LifeWaysLogo Teams | Human Resources | Policies & Procedures
I N T R A N E T

Policies & Procedures

1.00 GOVERNANCE

01 Board of Directors Authority, Membership and Responsibility
01 Board of Directors Authority
02 Board of Directors Membership
03 Board of Directors Legal and Ethical Obligation
04 Board of Directors Orientation, Education and Training
05 Board of Directors Evaluation
06 Board Executive Committee Role and Responsibility
02 Board of Directors Operations
01 Policy Manual
02 Board Meetings
03 Board Committee Meetings
04 Board Members Reimbursement and Documentation
05 Board of Directors Public Relations and Communications Protocol
06 Guidelines for Appointment to LifeWays Board of Directors
07 Board of Directors Risk Management Policy
08 Board Appointment to Region 5 Entity
03 Management Operations
01 Role and Responsibility of Executive Administration
02 Leadership Team Meetings
03 Financial Audit Services
04 LifeWays' Communication Process
04 Organizational Support
01 Policy and Procedure Management
02 Chief Executive Officer Supports
05 Conflict of Interest Policy
01 Regional Entity Board Member Conflict of Interest Guidelines
02 LifeWays Board Member Conflict of Interest Guidelines
06 Agency Records Management
01 Agency Record Retention Guidelines
02 Freedom of Information Act (FOIA) Requests
07 Delegation of Authority and Succession Planning
01 Organizational Chart and Succession Planning
02 Executive and Director Level Delegation of Authority
03 Processing and Signing Official Documents
08 Corporate Compliance
01 Corporate Compliance Officer and Compliance Committee
02 Detecting Non-Compliance
03 Investigation of Alleged Compliance Incidents
09 Whistleblower's Protection Policy
01 Whistleblower's Protection Process

2.00 RECIPIENT RIGHTS

01 Protection of Recipient Rights
01 Protection of Recipients of LifeWays Services
02 Suitable Services, Treatment Environment
03 Recipient Rights Training
04 Communication, Mail, Telephone, Visits
05 Personal Property
06 Seclusion, Restraint, Freedom of Movement
07 Fingerprinting, Photographs, Audiotope, or Use of One-Way Glass
08 Admission and Discharge
09 Resident Labor
10 Sterilization, Abortion, Contraception
11 Code of Responsibilities
12 Recipient Rights Liaisons
02Recipient Rights Advisory Councils
01 Recipient Rights Advisory Committee
02 Appeals/Appeals Committee
03 Protection of Recipient Information
01 Access to Case Records
02 Subpoena
04 Recipient Rights Reporting
01 Recipient Rights Death Reporting
02 Incident Report Process
03 Intervention Complaints
04 Abuse & Neglect Reporting
05 Investigation of Recipient Rights Complaints
06 Duty to Warn
07 Adverse Event Reporting and Review

3.00 FINANCIAL MANAGEMENT

01 Accounting
01 Cash Receipts
02 423 Funds
03 Accrual
04 Investment Policy
05 Schedules and Work Papers
06 Year End Financial Statements
02 Annual Budget
01 Preparation and Reporting of Spending Plans, Budgeting and Financial Reports
03 Expenses
01 Credit Card
02 Petty Cash
03 Maintaining Hospitalization Payment, Accruals and Balances Owed
04 Disbursements (Other than Claims)
05 Family Support Subsidy Program
04 Billing and Claims
01 Billing Cycle - Claims
02 Authorizing Services in a Child Caring Institution Setting and Expense Allocation
03 Children's Waiver II (CMWII) Process
04 Claims Payment Schedule Instructions
05 Revenue Contract Monitoring
06 Institute for Mental Disease (IMD) Reporting Requirements
07 Explanation of Benefits
08 Claims Payment
09 Ability to Pay/Fee Determination
05 Purchasing
01 Capital Asset Acquisitions
02 Pooled Funds
03 Purchase of Property
04 Purchasing Supplies, Equipment, and Other Program Materials
05 Purchasing Professional Services
06 Purchasing Process Permission Levels
06 Board & Staff Expenses
01 Travel and Training
02 Check Cashing and Lost Checks Procedure
03 EFT Payment Processing and Returned EFT
07 Rate Setting
01 Method for Estimating Costs/Rate Setting for Clinical Services or ASO Products
08 Financial Reports and Audits
01 Issuing Requests for Proposals (RFPs) for Annual Financing Auditing Services
02 Grant Writing, Reporting and Monitoring

