Family Services of Davidson County Policy Manual Revised October 2003

Transcription

Family Services of Davidson County
Policy Manual
Revised October 2003
Table of Contents
Agency Service Philosophy
Governance
Strategic Planning
Board Conflict of Interest
Delegation of Authority
Succession of Chief Executive
Agency Advocacy
Policy Development & Implementation
Evaluation of Chief Executive
Risk Management
Finance
Financial Accountability
Alignment of Financing with Mission
Financial Plan
Funding Sources
Budget Preparation and Approval
Reconciliation of Bank Accounts
Reconciliation of Balance Sheet
GAAP/Audit Requirement
Accounting Policies and Separation of Duties
Purchase Requests and Cash Disbursements
Sales Tax Recoupment
Payroll
Quarterly Reports
Inventory
Service Revenues and Unit Costs
Denial of Payment
Finance Director
Human Resources
Affirmative Action
Diversity and Equal Employment
Vacant Positions
Recruitment & Selection
Employee Retention
Staff Assessment & Strategic Planning
Workload Evaluation & Assignment
Volunteer, Student & Intern Administration
Use of Adjunct Personnel
Personnel Records
Employee Benefits
Annual Performance Appraisal
Employee Grievances
Progressive Discipline
Sexual Harassment
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Discontinuation of Employment
Whistleblower Protection
Employee Conflict of Interest
Alcohol & Drug-Free Workplace
Employment of Relatives
Evaluation of Employment Data
Outside Employment
Training & Supervision
Staff Orientation & Training
Staff Training Development & Supervision
Assurance of Staff Training for Special Modalities
Training Staff about Client Rights
Supervisor Qualifications
Workload Evaluation
Facilities
Safe & Hygienic Work Environment
Contagious Disease
Smoke-Free Environment
Conservation
Facility Accessibility
Shelter Handicap Accessibility
Facility Safety for Victims
Crisis Policy
Emergency Response
Vehicle/Driver Management
Internet Use
Performance & Quality Improvement
PQI/CQI
90-Day Review
Utilization Review
Client Tracking & Outcomes
Ethical Practice
Ethical Conduct
Culturally Competent Practice
Productivity Expectations
Client Rights
Client Confidentiality
Clients Rights
Informing Clients of Rights
Client's Rights Committee
Client Grievance
Incident Reporting
HIPAA Authorization
HIPAA Compliance
Behavior Support & Management
Use of Restrictive Interventions
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Clinical Services
Service Eligibility
Person & Family Centered Assessment
Person & Family Centered Intake
Person & Family Centered Intervention
Family Involvement & Participation
Crisis Planning
Continuity of Care & Case Assignment
Case Coordination & Management
Discharge, Discontinuation & Aftercare
Intensive Services for Victims of Abuse or Neglect
High-Risk Interventions
Collaborative Activities
Credentialing
In-Home Services
Psychiatric Services
Fees
Substance Abuse1
Crisis Intervention
DV—SA Policies
Crisis Intervention Service Philosophy
Community Partnerships
Community Access to Services
Client Access to Services
Access to Services for Secondary Victims
Advocacy & Support Services
Crisis Client Assessment
Crisis Client Screening
Rights of Shelter Residents
Expelling Shelter Residents
Shelter Intake and Assessments
Client Accessibility
Shelter Special Populations
Shelter Safety and Security
Shelter Room Assignment
Recreation Consent
Promoting Child Well-Being
Case Closing
Record Keeping
Aftercare & Follow-up
Involvement of Perpetrators
Crisis Personnel Qualifications
Crisis Administrative Personnel
Crisis Staff Competencies
Crisis Staff Workloads
1
At the time this manual was created (December 2013) FSDC did not provide any Substance Abuse services.
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Crisis Hotline Polices
Crisis Line Service Definition
Crisis Line Service Philosophy
Crisis Line Quality of Service
Crisis Line Access to Services
Crisis Line Screening & Assessment
Crisis Line Information & Referral
Crisis Line Training and Services
Crisis Line Personnel Supervision
Crisis Line Personnel
Crisis Line Access and Handling Multiple Calls
Crisis Hotline and Support Services
Crisis Intervention and Response Services
Community Connections and Coordination
Abuser Intervention Program
AIP Service Definition
AIP Service Philosophy
AIP Provision of Group Services
AIP Personnel- Information and Referral
AIP Personnel- Education and Support
AIP Access to Services
AIP Education and Group Services
AIP Personnel- Training and Education
AIP Information and Referral Services
AIP Screening and Intake
Youth and Community Services
Keeping Up Program Policies
Engagement & Assessment
Assessments
Further Evaluation
Service Planning & Monitoring Timeframes
Collaboration & Coordination
Family Involvement
Educational Program
Maintaining Safety & Security
Search & Seizure
Transition & Aftercare
Intensive Family Preservation Services and Family Empowerment Program Policies
Circles for Davidson Policies
Family Services of Davidson County, Inc.
Agency Service Philosophy
JDT Service Philosophy
Policy
_______________________________________________________________
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Family Services of Davidson County, Inc. provides services that are evidenced supported,
client/family centered and culturally competent and that ensure appropriate and reasonable
interventions that meet each consumer’s needs. FSDC recognizes the need for staff competencies
and thus makes certain of supportive supervision and training. Staff is encouraged to develop
programming that is effective and measurable.
Procedures
________________________________________________________________
Clinical:
Provides outpatient mental health services based on the needs of the client/family. Services are
recommended based on consumer choice and appropriateness of requested interventions and staff
expertise.
 Counseling Services: A full spectrum of counseling and therapy for children and adults.
Modalities include individual, couple, family, and group settings, as well as play therapy for
young children. Treatment is systemic and holistic.
Crisis:
Crisis Intervention Services are provided under the Voluntary Services Model, which is a strengthbased empowerment approach to providing survivor services. In addition, Crisis Intervention staff
utilizes the Crisis Intervention Theory which is a logical approach of providing intervention to
produce quick and constructive change for survivors whose problems are short term. Crisis
Intervention Theory has been established as an effective modality for crisis hotlines, walk-in centers,
and crisis clinics provides immediate support.
Ultimately, empowering clients while promoting client safety is our program’s goal.
Survivors are provided comprehensive services including:
1. 24/7 Crisis Hotline- focuses on specific and time-limited treatment goals, clarifying and
assessing the client’s source of stress, assisting clients in developing problem-solving
mechanism functioning and exploring resources, providing emotional support for crisis line
clients.
2. Shelter - A safe temporary residence available 24 hours a day, 7 days a week for female
domestic violence and sexual assault survivors and their minor children.
3. Counseling – Free counseling services, treatment and support groups
4. Hospital Accompaniment – provided for domestic violence or sexual assault victims who
need medical intervention. Staff and volunteers are on-call to respond 24 hours a day at the
hospital to provide support, information and referrals, and clothing.
5. Law Enforcement and Court Advocacy – provides assistance with Protective Orders,
warrants, legal referrals and court accompaniment.
6. Case Management – provides information and referrals to other community agencies, goal
setting, and limited financial assistance.
7. Community Education – Programs regarding domestic violence and sexual assault for
schools, civic and church groups, and community agencies.
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8. Training– Education and information to individuals wishing to volunteer and to
professionals who work with domestic violence and sexual assault survivors
All Crisis Intervention Services are voluntary and provided free of charge.
Youth and Community Services:
Youth and Community Services address the needs of at-risk youth and young adults from a systemic
family based approach. These programs are guided by trauma informed care, recognizing these
youth and young families have been impacted by traumatic experiences that have limited their ability
to navigate stressors due to inadequate supports and resources.
At-risk and adjudicated youth and their families have multiple needs and interrelated problem
behaviors that are not likely to be successfully addressed by single-response, stand-alone initiatives.
Programs must address multiple needs by implementing a continuum of care. We believe that
family-based interventions are critical to making positive impacts on child and family functioning,
delinquent behavior and recidivism.
Programming includes:
 Intensive Family Preservation Services- in home clinical interventions for level 2 or 3
juvenile offenders and their families. This service is designed to decrease delinquent
behaviors and reduce the number of youth placed out of the home and in Youth
Development Centers.
 Keeping Up- provides academic support by means of web based educational programming
and skill building group intervention for youth who have been long term suspended.
Parents are provided support group opportunities and Parent Education classes.
 Circles for Davidson- an anti-poverty program for parents between the ages of 16 and 24.
Participants complete a 12-week course and then are matched with community volunteers
who mentor the young parents in developing resources.
 Family Empowerment Program- provides social work services to connect parents and
families with needed resources. Supports parents in developing appropriate structure in the
home to reduce negative behaviors and delinquency.
