sheet104Emergency and Accident Procedures105-108(Use of Vehicles)Central Registry of Offenders Procedures109Guardian CircularAppendix AInvestigation PolicyAppendix B UIR Reporting Contact Information Appendix C UIR Category ListAppendix D Inventory SheetAppendix E Establishing and Reviewing PolicyPolicy: Policies are established and reviewed in order to provide for the optimal development of the individual’s we serve.Procedures: Administrative staff reviews Keystone’s policies regularly, at least annually, to ensure best practice. More frequent reviews occur as needed.Administrative staff shall be responsible for making changes in their designated areas of responsibility as they become necessary. When changes or new policies become necessary, the pertinent administrative staff shall proceed as follows:Write and name policy, adding the date and the word “draft.”Attach the Review form and give the policy to the President for approval.Forward it to the President or designated staff, who will review it and return it to administrative staff.Make any needed corrections, remove the word “draft” and reprint the new plete the form entitled, “Manual Revisions.”Attach the completed form to the new policy and give them to the Director of Operations or designee.The Director of Operations or designee will ensure that the policies are copied and distributed according the “Manual Distribution” table.Staff and individuals may ask for a review of an existing policy or procedure by contacting any member of the administrative staff, or if they prefer anonymously though the suggestion box. A review meeting will be held and all interested parties will be invited to attend. The President will convey these results of the review to all interested parties.When appropriate, new policies and procedures will be explained during staff and/or program meetings prior to implementation. Staff and individuals input will be encouraged.Reviewed 6/2016NEW POLICY/PROCEDURE REVIEW FORMPerson requesting the procedure to be reviewed: _______________________Date of the Request: ______________________________Name of Policy/Procedure: __________________________________________Reason for revision (i.e. change in regulation, best practice, etc.): ________________________________________________________________________________________________________________________________If regulation, please cite, copy & attachAttach copy of old policy or procedure with changes highlightedAttach copy of the new policy, include the date and the word “draft”Is there a fiscal impact? _____________ If yes, estimate cost _______________Manual affected: _______________________________________________ (Procedures/Personnel/Behavioral, etc.)Date given to Ray Fantuzzi, President: _________________________________Presidential Review:No corrections needed ______Policy requires the following corrections(see below): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date Revisions returned to Ray Fantuzzi, President: ______________________President Review of Policy Revisions:Revisions Approved: _____________________Revisions Not Approved:__________________If Approved, complete a Manual Revision form, attach the revised policy and give to Kristen Fantuzzi, or designee: ______________________________________________Ray Fantuzzi, President_______________________________DateReviewed 6/2016MANUAL REVISIONSDate:To: All StaffRe: Revisions in the _________________________________________ Manual.Section:Please remove the following procedures/pages:Section:Please add the attached/pages:If you have any questions, please see Kristen Fantuzzi (908 757-1080 ex. 113)Reviewed 6/2016MANUAL DISTRIBUTION TABLEPlease note the table below. This explains how the manuals are distributed and the person who is responsible for updating each manual.MANUAL DISTRIBUTION RESPONSIBLE FOR UPDATINGPresidentKyle ThompsonAssistant Executive DirectorP. Lynne ConwayDirector of OperationsKristen FantuzziDirector of Human ResourcesLisa MixonDirector of Health ServicesJudith Foster, R.N.Director of Administrative ServicesLinda FantuzziDirector of Vocational ServicesJanet WaldenDirector of Support ServicesJennifer MoffettDirector of QualityDina EspositoProgram Director (Group Homes/Supervised Apts)Laurie DavisProgram Director (Residential/Group Homes)Halisha RogersProgram Director (Group Homes)Keisha HarrisProgram Director (Group Homes/SLP)Christine RojasNursesJudith Foster, R.N.Grant ApartmentHalisha RogersSupportive Living ProgramAseera ButlerBalmoral Group HomeKeisha HarrisBrandywine Group HomeKeisha HarrisBrookside Group HomeKeisha HarrisCatalano-Supervised ApartmentsLaurie DavisColton Rd. Group HomeHalisha RogersDunellen Group HomeHalisha RogersFords Group HomeHalisha RogersLawrence Group HomeLaurie DavisMiddlesex Group HomeChristine RogersNetherwood Group HomeLaurie DavisPiscataway Group HomeChristine RojasWaverly Group HomeKeisha HarrisWoodland Group HomeHalisha RogersVocational ProgramJanet WaldenIf your name appears on this list and you do not have a manual, please see Kristen Fantuzzi.Revised 6/2016NON-DISCRIMINATORY POLICYAdmissions, the provision of services, and referrals of those we serve shall be made without regard to race, color, religion, physical or mental disability, ancestry, national origin, age sex, sexual orientation, AIDS or HIV infection, atypical cellular hereditary blood traits or any other legally protected status.Reviewed 6/2016ADMISSION/TRANSFER/DISCHARGE PROCEDURESAdmission:Policy: Applications for admission to Keystone are considered without regard to race, sex, color, national origin, religion, age, physical or mental disability, ancestry, sexual preference/affiliation, including AIDS or HIV infection, atypical cellular hereditary blood traits or any other legally protected status.The following requirements are necessary:Have a primary diagnosis of mental retardationHave an absence of severe emotional problems that require a psychiatric setting.Procedures for Admission: The President or designated staff will ensure that prospective admissions and guardians receive information regarding the specific services provided by Keystone as well as fee structures for providing those services.The sponsoring agency will then forward pertinent information to administrative staff within 30 days. The President or designated staff will conduct a pre-placement interview and observation with the applicant, preferably in his or her current setting. An Inter Disciplinary Team or Pre-Placement meeting will be held to determine the course of visits to be undertaken; such as, spending a day in the Vocational Enhancement Program, having dinner and going to the movies with staff and peers, staying overnight, or spending a weekend.During the individual’s visits, an individualized log will be completed by the staff responsible for providing support to that individual. All information will be forwarded to the Director of Support Services. Accrued information will assist in determining the appropriate placement of the individual.Should the individual be accepted for placement, the President or designated staff will send a letter of confirmation along with a packet of required pre-admission forms.Admission will occur only after all of the necessary documentation has been received.Persons are accepted on a 30-60 day trial period, with the understanding that should serious medical, emotional, or behaviorally problems occur, immediate removal of the person from Keystone will be expected.A pre-admission report to acquaint staff with the individual will be written by the Assistant Executive Director or designated staff.Upon admission, the individual will receive an orientation to their new program. The Program Director is responsible for ensuring this orientation is conducted. The orientation shall include, but not be limited to:Introduction of other individuals receiving services as well as staff providing servicesA review of fire and safety procedures; as well as participation in a fire drillA complete inventory of personal funds and propertyA review and implementation of goal plansA description and explanation of leisure time opportunitiesThe individual will also receive the following:A copy of the written procedures for safekeeping of valuable personal possessionsA written statement explaining the individual’s rights as well as a list of available advocates to assist the individual in understanding these rightsA copy of the rules governing the programA copy of the grievance procedureA copy of the procedure regarding toll calls/chargesThe Manager or Program Director will make all necessary provisions to explain the above information to the individual. The guardian will be notified by writing that the individual has had this information explained to him or her. A copy of this notification shall be placed in the individual’s file.An initial Individual Habilitation Plan is developed within 30 days of admission. Individuals who meet all requirements for admission may be considered for respite placement. This determination is made by the President or designated staff.Transfer or Planned Discharge:Any major change in an individual’s residential service or supports shall include the utilization of the IDT.In the case of a planned transfer or discharge, at least 30 days prior to the anticipated discharge date, the following will occur:An addendum to the IHP shall update the existing plan and include the specifics of the transition.The Assistant Executive Director, in consultation with the individual and his or her guardian, as appropriate, the IDT, and a representative of the placing agency, will develop a discharge plan.The discharge plan shall assess the individual’s continuing needs and recommend a plan for provision of follow-up services in the individual’s new environment.The Assistant Executive Director will notify the appropriate Division regional office.The individual’s full records should be transferred.Emergency Discharge:Emergency discharges will only be requested when all possible intervention techniques have proven unsuccessful and the individual’s continual placement at Keystone poses a health or safety risk for the individual or others.The President or designated staff will request to the sponsoring agency the emergency discharge.The President will insure a referral packet containing pertinent information is prepared and sent with the individual at the time of discharge. A discharge summary will be sent, preferably at the time of, but no later than one week from the date of discharge.The President or designated staff, in conjunction with the Regional office will arrange for transportation. Keystone staff will be available to meet with representatives of the individual’s new placement and to discuss the individual’s needs.Pre-Admission RequirementsPre-Admission requirements are collected to provide necessary documentation and ensure an individual’s smooth transition into Keystone. Requirements include, but are not limited to, the following:Pre-Admission ApplicationSkill AssessmentPhysical ExaminationPre-Admission Medical RequirementsImmunization RecordFree of Contagious Disease Form (within 48 hours)Consent/ReleaseStatement of Personal RightsAuthorization for Assistance in Financial ManagementPersonal Property Inventory, including an adequate supply of clothing, individually marked or labeledSafekeeping Procedure of Personal PossessionsHouse rules of ProgramGrievance ProcedureToll calls/charges ProcedureList of Advocates Revised 6/2016GUARDIANSHIP: NEED, APPOINTMENT, CONTINUITYThe purpose of this procedure is to indicate that Keystone will assist and cooperate with the Division of Developmental Disabilities in any way necessary regarding following policies and procedures for assessing whether or not individuals with developmental disabilities, who have been formally determined eligible for services from the Division of Developmental Disabilities, are in need of guardianship as per Division Circular #6 (N.J.A.C. 10:43).See Attached CircularAppendix AAdhered 7/10Reviewed 6/16THE INDIVIDUAL HABILITATION PLANPolicy: The Individual Habilitation Plan is developed to ensure quality of individual programming.Procedures: All individuals will have an Individual Habilitation Plan developed and put into effect within thirty days of admission. Subsequent meetings will be held on a yearly basis.The individual’s input and understanding of the IHP process is extremely important. The individual’s IHP is scheduled to coincide with his or her schedule. If the individual chooses not to attend, the Manager, Program Director or designated staff member will review the results of the IHP meeting with the individual within twenty-four hours of the meeting date.During the IHP meeting, a brief history and overview of the individual’s placement and adjustment will be given. Following this, the individual’s preferences, capabilities and needs will be discussed. The Manager or Assistant Manager will present a skill assessment. This assessment will include an Adaptive Behavior/Health/Safety/Risk Assessment and/or such self-management competencies as the ability to self-medicate, remain unsupervised and/or manage money. Annual goals will be established based upon the individual’s strengths and weaknesses.The understood universal goal for each individual is the enhancement and development of skills needed for greater independent functioning. Recommendations will be made regarding the appropriateness of the individual’s current placement. Discharge and transfer plans will be developed when appropriate and necessary.The Manager, Program Director and/or designated staff will review the individual’s program on a monthly basis. Monthly progress reports will be written by the Assistant Manager and become part of the individual’s file. Recommendations and comments regarding the individual’s program will be recorded. Goal accomplishments and the need for additional goals and programming will be noted. The IDT will reconvene to determine the individual’s current needs.Reviewed 6/2016TABLE OF IHP PROCESS TIME FRAMESSTEPS IN THE IHP PROCESSWHO DOES ITWHEN IS IT DONEConfirm or determine who is on the interdisciplinary teamManager/Individual Served30-60 days before meetingSchedule the IHP meeting with all team membersManager/Individual Served30-60 days before meetingComplete Life Plan with individual (and help from others if needed)Manager or Designee30-60 days before meetingComplete AssessmentsManager or Designee30-45 days before meetingReview previous IHP, assessments and medical records for additional informationManager or Designee15-30 days before meetingReview assessments with individual, family and other team membersManager10-15 days before meetingWrite up narrative sections of IHP (Sections 1-15)Manager or Designee10-15 days before meetingConduct the IHP meetingManager/Individual ServedNot ApplicableComplete the written IHP documentManager/Individual Served or DesigneeWithin 10 days after meetingDevelop implementation guides & tracking recordManager or DesigneeWithin 20 days after meetingBegin implementation of IHPAll designated team membersMtg. < 15th next monthMtg. > 15th-2nd monthSend IHP to individual, DDD case manager, other programs serving individual, guardian and familyManager*Make copy of cover sheetBy 10 days after meetingGather data for monthly monitoring and write & mail progress reportManager or DesigneeEvery monthConvene additional meetings if individual’s circumstances changeManagerWhenever NeededReviewed 6/2016“IN-CHARGE PERSON” ON A TWENTY-FOUR HOUR BASISPolicy: The President is responsible for the overall operation of the agency on a twenty-four hour basis.Procedures: When not in the office, the President may be reached by telephone. When out of the area, the President will designate a staff until he returns. The designated staff will also be accessible through the telephone.Each shift, (7-3p; 3-11p; & 11-7a) has a “Shift Coordinator” who is responsible for the overall program during his or her shift. The “Shift Coordinator” makes certain the program runs smoothly and that all procedures are followed. The “Shift Coordinator” reports directly to the Manager and/or his designated staff.The shift coordinator completes a written report in the Critical Log Book.Reviewed 6/2016PROCEDURE FOR INSURING ROUND-THE-CLOCK ACCOUNTABILITY OF INDIVIDUALSIt is the policy of Keystone to ensure the safety and accountability of our individuals at all times.Procedures: Each Direct Service Staff is responsible for serving the needs of the individuals in his/her care. The Direct Service Staff is expected to know where each individual is at all times.At the end of each shift, each Direct Service Staff is responsible for verbally communicating which individuals are present and which are not, to the arriving staff. He/she is also responsible for listing the names of these individuals in the Daily Log Book.If at any time an individual is missing or has not returned from work or school at the usual time, the “In-Charge” Person should be notified immediately.In regards to the Keystone Residential Program, the “In-Charge” Person is responsible for documenting, in the Office Report Book, the names of all individuals who are not present in the building at the end of his/her shift. Additionally, documentation is necessary whenever individuals leave for any period of time with family or friends.When an individual leaves his/her program for an overnight visit, the “In-Charge” Person is responsible for recording the date of departure in the Census Book or Log Book; as well as recording the date of return.Reviewed 6/2016BUILDING PROCEDURES FOR KEYSTONE RESIDENTIAL(154 FRONT ST.)It is the policy of Keystone to maintain its residence in a safe and secure manner. The following procedures should be adhered to.6:30a.m: The Shift Coordinator will unlock Front St. Main Doors; outside and internal doors.7:00a.m: The “Shift Coordinator will unlock Hamilton Blvd. outside office door.7:00a.m: All will enter building from either Front St. side or Hamilton Blvd. office door.9:30a.m: All external doors will be locked, except the office entrance on Hamilton Blvd. and main doors on Front St. side of building. These will be the only means of entry during the day, Monday through Friday.2:30p.m.: The Shift Coordinator will unlock the internal and external doors both on Front St. and Hamilton Blvd.9:00p.m: The Shift Coordinator will lock the external doors on Hamilton Blvd. including the Main Office Door, and all internal doors.11:00p.m: The Shift Coordinator will check all doors to insure they are locked.SPECIAL NOTESUNDER NO CIRCUMSTANCES shall anyone not associated with Keystone, be allowed to enter into an apartment without first contacting the Shift Coordinator. There shall be no deviation from this rule.Individuals and staff should avoid “cutting through” other apartments. This deters from the concept of individual homes and is disruptive.If an individual is going to run an errand, staff should contact the Shift Coordinator and other pertinent staff prior to the individual leaving the area.All those we serve as well as staff should inform the Shift Coordinator prior to leaving the building.The Direct Service Staff should inform the Shift Coordinator when individuals bring home notes regarding program closing or special program needs. Keystone staff is not to visit the Group Homes, Supervised Apartments, or Supportive Living Programs, on personal time without authorization from the Program Directors and/or Program Managers. Reviewed 6/2016PERSONAL RIGHTSPolicy: Fundamental to the philosophy and purpose of Keystone is the belief that individuals with developmental disabilities are entitled to exercise the same human and civil rights enjoyed by other citizens. These rights shall include, but are not limited to, those delineated in the “Rights of the Developmentally Disabled” as set forth in NJSA 30:6D-1 et seq. It is the responsibility of staff to advocate for and protect the rights of the individuals Keystone supports.Procedures: An individual’s exercise of his or her rights shall not be prohibited or be used as a cause for retribution against him or her.All employees who work directly with individuals supported by Keystone receive ongoing training to ensure familiarity with and observation of individual rights.Upon admission to the program and then upon subsequent request, the individual and, if applicable his or her guardian, will receive: 1) a copy of the Division’s rights document and 2) the names, addresses and telephone numbers of advocates available to assist the individual in understanding and enforcing these rights.Individuals receive training and support in order to understand options, make choices and exercise rights and responsibilities.Training and support are