4.00 UTILIZATION MANAGEMENT

01 Service Authorization
01 Authorization of LifeWays Network Services
02 Clinical Competency
02 Clinical Program Management
01 Clinical Case Reviews
02 Habilitation and Supports Waiver - C Waiver
03 Zero to Three (0-3) Infant Mental Health
04 Self Determination Practice Guideline
05 OBRA Coordination
06 Wraparound Implementation
07 Children's Waiver Service
08 Alternative Treatment Order Monitoring
09 Respite
10 Recovery-Based Services
11 Transition/Discharge Planning
12 SEDW Services
13 Residential Services
14 Monitoring and Reassessment
15 Behavior Health Treatment Services for Children with Autism Spectrum Disorders
16 Inpatient Hospitalization Coordination of Care
17 Supports Intensity Scale (SIS)
18 Involuntary Commitment Court Proceeding
19 Involuntary Admission Deferral of Hearing
20 Voluntary vs. Involuntary Inpatient Admissions of Adults
21 Housing Assistance
22 Person-Centered Planning
23 Enhanced Health Services Prescription Requirement
24 Mental Health Court Jail Diversion
25 Multisystemic Therapy (MST)
03 Utilization
01 Utilization Management Criteria
02 Utilization Management Committee
03 Medicaid Fair Hearing Procedure
04 Diversion Committee
05 Utilization Review


5.00 CLINICAL CARE SERVICES

01 Clinical Care
01 NARCAN (naloxone HCI) Nasal Spray
02 Utilization of Credentialed LifeWays Staff (the "Bench")
03 Team Meetings | Clinical
04 Choice of Treating Providers
05 Patient Education CEHR Clinical Summary
06 Trauma Informed Care
07 Referral Process Within the LifeWays Provider Network
08 Best Practice Guideline Development
09 Advance Directives
10 Consent for Treatment | Participation
11 Culture of Gentleness
12 Improving Practices Leadership Team
13 Coordination of Care
14 Special Treatment Procedures
15 Crisis Plans and Safety Plans
16 Behavior Treatment Committee
17 Financial Determinations


6.00 CUSTOMER SERVICES

01 Consumer Relations
01 Consumer Advisory Council
02 Planning and Supports for Persons with Communication Barriers
02 Customer Services
01 Grievance and Appeal
02 Customer Service Standards
03 Customer Services Department
04 Meeting Room Scheduling/Meeting Aids
03 Medical Record Management
01 Medical Record Release of Information
02 Consumer Access to Medical Records
03 Retention and Disposal of Medical Records

7.00 INFORMATION SERVICES

01 Information Systems Infrastructure, Strategy and Management

02 Information Security and Risk Management
01 Business Continuity and Disaster Recovery
02 Information Access and Systems Security
03 Data Backup and Restore
04 Virus Protection, Detection and Removal
05 Use and Disclosers of Protected Health Information
06 Virtual Private Network (VPN) Remote Access
07 Acceptable Internet Use
08 Email Guidelines and Requirements
03 Computer Systems
01 Technology Inventory and Asset Management
02 Information Systems Service Desk
03 Software Standards and Compliance
04 Technology Equipment Requests
05 Computer Lifecycle and Replacement Schedule
04 Telecommunication Systems
01 Telephone Usage
02 Employee Cellular Telephone Assignment & Usage

8.00 QUALITY IMPROVEMENT

01 Quality Improvement Program
01 Quality Improvement Plan
02 Quality Improvement Council
02 Performance Management
01 Quality Improvement Role in Strategic Planning
02 Performance Indicator Development and Monitoring
03 Mission Based Performance Improvement Systems (MIMBPIS) Reporting
04 Provider Scorecard Report
05 Service Fidelity and Outcomes Monitoring
06 Quality Improvement Role in Behavior Treatment Committee
07 Sentinel Event and Root Cause Analysis Process
08 National Core Indicators
03 Quality Improvement
01 Stakeholder Input and Customer Satisfaction
02 Quality Improvement Process Facilitation
03 Recovery Assessment Scale
04 Quality Improvement File
05 Satisfaction Surveys
06 Communication Efficiency
04 Accreditation
01 Behavioral Health Accreditation
05 Health Information Management
01 Behavioral Health Treatment Episode Data Set (BH-TEDS)
02 Electronic Medical Records Management
03 Data Validation and Management
04 Report and Data Requests
05 Use of Multiple Data Platforms
06 Encounter Data Reporting Process
07 EMR Documentation