 Parent Education- is a structured 8 week group intervention that provides parents with the
knowledge of child development, limit setting, behavioral intervention and positive nurturing
habits.
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Governance
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Policy No.: 1.0
Policy: Strategic Planning
Latest Revision/Approval: October 2013
Approved by: Board of Directors
Policy
______________________________________________________________________________
Strategic Planning is essential for agency sustainability and includes consideration of both internal
and external factors. This process is overseen by Family Services’ Board of Directors.
Purpose
The purpose of Strategic Planning is to assess areas of strengths and weakness; determine goals and
objectives that support the vision and mission of the agency; and to make decisions on allocating
resources to support/pursue this strategy.
While this process is an on-going part of program management, an agency-wide Strategic Planning
review will be led by the FSDC Board of Directors at least every 4 years.
______________________________________________________________________________
Program / Service Assessment:
Program Managers and staff work directly with clients and stakeholders within the FSDC
community and are acutely aware of emerging program needs and/or trends.
Statistical reporting by each program/unit provides an opportunity for detailed data analysis to
identify, review and understand changing/emerging service needs.
As trends emerge, internal assessments are “benchmarked” with external community partners (i.e.
United Way, Davidson County Health Dept., Law Enforcement, etc.) to provide a balanced “needs
assessment” picture.
Recommendations for program changes, enhancements, closures/additions are made by the
Executive Director/Management Team, to the FSDC Board of Directors. It is intended that this
feedback will serve as part of the overall Strategic Planning process.
Succession Planning:
Succession Planning is also a critical component of strategic planning. Grooming and preparing
qualified, existing employees for increased roles/responsibilities is critical to FSDC’s growth.
Program Directors are responsible for working with staff during supervision to assess professional
goals and to develop a plan to develop skills/abilities in those areas. Development may include
training, projects, or additional responsibilities as overseen by the program director.
Strategic Planning:
Family Services’ Board of Director’s ultimately oversees strategic planning for the agency. However,
stakeholders may also include clients, staff, community resources and other service providers. While
the specific strategic planning process may vary, the overall goal/result is to continue to provide
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meaningful, quality service to our clients. Therefore, the planning/review process may include the
following components:
 An identified community need for which Family Services may be an appropriate resource
 Feasibility of providing service in regards to agency philosophy, standards, existing client
services, staffing, funding, etc.
 Additional resources that may be necessary to implement service – such as facility needs,
operational hours, administrative and/or technical support, etc.
Additionally, the FSDC Board of Directors incorporates the following components as part of the
Strategic Planning process:
 Financial Health / Sustainability
 Internal Operations / Resources
 Employee Compensation / Benefit Programs
 Succession Planning for key leadership positions
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Policy No.: 1.1
Policy: Board Conflict of Interest
Board Conflict of Interest
POLICY
_________________________________________________________________________
Family Services of Davidson County, Inc. is a private non-profit organization, which
uses both private contributions and tax money for its support. As such, its resources
must be used prudently. This can be promoted most clearly when members of its
governing body, administration, consultants, and staff have no direct or indirect
financial interests in the assets, leases, business transactions, or professional
services of the organization.
PROCEDURES
__________________________________________________________________________
1. When direct interests do exist, said members of the governing body,
administration, consultants, and staff shall disclose such interests and withdraw
from active participation in any deliberations and decisions related to those
interests.
2. Members of the governing body will not accept honoraria from the organization.
3. Preferential treatment will not be given to members of the governing board,
advisory boards, personnel or consultants in applying for and receiving services
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Policy No.: 1.2
Policy: Delegation of Authority
POLICY
____________________________________________________________________
The purpose of this policy is to provide a clear delegation of authority during
times when the Chief Executive is absent.
PROCEDURES
____________________________________________________________________
Short-Term Absences (Up to 30 days)
A. Before the Chief Executive leaves for a planned absence, he/she appoints
the Management Team to function collectively as the Directors-on-Duty. The
team will work together in carrying out the responsibilities & operations of the
agency. The team will perform all duties that ordinarily
would be done by the Chief Executive.
B. If the absence is unplanned or unexpected, the Management Team will
serve collectively as the Directors-on-Duty to maintain the activities of the
agency.
C. In the event the Management Team cannot reach consensus or the
decision requires individual action, the 2 most senior members of the
team will share final responsibility.
Long-Term Absences: (Over 30 Days)
In the event of prolonged absence, the Chief Executive and/or the Board
Executive Committee may elect to appoint an an interim director who will serve
until the return of the Chief Executive.
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Policy No.: 1.3
Policy: Succession of Chief Executive
Succession of Chief Executive
POLICY
This policy describes the process by which the Board maintains continuity of operations during the
period of replacement of the chief executive.
PROCEDURES
The Executive Committee of the Board will meet to review the current state of the organization at
the point where there is a vacancy of the chief executive position.
The Executive Committee will assign an interim management drawing upon both
the internal staff or, where appropriate, an external resource.
The interim director will serve as the link between the Board of Directors and the
service operations of the agency. A schedule of meetings will be decided to
ensure continuity and oversight during the interim period.
After appointing an interim management, the Executive Committee will appoint a
search committee to begin the process of filling the Chief Executive position.
The Board will provide the necessary resources to the committee. The search committee will work
with the Board, and any consultants (if desired) in determining
the needs of the organization and the desirable skill sets for the new leadership.
The search committee will solicit applications and review candidates that fit the
profile.
Upon selection of a candidate, the search committee will bring their
recommendation to the full Board.
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Policy No.: 1.4
Policy: Agency Advocacy
Agency Advocacy
POLICY
As a leading human services agency in the community, Family Services of Davidson County, Inc.
assumes responsibility on behalf of individuals as well as general groups of individuals to work
toward systematic change to better the lives and social conditions of the citizens of Davidson
County. Staff is expected to recognize the competence and abilities of all individuals served, with
particular emphasis placed on handicapped or disadvantaged individuals. The Agency (Board and
staff) are moreover expected to advocate for occupational and social inclusion of handicapped
individuals. In this regard, efforts will be undertaken to advocate on behalf of individuals (“case
advocacy”), groups or social conditions (“cause advocacy”).
PROCEDURES
All professional staff members are expected to be aware of advocacy needs on behalf of clients
or groups of clients. The clinician or staff member working directly with a client typically
identifies a need for “case advocacy.” In these instances, the specific need or issue is identified
and a plan of action is developed in keeping with the treatment plan. To empower the client, the
staff member works with the client to shape the action plan so that the client is actively involved
in the advocacy efforts. Types of “case advocacy” efforts include:
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Addressing concerns with school professionals regarding a child’s academic or social issues
Assisting a domestic violence victim in court so that his/her needs are adequately addressed
by court officials
Intervening with medical professionals so that a rape victim receives a healthcare response
that meets their needs for recovery
Contacting available resources in the area of housing to assist a client acquire affordable
living arrangements
Referral for client(s) who meet criteria for Vocational Rehabilitation Services as well as work
reentry services through Davidson County Community College (DCCC) or Job Training
Employment Center (JTEC).
Staff and Board members identify needs related to “cause advocacy” in a variety of ways, including:
 Informally sharing issues regarding common social concerns with other staff
 Formal discussions of common client needs within supervisory groups or quality
improvement meetings
 Feedback from consumers in the form of client and community surveys
 Staff and Board participation on various community/statewide coalitions
Types of “cause advocacy” efforts include:
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Serving on local or statewide coalitions to address the problem of domestic
violence
Planning and overseeing community-wide vigils on victims’ rights
Assisting with the drafting of legislation or meetings with elected officials to
educate them regarding social concerns
Organizing publicity efforts, including press releases, media interview, etc.
Participating in local forums and events regarding issues the Agency is involved
with such as mental health, substance abuse and child safety concerns.
In addition to the external, community-focused advocacy efforts described
above, staff is also mindful of internal, agency-directed advocacy efforts.
Examples of these include instances in which agency procedures or policies
need to be developed or changed so that they are more responsive to client
needs. Management will regularly review all recommended agency-directed
advocacy suggestions and implement whenever possible
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Policy No.: 1.5
Policy: Policy Development & Implementation
Policy Development & Implementation
POLICY
______________________________________________________________________________
Family Services seeks to have a clear and consistent process by which the agency creates or changes
administrative and/or Board policies and disseminates information to staff.
PROCEDURES
______________________________________________________________________________
The need for a change or development of policy can emerge from staff, management, Board or
agency stakeholder.
Policy development is for the purposes of compliance to regulations, establishment of good business
practices, or enhancement of services to customers.
The need for a policy development or revision is communicated through the supervisory structure,
from the CQI teams, management meetings, or board committees.