provided in a manner that the individual can understand. Continual evaluation of individuals is needed to insure proper guidance and training can be provided.Program meetings and teachable moments are used to continue to educate and encourage individuals to exercise their rights.Individuals who are deemed able will be asked to sign a consent form indicating their understanding and acceptance of these personal rights. (See Appendix B)Notices of advocacy or self-advocacy conferences, seminars or meetings shall be made available to all individuals unless determined otherwise by the Inter Disciplinary Team.Staff will help identify individuals who want a personal advocate or who wish to participate in a self-advocacy group.Individuals who wish to obtain a personal advocate or join a self-advocacy group will be provided the necessary assistance to do so.Personal rights shall not be limited or modified unless the individual’s disability limits the exercise of these rights and it is indicated in the individuals’ record.Reviewed 6/2016HUMAN RIGHTS COMMITTEEPurpose: The purpose of the Human Rights Committee is to ensure the human and civil rights of the individuals we support are exercised and protected. These rights shall include, but are not limited to, those delineated in the “Rights of the Developmentally Disabled” as set forth in NJSA 30:6D-1 et seq. Role:The Human Rights Committee shall exercise an advisory role to the President.The President shall make the final decision on any issue regarding the rights of an individual receiving service, and when proceeding against the advice and recommendations of the HRC, shall document the substantive reasons for proceeding against the advice and recommendations of the HRC in the individual’s record.The orientation of the HRC shall be proactive and preventative. The committee shall recommend procedures and programs that safeguard the rights of the individual.Membership:The HRC membership may be drawn from the following representative groups:?Individuals with developmental disabilities, including individuals served;?Family members and/or guardians of individuals with developmental disabilities;?Persons who have experience and background with rights issues such as those in the legal profession, members of the clergy, ethicists, social workers;?Persons who have prior experience serving on the Human Rights Committees;?Interested citizens from the local community; and?Employees familiar with programs and services for individuals with developmental disabilities.Members of the HRC who are not Division or agency employees will be required to sign a written statement that they will agree to protect individual information in accordance with Federal and State laws and Division rules. Persons who violate this subsection will no longer serve as a member of the HRC.Appointment of membersThe President shall appoint the members of the HRC for a two-year term. The term may be renewable. (For a current list of Human Rights Committee Members, see page 25). Individuals who are appointed to the Human Rights Committee shall receive informational and instructional material relevant to the services provided by the Human Rights Committee. They will also be afforded the opportunity to ask questions pertaining to the material and/or the committee.The Human Rights Committee shall consist of a minimum of five and a maximum of 15 members, at least one-third of whom shall not be employed by Keystone.There shall be no more than one-third common membership of the Behavior Guidance Committee and the Human Rights Committee.Regularly assigned members and the Chairperson and the Vice-Chairperson shall have voting rights.The Division shall have the option of assigning an observer who is not a voting member to the HRC. The observer shall be familiar with the agency, its manual and the general committee functions. Any concerns noted by the observer should be brought to the attention of the President.Any change in the membership of the committee shall be reported to the Regional Administrator within 30 days. Appointment of chairperson and vice-chairpersonA chairperson and vice-chairperson shall be elected by a majority vote of the HRC. They shall each serve a two-year term to which they may be re-elected.The vice-chairperson shall assume the responsibilities of the chairperson in his/her absence.Filling vacancies created by unexpired termsAny Human Rights Committee Member who cannot complete his or her term shall communicate this in writing to the President at least two weeks before the date of resignation.The President shall appoint a replacement within 30 days of the creation of a vacancy on the HRC.If the chairperson cannot complete his or her term, the vice chairperson shall become the chairperson for the remainder of the chairperson’s term. The HRC will elect a replacement for the vice chairperson as soon as possible.Removal of human rights committee membersA committee member may be removed by the President, for a good cause, based upon a two-thirds majority vote of the full committee. The member who may be removed shall not vote on the action.Meetings:The HRC shall meet preferably monthly, but not less than every two months.The Chairperson shall also have the authority to call special and emergency meetings as necessary.The decision making process of the HRC will be based on consensus.A simple majority of the members of the HRC shall constitute a quorum. A quorum is necessary for all issues requiring consensus.Any HRC member involved in the development or implementation of a proposed restriction will abstain from participation in the consensus process for that agenda item.The President shall ensure that the committee is offered a private meeting area and an atmosphere respectful of its independence and objectivity as a review group.The President will provide support staff to the Chairperson for completing tasks necessary for the HRC to function. These would include tasks related to material preparation, communication, and some aspects of information mittee Functions and Responsibilities:The functions of the HRC shall include, but not be limited to, the following:To advise the President with regard to issues concerning the human and civil rights of individuals, bringing to his attention existing or potential infringements upon, or impediments to the free exercise of individuals’ rights including recommendations for action;To contribute to the development or revision of policies and procedures directly relating to individuals rights;To review alleged or suspected violations of the rights of individuals or groups of individuals brought to the attention of the HRC and to recommend investigation of violations, as deemed appropriate by the Committee;To review behavior guidance plans which employ the use of procedures not prohibited by law or rule that may present an element of risk and/or restriction to an individual’s rights; andTo review the proposed involvement of individuals participating in research projects.To review the use of psychoactive medications prescribed for individuals without a documented psychiatric condition.The HRC shall have available to it all information that is necessary to perform its functions. The Committee shall have the right to observe programs and activities and conduct interviews in order to clarify a problem. The committee members shall observe confidentiality of all information obtained.The HRC shall have the right to request expert advice from outside the committee, as the committee deems appropriate.HRC Procedures:To the extent possible, committee members, the President and any other appropriate parties will receive the agenda and any accompanying documents in advance of the meeting. The individuals with potential rights restrictions and their guardians will be invited to attend the meeting.The individuals listed on the agenda will have their individual records made available for the meeting, if necessary.The HRC members shall carefully review each issue and the data presented to analyze risk, evaluating alternatives and assuring rights are not recommended for restriction due to staff convenience. They will provide a consensus based upon this discussion. If necessary, the HRC will include recommendations for further actions to the President.The HRC will provide, in writing, to the President, a copy of all recommendations within 10 working days of the meeting. The HRC Chairperson may provide a verbal recommendation to the President if immediate implementation is deemed necessary.The President, or designee, will respond in writing to the HRC Chairperson, as well as the individual or his or her legal guardian, within 10 working days on routine referrals, or immediately on emergency referrals, regarding the acceptance, qualified acceptance, or non-acceptance of the recommendations. The President will explain the basis for the HRC review and the rationale for his or her decisions.The chairperson will incorporate the President’s decisions and comments into the minutes of the meeting, which will be distributed to the committee members as the first agenda item of each meeting. The committee will review the President’s responses and implementation plan. The Chairperson will then outline the President’s decisions to the person or persons who presented the referral to the HRC.A copy of the notification of the decision to the individual or his or her legal guardian, as indicated above, is to be maintained in the individual’s record.The HRC may request progress reports on the review recommendations through the President.Where disagreement exists between members, an effort shall be made to reach consensus. Where that is not possible, the HRC may vote on its recommendations and submit the results and positions reflected to the President. The results of the vote shall be indicated in the meeting minutes.Conflict of Interest:If any matter that arises in the Committee’s deliberations should constitute a conflict of interest for a member of the Committee, that member shall abstain from voting on that issue.A conflict of interest shall be determined to exist if the HRC member in question is the person who submitted the referral for review by the HRC, the person is a member of the Behavioral Guidance committee and it is a recommendation of the Behavior Guidance Committee that is the matter before the HRC; or the HRC member is in any way directly involved in the matter before the HRC,. A final determination of conflict of interest will be the decision of the Chairperson.Representatives of legal services, such as the New Jersey Protection and Advocacy, Inc or other agencies, who may represent future individual interests, shall not be appointed members of the HRC, Their role and authority exist independent of the HRC,Dispute Resolution:Where the individual, guardian or advocate disagrees with the decision of the President, the individual, guardian or advocate may submit a written statement of disagreement. This statement of disagreement shall be sent, prior to the next HRC meeting, to the President for reconsideration and resolution. The President shall notify the Chairperson of the HRC, in writing, of any disagreements and resolutions. This statement will be maintained in the client record.If the individual, or his or her guardian or advocate, continues to disagree with the decision of the President, the individual, or his or her guardian or advocate, may appeal the decision in accordance with NJAC 10:48-1.1 Responsibilities of the HRC Chairperson:Providing a schedule of HRC meetings to committee members, the President, the Regional Administrator and other appropriate parties.Calling emergency HRC meetings as needed.Receiving and reviewing referrals to the Human Rights Committee.Determining if the issues addressed in the referrals constitute an actual or potential infringement upon the free exercise of an individual’s rights. If the Chairperson determines that the referral should not be reviewed by the committee, he or she shall draft an explanation for the next committee minutes and will review with the full committee, which will be the final arbitrator of any concerns regarding the relevancy of referral issues. If the request for HRC review was initiated by the individual or his or her legal guardian, the Chairperson shall provide a written explanation why the referral should not be reviewed by the HRC.Immediately reviewing emergency referrals with the President. To the extent practicable, developing and distributing an agenda based upon referrals received and issues to be discussed.Arranging for recording and transcription of minutes and that minutes are distributed and maintained.Presiding at meetings and performing all duties relevant to the office of the Chairperson.Requesting consultation from outside the committee based upon a decision of the committee.Ensuring the relevant, necessary meetings and reviews precede referrals to the HRC. Educating the HRC members on their responsibilities.Minutes of meeting:The minutes of all meetings shall be maintained in the office of the President and made available for review by Division staff as authorized by the Division Director.The committee chairperson shall forward the meeting minutes to the Committee members, the President, and other appropriate parties within 10 working days. In emergency situations, the recommendations shall be conveyed to such persons immediately, in person or by telephone. When concerning an individual, the HRC minutes shall be marked as “Confidential” and a copy placed in that individual’s record.Minutes of the HRC are considered Keystone’s records. All individual identifying information contained in the HRC minutes shall be redacted prior to disclosure to the public.The minutes of the HRC meetings shall be forwarded to the Regional Administrator for review.Human Rights Committee MembersJanay BrownDirect Service Staff/Group HomeRobert CordtsPeer AdvocatePamela DrotarParentDina EspositoDirector of Quality AssuranceRose HearneDirect Service/Group HomeJohn JayeolaProgram FacilitatorVincent LombardoParentJanet WaldenDirector of Vocational ServicesMary Ann WilliamsVocational SupervisorReviewed 6/2016 HOUSE RULESPolicy: At Keystone, we believe accepting responsibility for one’s actions is an important key in becoming independent. If those we serve are expected to become responsible and productive citizens, a normalizing environment that is based on fair rules and consequences for appropriate behavior must be provided.Procedures: The program rules will be developed by the program director and program manager. All leadership is responsible for implementation and monitoring of program rules. Individuals will be involved in the development of the rules prior to their implementation. Program rules will be reviewed and revised annually by the Program Director and more often when deemed necessary. Rules will be discussed and reviewed during monthly program meetings.The Manager will schedule program meetings. Meetings will occur monthly or more often if necessary. During the course of each meeting, those we serve will be encouraged to introduce topics for discussion and voice their concerns. Rewards for compliance with program rules may include but not be limited to:Verbal PraisePositive RecognitionSpecial Privileges and ActivitiesAdditional Responsibilities and/or PrivilegesConsequences for non-compliance with program rules may include the following:Verbal CorrectionCounselingInterdisciplinary Team MeetingConflict ResolutionReviewed 6/2016GRIEVANCE PROCEDUREPolicy: At Keystone, we believe persons with developmental disabilities have a voice and should be provided ample opportunities to express concerns, opinions, and ideas within the many facets of their lives. Our individuals at Keystone are encouraged to communicate desires, preferences, interests, likes, and dislikes; voice concerns at any given time. If an individual has a grievance he/she may speak to any party of the Keystone Family. However, it is encouraged to initially speak with immediate staff persons within the “home.”Individual grievances may be discussed within the context of the program meetings or in private with the immediate “In-Charge” Person. If an individual has a grievance, he/she is encouraged to immediately speak with staff persons within the home which includes the “In-Charge” Person, if the Manager is unavailable. If he/she is desirous to speak with a Manger of the home to resolve the issue, the “In-Charge” Person will notify the Manager or designee within a 24-48 hour time period. If the grievance is not resolved, the Manager should notify the Program Director within a 24-48 hour time period.If there is no resolution for the individuals’ grievance after conferring with the Program Director; the Program Director should speak with the Director of Operations or the Assistant Executive Director. The President will have the final disposition, if the individual’s grievance is not resolved after speaking with the Director of Operations or the Assistant Executive Director. Individuals interested in obtaining a personal advocate or joining a self-advocacy group will be encouraged to do so by staff. ____________________________Individual Signature____________________________ _________________Guardian Signature (if applicable) DateReviewed 6/2016ABUSE, NEGLECT AND EXPLOITATIONPolicy: Committed to providing a safe environment that protects and nurtures all individuals receiving services, Keystone strictly prohibits abuse, neglect, and exploitation of individuals served. Actions which result in abuse, neglect and exploitation, or failure to report suspected cases are considered sufficient cause for disciplinary action up to and including termination of employment or criminal charges. Individuals with developmental disabilities may lack the power, personal resources, experience, communication skills and survival ability needed to protect them. Therefore, it is imperative that all employees successfully complete the necessary training to recognize and acknowledge the responsibility of reporting possible signs of abuse, neglect and exploitation. Definitions:Abuse: physical, sexual or verbal acts against a person served that cause pain, physical or emotional harm, mental distress, injury, anguish, and/or suffering. This includes, but is not limited to hitting, kicking, slapping, shoving, pinching, name calling, yelling, ridiculing, harshly criticizing, kissing, fondling, and threatening. Any violation of personal rights, as found in appendix A, is considered abuse.Neglect: the failure to provide the needed services and supports to ensure the health, safety and welfare of the service recipient. This includes, but is not limited to providing an adequate degree of care and supervision, particularly in regard to food, clothing, shelter, programming and medical needs.Exploitation: any willful, unjust, or improper use of a service recipient or his/her property/funds, for the benefit or advantage of another, condoning and/or encouraging the exploitation of a service recipient by another person.For more comprehensive definitions please refer to Division Circular #14 (state.nj.us/humanservices/ddd/DCs.html)Procedures:Employee Responsibilities and Reporting Requirements:An allegation of abuse, neglect or exploitation may by reported from any source, anonymous or known.Each case reported is deemed “alleged” until after a thorough and complete investigation has been conducted.Employees are responsible for cooperating with any conducted investigations that may occur.Anyone who witnesses abuse, neglect or exploitation first-hand, should immediately step in the stop it.The individual involved should then be provided medical treatment or support as needed.It is the responsibility of every employee to immediately report to the On-Call Person any knowledge of cases where mistreatment or abuse is even remotely suspected. To the degree possible, reporting should be conducted in a manner which respects the privacy of all individuals involved.The reporting employee should fill out an Unusual Incident Report. This must be done as soon as possible, but definitely before the end of the shift.The On-Call Person Receives all necessary verbal and written information.Ensures the individual has been provided with necessary medical treatment or support.Ensures immediate protective measures, such as temporarily suspending employment for staff involved are taken.Ensures an initial investigation is completed. Notifies the President or designated staff.The President or designated staffEnsures a complete and thorough investigation is completed within 24-48 hours.Determines whether local authorities need to be contacted.Ensures that the proper notifications are made in a timely manner.Ensures the incident