9.00 PERSONNEL MANAGEMENT

01 Staff Qualifications and Hiring
01 Hiring Practices
02 Job Descriptions
03 Credentialing of LifeWays Staff
04 Background Checking
05 Workplace Accommodations
06 Volunteers, Students and Interns
07 Publications and Research Projects
08 Onboarding and New Employee Orientation
09 Equal Opportunity Employer
10 Staff Motor Vehicle Use
02 Salary, Benefits and Payroll Administration
01 Salary Administration
02 Exemption Status
03 Teleworking
04 Family Friendly Workplace
05 Benefits Coordination
06 Paid Time Away from Work
07 Leaves of Absence
08 Holidays
09 Bereavement Leave
10 Jury Duty
11 Health, Injury and Wellness
12 Personnel Files
03 Competency and Training
01 Annual Training Plan
02 Performance Evaluation
03 Conference Requests
04 Supervision
04 Workplace Conduct
01 Appropriate Workplace Conduct and Expectations
02 Ethical Standards
03 Conflict of Interest/Secondary Employment
04 Dress Code
05 Drug-Free Workplace
06 Anti-Harassment
07 Counseling and Discipline
08 Attendance
09 Employee Problem Resolution
10 Work Schedule and Break Time
11 Mental Health Treatment of Employees
12 LifeWays After Hours On-Call
13 Termination/Exit
14 Social Media
05 Employee Recognition
01 Annual Staff Appreciation Event
02 PERKS Committee
03 LifeWays Retiremenet Recognition
04 Staff Celebrations/PERKS Events
05 Employee Support During Critical Events

10.00 NETWORK MANAGEMENT

01 Provider Network Membership
01 Provider Manual
02 Procurement of Provided Services
03 Network Development and Capacity Evaluation
02 Provider Network Contract Management
01 Auditing Certification and Accreditation
02 County of Financial Responsibility (COFR)
03 Out of Network Contracting
04 Delegated Managed Care Functions
05 Provider Communications
06 Provider Network Contract Development and Distribution
07 Environment of Care Standards for Residential Providers
03 Provider Network Credentialing
01 Requesting/Delineating Clinical Privileges
02 Provider Network Credentialing Application
03 Provider Network Credentialing Appointment and Committee
04 Suspension of Credentialed Status and Appeal
05 Provider Training Requirements
06 Disclosure of Ownership Control and Criminal Conviction
04 Provider Relations
01 Provider Orientations
02 Provider Grievance & Appeals Process

11.00 FACILITIES MANAGEMENT

01 Safety and Security
01 Building Access, Safety and Security
02 Behavioral or Medical Emergency
03 Emergency Preparedness Plan
04 Equipment Management Plan
05 Fire Safety Management Plan
06 Hazardous Materials Management Plan
07 Medical Waste Management Plan
08 Tobacco-Free Campus
09 Service Animals
10 Vandalism or Theft
11 Utilities Management Plan
12 Workplace Safety
02 Tenants and Space Management
01 Inspection of LifeWays Buildings
02 Facilities Coordination
03 Division of Responsibility in LifeWays Owned or Leased Facilities
04 Space Management
03 Maintenance and Custodial Services
01 Maintenance and Repair
02 Unwelcomed Insect Sightings
04 Agency Vehicle/Transport Services
01 Agency Vehicle Use
02 Safety and Security
03 Vehicle Accident Reporting
04 Vehicle Safety and Maintenance
05 Vehicle Refueling
06 Use of Personal Vehicle for Transport


12.00 STRATEGIC RELATIONS

01 Public Relations
01 Media Contact Guidelines
02 Newsletters
03 Brand Management
04 Information Dissemination
05 Readability
06 Annual Report
07 Corporate Responsibility
08 Process Alerts
02 Community Benefit Policy
01 Requests for Community Financial Support
03 Central Michigan 2-1-1 Services
01 Inclusion/Exclusion Criteria
02 Data Back Up
03 Donations
04 Entering Transactions
05 Follow Up
06 Performance Monitoring Plan
07 Program Effectiveness
08 Resource Management - Standardization
09 Responding to Calls
10 Specialized Information & Referral Programs
11 Taxonomy
12 Unmet Needs
13 Updating Records
14 Volunteers
15 Challenging Callers
16 Live Chat Response
17 Hearing Speech-Impaired Callers
18 Welcome Message Recording
19 Domestic Violence/Sexual Assault Calls
20 Medical/Police/Fire Emergency
21 Mental Health Crisis Calls
22 Community Announcements and Updates (2-1-1 Email Blasts)
23 Technology
24 Central Michigan 2-1-1 Training Procedure
25 Social Networking Sites
26 After Hours Follow-Up
27 Database Audit Procedure
28 Central Michigan 2-1-1 Confidentiality Policy
29 Advocacy
30 Email and Social Media Response
31 Information & Referral Call Monitoring
32 Program Coverage
33 Emergency Succession Planning
34 Disaster Emergency Management 2-1-1 Response
35 Financial Procedure for Central Michigan 2-1-1 Program
04 Prevention Policy
01 Mental Health Education
02 Critical Incident Stress Management (CISM)
03 Prevention and Health Promotion Plan
04 Wellness Programs
05 Wellness Coaching