The request is placed on the management team agenda with a statement of need that includes the
rationale, the current policy statement (if any), and the necessary revisions recommended (if known).
The request for a policy can result in several actions:
a.) The management team drafts the change.
b.) The management team seeks outside consultation.
c.) The issue is referred to a staff group for more research.
d.) The request is determined to be not warranted.
When the new policy is drafted it is reviewed by the management team for final wording,
numbering, and cataloging. The resultant document is then considered for adoption in the following
manner:
a.) In the case of an Administrative Policy or procedure, the approval of the
Executive Director authorizes implementation.
b.) In the case of a Board level policy (governance or direction related) then
both the authorizations of the Executive Director and the Board of Directors are
required. The policy becomes effective at the point of final authorization.
IMPLEMENTATION:
Upon approval, all relevant electronic and/or hard copy policies and guidelines will be
updated. FSDC staff and Management Team will be notified of any policy/guideline
changes.
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ACCESIBILITY:
It is the responsibility of FSDC staff to remain abreast of new and/or updated agency
policies and guidelines. Both the FSDC policy manual and employee handbook are
accessible on the agency “S-Drive” and all employee’s have access to this information.
A variety of methods/tools are utilized to communicate policy updates to staff:
-Monthly agency-wide staff meetings
-Unit/Team meetings
-Individual supervision meetings
-Agency-wide e-mail distribution
-Hard Copy notices posted or in each employee’s mailbox
-Minutes from meetings (i.e., Staff, Clinical, Management Team, etc.)
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Policy No.: 1.6
Policy: Evaluation of Chief Executive
Evaluation of Chief Executive
POLICY
______________________________________________________________________________
The Executive Committee of the Board of Directors will provide oversight and
evaluation of the Chief Executive Officer (Executive Director).
PROCEDURES
______________________________________________________________________________
-The Executive Committee of the Board will review the performance of the
executive director on a yearly basis.
-The Executive Committee will request the executive director complete a
self- evaluation to be based on criteria from the approved job description and
other factors, as may be requested by the Executive Committee.
-The Executive Committee will review the self-evaluation and complete the
Evaluation of the Executive Director form.
-Concurrent with the evaluation, the Executive Committee will review the
compensation of the Executive Director and make an adjustment, as
appropriate.
-In a manner to be determined by the Executive Committee, the evaluation will
be shared with the Executive Director and compensation will be set.
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Policy No.: 1.7
Policy: Risk Management
Latest Revision/Approval: April 2013
Risk Management
POLICY
Family Services is committed to practicing effective risk management to protect the
safety, dignity, and legal rights of others as well as our human, financial, and intangible
assets. Family Services seeks to ensure the organization's continued ability to perform
its mission, grow and maintain good health and preserve its responsibility and
commitment to the community. This is accomplished through a continuing process of
evaluation and review of the various risks to which FSDC may be exposed. Because
Family Services has a responsibility to its stakeholders, maintaining the public trust is
essential for the organization's existence. By maintaining an effective risk management
program, the more confident the Board of Directors, senior management, staff, and
volunteers can be that the mission and operations will be achieved.
Information related to risk management will be distributed as considered appropriate to
board members, employees and volunteers, including, but not limited to posting on
agency bulletin of pertinent insurance information
PROCEDURES
______________________________________________________________________________
Purposes and Benefits of a Risk Management Program
Family Services needs a risk management program because:
-Risk management can help Family Services protect its stakeholders from harm,
-Risk management is a means for Family Services to examine the safety of its
Facilities, the fairness of its criteria for service delivery, the methods by which it
serves clients, the manner in which it trains paid and volunteer staff, and the quality
of the organization interaction with the public and
-It also provides a method for examining the degree to which the Board of Director's
fulfills its governance and legal responsibilities.
The number of claims and lawsuits filed against nonprofit organizations continues to
rise: In the past, nonprofit organizations were protected from litigation by the legal
defense known as charitable immunity. This type of defense has suffered in recent
years through numerous reversals in the courts. The courts have reasoned that since
non-profits have some degree of control over the activities of their paid and volunteer
staff, they are in the position to take precautions against injuries caused by them.
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Nonprofits face litigation as a result of:
-Violation of the state's charitable solicitation act
-Wrongful termination
-Defamation of character or invasion of privacy for inappropriate release of
confidential information on a client or volunteer
-Bodily injury
-Employment discrimination
-Breach of contract
Even in those cases where a nonprofit is likely to prevail, the time and money required
to defend an action may be considerable. Accidents, crises and adverse situations are
often preventable: Because risk management activities have the potential for identifying
areas within the organization that pose potential threats, the process of risk management offers a
means for minimizing the possible damage.
A risk management program can identify circumstances that could contribute to a crisis
in public confidence or result in negative publicity: Risk management actively works to
identify hazards that would diminish the public's confidence in the organization or generate negative
publicity.
A risk management program has the added potential to make the organization
attractive to competent board members. The presence of a risk management program
demonstrates to potential board members, and to the community at large, the organization's
commitment to maintaining its health and viability.
Goals
The goals of Family Services' risk management program are:
-Maintaining adequate internal controls in place to safeguard the organization's
financial assets;
-Maintaining the safety of the physical plants to protect its stakeholders from injury,
disability, and death;
-Maintaining adequate security and fire systems in place to monitor the security of
the physical environment;
-Providing adequate training for paid and volunteer staff in the areas of personal
safety measures, de-escalating conflict and handling emergencies, and handling
emergencies;
-Setting guidelines for providing services to children/families with infectious diseases
-Maintaining employment practice policies to minimize risk associated with:
Employee selection; Wrongful termination; Employment discrimination lawsuits
-Establishing a disaster recovery plan to minimize the loss of client, corporate
and financial data due to fires and environmental factors;
-Minimizing the risks of data/information integrity such as: computer viruses
access to client information by employees or those outside the agency; Unauthorized
use of computers to communicate with clients in an inappropriate capacity;
-Maintaining adequate property and liability insurance coverage
-Diversification of the revenue base to reduce reliance on a single source of
funding
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Assignment of Function
The risk management function is assigned to the Executive Director and the Executive Committee
of the Family Services Board of Directors. Senior management team members are also responsible
for developing and implementing the risk management program, as well as making
recommendations for its improvement.
However, in order to be successful, risk management must be a consciousness-raising
activity. Everyone must understand what risk management is about and what role each
person within the organization plays in promoting safety, reducing the likelihood of
accidents, and responding appropriately when precautions fail and an accident occurs.
Risk management should motivate everyone in the organization to consider the
consequences of their actions. Family Services’ CQI Committee plays a critical role in this process.
*CQI (Continuous Quality Improvement) is an internal oversight committee comprised of FSDC
management team members and staff representation from all units. An elected committee chair
(non-management team) is coordinates all meetings, which are held on at least a quarterly basis.
Minutes and reports for each meeting are maintained in a CQI binder, which resides with the
Program Chair. Committee participants typically serve a 2-year membership on this committee
(*with the exception of management staff) . * See also Policy Number 7.1 (PQI/CQI)
The Process
The risk management process is a continuous loop - The risk management process
covers four steps. These are (1) acknowledge and identify risk, (2) evaluate and
prioritize risk, (3) implement selected risk management techniques, and (4) monitor and
update the risk management program. Risk management is not a one-time activity.
As Family Services takes each step in the process, it logically leads to the next, until this process is
fully integrated into the life of the organization:
1. Acknowledge and Identify the Risk: What can go wrong? Consider:
-Operational-Loss of personnel through disability, death, retirement; Physical
Damage to its property and property of others; Consequential Losses; Criminal
Activity by staff, volunteer, director or a client; and Loss of Data
-Legal-Contractual liability, statutory liability, and tort liability
-Financial and Market-Financial loss due to investing or reliance on a single funding
source;
-Interest rate risks; and Banking risks;
-Political-Changes in rules, regulations and laws; and social action
-Programs-identify risks by program;
-Administrative operations-Physical office policies and procedures, employment
practices, computer equipment and data, and accounting and financial activities;
-Tools to identify risk
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-Insurance applications
-Internal documents - Employee manual, audits, written policies and procedures,
minutes, internal memos
-Financial statement and records
-Workflow-map out the workflow and processes used to deliver services
-Personal inspection of facilities
-Interviews-employees, volunteers, donors, clients, families and other service
providers
-Loss history-review incident reports
-Similar organizations
Function is assigned to member of management team Reporting to the Board of Directors
2. Evaluate and prioritize risks – frequency and severity
Assign high/ low probability and classify each risk by its frequency/severity grading:
Risks graded high frequency-high severity can be catastrophic to Family Services.