is reported to the Division of Developmental Disabilities as per Division Circular #14.In consultation with the Director of Operations or Director of Human Resources, determines proper course of action regarding staff in question.Reviewed 6/2016UNUSUAL INCIDENTS AND REPORTING METHODPolicy: In order to provide for the safety and well-being of those we serve and support as well as our staff at Keystone, Unusual Incidents are reported promptly and documented in an efficient and timely manner.Definition: An Unusual Incident means an event involving an individual served and/or employee. Unusual Incidents include but are not limited to; indications or allegations of injury, criminal actions, negligence, exploitation, abuse, clinical mismanagement, medical malpractice; major unforeseen event, such as a serious fire, explosion, or power failure that presents a significant danger of a newsworthy event.Purpose: It is imperative to report and document incidences which involve individuals served and employees of Keystone, as we are committed to ensure all incidences are reported, documented, and followed-up on in a timely and efficient manner by appropriate staff.Procedures:Unusual Incidents must be reported to the Shift Coordinator immediately. This is a verbal reporting method.An Unusual Incident Report will be completed prior to the end of the employee’s current shift.The Shift Coordinator must report the Unusual Incident to the Keystone on call phone. The person on call makes certain all relevant personnel and immediate safety issues are handled in a timely and appropriate manner.In cases of abuse, neglect, or exploitation; the President or designated staff completes an investigation within a 24-48 hour period. Staff persons’ accused of abuse, neglect or exploitation will be suspended pending the final results of the investigation. In cases where abuse, neglect, or exploitation is substantiated, the employee in question will face dismissal and possible legal action.The President or designated staff makes certain that all reporting requirements are accomplished in a timely manner, including notifying Legal Guardians of A+, A and B incidents.REPORTABLE UNUSUAL INCIDENTSCategory A+: Incidences are highly unusual incidents or events posing imminent threat to life or safety. These include physical and sexual abuse with major injury, homicide, suicide, major fires, bomb threats and hostage taking.Category A: Means a serious threat to life and/or safety. These include incidents of sexual and physical abuse with moderate injury, assault and elopement.Category B: Means an occurrence where the threat to life or safety is not imminent. These include verbal abuse, moderate injuries, and natural or unexpected deaths.LEVEL OF INJURYNo Injury: No evidence of abrasion or bruising and no complaint of pain following, for example a fall.Minor Injury: Any small bruise or abrasion that does not require treatment and will heal within several days. Examples include nose bleeds, small lacerations without sutures (cleaned, ice applied).Moderate Injury: Injury requiring medical treatment beyond physical examination that is not considered major. For example, a small cut that requires suturing (up to 6 sutures), bone injury or soft tissue damage that does not meet the criteria for major injury or a human bite. Bruises and contusions are considered moderate if they require treatment.Major (Serious) Injury: Includes but not limited to any fracture skull, long bones, ribs, spine, or pelvis; head injury, such as a concussion; wounds requiring extensive suturing (7 or more); any adult bites to a child; extensive burns; bodily injury resulting in gastrointestinal symptoms or genitourinary symptoms; teeth knocked out; injury to the eye causing large or multiple hematomas; choking injury leaving marks; any injury requiring hospitalization.ABUSEAbuse means any act or omission that deprives an individual of rights or which has the potential to cause or causes actual physical injury or emotional harm or distress.Examples of abuse include, but are not limited to acts that cause pain, cuts, bruises, loss of body function, sexual assault, temporary or permanent disfigurement, death, striking with a closed fist or open hand; pushing to the ground or shoving aggressively; twisting a limb; pulling hair; withholding food; forcing an individual to eat obnoxious substances; use of verbal or other means of communication to curse, vilify and/or degrade an individual or threaten with physical injury.PROPERTY DAMAGEMajor property loss or damage means any damage which renders a facility, vehicle or equipment valued at more than $5,000 unusable and/or interferes with the care of the individual or facility operations. Also, the loss or damage from a pattern or series of related incidents for an individual being served may define major loss; major property loss is denied as anything of a greater value than $100.Refer to attached N.J. DHS-OPIA ASSIGNMENT-ADULT/JUVENILE SR’S-IN-STATE PROVIDERS; As per Administrative Order 2:05; Division of Human Services Community Incident Category List for further categories of incidents.REPORTING PROCEDURES:As per Division Circular #14, Unusual Incidents must be reported to the Division of Developmental Disabilities in the following time frames:A+Reported ImmediatelyAReported the same working day if the incident occursduring normal working hours. Report the incident thenext working day if it occurs after hours.BReport the incident by the next working day.The UIR Coordinator or designee will review all incident reports and completing follow-up procedures accordingly.Unusual Incident Reports are maintained in a file in the administrative offices.Reviewed 6/2016Unusual Incident Report InstructionsAll sections of the report are to be completed. All information must be legible. The person reporting the incident must complete the following information on the front of the UIR form.Name: Name of the individual(s) involved.Witness: Include all names of individual(s) who witnessed the incident.Date of Incident: Provide the date the incident occurred. If the date is unknown, write “discovered on” and date.Time: Write the time the incident occurred and check am, pm, or overnight. If time is unknown, write “time discovered” and the time.Location: Give the exact location of where the incident occurred or allegedly occurred. If incident occurred at or during a community out such as the movies, dinner, or Special Olympics; specify the exact location.Type of Incident: Check the category that describes the type of incident.Restraint Use/Authorization Received: If Non-Crisis Intervention must be used for the safety of those involved, the Program Supervisor must complete this section and an Emergency Restraint Form must be completed and attached.Describe Incident: Provide a concise summary that explains what happened.When incident occurredWhere it occurredWho was involvedWhat happenedImmediate course of action taken: Provide details on the action taken.Who was notifiedWhat they didSignature of person reporting incident: The person reporting the incident must sign and date form. The form must then be given to the Shift Coordinator.The back portion of the form is for: Administrative Use Only and must be completed by the Shift Coordinator or designated staff. Notifications: Contact and check all that apply. Include names, time and date. See form for telephone numbers and appropriate contacts.PLEASE NOTE: WHEN CONTACTING THE CASE MANAGER, YOU MUST SPEAK TO A PERSON “NO MESSAGE” CAN BE LEFT.If a message is left for a parent or guardian, please note “message left” (included time/date) on form.If at any time you are unsure or have a question, please contact Keystone’s On-Call Person for direction.Signature of person reviewing incident: Review report and make sure all information is complete. Sign and date form. Place completed form in the mailbox of Dina Esposito.Follow-Up Recommendations: The UIR Coordinator or designee will complete this section.Reporting Level: The UIR Coordinator or designee will complete this section.Appendix B: Investigation PolicyAppendix C: UIR Reporting Contact InformationAppendix D: UIR Category ListReviewed 6/2016Use for KCR 154 Front Street onlyUNUSUAL INCIDENT REPORTName of Individual(s) Involved: ____________________________________________ Date of Incident: ________ Time: _______ AM__ PM__ Location: _______________________________________________________________________________________TYPE OF INCIDENT: Please check: Injury____ Assault____ Alleged Abuse____Danielle’s Law/911___ Criminal Activity___ Death____ Elopement___ Exploitation___Medical/Disease_____ Illness___ Medication Administration Error_____ Medication Documentation Error_____ Operational___ Sexual Contact/Assault____ Suicide Attempt____ Walk Away____ Restraint Use_____Restraint Use/Authorization Received: Yes___ No___ Time___ Form Attached___Authorizing Person____________________________________________DESCRIBE INCIDENT: Give details of what occurred (Who Was Involved; What Happened; Where Incident Occurred; and How Incident Occurred)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMMEDIATE COURSE OF ACTION TAKEN: Give details of action taken (i.e. First Aid, 911call, Staff Suspension, Repair Service etc…____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SIGNATURE OF PERSONREPORTING INCIDENT: _________________________________ Date__________ ADMINISTRATIVE USE ONLYNOTIFICATIONS: To be completed by Program SupervisorKEYSTONE ON CALL: 908-304-4548Yes___ No___ Time________ Name______________________________________CASE MANAGER/DDD: PLEASE NOTE: Notifications between business hours (9-5) YOU MUST SPEAK TO THE CASE MANAGER OR THE COVERING SUPERVISOR. DO NOT LEAVE A MESSAGE. Call Main office and ask for covering supervisor/ on call person if unable to reach case manager. After Business Hours call DDD On Call # . See Below for assigned On Call #. Sildamise Pierre (154 Front St. only) 609-292- 5192 Main Office: 609-292-1922 Notification: Yes___ No___ Date ______ Time______ After Hours /Weekends Call DDD On–Call # 609-292-1922After Hours / Weekends DDD On-Call NotificationYes ____ No____ Name of Covering On-Call Person_____________________ Date_____ Time______PARENT/GUARDIAN: BGS Danielle Delgado BGS 609-689-6701 / Main Office- 609-631-2209 -Trenton Wes Cowperthwaite BGS 973-648-4368 / Main Office – 973-648-4638 -Newark Please check your Fact Sheet for assigned Guardianship/Parent Name _____________________________ Date_________ Time_______Self Guardian _______Program Supervisor Signature: ___________________________________TO BE COMPLETED BY UIR COORDINATOR FOLLOW-UP RECOMMENDATIONS:___________________________________________________________________________________________________________________________________________________________________________________________________________________________REPORTING LEVEL: A+___ A___ B___ C___UIR COORDINATOR SIGNATURE___________________________ Date_______ Group Homes/Supportive Living/Supervised Apartments/Keystone Vocational Use OnlyUNUSUAL INCIDENT REPORTName of Individual(s) Involved: ____________________________________________ Date of Incident: ________ Time: _______ AM__ PM__ Location: _______________________________________________________________________________________TYPE OF INCIDENT: Please check: Injury____ Assault____ Alleged Abuse____Danielle’s Law/911___ Criminal Activity___ Death____ Elopement___ Exploitation___Medical/Disease____ Illness___ Medication Administration Error_____ Medication Documentation Error______ Operational___ Sexual Contact/Assault____ Suicide Attempt____ Walk Away____ Restraint Use_____Restraint Use/Authorization Received: Yes___ No___ Time___ Form Attached___Authorizing Person____________________________________________DESCRIBE INCIDENT: (Who was Involved; What Happened; Where Incident Occurred and How Incident Occurred)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMMEDIATE COURSE OF ACTION TAKEN: Give details of action taken (i.e. First Aid, 911call, Staff Suspension, Repair Service etc…________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________NOTIFICATIONS: To be completed by Program Supervisor, Program Coordinator, Group Home /Supervised Apt. /Supportive Living Staff and Keystone VocationalKEYSTONE ON CALL: 908-304-4548Yes___ No___ Time________ Name______________________________________CASE MANAGER/DDD: PLEASE NOTE: Notifications between business hours (9-5) YOU MUST SPEAK TO THE CASE MANAGER OR THE COVERING SUPERVISOR. DO NOT LEAVE A MESSAGE. Call Main office and ask for covering supervisor/ on call person if unable to reach case manager. After Business Hours call D.D.D. On-Call #. Refer Below for assigned On Call #. Please Check Fact Sheet for individuals Case ManagerShaheerah Patterson: (Please Refer to Fact Sheet) Direct Line: 609 292-5192 Main Office/D.D.D. On-Call: 609 292-1922 (After Hours/Weekends/Holidays) Notification: Yes___ No___ Date ______ Time______ Trinisha Lee-Symister (Please Refer to Fact Sheet) Direct Line 609-292-2410 Main Office/D.D.D. On-Call: 609-292-1922 (After Hours/Weekends/Holidays) Notification: Yes___ No___ Date______ Time_____ Emilia Riehl and Brandon Whigham (Catalano Apts.) 732-424-3313 Main Office 732-968-6000After Hours /Weekends Call DDD On–Call # 908-226-7800 Yes____ No ______ Date_______ TimeAfter Hours / Weekends DDD On-Call NotificationYes ____ No____ Name of Covering On-Call Person__________________________________ (Print Clearly First and Last Name)Date_____ Time______PARENT/GUARDIAN: BGS Danielle Delgado BGS 609-689-6701/Main Office- 609-631-2209 -Trenton Wes Cowperthwaite BGS 973-648-4368/Main Office – 973-648-4638 -Newark Please check your Fact Sheet for assigned Guardianship/Parent Name _____________________________ Date_________ Time_______Self Guardian _______SIGNATURE OF PERSONREPORTING INCIDENT: _________________________________ Date__________TO BE COMPLETED BY UIR COORDINATOR FOLLOW-UP RECOMMENDATIONS:__________________________________________________________________________________________________________________________________________________________________________________________________________________________REPORTING LEVEL: A+___ A___ B___ C___UIR COORDINATOR SIGNATURE___________________________ Date_______PROCEDURES FOR DAILY WRITTEN COMMUNICATION WITHIN PROGRAMSPolicy: At Keystone, we believe communication among staff is of the utmost importance. It is through communication that accountability and quality are maintained.Procedures: Staff who work directly with those we serve are responsible for completing a written report in their program’s log book during and prior to the end of their shift. This written communication should contain the following:A program census at the beginning of the shift and at the end of the shift.A brief and concise description of each individual’s overall behavior & response to programming.Notation and resulting staff response to any Medical & other Critical Information including but not limited to:Signs of IllnessAny InjuryAny changes in behaviorOTC medications given (including reason given, dosage, and time)Consults with support staffUpcoming appointments scheduledAny medication or treatment changes or additionsAny change in programmingAny UIR’s that occur during the shiftAny repairs or other safety issues identified.For every notation in the Critical Information section there must be a follow up written in the report at hand or subsequent Critical Information section reports to indicate follow through and closure on issues reported and noted.All daily shift reports must be signed and dated by the staff working. All entries must be reviewed and initialed by staff for all shifts for which they were not present. Staff Responsibilities:At the beginning of the shift, staff must read the log book and initial all critical information pages; indicating he/she has read the log book which contains critical information since the last day worked.Critical Information is noted by highlighting areas to be followed up on regarding individual’s serve and program issues.The daily report will be reviewed and signed by the Manager or designated staff every 72 hours.Reviewed 6/2016STAFF MEETINGSPolicy: Staff meetings are scheduled to promote team building, communication and consistency in programming.Procedures: Staff meetings will be scheduled on a monthly basis by the Manager in conjunction with the Program Director.All staff meetings are mandatory. Managers must be informed at least 48 hours in advance that you are unable to attend the meeting.Employees should not miss more than three meetings in one year; otherwise it will result in a corrective action.The minutes from the missed meeting must be reviewed with your manager on the next scheduled day of work. Meeting minutes are maintained in each program.Reviewed 6/2016PROCEDURE IN CASE OF MISSING PERSON Staff is responsible for ensuring the safety and well-being of the individuals supported by Keystone. The amount of supervision required is noted in the Individual’s Habilitation Plan. It is imperative that each staff knows where the individuals he or she supports are at all times. As soon as it is learned that an individual is unaccounted for, the following procedures should be followed:The employee responsible for the missing individual uses all staff available to conduct a quick but thorough search of the home, grounds and immediate neighborhood.After 10 minutes with no success, the employee then notifies the On-Call Person.The On-Call Person contacts the local police, giving a description of the missing person. The description should include information such as physical description, level of functioning, medical problems, etc.The On-Call Person then notifies the President or designated staff.The President or designated staff contacts the individual’s parents and or guardian.The President or designated staff reports the missing person to DDD as per Circular #14.When the missing person is located, all persons previously notified of the disappearance will be informed by the On-Call Person.The President or designated staff will ensure a thorough investigation is conducted.Reviewed 6/2016PROCEDURE IN CASE OF DEATH The employee who discovers the individual calls 911.That employee then calls the On-Call Person.The On-Call Person notifies the President or designated staff.After the individual has officially been pronounced dead, the President or designated staff notifies the family and/or guardian.The family or guardian has the responsibility of making funeral arrangements. Keystone staff shall provide assistance as needed.The President or designated staff ensures the individual’s medical records are updated with the circumstances surrounding the death, including but not limited to date, time and cause.The President or designated staff ensures proper Unusual Incident Reporting to DDD as per Circular #14.The individual’s manager gathers any personal belongings to present to the family. In the absence of family, the IDT determines the proper course of action to take regarding personal possessions.Reviewed 6/2016VOLUNTEERING AT KEYSTONEPolicy: Keystone does not use volunteers. However, on occasion, community groups or individuals may provide entertainment or complete service projects, provided 1) they have received prior approval from the President or designated staff, and 2) they are not left alone with any of the individuals Keystone supports. If volunteers were to be used, they would first need to meet all of the pre-employment requirements of an employee.Reviewed 6/2016MANAGEMENT OF CLIENT FUNDSBASIC PRINCIPLESKeystone recognizes the right of every individual to manage his/her personal finances to the best of his/her ability. Individuals shall be involved to the greatest extent feasible in banking and management of their own funds, consistent with development and based upon the individuals’ ability as determined through assessments by the interdisciplinary team. Annual plans will reflect goals in this area, as appropriate. Individuals shall also be involved to the greatest extent feasible in making decisions about their personal expenditures. In most instances, the responsibility for the management and safeguarding of the individual’s funds is delegated to an employee of Keystone, generally a manager or assistant program manager. A monthly accounting of financial transactions on behalf of the individual will be made and will be available to the individual, other pertinent Keystone staff, guardian, or other interested parties such as representatives of the State of New Jersey. The President or his/her Designee will assign a staff person for Quality Assurance. This individual is responsible to ascertain that Keystone’s financial policies