13.00 ACCESS SERVICES

01 Functions of Access
01 Welcoming
02 Open Access
03 Rapid Access
04 Triage
05 Warm Handoffs
06 Outreach
07 Follow Up
08 Floor Supervisor
02 Crisis Line
01 Crisis Line Call Response
02 Callback Que
03 After Hours Crisis Line
03 Pre-Admission Screening to Inpatient
01 Conducting a Pre-Admission Screening
02 Placement Logs
03 Inpatient Screenings at Henry Ford Allegiance Health
04 Inpatient Screenings at Hillsdale Hospital
05 Courtesy Screens
06 Petitions
07 Diversions
04 Brief Screen to Determine Eligibility for Services
01 Conducting a Brief Screen
02 Eligibility Determination
03 Prison Release Request for Services
04 County of Financial Responsibility (COFR) Presentations to LifeWays Access
05 Referrals [place holder]
05 Substance Use Disorder Screenings
01 REMI Brief Screening and Level of Care Determination
02 Priority Populations
03 Screening, Assessment, Referral, Follow-Up
06 Crisis Intervention
01 Phone Crisis
02 Face-to-Face Crisis
03 Assisting Law Enforcement Officers
04 Provision of Emergency Services
05 Safety Plan [place holder]
07 Initial Evaluations
01 Conducting an Initial Evaluation
02 Interim Plans
03 Orientation to Services
04 Wait List
08 Autism Screening
01 Autism Eligibility and Evaluation
02 ADOS and ADIR [place holder]
03 Autism Packet [place holder]
09 SED Screening for Foster Care
01 [place holder]
10 Serious Emotional Disturbance (SED) Waiver Coordinator
01 SED Waiver Eligibility [place holder]
02 Enrollment [place holder]
03 Application [place holder]
04 Annual Recertification Process [place holder]
05 Termination of SED Waiver Services [place holder]

14.00 CRISIS SERVICES

01 Crisis R&R
01 Eligibility and Exclusionary Criteria
02 Services and Programming
03 Utilization of Crisis R&R
04 Follow Up Post Crisis R&R
02 Mobile Crisis Team for Adults
01 Eligibility, Exclusion and Transition Criteria
02 Response Protocols
03 Consumer Care
04 Mobile Crisis Services and Provider Expectations
05 Removal of Consumer Access to Medications and/or Sharps
06 Mobile Crisis Services Debriefing
07 Screening Questions for In-Home Response
03 Intensive Crisis Stabilization Services (ICSS) for Children
01 Components of Service Delivery
02 Referral Process for ICSS
03 Criteria for ICSS
04 Individual Plan of Service for ICSS
05 Family Needs
06 ICSS Follow Up Services
07 Training and Supervision

15.00 INTEGRATED CARE SERVICES

01 Integrated Health Services
01 Integrated Health Nursing Assessments
02 HEDIS Measures and Monitoring (Risk Reduction of Metabolic Syndrome)
03 CoVita Smokerlyzer
04 HgA1C Point of Care Testing
05 Cholesterol Point of Care Testing
06 Comprehensive Care [place holder]
07 Population Health [place holder]

16.00 OUTPATIENT SERVICES

01 Targeted Case Management
01 Features | Hours [place holder]
02 Service Expectations [place holder]
03 Habilitation Supports Waiver (HSW) Brokerage Model | Oversight
02 Supports Coordination [place holder]
01 Features | Hours [place holder]
02 Service Expectations [place holder]
03 Outpatient Therapy
01 Criteria for Outpatient Therapy
02 Outpatient Therapy Service Expectations
03 Solution Focused Services [place holder]
04 Jail Services
01 Criteria for Inmate Services
02 Documentation for Services to Inmates
03 Care Coordination and Follow Up Services
04 Psychiatric Services for Inmates
05 Mental Health Court
01 Mental Health Court Jail Diversion
06 Medical Services
01 Medication Guidelines
02 Prior Authorization - Medications and Services
03 Medication Payment Assistance
04 Medication Management Only Exception Request
05 Clozaril Process
06 Injection Clinic
07 Meaningful Use and PQRS
08 Laboratory Reporting
09 Telemedicine Services
10 Adverse Medication Reporting
11 Non-Engagement Process
12 LifeWays Medical Services Referrals
07 Outpatient Peer Supports [place holder]
01 Support Groups [place holder]
02 Engagement [place holder]