These risks should receive top priority. Family Services may best be served by
avoiding the risk or completely transferring it to another party.
Risks graded as low frequency-high severity - such as a large property loss, severe
auto accidents, or debilitating worker injuries can happen, and when they do they have
expensive consequences. Therefore, these risks should be shared and assigned the
next level of priority. Family Services can either insure against or retain a high
frequency-low severity risk (minor auto accidents, liability losses) so these risks are
rated as a moderate priority.
Low frequency-low severity risks - Family Services can retain the low priority risks, often
as part of an insurance policy deductible. Focus should be placed on the high priority risks that
might occur and could prove expensive, such as a wrongful termination complaint. In contrast, place
a low priority on those risks that are unlikely to occur or that involve an insignificant expense. After
establishing priorities, evaluate each risk and select the appropriate risk management technique.
3. Select and implement risk management techniques - develop a brief written plan
outlining how Family Services will manage its high priority risks. The plan should
address each of the principal risks identified and described the suggested strategy or
combination of strategies to be used. The four strategies are:
Avoidance - Family Services can decide not to offer a service or conduct an activity that
it considers too risky.
Modification - Family Services can change an activity so that the chance of harm
occurring and the impact of potential damage are within acceptable limits.
Retention - Retention is simply Family Services acceptance of all or part of a risk,
including preparing for the consequences. Retention is a sensible alterative for small
losses that will not unduly disrupt or affect Family Services' financial base.
Sharing - Sharing risks involves the full or partial transfer of an activity-or the financial
consequences.
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4. Monitor and update the Risk Management Program - The Executive Director and
Exec. Committee will review/revise the risk management program annually.
The Role of Insurance
The purpose of insurance is to share the financial responsibility for a loss. Because
insurance provides an important safety net, the Executive Director, Management Team and board
should be well versed in the role of insurance in Family Services' operations.
On an annual basis, the Executive Director and Management Team will meet with a representative
from the Agency’s insurance carrier. At this time, Agency insurance policies for property and
casualty, professional liability, director’s and officer’s
liability, workers’ compensation and any other coverage deemed appropriate will be
reviewed. The purpose of such review is to evaluate potential loss and liability and to
the extent considered feasible, reduce such loss and liability to an acceptable amount.
It may be necessary to rely on the expertise and the experience of insurance
professionals through work through the maze of insurance.
Based upon professional recommendations, Family Services has selected the following insurance
coverages:
Property Insurance - covers Family Services against damages to property such as
buildings, computers, furniture, documents and equipment.
Liability Insurance - protects Family Services against claims including litigation alleging
the agency's operations or actions that caused damage to another person or
organization. Included coverages are:
Professional Liability - Insurance will pay for damages because of any bodily injury,
property damage or personal injury caused by a professional incident
Automobile Liability - Insurance will pay for bodily injuries or property damages that
result from the ownership, maintenance, use of a covered vehicle and is caused by an
accident that happens while the insurance is in effect.
Directors' and Officers Insurance - Insurance will pay for (1) losses resulting from the
wrongful acts of Family Services and (2) losses resulting from allegations
including but not limited to false arrest, libel, slander, defamation of character, and
invasion of privacy.
Other coverage:
Employee dishonesty bond - Family Services carries employee dishonesty insurance.
This insurance pays for loss of or damage to, money, securities and other property that
results directly from employee dishonesty. This covers all employees, including those
handling cash and signing checks. Notwithstanding the insurance coverage, Family
Services, maintains a level of internal controls to minimize losses due to employee
dishonesty.
Workers Compensation:
The State of North Carolina requires all employers of three or more employees to carry workers
compensation insurance. Workers Compensation insurance applies to bodily injury by accident or
bodily injury by disease. Bodily injury includes resulting death. Family Services carries Workers
Compensation insurance through an insurance company authorized to do business in North
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Carolina. All employees are covered under this policy. The annual premium is based upon annual
payroll-and risk rates established by the Insurance Board of North Carolina.
Employees fall under two risk categories - the first category covers all clerical (support) staff and the
second category covers charitable organization (non-clerical) staff.
In conjunction with professional liability coverage, FSDC will provide and assume the
cost of legal assistance to personnel against whom claims are made related to lawful,
authorized actions taken in the course and scope of their employment, unless to do so
would represent a conflict of interest according to legal counsel. The Board of
Directors is provided a report on an annual basis that apprises them of Family Services
insurance coverage. This report highlights the type of coverage, the carrier, and the
amount of coverage. Paid and volunteer staffs are apprised of insurance coverage at
the time of orientation.
Security and Safety Procedures
It is the goal of Family Services to ensure the safety of its paid and volunteer staffs and
clients. The success of this policy depends on the alertness and personal commitment
of all parties as well as staff training. Training can ensure that the staff understands
how to avoid being placed in compromising situations. Family Services is also
committed to providing all staff maximum safety by protecting them from exposure to
blood-borne pathogens.
Family Services provides its staff members with training in the following areas:
-Staff members are oriented to the use of the security and fire systems in the various
facilities. Training includes - location of security and fire devices, use of these
devices, and procedures to follow in the case of fire and other emergencies. Staff is
trained to use the security devices if the need arises.
-Staff members are also trained in procedures to de-escalate conflict and handling
emergencies. Staff members are encouraged to report threats to their supervisors
and local law enforcement agencies if necessary. Any individual that commits an
act of violence or threatening behavior may be subject to criminal penalties.
-The Agency will provide the opportunity for training with regard to personal safety
measures and guidelines for providing services to children and families with
infectious diseases. (Refer to policy on Blood-borne Pathogens for more details.)
Staff members are instructed to take the following precautions relative to bloodborne
pathogens:
-Each program area shall evaluate its routine and reasonably anticipated tasks and
procedures to determine if and where there is actual or potential exposure to human
blood or other potentially infectious materials if the nature of the risk or activity
potentially results in the employee having direct contact with blood or other body
fluids to which universal precautions apply, personal protective equipment and
clothing shall be available and worn.
-Barrier precautions: all staff shall routinely use appropriate precaution to prevent
exposure when contact with blood or other body fluids from any human source is
anticipated. Gloves shall be worn for touching blood and body fluids, mucous
membranes, or the non-intact skin of all employees, volunteers, and clients and for
handling items or surfaces soiled with blood and body fluids.
-Hand washing: hands and other skin surfaces shall be washed thoroughly with soap
24 | P a g e
and water immediately or as soon as feasible if contaminated with blood or other
body fluids following contact. Hands shall be washed immediately after gloves or
other personal protective equipment are removed and upon leaving the work area.
-Protective clothing: Appropriate protective clothing shall be mm Men the employees
have a potential for exposure to blood and other potentially infectious materials.
Type and characteristics will depend upon the materials and upon the task and
degree of exposure anticipated.
-Cleaning: All equipment shall be properly cleaned and disinfected after contact with
blood or other potentially infectious materials.
Family Services has installed fire detection systems at its facilities. When the systems
detect a fire danger, the systems will alert the occupants of the building of potential
danger and will also alert the central station. The central station in turn will notify the
fire department of the danger.
As soon as the system alerts the occupants of the building of the potential danger, all
staff members and clients will leave the building by using the fire escape plan that is
posted in each office. Designated staff members will ascertain that all rooms have
been vacated throughout the facility. No one should re-enter the building unless it has
been authorized as safe to do so.
Family Services has installed security systems at each location These systems serve
several purposes. They serve to protect the facilities from unauthorized entrance into
the building after-hours. If the system detects an unauthorized entrance, it notifies the
central station, which in turn notifies the police department. A police unit is dispatched
to investigate the unauthorized entrance. In order for the system to work at capacity,
everyone must understand what role each person within the organization plays in
protecting the security of the facility to minimize the likelihood of unauthorized entrance
in the buildings. Each staff person is asked to be cognizant of who is in the facility
after-hours and arm the system as needed. The last person to leave the facility is
assigned the responsibility of the arming the security system. On the other hand, the
first person to enter the facility is assigned the responsibility of disarming the system.
Only staff members that are authorized to enter their facility have been provide codes to
arm and disarm the security system. If a staff person has not been assigned a code,
that person is not authorized to enter the building unless accompanied by an authorized
staff person.
The systems also serve a safety purpose. The security systems in place have panic
buttons to use to alert others of impending danger with a client or visitor. The panic
buttons are strategically placed in each office (and carried by the Shelter staff) and are
used to alert others in the building of problems with a client or a visitor. If the panic
button is activated, the receptionist is alerted to the location of the problems and others
are dispatched to assist to de-escalate the disturbance. The panic button also alerts
the central station, which in turns notifies the police department and police unit is
dispatched to investigate. (See Crisis Plan for more information.)