are implemented and maintained. This includes auditing or presenting for auditing all accounts and regular reviewing of financial records including receipts.In instances where an employee has been assigned and accepted the responsibility to manage funds on behalf of an individual Keystone serves, he/she has accepted a fiduciary role with legal obligations and responsibilities. This fiduciary role requires the employee to act in a trustworthy and confidential manner when handling resident funds and is financially responsible for the funds.As part of the legal, fiduciary responsibilities and obligations, employees are responsible for the sound management of funds, all required accounting documentation and reporting of such management and advocacy in assuring that the individual is receiving all funds to which he or she is entitled.The annual IHP shall include a financial plan to ensure the satisfaction of current and future needs including planning for the individual’s benefits, and assuring that money management training is provided and that specific goals are included.Role of the Representative PayeeKeystone serves as the representative payee for social security for some of its individuals. Keystone adheres to the regulations and guidelines set forth by the social security administration. As a representative payee, Keystone is appointed to manage Social Security funds and ensure that the basic current needs are met, such as, medical and dental expenses, personal care items, clothing, rehabilitation expenses, etc. After paying those expenses, Keystone (the payee), can use the rest of the money to pay any past-due bills the individuals may have and give the individual spending money. If there is money left, it will be kept in the individuals’ personal interest bearing account at a community banking institution.Once checks are received, they will be deposited in the Keystone Community Living Resident Trust Account. An account ledger will be maintained for each individual in which documents all money received from social security and all checks that are written on the behalf of each individual. Within a reasonable period of time (not more than five business days) checks will be written to each individual to be deposited into their own banking account.Keystone will keep accurate records of how each beneficiary spends their money. Each year, social security requires the payee to complete a form to account for the benefits that were received. In order to continue receiving SSI, an individual must not have more than $2,000 in cash at any time. Keystone’s policy is that an individual may not hold more than $1,200 in the bank at any time and no more than $100 cash on hand. ADVOCACY ROLEThe advocacy role in management of individual funds involves the responsible use of individual funds, which include:Making prompt bank deposits of all checks/monies received on behalf of the individual. The full amount of all checks deposited must be shown on the Personal Financial Report. Using funds solely for the benefit of the individual only and in accordance with any applicable regulations concerning use of funds.Documenting in accordance to each individuals IHP (Individual Habilitation Plan).Ensuring that receipts are available for all purchases.Ensuring that all expenses are recorded accurately and change is documented on the cash on hand sheet.Meeting individual obligations and ensuring that such charges to the individual are made accurately and fairly, including: medical/dental expenses, taxes, clothing, personal spending, etc.Developing an acceptable budget with the individual for personal spending and documenting such process in the individuals’ records.Obtaining authorization from the Program Director for an expenditure over $100.Maintaining funds in the most secure manner as possible. Financial records are confidential business records and may not be removed from the premises. Exceptions to this may only be authorized by the President or his/her designee. Commingling of funds is prohibited. No resident’s funds shall be commingled with petty cash, personal funds of staff, or general facility funds.Keeping no more than $100 cash-on-hand for an individual at the program site unless authorized by the President or his/her designee.Monies must be kept in a secure area and the accessibility limited to the staff who has been assigned responsibility for managing funds. The majority of resident funds are kept in individual bank accounts in the resident’s name with sole ownership resting with the individual. If the individuals have a non-bearing interest account, there must be documentation from the guardian stating they are in agreement with this. ACCOUNTINGThe responsible staff person will monitor with the oversight of the Program Director the level of accumulated funds to ensure that SSI (supplemental security income) and other benefits are not lost unnecessarily. Currently, accumulated assets may not exceed $2,000 without the loss of Social Security benefits. Keystone’s policy is that an individual may not hold more than $1,200 in the bank at any time and no more than $100 cash on hand. A statement, signed upon admission, authorizing Agency personnel to manage an account for an individual’s finances must be obtained from the individual and/or his/her guardian in all instances where control of funds is delegated to Keystone personnel. This form is called Authorization for Assistance in Financial Management. PERSONAL FINANCIAL REPORTThis report involves the account balance of each account including a checking and/or savings account. This report includes dates of all deposits and withdrawals and a description of each transaction and the signature of the person initiating the transaction. Individuals capable of participating, as per their IHP, must also sign off on each transaction. Deposit and withdrawal slips should be attached for all transactions. By the tenth day of each month, the Personal Financial Report for the previous month for each individual will be completed along with the Cash on Hand sheet. The Personal Financial Report, the bank statement, and the cash on hand sheet will all be stapled together. The Program Director will review and sign monthly. CASH ON HAND REPORT: This report involves the cash currently available in the house. Each individual should have their own separate pouch for their spending money locked up in safe. When there is a cash withdrawal from the bank, this will be documented as a deposit into the cash on hand sheet. All expenses must be recorded on this sheet. Receipts must be obtained and attached for each expenditure. An acceptable receipt is a cash register tape and must have the following information:Name of vendor (i.e. name of store/restaurant)Accurate address of vendor (if applicable)Date of purchaseTotal amount of saleDesignation of what items were purchasedAmount that was spent by each resident (if on one receipt)Amount of change, if any is due to the residentIf a register tape receipt is unavailable or is lost, acceptable alternatives are:Hand-written receipt signed and dated by the person who received the monies (in that person’s handwriting) with the total amount paid and designation of items/service purchased.Ticket stubs with the date and total amount paid validated by the selling establishment.Staff must be vigilant and assertive to ensure that accurate receipts are obtained. Staff should examine each receipt prior to leaving the establishment to ensure its accuracy and completeness.If an individual is getting spending money as per their IHP, a hand written receipt must be signed by the staff giving the money and the individual receiving the money. “Spending Money” should be written on the receipt. AUDIT PROCEDURE:An audit of individual funds will be conducted as follows:The Personal Financial Report and Cash on Hand sheet will be reviewed and signed off monthly by the Program Director pending on the individual’s residence for legitimacy of expenses.The Director of Operations or designee will audit financial records including bank statements, the Personal Financial Report, and the cash on hand on a quarterly basis.Discrepancies, questions or concerns arising from the audit will be documented in writing and sent to the staff person responsible for the individual’s funds. This memo will be filed in both individual’s file and the personnel record of the employee until resolution of the issue.When an audit reveals a discrepancy between the record of funds and the actual funds, the discrepancy must be reported immediately to the President or his/her designee who then must conduct an investigation of the discrepancy and resolve it. Alleged misuse of funds will be treated as an Unusual Incident and reported to appropriate persons in accordance with current regulations.If there has been miscounting, loss, or irresponsible use of funds, the employee responsible for the money will be asked to reimburse the funds found to be discrepant and may face disciplinary, legal action or discharge as a result.In addition, any expenses that require a receipt and do not have one will be cause for disciplinary action.When an employee resigns, an audit release and assignment of all funds at the program site must occur on or before the employee’s last day of employment. The Program Director is responsible for informing pertinent staff in advance pending transfers or discharges.SPECIAL EXPENDITURESSpecial expenditures made on behalf of the individual must have approval of the Program Director and the Director of Operations or designee if the amount spent is over $100. If in doubt about the legitimacy of any expenditure, staff must contact and gain approval of the Program Director and the Director of Operations or designee.Examples of special expenditures:MEALS EATEN OUT OF PROGRAM: As part of normalization and efforts to expose individuals to social opportunities, there may be an occasion when meals are eaten out. On those occasions when an individual chooses to eat out instead of eating the prepared meal in program, he/she will pay for his/her own meal. In those instances where more than one person is participating in the meal out, each individual will pay for his/her own meal; tax and tip will be split equally amongst the individuals. If a staff person accompanies the individuals, staff cost will be paid through petty cash, up to $15.00. Tax and tip, will be divided equally amongst both staff and individuals. When possible, individualized receipts which include tax and tip are recommended.PERSONAL PROPERTY: When personal property is received or purchased, the property must be listed immediately on the Inventory Sheet and must include date of purchase and identifying data. This procedure is in addition to documenting the financial transaction on the Cash on Hand sheet. VACATIONS: Vacations are a normal part of a quality lifestyle and are indeed encouraged for individuals served at Keystone. However, careful planning is required. In certain instances, individuals may go on vacation under the auspices of an Agency other than Keystone (i.e. Sprout) and in most other instances under the supervision of Keystone staff persons. In order for a vacation to be successful, we realize proper supervision is necessary.Vacations may occur only with the knowledge and approval of the Program Director and Director of Operations; and will be contingent upon the submission to the Case Manager for review and final approval of a vacation budget that includes all costs and their proposed allocation to the individuals served as well as staff hours required and other staff expenses.A “Service Provider Vacation with Individual Receiving Services” Form (see attached) must be completed at least 90 days prior to the vacation. A copy of each individual’s bank statements must be attached to the form, prior to submission. No transactions can be made (no signed leases; deposits; nor purchases for the trip) until approved.The Case Manager must receive the following information at least 30 days prior to the vacation:Verification the individual wants to go on the vacation; each individual is in agreement with the vacation plan, including expenditures, absence from work and any other relevant issues.Verification that the individual has sufficient funds; estimated cost of the vacation; verification the proposed vacation costs do not jeopardize any priority expenditures.Destination of the planned vacation and a brief description of the vacation activities.Description of the planned lodging/sleeping arrangements.Time frame for the vacation.Assurance that any special needs will be met (i.e. medical, behavioral, adaptive equipment, dietary, and safety).Identification of everyone who may need to be contacted (legal guardian, involved family members, physician, and employer).Consent is received from the legal guardian about the vacation.Staff schedule.The following are the items that need to be brought on the vacation:The individuals valid medical and prescription cardsA valid Consent-Release Emergency Treatment form, if neededThe individuals identification documentation as neededThe individuals emergency informationOther documentation and/or information as needed.The individual’s day program and/or employer should be contacted to inform them of the individual’s absence start and return date.All vacation receipts are to be kept in a safe place, as the Case Manager will ask to review them.If an individual is going on vacation with family members, the Program Director and Director of Operations must be notified within a reasonable amount of time. He/she will ensure proper documentation and notifications are fulfilled.Upon return, family members will ensure receipts are turned in to the appropriate person(s).SPECIAL ACTIVITIES: Special activities, or activities that are not part of an individual’s normal routine, such as trips to the theatre, circus, amusement parks, professional sporting events, concerts, etc. add to the quality of one’s life and provide an individual something special to look forward to, are encouraged. Special activities would not be possible unless proper supervision is provided by Keystone staff persons. In order to ensure that individuals have the opportunity to participate in special activities, certain staff costs related to the activity will be paid by Keystone. Activity costs includes transportation (other than transportation by Keystone vehicles), admission charges, etc. will be divided equally amongst individuals and staff persons attending the activity. For those individuals in a particular program unable to afford a certain activity, Keystone will pay that individual’s share on a case by case basis. In all instances, without exception, Keystone will pay all labor costs related to the special activity.Special activities may occur only with the knowledge and approval of the Program Director or designated staff. Approval by the Program Director or designated staff will be contingent upon the submission of the Director of Operations for review and final approval of a special activities budget that includes all costs and their proposed allocation to the individuals served as well as staff hours required and other staff expenses.SHARED COSTS: Transactions involving shared costs among individuals are discouraged. Joint purchases of fixed assets among residents are prohibited. For joint purchase of service (such as phone, newspaper, cable, restaurant meals, etc.), the cost must be split equally and fairly for each transaction. When there is only one receipt for more than one individual the following must be done:One individual will get the original receiptThe original receipt needs to have all of the initials of the individuals that participated in the purchase/activityThe remaining individuals will get a copy of the original receipt with everyone’s initials who participated for his/her records.The initials must be highlighted for each individual and kept for their financial records. NEWSPAPER/CABLE: These costs are incurred to the individual only if he or she has chosen to receive the services or if the services are recommended as part of their annual plan. If the service is necessary for the official operation of the program, it will be paid from program petty cash.PHONE: Individuals are responsible to pay all personal toll phone calls and applicable taxes. Individuals with insufficient funds will be encouraged to phone family/friends collect or correspond by mail.IRREVOCABLE BURIAL RESERVE ACCOUNT: These will be established for individuals who are deemed to have sufficient financial resources to meet present and projected financial needs. This will be discussed at the annual IHP meeting. RESTITUTION: An individual’s personal funds may be used as payment for damages if the individual is capable of giving consent and agrees to make restitution for the damage. An incident report will be completed to document the individuals’ written consent and will be kept in the individual record. A written record of consent is required by the individual or guardian for each incident of restitution.LOANS/SOLICITING: Individuals’ are prohibited from borrowing money from staff or other residents. If a resident is in need of money to meet expenses, the following procedures shall be used:The family/guardian will be contacted as a source of revenue.Special arrangements may be made with the President or designee to supply temporary loans for residents in need of funds. Written requests for temporary loans are made by the Manager together with the Program Director and submitted to the President for approval.Loans are treated as any other source of income/expenditure and as such, are recorded on the Personal Financial Report for the individual.Repayment of loans is required as soon as the individual has funds available.Under no circumstances will a staff person accept gifts or money from a resident or solicit residents to purchase goods or services.PERSONAL PROPERTY INVENTORY: A perpetual inventory of personal property of those items such as clothing and furniture purchased by the individual and used exclusively by the individual is maintained in their file. The inventory is considered part of the individual file and accounting system. Items purchased by the individual will be used exclusively by the individual. An inventory of personal property is conducted upon admission and reviewed and signed by the Program Director every six months thereafter. The inventory must be updated as possessions are acquired or discarded. The written inventory must be completed by the staff person assisting the individual at the time of receipt and the actual items must be witnessed by the Manger. Keystone’s inventory form can be found in Appendix E.Revised 6/2016KEYSTONE COMMUNITY LIVINGPERSONAL FINANCIAL REPORTName:?Residence:?Month/Year:?Bank Name:???Payee:?DateDescriptionReceipt #DebitCreditBalance?STARTING BALANCE*************????????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????Resident Signature: ________________________________Date___________Prepared by: _____________________________________Date___________Reviewed by:_____________________________________Date___________Auditor:_______________________________________Date___________KEYSTONE COMMUNITY LIVINGCASH ON HANDName:Residence:Month/Year:DateDescriptionReceipt #DebitCreditBalance?STARTING BALANCE*************????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????Resident Signature: ________________________________Date___________Prepared by: _____________________________________Date___________Reviewed by:_____________________________________Date___________Auditor:_______________________________________Date___________SPECIAL ACTIVITIES EXPENSE FORMStaff Requesting: ____________________Program:______________Proposed Date: ______Departure Time: ______Return Time: ______Description of Special Activity_______________________________________________Trip ExpensesExpenseCostExplanationAdmission:Transportation:Meal(s): Spending Money:Other (Specify):Total:(A)Staff ExpensesExpenseCostMultiply by # StaffLine TotalAdmission:Transportation:Meal(s) (Specify):Other:Total Staff Expense:(B)Actual Cost equals: (B) Total Staff Expense, (divided by number of Individuals served participating) plus (A) Trip ExpensesB divided by #AttendingPlus ATotal Cost Per IndividualPetty Cash RequestedPurpose(s)Individuals Served/Source of Funds (use back of page if necessary)NamePersonal AccountOther (Keystone, Parents)Staff AttendingSchedule# HoursOT (y or n)________________________________________________________________________Approved Yes/No Approved Yes/NoProgram Director______________Director of Operations________________AUTHORIZATION FOR ASSISTANCE IN FINANCIAL MANAGEMENTI,_____________________, consent to have Keystone staff assist and handle my personal finances. This consent will encompass assisting in the payment of expenses, holding and dispensing personal funds, as well as holding savings and/or checking accounts. This consent may also encompass a combination of any mentioned areas deemed to require assistance. The types of funds to be handled are (check those that apply):PNA/PTF(personal needs and patient trust funds)_______Gifts____Payments from family members_____Paychecks_____SSI/SSA_______Tax refunds_____Transportation Reimbursements_____Debit Card_____Disability Payments_____Insurance claims______Public Assistance______Please Specify Other Funds Not Listed Above (if any)_____________________I also agree to take an active part as much as possible in handling my personal finances and participating in a plan that will enable me to prepare for financial independence.I agree to the terms of this agreement and understand the responsibilities of all parties concerned.