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Use of Family Services Facilities By Others
The Executive Director must evaluate the extent of liability associated with contractual
relationships arising from the use of Family Services facilities by others.
From time to time, Family Service may be asked whether its facilities or portions of their
facilities are available for lease or short-term use for meetings or other similar functions.
In considering whether to allow this, senior management will consider the extent of
liability associated with this type of relationship. The Executive Director and Finance
Officer will review all proposed contracts, including leases and will consider the impact
of those relationships when determining the amount of liability coverage. The Agency
will also consider the potential financial impact of the contractual relationship including
but not limited to the risks related to participation in managed care contracts or
participation in a provider network. These types of transactions will be dealt with as
follows:
Short term use - Family Services will require the party using the facility to enter into an
agreement that: specifies the date and time of the function, number of people expected
at the function, level of compensation (if any), and an indemnification provision whereby the
contractor agrees to pay for specified losses (certificate of insurance from the
contractor or have the contractor add Family Services as an additional insured in their
applicable insurance policy). The agreement will also inform the user of the space that
it is their obligation to maintain the facility, supplies, and equipment in a manner that
reduces hazard to the persons served and/or liability to the organization.
Leases - The Facilities Committee of the Board of Directors must approve
arrangements of this nature. In considering a lease transaction, the committee must
evaluate the extent of liability associated with the contractual relationship of this nature.
The committee must also evaluate the contractor's ability to fulfill the responsibilities of
a lessee. If approved, the Finance Officer will enter into a contractual agreement with
the lessee that sets forth the terms of the lease. The agreement will also inform the
user of the space that it is their obligation to maintain the facility, supplies, and
equipment in a manner that reduces hazard to the persons served and/or liability to the
organization. The lessee must also provide a certificate of insurance whereby the
lessee agrees to pay for specified losses.
Fee For Service Provider
Family Services provides services to its clients using a sliding fee scale to make its
services available to a larger cross section of the general public. Family Services is a
fee-for-service provider. As such, it uses the following methods to be reimbursed for its
services:
-Third part reimbursement
-Direct billing
-Direct billing of sliding fee scale
-Managed care participation
The client's well being and care is Family Services' primary concern. In situations
wherein the client carries insurance, Family Services will:
-Request the client to complete an application form that includes any insurance
information.
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-Based upon information obtained from the above application and client interview,
the staff computes the per session fee either (1) insurance reimbursement and copay
or (2)the sliding fee scale, (3) grant/contract subsidy and informs the client of the fee.
-If services are covered by insurance, Family Services accepts a co-pay from the
client and files periodic claims with the insurance company for the remainder.
-Many times insurance company only cover a limited number of examinations. If this
is the case, Family Services will continue offering services to the clients based upon
assessed need. It is Family Services policy to provide clinical services to clients
regardless of their ability to pay for these services.
Finance
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Policy No.: 2.1
Policy: Financial Accountability
Financial Accountability
POLICY
____________________________________________________________________________
The purpose of this policy is to ensure the Agency is accountable to its Board, the community, its
clients, its creditors, and its funding sources for prudent financial management. Therefore, it makes
available an annual audit report of fiscal, statistical and service data that includes summary
information regarding its financial position.
PROCEDURES
___________________________________________________________________________
A. Public Disclosure
Since Family Services receives money from a number of funding sources, it is committed to public
disclosure about:
1. The way resources have been used to meet the organization’s objectives
and external requirements;
2. The organization’s principal program and their costs;
3. The degree of control exercised by funding sources over the use of
resources; and
4. Helping the user evaluate the organization’s ability to carry out its fiscal
objectives.
Using a number of different reports, the Agency reports its activities to the Board of
Directors, its funding sources, the community, and its clients. These include but are not
limited to:
1. Monthly reports to the Board of Directors that report on the operating results
of the Agency and its programs;
2. Periodic reports to the funding sources. These reports are submitted periodically as dictated
by the funding sources and include information regarding Agency or program operating results
or expenditures and/or client sessions.
3. Expense reimbursement reports to the funding sources;
4. An audit report is submitted to all funding sources.
Financial records, supporting documents, statistical records, and all other records pertinent to
Family Services’ grants and awards shall be retained for a period of three years from the date of
submission of the final expenditure report. These records are to be made available without
restriction, to its independent auditor or any funding source.
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B. Annual Audit
On an annual basis, within 180 days of the end of the fiscal year, the agency will be
audited by an independent certified public accountant that has been selected and
approved by the Agency’s Board of Directors. The audit must be performed in
accordance with generally accepted auditing standards (GAAS) and generally accepted
government auditing standards and must review for, among other things:
1. Compliance with OMB Circular A-133
2. Compliance with terms of conditions of funding provisions
3. Adequacy of Internal Controls
4. The qualifications of management and oversight of the governing board
5. Special items requested by the Board of Directors or the funding sources
For each audit, the auditor and the Agency should establish the scope of services to be
performed and the reports to be issued. The Agency should also ascertain that the
scope of the audit satisfies all relevant contractual, legal, and regulatory requirements.
The scope of the audit is set forth in the engagement letter that is provided to the auditor
prior to the start of the audit fieldwork.
C. Review of the Audit
Shortly after the completion of the fieldwork, but before the issuance of the final draft of
the audit report, the Executive Director and Finance Director will meet with the independent
auditor to review the audit findings, financial statements, and the management letter. If the
independent auditor issues a management letter, the Executive Director and the Financial Director
will inquire into the sources of the deficiencies and formulate corrective action.
As part of the review of the audited financial statements, the Executive Director, Finance and/or
Executive Committee of FSDC Board, and the Finance Director will analyze unit costs based on
audited financial data.
D. Board Approval of the Audit Report and Corrective Action
Within 180 days of the close of the fiscal year, the Treasurer will present the audit report
to the Board of Directors for its approval. The report to the Board should highlight audit
findings, financial statements, and any deficiencies that were noted in the management
letter and disclose and transactions involving governing body members, staff or their
immediate families. If warranted, the Treasure should request the independent auditor’s
attendance at the board meeting to discuss his findings and to respond to any questions
the Board members may have. Review of the audit report and its approval must be
documented in the corporate records.
If a management letter has been issued, the Board will request the Executive Director
and the members of the management team to promptly initiate corrective action as
recommended in the management letter. They will be requested to provide specific
details on how corrective action will be implemented and will also be instructed to
implement corrective action within a specified time frame.
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E. Submission of Audit Report to Funding Sources
Upon acceptance of the audit report by the Board of Directors, the Finance Director will
distribute copies of the audit report to all funding sources that request a copy.
F. Operating Committees
As needed, the Board chair will appoint committees to oversee and review the investment of funds,
management, purchase, or sale of real estate, securities and other assets .On a periodic basis, the
need may arise wherein it will be necessary for the formation of a Board committee to provide
oversight and review the management of the Agency’s assets.
G. Conservation of Financial Resources
The Agency is a tax-exempt organization and the Executive Director and Finance Director are
charged with the responsibility of ascertaining that it takes full advantage of its tax-exempt status.
The agency is exempt from paying federal and state income taxes and franchise taxes and property
taxes.
The Finance Director (or designee such as the Board Treasurer) is charged with the responsibilities
of:
1. Submitting Form 990 to the IRS on a timely basis. This report is filed annually and is due by
March 15th of each year, unless IRS approved extensions have been obtained. This report is
prepared by the independent certified public accountant.
2. Maintaining accurate records to facilitate the filing of Form E585, Claim for Refund of State and
County Sales and Use Tax with the North Carolina Department of Revenue. Family Services pays
sales and use tax to North Carolina, however, on a semi-annual basis, we submit a Form E-585 for
reimbursement of sales and use taxes paid during the preceding semi-annual
period. This report is prepared internally by the Finance Director.
3. File Applications for Property Tax Exemption with Davidson County as needed. Whenever
Family Services purchases an asset that is subject to personal property or real estate property taxes,
the Finance Director is charged with responsibility of submitting a tax exemption application with
Davidson County.
4. Family Services provides documentation to benefactors and prospective
benefactors that it is a tax-exempt charitable organization.
5. Family Services acknowledges all gifts of money and goods to provide a
donation trail for the donor.
6. Many vendors provide special rates or discounts for non-profit organizations.
Family Services attempts to use these special rates and discounts when
possible.
Not withstanding it’s not for profit and tax-exempt status, the Executive Director and all
senior management as well as the Board of Directors is charged with the responsibility
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of operating the Agency in a safe and sound manner, consistent with generally accepted
business practices. In so doing, they are charged with the responsibility of maximizing
revenues and minimizing expenses.
H. Procurement
Family Services will attempt to minimize expenses and maximize cash flow by establishing
procurement procedures that ensure that it purchases quality goods and services at competitive and
fair prices. Staff members, including management staff, are apprised that they should avoid placing
themselves in a situation that creates a conflict of interest or the appearance of a conflict of interest
when they are involved in a procurement situation.
All procurement transactions shall be conducted in a manner to provide, to the maximum extent
practical, open and free competition, with minimizing expenses as the intended goal.
Procurement procedures are divided into three categories. The first category covers supplies,
including office, janitorial and food supplies. The second category covers goods and services with an
initial cost under $4,999.99 and the third category covers goods and services with an initial cost of
$5,000 or more. In all cases, however, certain procedures will be applicable for all categories. These
are:
a. Avoid purchasing unnecessary items.
b. When appropriate, an analysis is made of lease and purchase alternatives to determine which
would be the most economical and practical procurement.
c. Cost or price analysis shall be made and documented in the procurement files in connection
with each procurement purchase.
d. A clear and accurate description of the technical requirements for the material, product or
service to be procured.
e. Positive efforts should be made to use small business, minority-owned businesses and
women’s business enterprises, whenever possible.
f. Consider the provider’s ability to perform successfully under the terms and conditions of the
proposed procurement.
g. Justification for lack of competition when competitive pricing are not obtained.
h. A Purchase Request form must be completed and approved by the appropriate Program
Manager prior to any purchase of goods/materials.
1. Office, Janitorial and Food Supplies:
Office, janitorial, and food supplies are some of Family Services largest expenses. In
order to avoid unnecessary expenditures and time consumption, the following steps
should be taken:
On a regular basis, the Office Manager will research the most cost effective options to
determine the lowest cost options.
2. Equipment, Goods or Services under $4,999.99
Each request for purchase for equipment, goods or services under $4,999.99 should be submitted in
the form of a purchase request to the Program Director and then forward a
copy to the Executive Director. The purchase order should specify a clear and accurate
description of the technical requirements for the equipment, goods or services; function
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to be performed by the equipment, goods or services; and brand name or equivalent
description. The appropriate Program Director should sign the purchase order. Upon receipt
of the purchase request, the Finance Director, or his designee, will determine the most advantageous
provider and get proposals.
Interviewing proposals The Finance Director (or designee) will consider that the lowest bid is not
always the best bid to accept. Other factors to consider include the bidder’s ability to perform,
reasonableness of the bid in relation to the other bids received, and the ability to provide service
after the sale. Before making the offer to purchase with the vendor, the Finance Director will also
consult with the individual that submitted the purchase request to arrive at the consensus regarding
the vendor and the price to be paid for the equipment. After consensus is reached, the Office
Manager will place an order to purchase the equipment and negotiate the form for payment.
3. Equipment, Goods or Services With a Cost in Excess of $5,000 (or an aggregate cost in excess of
$5,000). The same procedures will apply for equipment, goods or services with a cost in excess of
$5,000 as apply to equipment under $4,999.99, except that the Family Services Executive
Director must approve the request for purchase as well the choice of
vendor and price.
I. Payment
Payment for equipment, goods, or services will not be made until they are received. Payment will be
made in accordance with the terms of the purchase agreement so that Family Services can take full
advantage of discounts offered. When billed, the Finance Department will ascertain that Family
Services is paying the agreed upon price.
J. Conflict of Interest
All person’s involved in the purchasing process should avoid placing themselves in situation that
creates a conflict of interest or the appearance of a conflict of interest.
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Policy No.: 2.2
Policy: Alignment of Financing with Mission
Alignment of Financing with Mission
POLICY
__________________________________________________________________________
The purpose of this policy is to secure funding from a broad range of stable and predictable sources
to support the cost of capital and program needs, as well as administrative services. It is the policy of
the Agency to pursue applications for grants and contracts from both public and private funding
sources. All grants for which the agency applies shall be for the purpose of developing programs or
providing services that are philosophically in accord with the agency’s basic mission and purpose.
The Board of Directors is responsible for overseeing overall fund development efforts. These
efforts will include both soliciting and receiving funds from the following sources:
-United Way of Davidson County, Inc.
-Federal, state and local government agencies
-Foundations, private and corporate
-Private individuals
-Corporations
-Groups, both civic and religious
-Program fees
-Fund raising efforts initiated by the agency as well as those initiated by outside sources*
* Specific fundraising efforts will be handled in manner consistent with the administrative policies
on supplemental fundraising activities as issued by the United Way. In addition, agency approved
supplemental fundraising will only be conducted when it can be assured that the effort will promote
a positive, professional image of the agency.
All fundraising activities will comply with the applicable requirements as set forth by the State of
North Carolina.
All fundraising activities will be conducted in an ethical manner, without material omissions,
misstatements of fact or misrepresentations of the use of the requested funds. Funds will be spent
for the purpose for which they were solicited except for reasonable costs of administration of the
fundraising program. The Finance Department will maintain appropriate accounting for restricted
funds.
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PROCEDURES
_________________________________________________________________________
The Executive Director (as well as designated members of FSDC’s Management staff and Board of
Directors) has responsibility for applying for grants and contracts from public and private sources in
accordance with the defined needs of the agency and as determined by the agency budget.
Permission of the Executive Director shall be requested by Program Directors to pursue a
grant/contract application in advance of the proposal deadline of at least two weeks. The
Executive Director shall determine that (1) the grant/contract will meet a defined agency
need according to program and/or agency goals, (2) that the amount requested shall meet
a defined budgetary need for the fiscal year, (3) that the agency can comply with the requirements
and preconditions of the grant/contract source, and (4) that the mission/purpose
of the grant/contract does not conflict with the mission of FSDC.
Program Directors have responsibility for drafting the grant/contract proposal following
approval from the Executive Director to pursue the application. The Finance Director has
the responsibility of reviewing and revising the draft proposal at least one week in
advance of the proposal deadline and ensuring that all the conditions of the grant/proposal
source are met and that the budget has been formulated correctly and in accordance with
agency salary scales, fringe benefit costs and other actual cost of operation. The final
copy of the proposal is prepared with a cover letter for the signature of the Executive
Director and/or Board Chairperson at least 48 hours in advance of the proposal deadline
for review and revision if necessary.
Application for and receipt of all grants and contracts shall be reported to the Board of
Directors by the Executive Director a monthly board meetings. Such information shall be
documented in the minutes.
Donor contributions will be acknowledged in writing by the Executive Director (or designee) as
soon as possible following the receipt of the donation. Upon request from a donor, anonymity
will be protected. The agency will ensure that these donor names are not published or listed in
newsletters, articles, annual reports or other public documents. Donors contributing to major
campaigns will be asked to provide, in writing, permission for their name to appear on donor
recognition material.
Donors will receive financial and/or program information promptly upon request.
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Policy No.: 2.3
Policy: Financial Plan
Financial Plan
POLICY
_______________________________________________________________________
The purpose of this policy is for the Agency to have a financial plan that is updated every
two years that sets financial goals that are in line with meeting the organization’s long term
planning and quality improvement goals.
PROCEDURES
_______________________________________________________________________
The financial plan will be prepared by the Executive Director and Finance Director and appropriate
members of the management staff and/or FSDC Board of Directors. The process will include:
1. An assessment of the Agency’s long-term goals;
2. An assessment of the Agency budget for the coming year;
3. Identification of potential funding sources that may be acquired midway in the coming year or
the following year;
4. Identification of necessary staffing increases to meet increasing program needs.
5. All of the above-mentioned issues will be presented to the Board of Directors at the monthly
Board Meetings in the Executive Director’s report. In the instance this information is no
longer presented this way, a financial plan will be produced for the Board of Directors.
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Policy No.: 2.4
Policy: Funding Sources
Funding Sources
POLICY
______________________________________________________________________
The purpose of this policy is to maintain current information about its funders’ payment
and reimbursement procedures and other payment and revenue sources for each of its services.
PROCEDURES
______________________________________________________________________
1. Contracts between the Agency and its funding sources are reviewed by the Executive Director
and Finance Officer so that the reimbursement of funds is requested in accordance with the
contracts.
2. After the close of the month, or other period specified by the funding source, the Finance Officer
prints a trial balance report from the general ledger and pulls from this report the expenses incurred
for a specific funding source.
3. This information is entered into a spreadsheet, called the grant ledger, created and maintained by
the Finance Officer which outlines which expenses are covered under each funding source.
4. The required documentation is then submitted within the time frame specified in
the contracts.