___________________________ ______________Individual’s Signature Date_________________________________________Program Director DateAs legal guardian of__________________________, I am aware of and approve of his or her execution of this authorization. I certify that I have read this document and agree to be bound by its terms._________________________________________Legal GuardianDate Revised 9/2015SAFEGUARDING PROCEDURESIndividuals are expected and encouraged to take responsibility for and maintain their own personal possessions.Keystone is never the payee for an individual’s personal benefits. Bank accounts are always in the individual’s name.Any individual who is missing any of his or her personal possessions is to report the same to the staff in charge.An internal investigation will take place and the results will be noted in the report book. The Manager or designated staff will report the same to the Program Director and/or the Director of Operations.Individuals always have the right to file a grievance with appropriate staff as per Keystone policy._______________________________________________________________IndividualDate_______________________________________________________________Legal Guardian (if applicable) Date_______________________________________________________________Program Director DateReviewed 6/2016LEISURE PROGRAMMINGPolicy: Keystone provides its individuals with an active community-oriented program based on the principles of normalization and age-appropriateness.Procedures: The leadership staff will develop a monthly activity calendar for each program based on leisure preferences and interests of the individuals being served. New activities/special events will be discussed at the monthly house meetings. All monthly activity calendars are to be approved by the Program Director. All activities are subject to change at the request of the individuals, inclement weather, or other safety concerns for the individuals. An activity should only be changed for one of the listed reasons and with the knowledge and permission of the program leadership. Leadership will ensure that each calendar has a well-balanced program that includes both active and passive pursuits. Individual hobbies should also be included in the calendar. Activity calendars are posted in each program and reviewed daily. All activities need to be planned and structured in a timely manner. Leadership will submit a special trip/expenditure form to the Program Director for any activity that requires the purchase of tickets or overnight stays at least two weeks prior to the event. For any activity/special event that will take place out of state, leadership will contact guardians and case managers for permission prior to making any purchases or reservations. In addition, case managers must also be contacted for any trip or activity that will cost over $100.00 as per DDD guidelines/regulations. Activities will also be planned to coincide with the seasons and holidays. All activities need to be age appropriate. The activities will also be selected according to the functional level of the individuals in the program. In addition to the weekly activities, the monthly activity calendar will also include special outings, to professional sporting events, zoos, circuses, museums, amusement parks, camping trips, etc. A variety of community resources will also be utilized on a regular basis. These include the YMCA, theater, parks, churches, malls, bowling, township recreation centers etc.Reviewed 6/2016LEISURE TIME ASSESSMENT FOR GROUP HOMES/SUPPORTIVE LIVING AND SUPERVISED APARTMENTS Policy: In order to ensure a well-rounded leisure and recreational program for those we serve, a Leisure Time Assessment is completed.Procedures: The Program Director makes certain a Leisure Time Assessment is conducted annually.With staff guidance, each person we serve is asked to evaluate his/her leisure time program. Possible new activities are discussed. The emphasis is upon fully utilizing community resources to provide each individual with a well-balanced and normalized program based on individual preferences and current needs.Individual’s discussing daily or weekly programs long range planning including special outings, vacations, etc. is an essential component of the Leisure Time Assessment.The results of the Leisure Time Assessment are documented on the corresponding form and maintained in the individual’s file at her/her residence.Reviewed 6/2016KEYSTONE ANNUAL LEISURE TIME ASSESSEMENTRESIDENT NAME: _________________________ DATE: ______________DIET RESTRICTIONS: ______________________ PROGRAM: _______________Check All That Apply for Each COGNITIVE FUNCTIONING ( ) ABLE TO FOLLOW INSTRUCTIONS( ) ABLE TO MAKE PREFERENCES KNOWN( ) 1:1 GUIDANCE( ) AWARE BUT UNABLE TO MAKE NEEDS KNOWN( ) ABLE TO DO SOME READING COMMUNICATION HEARING EYE SIGHT( ) VERBAL ( ) NORMAL ( ) NORMAL ( ) SIGN LANGUAGE ( ) HARD OF HEARING ( ) WEARS GLASSES ( ) GESTURES ( ) HEARING AID ( ) NEEDS LARGE PRINT( ) REQUIRES TIME TO REPLY( ) OTHER LIMITATIONS: __________________________________________________________LEVEL OF PARTICIPATION/ SOCIALIZATION ( ) ACTIVE ( ) INITATES ( ) VERBALLY DISRUPTIVE/INAPPROPRIATE ( ) PASSIVE ( ) COOPERATIVE( ) ACTIVELY OBSERVES( ) PERIODS OF AGITATION ( ) APPROPRIATE PREFERRED GROUP SIZE & SETTING ( ) ENJOYS GROUP ACTIVITIES( ) PREFERS INDEPENDENT ACTIVITIES ( ) PREFERS SMALL GROUPS (4 OR LESS)( ) DOES NOT ENJOY LARGE ACTIVITIES( ) HOME ACTIVITIES ( ) COMMUNITY/OUTDOOR ACTIVITIESCURRENT LEISURE/INTERESTED IN LEARNING CICICICARD/GAMESSHOPPINGPETSCRAFTS/ARTSWALKS TRAVELINGEXERCISE/SPORTSTELEVISION/MOVIESCOOKING MUSICGARDENING READINGWRITING TALKING TABLE GAMESRELIGION COMPUTER OTHER:_______________ADDITIONAL INFORMATION/CHANGES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MANAGER SIGNATURE AND DATE: ______________________________________________Reviewed 6/2016TELEPHONE USE Policy: Keystone’s individuals are permitted to make telephone calls unless contra-indicated within the Individual Habilitation Plan. Supervision and assistance are provided as needed.Procedures: Individuals have the right to use the apartment or house phone unless contra-indicated in their Individual Habilitation Plan. Supervision and assistance are provided as needed.Individuals must make certain that the phone is not tied up for an extended period of time. Individuals are responsible to pay for long distance calls. The Director of Administrative Services will review phone bills and coordinate with the respective Program Director to bill individuals on a monthly basis. Managers will be responsible for arranging any payments made on the behalf of individuals. Reviewed 6/2016LONG DISTANCE PHONE CALL CONSENTI,___________________________________________________, agree to pay any long distance telephone bill charges that I have made during the month. These charges will be shown and explained to me by the Program Director or Manager.If I do not agree with the charges, I have the right to meet with the next level of authority to discuss those charges in which I do not agree.Individual’s Signature______________________________________________________Guardian’s Signature________________________________________________________________________DateReviewed 6/2016FOOD STORAGE Policy: To insure our food is handled in a safe, hygienic manner, the following procedures are adhered to:Non-Refrigerated Foods:1. Perishable products purchased will be placed in their appropriate areas.2. Cleanliness of food storage areas is of the utmost importance.Frozen Food:1. Products that are purchased that require freezing, will placed in the freezer immediately. Any item that needs to be defrosted for a meal should be put in the refrigerator 24hours prior to the day is it scheduled to be prepared. 2. Any food item that is not used in its entirety, needs to be placed in a zip lock bag with the date written with a permanent marker. 3. Individual thermometers are purchased for all freezers. Freezers are cleaned as per program chore list, but at minimum once a month.Refrigeration: 1. Products that are purchased that require refrigeration, are placed in the refrigerator immediately. If the item has a manufacture date of expiration it does not require a written date on it, i.e. a bottle of Heinz Ketchup. If there is not a manufactured date on the item, the date needs to be written with a permanent marker. 2. Refrigerator should be kept clean on a daily basis. 3. Individual thermometers are purchased for all refrigerators. Reviewed 6/2016FOOD SERVICE OPERATION/FOOD SHOPPING POLICYPolicy: The objective of our food service operation is to ensure that our individuals are offered a well-balanced and nutritious diet.Procedures: All community programs shop according to the weekly menu. Menus are prepared according to any special diet the individual may have been prescribed. Programs shop at local supermarkets for all of their food needs. All programs follow the food shopping procedures. Each program has been given a checking account, with a monthly budget, and they shop accordingly without going over budget. If there is something extra needed or was forgotten during the weekly shopping, the managers have the option to go to another supermarket, if the preferred has a limit on checks per month, or they can use program petty cash to make the purchase. Keystone Community Residential contracts out, with several food companies, who deliver food, paper and cleaning products to our premises. Our Director of Administrative Services orders food for the main facility, Keystone Community Residential Program. She maintains close contact with and supervises all delivery personnel. Food is delivered regularly on a weekly basis, more often if necessary.In our main facility, the majority of perishable and non-perishable food supplies are stored in the “Main Kitchen,” while paper goods and cleaning supplies are stored downstairs in the “Cleaning Supply” room, located across from the “Main Kitchen.” Individuals bring food and any necessary paper goods and/or cleaning supplies to the apartments, as it is needed for each day. Open packages and loose items are stored in closed containers. The kitchen area is cleaned daily. Refrigerators are cleaned weekly. Spoiled or outdated food is discarded.Reviewed 6/2016FIRE SAFTEYFire Safety is an ongoing and important responsibility for all of us. The lives of the persons in our home depend on a thorough, conscientious fire safety program. The following procedures are adhered to:A. LOCATION AND USE OF FIRE EXSTINGUISHERS/EMERGENCY NUMBERS/CARBON MONOXIDE DECTECTORS: Fire extinguishers, smoke and heat detectors, and carbon monoxide detectors have been placed in areas recommended by local fire authorities. It is important to know how to operate the fire extinguishers and how to maintain the smoke detectors and carbon monoxide detectors. The telephone number of the local fire department is posted near every telephone.To operate the extinguisher, follow these steps:Remove the extinguisher from the wall bracket.Pull the safety pin out from the handle release.Hold the extinguisher upright.Stand back 8-12 feet.Aim the nozzle at the base of the fire.Squeeze the handle release.Side to side sweeping motionThe best way to remember is by the acronym PASS(P) Pull(A) Aim(S) Squeeze(S) SweepB. PROCEDURES TO FOLLOW IN THE EVENT OF A FIRE AT KEYSTONE RESIDENTIAL, 154 FRONT ST. In the event that you discover a small fire, your first response should be to attempt to put the fire out using the nearest fire extinguisher. If necessary, use more than one fire extinguisher. If it becomes apparent after a few seconds that you cannot put out the fire, then proceed as follows:Remove all persons from the room where the fire is located.Sound the alarm from the nearest pull station.Immediately proceed with evacuation from the building.C. PROCEDURES TO FOLLOW AT OUR GROUP HOMES/SUPPORTIVE LIVING/SUPERVISED APARTMENT PROGRAMS:In the event you discover a small fire; your first response should be to attempt to put the fire out using the fire extinguisher. If necessary, use more than one fire extinguisher. If it becomes apparent after a few seconds that you cannot put out the fire, then proceed as follows:Pull the nearest fire alarmProceed with the program’s evacuation planNotify the on call person or designated staff immediately after evacuation is complete.D. LOCATION AND USE OF THE FIRE ALARM SYSTEM AT KEYSTONE RESIDENTIAL, 154 FRONT ST.It is imperative that you know the location of the pull stations to operate the fire alarm. To sound the fire alarm, follow these steps:Lift the clear plastic cover upPull down the white barThe fire alarm rings bells throughout the entire building. Whenever the fire alarm rings, you must proceed with evacuation unless otherwise advised by the shift coordinator (e.g. when the system is being repaired or tested).E. FIRE PREVENTIONIf you see any condition in the home that is a potential fire hazard, you must eliminate and/or report this to the Shift Coordinator. Combustible material must be properly stored. Paints, varnishes, and oily rags should be stored in air tight metal containers, outside of the home if possible, to prevent spontaneous combustion. Do not overload wall sockets with multiple plugs and extension cords. Regular inspections of appliance cords should be conducted to ensure they are not defective. Extension cords can be hazardous, therefore surge strips must be provided when multiple items are utilized.It is required to conduct monthly fire drills to acquaint individuals and staff with the proper procedures for evacuating the home. The coordinator of the shift will complete a Fire Drill Form to properly document the fire drill. An outside meeting place has been designed for each home where everyone waits once evacuated which is called the point of safety. Smoking is not permitted within Keystone Residential, Group Homes, Supervised Apartments or Supportive Living Programs.F. FIRE EVACUATION PROCEDURESFamiliarize yourself with the emergency exits. Upon hearing the alarm, gather the individuals in your care and proceed to the closest exit.Evacuate quickly, but maintain order and provide assistance to those in need.Do not take the time to get the individuals dressed or collect valuables.Take a moment to close windows and doors (this will help contain the fire and smoke).Once evacuation is complete, proceed to the point of safety.When at the point of safety, re-check attendance, maintain order and await instructions from the shift coordinator or the Fire Department.Once the “all clear” signal is given, return to your home in a calm, orderly manner and re-check attendance.Go over the emergency evacuation plan with all individuals, noting positive performance as well as areas of concern.Report any problems, such as individuals who failed to respond or resisted evacuation or any physical plant issues, to the shift coordinator.Remember that the elevator (located at our main facility) is not to be used during evacuation-real or simulated.If evacuation of premises is 3 or more minutes, another drill will be conducted within 24 hours of the first, in order to provide our individuals and staff with the necessary fire safety precautions.G. FIRE EVACUTION PLAN FOR OVERNIGHT SHIFT AT 154 FRONT ST.When the fire alarm rings, everyone must evacuate as quickly and orderly as possible. Each apartment evacuates through their primary exit route unless conditions require alternate routes (Refer to the Fire Evacuation Diagram). The staff person from each apartment has primary responsibility to safely evacuate everyone and to account for each individual.The two staff from Grant Apartment directs the evacuation of all Grant individuals exiting Main Doors (Hamilton Blvd.) and utilizing the Ramp adjacent to the living room. The Overnight shift coordinator will have in his/her possession an Overnight Evacuation Information Sheet in which provide the names of all Overnight Staff persons and individuals present; he/she will assess the building by conducting a thorough check of each apartment and ensuring all are evacuating in a prompt and orderly manner; and provide assistance as necessary. The Overnight shift coordinator will conduct a thorough check outside of the building, at all evacuation meeting points. Once given the “All Clear,” he/she will ensure all return safely and orderly to their respective programs.The Overnight shift coordinator will contact the “On-Call” Person to inform him/her of the evacuation and its outcome. Before the end of the shift, the Overnight shift coordinator should conduct an assessment of events with all Overnight Staff members present and complete all proper documentation.SPECIAL NEEDS & HOME SPECIFIC ADDENDUM(Individuals with special needs residing at 154 Front Street)Individuals served and supported may require specialized assistance due to underlying medical conditions which may impede their ability to independently evacuate the premises.All posted Evacuation Plans indicate the bedroom of any individual that possesses an underlying medical condition that might be a barrier to the individual’s evacuation during a real emergency.The South Plainfield Fire Department has reviewed these plans with Keystone Personnel.Keystone Community Residence continues to be directly tied into South Plainfield’s Fire Department’s Panel.The following procedures will be followed in cases of emergencies requiring evacuation according to individual’s specific living arrangements.Grant Apartment:There is currently one individual living in the Grant Apartment who requires a wheel chair for mobility. He has a fire department approved symbol on his bedroom door and window indicating this.The following procedure will be followed for the individual who requires a wheel chair for mobility. In the event of an emergency between the hours of 7a-11p:One of the staff in Grant Apartment will transport the individual to the primary exit, located on Hamilton Blvd by using the ramp.At this time, Emergency Management Personnel will be on the scene and will assist with the evacuation of the individual.If the primary evacuation exit impedes evacuation, the individual will be transported to Front St. through the Vocational Program; where Emergency Management Personnel will be on the premises.The shift coordinator will properly document the incident on the Fire Drill/Emergency Evacuation Record and complete a UIR.The shift coordinator will make all necessary notifications (i.e. “On-Call” Person; Parents and/or Guardians; President or designee).In the event of an emergency between the hours of 11p-7a:The Overnight Direct Service Staff will transport the individual to the primary exit, located on Hamilton Blvd by using the ramp.At this time, Emergency Management Personnel will be on the scene and will assist with the evacuation of the individual(s).The Overnight shift coordinator will properly document the incident on the Fire Drill/Emergency Evacuation Record and complete a UIR.The Overnight shift coordinator will make all proper notifications (i.e. “On-Call” Person; Parents and/or Guardians; President or designee).In the event that an individual has a seizure or other medical emergency prior to evacuation during the hours of 7a-11p, the following procedures will be followed:One staff person attends to the individual while the other staff person ensures all individuals have evacuated the premises.The Nurse “On-Duty” is notified, and assists the staff and individual in evacuating the premises, if possible.The shift coordinator is also notified.The shift coordinator informs the responding Emergency Management Personnel, that an individual is experiencing a medical emergency and their location.The shift coordinator will document all pertinent information on the