5. Copies of the grant ledgers are given to each program director by the second of the
bi-monthly management meetings and presented by the Finance Officer. Items discussed include
balances remaining in each funding source, comparison of expenses between the current and prior
month, and if the year-to-date percentage of the funds is in proximity to the point in time of the
grant period.
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Policy No.: 2.5
Policy: Budget Preparation and Approval
Budget Preparation and Approval
POLICY
________________________________________________________________________
The purpose of this policy is to fill the requirement of preparation of a written budget for
the calendar year to be approved by the FSDC Board of Directors.
The purpose of the budget is:
-To guide the financial affairs of the agency to a desired goal,
-To provide information necessary to match the anticipated cost of the
agency’s services with the resulting revenues; and
-To provide the necessary tool for fiscal control and administrative
guidance.
PROCEDURES
________________________________________________________________________
The annual budget will be prepared by the Executive Director and Finance Director with input from
the Program Directors and the Executive Committee and/or Finance Committee of the FSDC
Board, if necessary. The budget process will include:
1. an assessment of the agency’s annual budget in relation to the long-term and short-term
planning processes;
2. an assessment of the organization’s services;
3. the fixed and variable costs of operating each program of the agency;
4. contractual requirements;
5. identification of potentially changing costs and conditions; and
6. funding anticipated during the year by program. The proposed budget will be reviewed by the
Board of Directors each September prior to the beginning of the budget period.
The Board of Directors of FSDC shall review and approve all planned deviations from
and revisions to the budget prior to implementation as well as review and compare
budgeted numbers to actual numbers after year end numbers are finalized. Such review
and approval shall be documented in the minutes.
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Policy No.: 2.6
Policy: Reconciliation of Bank Accounts
POLICY
____________________________________________________________________________
The purpose of this policy is to ensure that all bank accounts reconcile to the general ledger on a
monthly basis.
PROCEDURES
_____________________________________________________________________________
1. The Finance Director will retain the bank statement and record any interest income and
investment income. Any other reconciling items will be recorded via the Bank Transaction entry
feature of journal entry.
2. Each account will be reconciled by the Finance Director via the accounting software.
3. The Executive Director and Board Treasurer and/or Finance Committee will review each
reconciliation and initial documentation.
4. After the account is reconciled copies of each bank reconciliation will be maintained in the office
of the Finance Director.
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Policy No.: 2.7
Policy: Reconciliation of Balance Sheet
Reconciliation of Balance Sheet
POLICY
__________________________________________________________________________
The purpose of this policy is to ensure the Finance Department provided a mechanism to
reconcile all balance sheet accounts on a monthly basis to ensure accurate financial statements and
to analyze financial performance between months and years. This will provide a framework of
essential information that will assist management with directing the operations of the Agency.
Accounting records are kept up-to-date as demonstrated by:
-Reconciliation of the bank statement to the general ledger;
-Reconciliation of subsidiary records to the general ledger;
-Monthly updating of the general ledger.
PROCEDURES
_________________________________________________________________________
The Finance Director will reconcile monthly all balance sheet accounts as follows:
1. Cash in bank will be reconciled to the monthly bank statements to ensure all checks, deposits,
bank drafts and service charges are applied appropriately. Cash restricted by donor will be presented
separately on the financial statements.
2. All receivables from grantors will tie to the various reimbursement requests.
3. Any receivables for services will tie to the client accounts receivable maintained
by the Administrative Assistant.
4. Sales tax receivable will equal the amount that would be available for recoupment
for sales and use taxes paid.
5. Reconciliation of Prepaid Expense Schedules is practiced to serve as a control measure to
apportion expenses to the current period. The reconciliation of prepaid expenses will also match
revenues and expenses and allow for adjustment of the asset account for the unexpired amounts.
The reconciliations will include prepaid insurance, rent and dues.
6. Land will total the agency’s investment in real estate.
7. Buildings will total the cost of construction/purchase price of buildings owned by the agency.
8. Leasehold Improvements will total the amount the Agency has paid for any improvements that
will not be movable from location to location, i.e., walls, wiring of computers or phone.
9. Equipment, Furniture and Fixtures will total the amount of all equipment office furniture and
fixtures that the Agency has purchased that exceeds $400.00.
10. Accounts Payable will equal the amount of unpaid invoices for services rendered or items
received in the current month. A clean cut off will be performed monthly in a timely fashion as to
meet financial statement deadlines.
11. Federal Withholding will equal the amount of federal income tax withheld from employee’s
payroll but not yet deposited at the end of the month.
12. FICA Withholding will equal the amount of FICA tax withheld from employee’s payroll but not
yet deposited at the end of the month.
13. Medicare Withholding will equal the amount of Medicare tax withheld from employee’s payroll
39 | P a g e
but not yet deposited at the end of the month.
14. North Carolina Withholding will equal the amount of North Carolina income tax withheld from
employee’s payroll but not yet remitted at the end of the month.
15. United Way Withholding is the total of all voluntary payroll deductions for contributions to
United Way not yet remitted.
16. Employee Pension Withholding is the total of all voluntary payroll deductions for contributions
to the Agency’s 403 (b) plan not yet remitted to ING.
17. Insurance Withholding is the payroll deduction for amounts of premiums for elective insurance
coverage for spouse, child (ren) and/or family.
18. Section 125 Plan Withholding is the total of all voluntary payroll deductions for
voluntary payroll deductions to the Section 125 plan.
19. Accrued Wages will tie into the gross amount of the next payroll divided by 15
and multiplied by the number of day remaining in the month of the financial statements.
20. Accrued Pension is the monthly accrual of the employer’s match for eligible employees
participating in the 403 (b) plan. A schedule is prepared by the Financial Director each month.
21. Accrued Payroll Taxes will equal the employer’s portion of FICA and Medicare
taxes not deposited at the end of the month.
22. Accrued Other Expenses is the accrual for each employee’s unused vacation hours
at the end of the month multiplied by their hourly rate. Vacation hours are tracked by the Finance
Director.
23. Once all accounts are reconciled, the appropriate journal entries will be prepared and posted by
the Finance Director.
24. The financial statements will be prepared monthly using the accrual basis of accounting.
25. An Analysis of Revenues and Expenses will be prepared by the Finance Director and
fluctuations will be addressed in narrative and numeric form.
26. Financial statements will be reviewed with the Executive Director prior to the monthly,
Executive Committee meeting.
29. Financial statements will be presented at the monthly Board of Directors meeting by the Board
Treasurer.
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Policy No.: 2.8
Policy: GAAP/Audit Requirement
GAAP/Audit Requirement
POLICY
___________________________________________________________________________
The purpose of this policy is to ensure an audit is performed by an independent certified public
accountant on an annual basis and have annual financial statements prepared in accordance with
Generally Accepted Accounting Principles.
PROCEDURES
____________________________________________________________________________
1. The annual audit will conform to the North Carolina guidelines as established in G.S. 143-6.1.
2. The auditor’s report and accompanying financial statements along with any audit findings and
management letter will be presented to the Finance Director and the Executive Director.
3. The Executive Committee will review the information prior to submission to the full Board.
4. Any management letter comments will be reviewed by management, and management will address
the recommendations of the management letter.
5. Copies of the audit report will be distributed as appropriate to the various funding sources.
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Policy No.: 2.9
Policy: Accounting Policies and Separation of Duties
Accounting Policies and Separation of Duties
POLICY
_____________________________________________________________________________
The purpose of this policy is to insure the agency follow and review standardized accounting
policies, procedures and controls. The Agency acts in accordance with an internal accounting
control system that addresses:
-Prevention of error, mismanagement, or fraud;
-An inclusive and descriptive chart of accounts;
-Prompt and accurate recording of revenues and expenses
-Prompt payment of expenditures
-Information on all funds, including each fund’s source and pertinent regulations governing
each fund;
-Safeguarding and verifying assets;
-Separation of Duties to the extent possible;
-Disbursement and receipt of monies; and
-Up-to-date posting of cash receipts and disbursements.
PROCEDURES
______________________________________________________________________________
A. The Finance Officer will maintain the Chart of Accounts. The format for each general ledger
account number is XXXX-XXXX-XX:
a. XXXX represents the revenue/expense account description, such as salaries;
b. XXXX represents the Cost Center, specifically the grant/funding source;
c. XX represents the location, i.e., agency office or location.
B. FSDC will promptly process and deposit any cash or checks received as payment for services
rendered, grant/contract payments, donations or any other support and revenue:
a. Payments received at the front desk will be processed by the Administrative Staff. If payment is
made by check, the back of the check will be stamped with the restrictive endorsement “For
Deposit Only” stamp. A receipt is generated by
Therapist Helper and given to the client.
b. A copy of the check will be retained as supporting documentation for the deposit.
c. Payments received via U.S. mail will be opened by the Office Manager. Each check will be
stamped with the restrictive endorsement “For Deposit Only” stamp for the appropriate depository
account.
d. If the check received via mail is for services rendered, a copy of the check will be made to attach
to the deposit. The amount will then be deducted from the Accounts Receivable subsidiary ledger
maintained by the Billing Specialist.