Fire Drill/Emergency Evacuation Record and complete a UIR.The shift coordinator will make all proper notifications as necessary (i.e. “On-Call” Person; Parent/Guardian; President or designee).Note: If there is no nurse on-duty, the Shift Coordinator will either delegate a “Support Person” to assist or the Shift Coordinator themselves will be the second responder.Bedrails: An individual may utilize a supportive device during their sleeping hours, such as bedrails to prevent the individual from injury during their sleep. These supportive devices are prescribed by the individual’s primary care physician and are only used during the individuals sleeping hours.There is one individual in Grant Apartment that has bed rails. The following procedures will be adhered to:Staff will ensure all individuals are up and begin proceeding out of the residence.Staff will then proceed to the individual’s room where bedrails are present.Staff will assist the individual as needed. This may require staff to provide support to the individual as he/she is getting out of bed.Staff will direct the individual towards the exit.In the event that an individual has a seizure or other medical emergency prior to evacuation during the hours of 7a-11p, the following procedures will be followed:A. One staff person attends to the individual while the other staff persons assist the other individuals in evacuating the premises.B. The Nurse “On-Duty” is notified to assist the staff person, with individuals relocation if possible.The Shift Coordinator is also notified.The Shift Coordinator Person will inform Emergency Management Personnel on site, of the location and persons with the individual.The Shift Coordinator will document incident on the Fire Drill/Emergency Evacuation Form and complete an UIR.The Shift Coordinator will make all proper notifications (i.e. “On-Call” Person, Parent and/or Guardian, President or designee).In the event that an individual has a seizure or medical emergency prior to evacuation during the Overnight Hours of 11p-7a, the following procedures will be followed:A. Inform the Overnight Shift Coordinator that an individual is having a seizure or medical emergency.D. The Overnight Shift Coordinator will inform Emergency Management Personnel on site, of location and staff person(s) attending to the individual.E. The Middlesex Apartment Overnight Staff will assist the Overnight Shift Coordinator to move the individual to a safe area, if possible. If the individual cannot be moved, due to injury, staff is to wait with the individual until Emergency Management Personnel arrive and take over.F. The Overnight Shift Coordinator will properly document the incident and make all necessary notifications (i.e. “On-Call” Person; Parents and/or Guardian; President or Designee).Visually Impaired: Individuals who have difficulties evacuating the residence due to visual impediment, staff persons will escort the individual(s) out of the residence to a safe place.During the hours of 7a-11p, as the alarm sounds, a staff person will seek individual(s) and either guide them towards or escort them out the evacuation exit.During the hours of 11p-7a, as the alarm sounds, the Middlesex Apartment Overnight Staff Person will seek out individual(s); then either guide them towards or escort them out the evacuation exit. The Overnight Shift Coordinator will assist the Middlesex Apartment Overnight Staff in ensuring individual(s) have evacuated.H. FIRE SAFETY EQUIPMENT CHECKOn an annual basis Simplex Grinnell checks the fire alarm and sprinkler system at 154 Front Street. The Manager or designed staff is responsible for inspecting Group Homes, Supervised Apartments and Supportive Living programs. The inspection is documented on the Monthly Safety Monitoring section of the Fire Drill Record Form. If equipment is faulty, corrective action will begin immediately.If the fire system (smoke detectors, fire alarm system, fire extinguishers, carbon monoxide, etc.) is found to be inoperative, proceed as follows:Notify the Program Director or designated staff.Make a repair order (complete a maintenance work order form).Notify the local Fire Authority for those with direct tie-ins to the fire rm residential staff and individuals, if appropriate, of inoperative status and maintain a continuous fire alert.When the repair is made, notify the local fire authority as well as all pertinent individuals and staff persons.FIRE EVACUATION PROCEDURES (154 FRONT ST.)To be followed Monday-Friday 9am-3pm during a typical weekdayWhen the fire alarm sounds, the following shall occur:A. Staff who is present in a common area shall communicate to one another which areas the will check before evacuating.These areas include:Office; all areas north of and including the boiler roomBasement south of boiler room; including elevator, gym, kitchen, program director’s offices, conference room and storage roomFirst floorSecond floorThe maintenance staff is responsible for ensuring all are evacuated on the floor in which they are working prior to exiting the building.The vocational staff and anyone who is scheduled to assist individuals not in the vocational program during this time will evacuate all persons in their charge, according to regular fire evacuation procedures.Upon hearing the alarm, the Shift Coordinator shall follow these steps in the order listed:Proceed to the office to obtain the list of individuals home.Check each level of the building to ensure all are evacuated.When confident that the building is “all clear,” proceed outside to the evacuation check points to insure all have exited the building. (Hamilton Blvd. sidewalk considered the back of the residence; then towards the grass area adjacent to the parking lot on the Front St. side of the residence).Meanwhile, due to our “tie-in,” the fire alarm company will automatically notify the South Plainfield Fire Department, who in turn will dispatch help.When the fire department has assured the building to be safe, the Shift Coordinator will give the “All-Clear” to return inside the building.The Shift Coordinator will complete all necessary documentation. If specific repairs are needed to the alarm system, the Shift Coordinator will first notify the “On-Call” Person, and secondly notify Simplex Grinnell.Revised 6/2016SEVERE WEATHER PROCEDURESTo insure the safety of the individuals we serve, all staff should proceed as follows during a severe weather condition which requires additional safety precautions to be taken, other than evacuation, such as a snowstorm, tornado, hurricane or flood:When a severe weather watch is issued, follow normal routines while listening to the radio or watching the news for updates on the weather.When a severe weather warning is issued for any weather which could potentially jeopardize the safety of our individuals, immediately take any and all of the following precautions, as appropriate to the type of weather occurring. (i.e. a severe weather warning for a snow storm does not require all of the following precautions. Bring all individuals to the basement, if one is available and has an approved EGRESS procedure to evacuate from (except during a flood), or take shelter in a small room such as a bathroom or closet in the center of the house, away from all windows. Take a flashlight, battery-powered radio, and spare batteries into the shelter with you.If the administration of medication will be affected due to an extended storm, the Manager or Shift Coordinator should secure all necessary medications, supplies and documents into the shelter. If time and safety permits, secure objects, such a lawn furniture and garbage cans, outside the house.All staff will provide reassurance for the individuals throughout the duration of the stormStaff will monitor progress of the storm by listening to local radio stations.All staff and individuals are to remain in the designated shelter, unless directed to otherwise by local authorities or the Program Director.After the storm, keep individuals away from all environmental dangers both inside and outside of the house, such as broken glass, fallen trees, live wires and other wreckage.Program Directors will communicate with all programs during the weather event and coordinate with the Director of Operations if any additional precautions need to be taken. Reviewed 6/2016EMERGENCY EVACUATION AND TEMPORARY RELOCATIONPolicy: In order to provide for the safety and well-being of those we serve and support, as well as our employees, Keystone’s emergency evacuation and temporary relocation procedures will be followed.Procedures: Emergency evacuations could stem from diverse causes, such as a gas leak, fire, or severe weather conditions or other natural disasters.In the event of an emergency evacuation and temporary relocation for those residing at any of our Group Homes, Supervised Apartments, or Supportive Living Programs, or main building (154 Front Street), the following will occur:The “Shift Coordinator”:Will ensure everyone in the home has evacuated the premises in a timely and orderly fashion.Will contact local authorities, if not already notified (i.e. PSE& G for a gas leak).Will contact the “On-Call” Person.Will contact the President or Designee, if the “On-Call” Person cannot be reached. Will contact the Program Director.Will complete an Unusual Incident Report and document all critical information in the daily log, if applicable. Will make proper notifications as soon as possible; including case managers, parents, Bureau of Guardianship Services, etc.The “On-Call” Person:Will ensure that immediate safety issues and protocol are attended to.Will contact the President or Designee.Will ensure initial notifications occur as soon as possible; including case managers, parents, Bureau of Guardianship Services, etc.The President or Designee:Will seek emergency living arrangements at nearby hotels.Will ensure transportation is provided by means of agency vehicles, public transportation, and/or staff vehicles, as authorized.Will ensure clothing, food and other necessary amenities are provided (i.e. personal hygiene supplies).Will contact and consult with outside service providers to assess situation.Will ensure all proper documentation is completed including proper notifications.Will ensure the incident is reported to the Division of Developmental Disabilities in a timely manner.Reviewed 6/2016Keystone’s Continuous Quality Improvement PlanMISSION STATEMENTKeystone’s mission is to provide people with developmental disabilities diverse opportunities to lead fulfilling lives.VISION STATEMENTWe intend to be the leader in the provision of quality services for people with developmental disabilities.VALUE STATEMENTSWe value and hold dear the following attitudes, beliefs, and commitments:We value the growth, health, safety, and happiness of the people we serve and support.We value our core attitudes of affection, caring and services.We maintain an atmosphere of mutual respect and support. We value a positive attitude and a sense of humor, enjoying our work while taking it seriously.We promote a sense of excellence in our work.We take pride in our efforts and responsibility for our outcomes.We value unity and teamwork.We are committed to developing and maintaining a highly trained and skilled staff.We value communication that is active, consistent and accurate throughout our agency.We continuously evaluate and improve the services we provide in response to the individual’s needs and preferences.We value diversity among the people we serve/support and employ.We value our responsibility and commitment to the people we serve and support.Keystone’s Continuous Quality Improvement PlanII. PROGRAMS & HISTORYIt is Keystone’s mission to provide the individuals served and supported diverse opportunities to lead fulfilling lives. Since its inception in 1983, Keystone has developed a myriad of programs in order to fulfill our mission.In the early 1980’s, New Jersey officials asked Keystone City Residence located in Scranton, Pennsylvania, to provide services in New Jersey. This request resulted in the founding and opening of Keystone Community Residence in 1983. Today both New Jersey and Pennsylvania programs are separate agencies serving individuals with developmental disabilities. However, both agencies share a rich history of integrating persons with developmental disabilities into community settings.In 1983, Keystone opened its community residence, Keystone Community Residence, in what was formally known as the Grant School within the South Plainfield School District. Keystone serving and supporting persons with developmental disabilities is comprised of five individual homes, which include the Grant, Union, Edison, Middlesex and Somerset Apartments.In 1989, our first group home opened in Middlesex Borough. This program enabled six individual residing at Keystone Community Residence to move into a single family home several miles away from South Plainfield. In order to meet the needs of the individuals we serve and support, our second group home opened in the borough of Dunellen during July of 1992. As part of the North Princeton initiative, Keystone opened its third group home in December of 1997 in Piscataway Township. Our Balmoral Group Home, located in Matawan, was opened in 1987 by another provider. This home became part of the Keystone Family in July 2002 at the request of the Division of Developmental Disabilities. In addition to our group homes, since 1991 Keystone has operated a Supportive Living Program at Gramercy Gardens in Middlesex Borough. This program added to the continuum of services Keystone provides person with developmental disabilities. Currently, our Supportive Living Program offers independent community living with support to six individuals.Keystone responded to the statewide shortage of day programming by opening a vocational program in July of 1991. This program currently provides vocational and pre-vocational training to 25 individual as well as opportunities for real work experiences in the community.Keystone also provides individual supports to persons with developmental disabilities living in their own homes. On March 11, 2013, Keystone opened the agency’s first Supervised Apartments, known as the Catalano Apartment, at the Brookside Apartment Complex in Somerville, N.J. A total of twelve (12) individuals stemming from Keystone’s existing Group Homes and Residential Program, which is another continuum of Keystone’s services to persons with developmental disabilities.On September 9, 2013 Keystone opened the Colton Group Home located in Edison, N.J. A total of four (4) men from the Residential Program made their transition.On November 4, 2013 Keystone opened the Lawrence Ave. Group Home located in North Plainfield, N.J. A total of four (4) men from the Residential Program made their transition.On November 15, 2014 Keystone opened the Summit Ave. Group Home in the Fords Section of Woodbridge. A total of four (4) men from the Residential Program made their transition.On December 15, 2014 Keystone will be opening the Brandywine Group Home in Piscataway, N.J. A total of four (4) men from the Residential Program will be making their transition.On March 20, 2015, Keystone opened the Netherwood Group Home located in Piscataway, NJ. Five (5) men from the Residential Program made their transition.On December 1, 2015, Keystone opened the Waverly Group Home located in South Plainfield, NJ. Five (5) men from the Residential Program made their transition. On May 2, 2016, Keystone opened the Brookside Group Home located in Piscataway, NJ. (5) ladies form the Residential Program made their transition. Individual supports provide individuals with developmental disabilities the opportunity to live independently in their own homes and/or apartments.All residential programs are licensed by the Division of Developmental Disabilities, New Jersey Department of Human Services.DESCRIPTION OF CONTINUOUS QUALITY IMPROVEMENT SYSTEMKeystone is dedicated to developing and maintaining an active, continuous quality improvement process that continuously seeks input to improve services and focuses on individual service outcomes.QUALITY IMPROVEMENT COMMITTEEThe overall responsibility of Keystone’s Quality Improvement System lies with the Quality Improvement Committee. The CQI Committee is co-chaired by the President and Director of Quality; and members include, the Assistant Executive Director, Director of Operations, Director of Support Services, Director of Human Resources, Director of Health Services, Director of Administrative Services, Director of Vocational Services and Program Directors. The CQI Committee meets at least quarterly. The agenda includes the following:Approval of MinutesProgram Audit ReportsQuality Team ReportsCurrent Action PlansAction Plans being developedAction Plans assigned to quality teamsCurrent Action Reports UpdatesSafety Committee SummaryHuman Rights Committee SummaryStaffing ReportTraining ReportHealth Services ReportContract/Fiscal ReportIHP Sample Review (Rotating Programs)Satisfaction Survey ReviewCustomer (Annual)Program (Annual)Staff (Annual)UIR ReviewNumber and specific reportsStatus of any InvestigationsAnalysis of trends and necessary remediationReview of Standards/Regulations/ProceduresNew Circulars/RegulationsCompliance/Process IssuesNew ProceduresQUALITY ACTION TEAMThe Quality Action Team is an integral part of Keystone’s CQI System. All Keystone programs have Quality Action Teams. Quality Teams include the following: Directors, Managers, Assistant Managers, Nurses, and Direct Line Staff. The Program Director serves as the Quality Team Chair and sets the agenda with input from other members and the Quality Improvement Committee. The Director of Operations makes certain that Team meetings are scheduled and assignments are understood and completed. The Assistant Executive Director keeps a log of all current and past Action Plans including their disposition. Please note that Program Directors may have Quality Action Teams consisting of two or more programs.The Quality Action Team meets regularly and reviews program and/or department issues including systems and practice related to Keystone’s mission and values. The primary purpose of the Quality Action Team is to formulate Action Plans that clearly explains the process to improvement.The Quality Action Team reports directly to Keystone’s Continuous Quality Improvement Committee through a report given by the Team Chair.Keystone’s Continuous Quality Improvement PlanIV. CONTINUOUS QUALITY IMPROVEMENT PROCESSAll Keystone CQI Committees will use the following process and format to develop Quality Improvement Action Plans.CHOOSE GOAL:Current challenge interfering with qualityAn outcome that will add to qualityWRITE GOAL:In measurable termsMake it clear and understandable to allMake it realisticDECIDE ON PROCESS (STEPS) TO ATTAIN GOAL:Be specificList all responsibilitiesBe time specificList all who, what, & when’sList evaluation methodologyCOMMUNICATE:Positive outcome expected & process to all partiesBe specificDon’t leave anybody outDO:Implement the processBe on timeEVALUATE:Gather the dataMeasure actual performanceCompare actual performance with the goalDetermine any root cause interfering with attainment of goal.ACT:CelebrateAdjust GoalAdjust AttitudesKeystone’s Continuous Quality Improvement PlanV. GOALS & OBJECTIVESThe general goals of Keystone’s Continuous Quality Improvement Program are:To establish, maintain, support, and document evidence of an ongoing quality improvement program that includes effective mechanisms for reviewing and evaluating service outcomes for those we serve and support to lead fulfilling lives.To objectively and systematically monitor and evaluate the quality and appropriateness of all programs and services, to resolve identified problems, and pursue opportunities to improve all programs and services.Keystone’s Continuous Quality Improvement PlanSATISFACTIONCustomer satisfaction is an essential part of Keystone’s Continuous Quality Improvement System.Satisfaction is measured in the following ways:Direct Program ObservationDiscussions with individuals served/supportedConversations with parent/guardiansStaff discussion/meetingsConsumer SurveysConsumer Interviews/SurveysStaff SurveysSuggestion Boxa. Direct Program Observation:All leadership staff including Directors, Program Facilitators, and Managers continuously assess program satisfaction and bring concerns to the attention to the Program Director in the form of a written memo or E-Mail. The Program Director will assess specific satisfaction concerns and place them on the agenda of the Quality Improvement Team for disposition.b. Discussion with individual’s served/supported:All staff will bring specific concerns to their immediate supervisor who will report them to the Program Director. The Program Director will assess specific satisfaction concerns and place them on the Quality Improvement Team agenda for disposition.c. Conversations with parents/guardians:All staff will bring specific concerns to their immediate supervisor who will report them to the Program Director. The Program Director will assess specific satisfaction concerns and place them on the Quality Improvement agenda for disposition.d. Staff discussion/meetings:The Program Director will assess any specific satisfaction concerns and place them on the Quality Improvement agenda for disposition.e. Consumer Surveys:Consumer Satisfaction Surveys are accomplished annually. Surveys are sent to family/guardian(s) of person’s served/supported, and State Officials. Results are analyzed and brought to the Continuous Quality Improvement Committee for disposition.f. Consumer Interviews/Surveys:Annual satisfaction interviews/surveys are conducted of individual’s served/supported. Results are analyzed and brought to the Continuous Quality Improvement Committee for disposition.g. Staff Surveys:Annual Staff Satisfaction Surveys are conducted. Results are analyzed and brought to the Continuous Quality Improvement Committee for disposition.Keystone’s Continuous Quality Improvement PlanVII. ASSESSMENT & DATA COLLECTIONIndividual Habilitation Plans:A quarterly review of IHP goals will be accomplished at the Monthly Continuous Quality Improvement Committee Meeting. Assigned Committee Members will review a random sample across programs of not less than 5 IHP’s each quarter to study the quality of training and goal achievement. Action pans will be initiated based on results.Consumer Satisfaction Surveys:Consumer Satisfaction Surveys are mailed out annually. Surveys are sent to family/guardian(s) of persons served/supported, State Officials, and other interested parties. Results are analyzed and charted; and compared to previous years. Results are then brought to the Continuous Quality Improvement Committee for disposition.Annual satisfaction interviews/surveys are conducted of individual’s served/supported. Results are analyzed and charted and brought to the Continuous Quality Improvement Committee for disposition.Annual Staff Satisfaction Surveys are conducted. Results are analyzed and charted and brought to the Continuous Quality Improvement Committee for disposition.Standards are reviewed annually at the Continuous Quality Improvement Committee Meeting. New standards and circulars are reviewed at the Continuous Quality Improvement Meeting and a plan of implementation is developed. Random Program Audits are conducted by the Program Directors and the Quality Improvement Coordinator to insure compliance. Results are documented in minutes and action plans are developed if necessary.Specific Unusual Incident Reports are discussed and analyzed at the monthly Continuous Quality Improvement Committee. UIR’s are charted in regards to category/program. Investigation results are also reviewed. Action Plans are developed if found relevant/necessary to lessen the likelihood of reoccurrence.The Director of Health Services monitors compliance with regulatory standards and health issues related to individuals supported and staff.The Continuous Quality Improvement Committee reviews staff training programs annually. The Director of Human Resources reports on the number of staff persons trained or in need of specific trainings. Action plans are developed if found relevant/necessary.The Continuous Quality Improvement Committee reviews minutes from Keystone’s Safety Committee monthly. Action plans are developed if found relevant/necessary.Annex A program descriptions are reviewed annually by the Continuous Quality Improvement Committee prior to contract renewal to insure their appropriateness.Keystone’s Continuous Quality Improvement PlanVIII. CQI REPORTINGCQI Reporting is accomplished in the following ways:Continuous Quality Improvement Committee Minutes documenting the work of the Committee are kept in the President’s and Director of Qualities offices and available for review by appropriate parties. Minutes are decimated to all members.The President or his designee(s) through Continuous Quality Improvement team meetings, staff meetings, employee memos, Keystone’s newsletter, and E-Mail, conveys results of all surveys to relevant staff for quality improvement purposes.An annual Continuous Quality Improvement Report is written by the President and decimated to all staff and relevant individuals.IX. ACTION PLANSAction Plans are developed by Keystone’s Quality Action Team and the Continuous Quality Improvement Committee following Keystone’s Action Plan Process.Revised 6/2016MAINTENANCE OF PHYSICAL ENVIRONMENTPolicy: The interior and exterior of all residences will be properly maintained and kept free form any health and/or safety hazard.Procedures: Keystone staff will note in their respective Daily Report Book any maintenance needs or concerns regarding health and safety issues. Maintenance Work Order Forms are also to be completed by staff persons for any repairs that are needed.The Manager or designated staff fills out a Maintenance Work Order Form and emails it to the Maintenance Supervisor. These forms can be found on the portal and in all programs.Our Maintenance Team ensures all repairs are completed in a timely fashion. Outside service personnel are involved as needed.Reviewed 6/2016PROCEDURE FOR THE USE OF SAFEGUARDING EQUIPMENTIt is the policy and practice of Keystone to use mechanical restraints only as a safeguarding method, not to control behavior.“Safeguarding equipment means devices which restrict movement used to provide support for the achievement of functional body position or proper balance; devices used for specific medical, dental or surgical treatment; and devices to protect the individual from symptoms of existing medical conditions, including but not limited to seizures, ataxia and involuntary self abuse.” Such devices include but are not limited to bedside rails, helmets, kneepads, elbow pads, etc.The procedure for the use of such restraints is as follows:The physician prescribes and documents the prescription of the safeguarding equipment.The Guardian and/or Parents are notified.The Habilitation Plan Coordinator/Program Director or Designee documents its use in the Individual Habilitation Plan.The Nursing Staff instructs all staff working directly with the individual in proper use of safeguarding equipment.The need for the use of safeguarding equipment will be re-evaluated at least yearly by the Interdisciplinary Team as well as the prescribing physician. If safeguarding equipment is determined to no longer be needed, the physician will give an order to discontinue its use. The Nursing Staff will inform all pertinent staff.Reviewed 6/2016CRIMINAL BACKGROUND CHECKSPolicy: Keystone is committed to providing an environment that ensures the safety, health and well-being of the individuals served. State Law (NJSA 30:6D-63 to 72) requires that the Department of Human Services not contract with any community agency unless it has first been determined that no criminal history record information exists on file in the Federal Bureau of Investigation Identification Division, or in the State Bureau of Identification in the Division of State Police, which would disqualify the community agency head or the community agency employee who may come into direct contact with individuals served from such employment. Additionally, it is Keystone’s policy not to employ any individual who has been adjudged civilly or criminally liable for the abuse of a person with developmental disabilities.General Standards:Except as otherwise provided in the Rehabilitated Convicted Offenders Act (N.J.S.A. 2A:168-1 et seq.), Keystone shall not employ any person who has been convicted of forgery, embezzlement, obtaining money under false pretenses, extortion, criminal conspiracy to defraud, crimes against the person or other like offenses.Individuals shall also be disqualified from employment for any of the following:In New Jersey, any crime or disorderly person offense:-Involving danger to the person as set forth in N.J.S.A. 2C: 11-1 et. Seq. through 2C: 15-1 et seq. including the following: murder, manslaughter, death by auto, simple assault, aggravated assault, recklessly endangering another person, terroristic threats, kidnapping, interference with custody of children, sexual assault, criminal sexual contact, lewdness, robbery.-against the children or incompetency as set forth in N.J.S.A. 2C:24-1 et seq. including the following: endangering the welfare of a child and endangering the welfare of an incompetent person-a crime or offense involving the manufacture, transportation, sale, possession or habitual use of a controlled dangerous substance as defined in N.J.S.A. 2C:24-1 et seq.-in any other state or jurisdiction, conduct which, if committed in New Jersey, would constitute any of the crimes or disorderly persons offenses described above.Procedures:All employees who have contact with persons supported by the agency must sign a consent and be fingerprinted in accordance with state law. Those who refuse to cooperate will not be considered for employment. The Director of Human Resources will give the new employee the consent form to complete and sign as part of the New Hire packet.After signing the consent, the employee will then be given the New Jersey Universal Fingerprint Form (see attached) to set up a fingerprinting appointment using the agency that is designated by the Department of Human Services.There will be no cost incurred by the employee for said fingerprints.After being fingerprinted, the employee is required to return the completed form, along with the receipt, to the Director of Human Resources.The Director of Human Resources will inform the employee when the criminal background check has been completed and results have been received by the agency. Employees cannot begin to work until their criminal history background check has been completed and results received by Keystone.Once a person has been fingerprinted, he or she remains in the state system for the duration of his or her employment, and the State of NJ will notify Keystone of any red flags.Every two years, the employee’s fingerprint information will be resubmitted to the State of New Jersey, Central Fingerprint Unit to check against the federal database. The Director of Human Resources oversees this process.Any employee who is flagged will receive immediate notification by the Director of Human Resources or designated staff and will be handled in a matter consistent with state regulations and guidelines.When an employee resigns or is terminated from employment, the Director of Human Resources will notify the Central Fingerprint Unit within the Department of Human Services to remove that person’s “flag” from The State Bureau of Identification files.Rehabilitation: No individual shall be disqualified from employment on the basis of any conviction disclosed by a background check if the individual has affirmatively demonstrated to the President clear and convincing evidence of his or her rehabilitation.In determining whether an individual has affirmatively demonstrated rehabilitation, the following factors shall be considered:The employee’s signed consent accurately reflects the received results,The nature and responsibility of the position that the convicted individual would hold, has held or currently holds,The nature and seriousness of the offense,The circumstances under which the offense occurred,The date of the offense,The age of the individual when the offense is committed,Whether the offense was an isolated or repeated incident,Any social condition which may have contributed to the offense, andAny evidence of rehabilitation including good conduct in prison or in the community, counseling or psychiatric treatment received, acquisition of additional academic or vocational schooling, successful participation in correctional work-release program or the recommendation of those who have had the individual under their supervision.The President shall make a determination regarding the employment of the individual. The determination shall be kept on file at Keystone.Appeals: The employee will have 30 days from receipt of the note of disqualification for employment to request an appeal. The appeal shall be made to the President, who shall make a determination based upon a review of information on record including any information regarding rehabilitation. The President shall advise the employee that any appeal of this determination shall be made to the New Jersey Superior Court.Reviewed 6/2016COMMUNITY AGENCY HEAD AND EMPLOEE CERTIFICATION, PERMISSION FOR BACKGROUND CHECK AND RELEASE OF INFORMATIONI hereby authorized the Department of Human Services to conduct a criminal history background check and I agree to be fingerprinted in order to complete the State and Federal background check process. I further authorized the release of all information regarding the results of my background check to the Department of Human Services.Check one of the options listed below:Option 1__________I hereby certify under penalties of perjury, that I have not been convicted of any offenses listed below and no such record exits in the State Bureau of Identification in the Division of State Police or in the Federal Bureau of Investigation, Identification Division.Option 2__________I hereby affirm that I have been convicted of the following offense listed below____________________________________________________________________On __________. (Date)If I have checked Option 2 or the criminal history background check reveals any conviction(s) for the offenses listed below, I understand that I may be subject to termination of employment.FOR PROVISTIONAL EMPLOYEES ONLY: As a provisional employee, I further understand that I may be employed by the agency for a period not to exceed six (6) months during which time a background check will be competed. I understand that I will work under the supervision of a superior where possible.Offenses covered under P.L. 1999, C. 358:In New Jersey, any crime or disorderly person offense:-involving danger to the person as set forth in N.J.S.A. 2C:11-1 et seq. through 2C:15-1etseq. including the following: MurderManslaughterDeath by AutoSimple AssaultAggravated AssaultRecklessly endangering another personTerroristic threatsKidnappingInterference with custody of childrenSexual assaultCriminal sexual contactLewdnessRobbery-against the children or incompetents as se forth in N.J.S.A. 2C:24-1 et seq. including the following:i. Endangering the welfare of a childEndangering the welfare of an incompetent person-a crime or offense involving the manufacture, transportation, sale, possession or habitual use of a controlled dangerous substance as defined in N.J.S.A. 2C:24-1 et seq.-in any other state or jurisdiction, conduct which if committed in New Jersey, would constitute any of the crimes or disorderly persons offenses described above.FOR COMMUNITY AGENCY HEAD: I understand the results of this background check will be reported to the President of the Board of my agency.PLEASE LIST THE NAME AND HOME OR BUSINESS ADDRESS OF THE BOARD PRESIDENT.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Employee Name (Print)Employee SignatureDate___________________________________________________________Witnessed by (Print)Witness SignatureDateReviewed 6/2016PROCEDURES TO FOLLOW IN THE EVENT OF AN EMPLOYEE INJURYKeystone is committed to providing its employees with a safe working environment. Workers Compensation Insurance is provided in an effort to protect employees who become injured on the job. (See Personnel Manual for details.)Keystone believes it is the responsibility of both employee and employer to maintain a safe working environment. Employees are responsible for attending and successfully completing all trainings, reporting any unsafe conditions, and following proper procedures in the event of employee injury.The On-Call Person is responsible for receiving all first reports of injury and recommending a treatment plan.The Director of Human Resources is responsible for reviewing all employee injuries, making follow up recommendations, and reporting all injuries to the Workers Compensation Insurance Carrier.In the event of employee injury, the following procedures should be followed:In cases of life-threatening emergency, 911 should be called and the employee should be transported to the nearest emergency facility. (The On-Call Person should be notified immediately by another employee on duty. Necessary documentation can be completed later.)In all other cases:The employee should complete the First Report of Injury form. (This can be found either in the office of each program or on the web portal.) If the injured employee cannot complete this form, another employee can assist.The employee should report the incident to the On-Call Person. (This should occur as soon as possible after the injury, but definitely prior to the end of the employee’s shift.)The On-Call Person receives the information from the injured employee and makes a determination as to whether or not outside treatment is needed.If outside treatment is deemed necessary, the On-Call Person directs the employee to complete a designated consent form and get a Physician’s evaluation form. (An employee who seeks treatment without a signed consent form will be considered in violation of agency procedures.) The On Call Person then directs the injured employee how to proceed.Post-treatment, the employee should share all documentation, including the completed First Report of Injury form, with the Director of Human Resources.The Director of Human Resources will review all documentation and make recommendations as to any needed follow up, including but not limited to accommodations, corrective action, further training, etc. The Director of Human Resources is also responsible for reporting any claims to the Workers Compensation Insurance Carrier. Reviewed 6/2016First Report of Injury(This section is for the Employee)Name of Employee: ________________________________________________Social Security Number: _______________________________________Address of Employee: _______________________________________________Date of Birth: ____________________Gender: ____F ____MJob Title: __________________________________________________ Employment Status: _____Full Time ______Part Time ______Per DiemMarital Status: ______Single/divorced ______Married ______Separated# of dependents: _________Phone number: ________________________# of days typically worked per week: _________Date of Incident: _________________Time of Incident: _________________ _____am or _____pmLocation of incident: ________________________________________________Address of location: ________________________________________________Type of Incident: circle: _____slip & fall ______assault _____strain/sprain ____other (if other, please explain) ________________________________________________________________________________________________________________________________________________________________________________________________________________________Part of Body affected _____________________________________________________Describe what happened: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date & Time On-Call Notified: _____________________________Was any first aid administered? No ______ or Yes _______ (explain_______________________________________________________________)List any witnesses and their phone numbers: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I request/decline outside treatment. (please indicate your choice below) _____ request_____ declineEmployee printed name: __________________________________________________Employee Signature: _____________________________________________________Date: _____________________(This section is for On-Call)In cases of life-threatening emergency, 911 should be immediately called. Otherwise, any outside treatment requires the prior-approval of the On Call Person, as well as a signed consent form by the supervisor/manager/or employee who calls the On Call Person.If outside treatment required, continue below:On-Call Person authorizing treatment: ________________________________________________________________________Employee sent to:_____Concentra _____JFK _____Other Please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________Any employee, who is treated by a facility other than Concentra, must be followed up by Concentra the next business day.Employee required assistance getting to treatment facility _____Yes _____NoIf yes, who assisted? (Must be an employee of Keystone) ________________________________________________________________________________________________________________________________________________________________________________________________________________________First Report of Injury Received: ______ Yes ______ NoEmployee’s Acknowledgement of Physician’s Panel Received: ____ Yes ____ NoDate/Time reported to Worker’s Compensation Insurance Carrier: _________________Employee’s Claim # ____________________________________ Telephone # of office handling claim __________________________________Printed Name of On Call Person _____________________________Signature of On Call Person _________________________________Date of Report: ___________(This section is for Director of Operations or Director of Human Resources)Date paperwork received: ____________________________Employee returned with no restrictions____________Employee returned with modified duty/restrictions____________Employee is placed out of workIf modified duty/restrictions, what accommodations will be needed?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Temporary Program Change required? _____ No _____ Yes Is correction action needed? ______ No ______ YesIs further training recommended? ______ No ____ YesDate Safety Committee Investigation Team Informed? __________________Safety Committee recommendations: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Printed name of Dir. of Operations/Dir. of HR ____________________________Signature of Dir of Operations/Dir of HR _________________________________Date: _________________(revised 2.24.2016)Return-To-Work ProgramKeystone Community Living, Inc. is committed to returning injured employees to modified or alternative work as soon as possible. All injured employees will be treated with dignity and respect and will be given the Workers’ Compensation benefits due under the law, including wage replacement and appropriate medical care to ensure a speedy recovery and return to work. This may be accomplished by temporarily modifying the employee’s job, or providing the injured employee with an alternative position. The employee’s medical condition, including any limitations or restrictions given by the attending physician, will be considered a priority when identifying the modified-duty position. All employees are expected to fully cooperate with their treatment plan and modified-duty requirements once released to work by their physician. The failure to do so could result in a loss of benefits or termination.Purpose:This program is intended to provide our employees with an opportunity to continue as valuable members of our team, while recovering from a work-related injury. We want to minimize any adverse effects of an ongoing disability on our employees. This program is intended to promote quick recoveries, while keeping the employees’ work and income consistent. We benefit from having our employees provide a service and contribute to the overall productivity of our business.Scope:This program applies to ALL employees of Keystone Community Living, Inc.Responsibilities:All injuries, no matter how minor, should be reported before the end of your shift to your supervisor.The Director of Human Resources, Lisa Mixon, will act as a liaison between Keystone Community Living, Inc., the injured worker, the attending physician, and our insurance carrier.Supervisors/Managers:In the event of an injury, the supervisor/manager/in-charge person will make sure that the employee receives first aid and/or proper medical treatment at one of the selected medical clinics on the Panel Physician list. If possible, the supervisor/manager/in-charge person will accompany the employee to the medical clinic. The attending physician shall be notified on the first visit that Keystone Community Living, Inc. has an established return-to-work program and that modified-duty work will be provided, if possible. The on-call person will work closely with the employee to coordinate return to work efforts and will be responsible for introducing the employee back into the work place in the modified-duty position. The on-call person will make sure the injured employee receives necessary assistance from co-workers and that the employee does NOT work outside of his/her restrictions. Employees:If any injury occurs on the job, the employee is required to report it to their supervisor/manager immediately or by the end of their shift. The employee must proceed to one of our selected providers for occupational injuries. If available, an employer representative will accompany the employee to the medical clinic. Together with the physician, the employee’s physical restrictions and limitations shall be discussed. All employees are expected to communicate the physician’s findings and discuss modified-duty work. Once an employee has returned to work, it is his/her responsibility to work within the physical limitations given by the treating physician. The employee shall perform only those duties assigned. An employee shall notify his/her supervisor/manager of any difficulty in performing the duties. The employee must also notify his/her supervisor in advance of any medical appointments. The employee shall keep his/her supervisor/manager informed of the recovery process and ability to perform modified or full-duty work.Adhered 7/2015Reviewed 6/2016 Physician’s Evaluation154 Front Street South Plainfield, NJ 07080Tel: 908.757.1080 Fax: 908.755.6810 An important aspect of our company’s Return-to-Work Program is returning an injured employee to work as soon as medically possible after the date of injury. Please complete the following information so we can place the employee in a suitable temporary modified job, if necessary.Employer/Injured Employee Information (To be completed by the employer prior to the physician’s office visit)Employer: Contact Person: Address: City: State: Zip: Employer’s Phone: ( ) - Insurance Carrier: Named of Injured Employee: Employee SSN: --Employee Phone: ( ) - Date of Injury: // Claim #: Occupation: Type of Injury: Physician’s Evaluation (To be completed by the employer physician)Diagnosis: Treatment: Lifting Ability: Please check the exact degree of work you feel this patient is capable of performing. Sedentary Work: Lifting 10 lbs maximum and occasionally lifting and/or carrying small articles and occasional walking and standing. Light Work: Lifting 20 lbs maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs. It involves sitting most of the time with a degree of pushing/pulling of arm and/or leg controls. Medium Work: Lifting 50 lbs maximum with frequent lifting and/or carrying of objects up to 25 lbs. Heavy Work: Lifting 100 lbs maximum with frequent lifting and/or carrying of objects no more than 50 lbs. Very Heavy Work: Lifting objects in excess of 100 lbs with frequent lifting and/or carrying of objects weighing 50 lbs or more.In an eight (8) hour day, the patient is able to perform at the following level:Standing □ Not At All □ Occasionally □ Frequently □ ConstantlyWalking□ Not At All □ Occasionally □ Frequently □ ConstantlySitting□ Not At All □ Occasionally □ Frequently □ ConstantlyDriving□ Not At All □ Occasionally □ Frequently □ ConstantlyBending□ Not At All □ Occasionally □ Frequently □ ConstantlySquatting□ Not At All □ Occasionally □ Frequently □ ConstantlyClimbing□ Not At All □ Occasionally □ Frequently □ ConstantlyPush/Pull□ Not At All □ Occasionally □ Frequently □ Constantly Grasp□ Not At All □ Occasionally □ Frequently □ Constantly Occasionally = <33% per day Frequently + 33%-66% per day Constantly = >66% per dayPatient can be exposed to:Unprotected Heights□ Not At All □ Occasionally □ Frequently □ ConstantlyUneven Surfaces□ Not At All □ Occasionally □ Frequently □ ConstantlyTemp. Changes□ Not At All □ Occasionally □ Frequently □ ConstantlyThe above restrictions are: Permanent Temporary Until Employee can resume modified work duties on: Employee can resume full/regular work duties on: Other restrictions or comments: Physician’s Name: Physician’s Signature: Date: Adhered 7/2015Smoking PolicyPolicy: For the health and well-being of the individuals Keystone supports, smoking is strictly prohibited in all of Keystone’s homes, programs and vehicles.Smokers must heed all safety precautions by keeping cigarettes and matches concealed when not in use and by placing all ashes in designated receptacles. Smokers should show concern for non-smokers by not smoking when food is being served and by not smoking when in the presence of non-smoking persons.Individuals who smoke will be provided ongoing instruction and counseling as to the health risks. Staff will actively support any individual who expresses a desire to decrease or stop tobacco use. Medical professionals will be involved as needed.Reviewed 6/2016MOBILE TECHNOLOGY IN THE WORKPLACEPolicy: With keeping up with modernization and the communication needs of our employee’s families, Keystone does not prohibit its employees to have a personal cell phone in the workplace. We, however, prohibit the habitual use when individuals served and supported are under the guidance and supervision of our employees. Upon hire, employees will be asked to read and sign this policy. This acknowledgement will then be placed in the employee’s personnel file.Procedures:Employees are responsible for the safety of individuals served and supported.Employees need to place cell phones on silent mode (ringer off and vibrate only) while working.Employees are not to use cell phones while driving Keystone vehicles.(Employees who ignore this directive will be subject to disciplinary action and responsible for any tickets received.)The use of Bluetooth devices, headphones, or earbuds is prohibited during work time.Other personal mobile technology devices such as tablets, e-readers, and personal laptops, MP3 Players and iPods are also prohibited, unless authorized by the President or designee.Keystone understands communication with family members is necessary especially those with school-aged children. Therefore, employees need to notify their immediate supervisors of their circumstances.Date: ___________________________Employee’s Printed Name: ________________________________Employee’s Signature: ___________________________________Trainer’s Signature: _____________________________________Reviewed 6/2016Emergency Calls and On-Site Treatment(Addendum 11/07/11)Policy: Hand held medical devices are being used by Rescue Squads to record information regarding 911 calls and are no longer providing a “hard copy” or paper regarding medical care.Procedure: In the event that 911 is called and results in an “On-Site” Evaluation or Treatment, and NO TRANSPORTATION to the Emergency Room, the following form must be filled out by the Emergency Management Team (EMT).All programs will keep copies of the form along with their Unusual Incident Reports.Program Managers and Shift Coordinators will ensure the forms are completed accordingly.The form is to be submitted to Dina Esposito, along with the Unusual Incident Report(s) within 24 hours of an incident.Reviewed 6/2016EMS SIGN OFF SHEETDate of Emergency/Time:Patients Name:Vital Signs:BP-Pulse-Temp.-Comment(s):EMS Chart Prid. No.:EMS Officer Code No.:Print Name:Signature:Adhered 11/11Reviewed 6/2016Emergency and Accident ProceduresUse of VehiclesPolicy: Keystone provides individual’s supported with an active community orientated program based upon the principles of normalization and age-appropriateness. Keystone vehicles that are used to transport individuals served by the agency are equipped with the following: spare tire, jack, three portable red reflector warning devices; a first aid kit including antiseptic, rolled gauze bandages, sterile gauze bandages, adhesive paper or ribbon tape, scissors, and adhesive bandages; snow tires and a 10:BC dry chemical extinguisher. All Keystone vehicles comply with applicable safety and licensing regulations established by the New Jersey Division of Motor Vehicles. Keystone maintains valid liability insurance on all its vehicles.In order to provide for the safety and well-being of all, the following procedures are followed.Before operating the vehicle:Only authorized drivers (staff persons who possess a driver’s license valid in the state of New Jersey, are in good standing with Keystone’s insurance company, are free from medication that adversely affects the ability to operate a vehicle, and have successfully completed driver’s safety training) are to drive Keystone’s vehicles.Seatbelts are to be worn by all passengers, including the driver. Staff is required to provide assistance to anyone who needs help buckling a seatbelt. The driver is responsible for any tickets incurred as a result of seatbelts not being worn.The visor organizer, above the driver’s side, will contain the vehicle’s registration and insurance cards. Before moving the vehicle, the driver is required to check the registration and insurance cards to insure: 1) they are present, and 2) they have not expired. If a card is missing or expired, the vehicle is not to be used. The driver is to immediately report this matter to the On Call Person.Non-standard equipment or labeling, such as bumper stickers are prohibited in Keystone’s vehicles.While operating the vehicle:Staff is to model and emphasize appropriate behavior while in the vehicle. Noise and movement should be limited. Body parts and objects are not to be placed out of the windows.Drivers are responsible for observing all speed limits and operating the vehicle in strict accordance with federal, state and local regulations. It is unlawful to use a cell phone while driving. The driver will be responsible for any tickets or citations received. Drivers wishing to use a cell phone must pull safely off the road before doing so.Drivers shall operate vehicles in a manner that creates a favorable impression on the public (i.e. with more than ordinary courtesy and consideration for other drivers and pedestrians).Drivers shall yield the right of way to other vehicles or pedestrians if there is any question as to which has the right of way.While exiting the vehicle:When parked on a main thoroughfare, everyone should use the passenger’s side to exit or enter the vehicle.Staff is never to leave individuals in a vehicle unattended.Ensure all trash is removed from the vehicle. Staff is responsible for keeping the vehicles clean at all times.Care and maintenance of the vehicles:Smoking, eating and drinking are prohibited in the vehicles.Managers are responsible for ensuring their program’s vehicles are well maintained. This includes regular oil changes, maintenance service checks; follow through with manufacturer recalls, and ensuring any repairs that might be needed.The gas gauge should never get below ? tank. Keystone uses a Company Gulf Fleet Card to obtain gasoline at any Gulf Station. Each program has a Blue Pouch for its vehicle. These pouches contain:Gulf Fleet CardName of vehicle including license plate numberPin number for the cardCustomer service numberInstructions for the use of the cardStaff will give the attendant the card, pin number and mileage for the vehicle in use. Once the tank is full, the attendance will give back the card along with the receipt.Staff places the receipt and card in the pouch.On a monthly basis, the program manager is responsible for providing these receipts to the Director of Administration. After using the vehicle, the driver is responsible for returning the pouch to its proper location in the program. Drivers are responsible for any fees incurred by Keystone relating to replacing lost cards.Mechanical Failure:In the event of mechanical failure; (i.e. dead battery, flat tire, etc.), the driver should contact the On-Call Person (908-304-4548) and follow directions provided. Staff is responsible for ensuring the safety of individuals supported until assistance arrives.The On-Call Person is responsible forObtaining all necessary information (including vehicle location, type of mechanical trouble, and phone number to reach driver.)Notifying the proper outside resources (either mechanic or maintenance personnel). If outside auto services are not immediately available, he/she will call the local police department to inform them of the situation.When appropriate, arranging to have another employee go to the location and transport everyone back to the pleting and submitting an Unusual Incident Report to the Director of Quality Assurance/UIR Coordinator.Vehicle Accidents:Vehicle accidents, no matter how minor, must be reported immediately. Staff, who are either driving or riding in the vehicle, should follow these steps: Pull over to the side of the road.Ensure all passengers are safe.Call 911Call the On-Call Person (908.304.4548)The driver and passengers will be checked by EMS personnel. Staff will accompany any individuals who are transported to a hospital. They will not leave until another employee arrives.File a police report; the program’s director will ensure it is picked up within 48 hours.Remain at the scene until the police investigation is plete an Unusual Incident Report prior to the end of the shift.The On-Call Person should follow these steps:Receive information about the accident, including location, number of people in vehicle, any injuries, etc.Notify the following: parents or guardians, case managers, Keystone’s President or designeeDelegate a support person to meet the staff and individuals (if required).Notify outside resources (if necessary) for assistance with vehicle concerns, such as a towing company.If an employee is injured in the accident, insure a Work-Related Injury report is completed.Review the UIR and Work-Related Injury Reports and document all pertinent information. Submit the completed UIR to the Director of Quality Assurance/UIR Coordinator with a copy to the Director of Administration.Submit the completed Work-Related Injury Report to the Director of Human Resources.Director of Quality Assurance/UIR Coordinator Responsibilities:Review the incident reports and follow up with persons involved in the accident.Document and report all findings to DDD and provide further information as needed.Director of Administration’s Responsibilities:Report all findings to the motor vehicle insurance carrier.Provide further information as needed.Director of Human Resources’ Responsibilities:Review the work-related injury report and follow up as needed.Report the injury to the worker’s compensation insurance carrier.Reviewed 6/2016PROCEDURES FOR CENTRAL REGISTRY OF OFFENDERS AGAINST INDIVIDUALS WITH DEVELOPMENTAL DISABILITIESPolicy: An important law, N.J.S.A. 30:6D-73, took effect October 27, 2010 establishing a Central Registry of Offenders against Individuals with Developmental Disabilities (Central Registry) within the New Jersey Department of Human Services (DHS).This law is designed to prevent caregivers who are offenders against individuals with developmental disabilities from continuing to work in the DD Community. The law protects the safety and well-being of individuals with developmental disabilities receiving care or services from:Facilities or programs licensed, contracted or regulated by DHS;State-Operated ProgramsState-Funded, Community Based ProvidersProcedures:Keystone’s procedures for reporting abuse, neglect and exploitation will be posted at each program site.All Employees will sign the consent form to allow their names to be checked against the Central Registry.The initial check of all employees was completed by the Director of Human Resources in October of 2010.The Director of Human Resources or designated staff is responsible for checking all new hires prior to their first date of employment.Upon completion of this check, the consent form will be signed, dated, printed and placed in the employee’s personnel file.The Department of Human Services Central Registry Office notifies the President each time a new name has been added to the list.To ensure adherence to checking the Central Registry alerts within 24 hours, the following occurs:a. The President forwards the alerts to the Director of Human Resources.b. The Director of Human Resources checks, prints, dates, and signs the alerts.c. In the event that either the President or Director of Human Resources is unable to carry out their duties within the designated time frame, they will appoint someone to take their place. This person will be designated via an email, and he or she will agree to the responsibilities assigned, including maintaining confidentiality, by signing and dating that email. 8. The file of Central Registry Alerts is maintained by the Director of Human Resources. 9. Any employee found to be listed on the Central Registry will be immediatelyterminated.Reviewed 6/2016 ................
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