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e. If the check is a payment from an insurance company, an “Explanation of Benefits” form should
be attached. A copy of the “Explanation of Benefits” form will be placed in the client’s financial file
while a second copy is retained as support for the deposit.
f. If the check is a reimbursement from a grantor, the stub and any other supporting documentation
will be retained as support for the deposit. The amount received will be retained as support for the
deposit. The amount received will then be deducted from the Accounts Receivable subsidiary ledger
for grant funds maintained by the Finance Officer.
g. In the case of donations, two copies of the check will be made. One copy will be attached to the
deposit as support for the deposit. The second copy will serve as the source document for the entry
into Donation Tracking software by the Executive Director (or designee). The Executive Director
will then generate acknowledgements to the donors.
h. A deposit ticket is prepared for all cash and checks received for the appropriate depository
amount(s). Deposit tickets are prepared by the Billing Specialist or the Finance Director.
i. The deposit will be taken to the bank by the Office Manager or the Finance Director.
j. The validated deposit ticket along with the supporting documentation will be routed to the
Finance Officer for posting to the general ledger.
k. Deposits will be daily, or secured in fire proof cabinet until the next business day
C. FSDC will remain current on the terms of accounts payable to maintain an excellent credit
standing and the take advantage of purchase discounts where feasible.
a. Invoices are routed to the Finance Officer to be matched up with the purchase requests and
packing slips as appropriate.
b. Each invoice is assigned a general ledger expenditure account number by the Finance Director
who then assigns an invoice number (if not already on the purchase request) and enters the invoice
into the general ledger system.
c. A voucher number is assigned to each invoice to provide an audit trail.
d. After entry, the Finance Officer will add up all invoices entered and compare the amount to the
batch total per the general ledger system.
e. Once the batch total is in agreement with the actual invoices, the batch will be posted.
g. Checks will be printed for the approved amounts.
h. Checks may be signed by either the Executive Director, Finance Officer or Board approved
designee
i. Checks are prepared for mailing by the Finance Director.
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Policy No.: 2.10
Policy: Purchase Requests and Cash Disbursements
Purchase Requests and Cash Disbursements
POLICY
___________________________________________________________________________
The purpose of this policy is to ensure FSDC conserves its fiscal resources by:
-Maintaining sound policies regarding purchasing and inventory control;
-Coordinating the purchase of goods or services among internal programs;
and
-Using competitive bidding, when applicable, according to governing body
policy and law.
This policy allows for proper control over requests for cash disbursements in order to
maximize purchasing power and cash flow as well as adhere to purchasing requirements
of funding sources and budgetary limits. Therefore, it is also the policy of FSDC to
require (3) quotes for items expected to exceed $750 and retain proper documentation of
such.
PURPOSE
____________________________________________________________________________
The purpose of the purchase request system is:
-To ensure that items requested are necessary and appropriately authorized
as well as in compliance with funding source guidelines;
-To obtain items of an acceptable quality at the best price in an attempt to
maximize the purchasing power of the Agency; and
-To provide adequate fiscal and accounting controls over all purchases for
the Agency.
PROCEDURES
____________________________________________________________________________
1. A purchase request form will be completed by the staff member requesting any item or service.
This form will include a complete description of the item/service requested, desired quantity, and
reason for the request. Any attachments to provide additional information should be included with
the purchase request.
2. The purchase request is then submitted to the staff member’s immediate supervisor who will
review the request.
3. The supervisor will determine if there are funds available for the request based upon the program
that is requesting funds. This information can be obtained from the monthly grant ledgers prepared
by the Finance Director. If the supervisor is uncertain as to the current level of available funds,
he/she should contact the Finance Director for additional information.
4. For purchases of routine office supplies, workshops, items, services we have a contract, utilities,
and similar expenditures, three (3) bids are not required for each purchase.
5. Once the purchase request is approved by the supervisor, and bids documented and attached, it is
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routed to the Executive Director for approval. In the absence of the Executive Director, the
Finance Director may approve purchase requests.
6. Orders will be placed by the Office Manager and the purchase request will be retained by the
Finance Director to be matched up with the packing slip/invoice as appropriate.
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Policy No.: 2.11
Policy: Sales Tax Recoupment
Sales Tax Recoupment
POLICY
______________________________________________________________________
The purpose of this policy is to ensure FSDC takes advantage of its tax-exempt status; it is the
policy of FSDC to provide a mechanism to recoup all sales tax paid directly by the agency. A semiannual Claim for Refund of State and County Sales and Use Tax Report is completed in order to
recoup all sales tax paid.
PROCEDURES
1. The Finance Director will maintain appropriate records of all stales tax paid.
2. The Finance Director will prepare the Claim for Refund of State and County Sales
and Use Tax semi-annually in accordance with the state rules for recoupment of
moneys paid for sales and sue taxes on behalf of the agency.
3. The reports are due to the North Carolina Department of Revenue by the 15th of the fourth
month for the previous six months. Due dates are April 15th and October 15th respectively.
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Policy No.: 2.12
Policy: Payroll
Payroll
POLICY
________________________________________________________________________
The purpose of this policy is to insure FSDC’s payroll practices to be in compliance with
Federal and State wage and hour laws and to conduct its payroll practices in such a
manner that:
-Payroll expenditures are reviewed and approved;
-Changes in time and overtime records are documented;
-Payment for new hires and severance for terminated employees are
authorized;
-Mandatory deductions and rates of pay are overseen; and
-Payroll funds are kept separate from other funds.
PROCEDURES
________________________________________________________________________
1. Accurate time sheets are to be completed by all Agency staff and submitted to
their supervisor at the end of each semi-monthly pay period. The supervisor will
review and sign the timesheets.
2. Timesheets are due to the Finance Director by 9:00am 2 days before the pay date.
Late timesheets may not be included in the upcoming payroll. It is the responsibility of
staff to make certain their timesheet is turned in on time. It is also the supervisor’s
responsibility to make arrangements for another supervisor to review and approve their
staff’s timesheets in the event of their absence.
1. Once approved, Timesheets are forwarded to the Human Resources Manager for review and
processing
2. FSDC has contracted with FlexPay to process employee payroll
3. The HR Manager prepares the payroll spreadsheet and submits the report to the assigned
Payroll Specialist at FlexPay
4. The Payroll Specialist uploads this information to the FlexPay system and generates a
“preview report” that is sent to the HR Manager for review.
5. The HR Manager reviews for accuracy and either requests changes, or approves
6. Once approved, the Payroll Specialist electronically sends all payroll reports to the HR
Manager, Finance Officer and Board Treasurer for review
7. Within 24 hours funds (based on amount indicated in payroll reports) are transferred by
either the Finance Officer or Board Chair to the FSDC payroll account
8. Employee pay is received via direct deposit the following morning
Additional Items:
1. All staff have the ability to the FlexPay “Pay Entry” system in order to review their personal
account information
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2. Any changes in employee payroll information (new hires, terminations, salary increases,
garnishments, etc.) are documented in the personnel file, and forwarded to FlexPay for setup and/or processing
Reporting/Additional Responsibilities:
1. FlexPay is also responsible for ensuring that all payroll tax deposits are computed
accurately and timely deposited to avoid any interest or penalties.
2. Flex-Pay is also responsible for producing yearly federal forms (W-2s) to ensure annual
reconciliation of gross pay, FICA withheld and employer FICA
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Policy No.: 2.13
Policy: Quarterly Reports
Quarterly Reports
POLICY
_____________________________________________________________________________
It is the policy of the Agency to make timely payments to, or provide proof of exemption from,
the following taxing authorities:
The Internal Revenue Service;
State and local employment tax bodies;
FICA; and
Property tax assessors
PROCEDURES
______________________________________________________________________________
_
Quarterly reports required include: 941 Quarterly Federal Tax Return, State Quarterly Income
Tax Withholding Return and Employment Security Commission SUTA Report.
All reports will be prepared by the Finance Director and forwarded to the Executive Director for
review.
Once the reports have been approved, a signed copy will be retained to verify the information
submitted.
All reports will be filed by the 30th of the month following the end of the quarter.
The Finance Officer will prepare an Excel spreadsheet to allocate SUTA among cost centers.
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Policy No.: 2.14
Policy: Inventory
Inventory
POLICY
________________________________________________________________________
The purpose of this policy is to insure FSDC conducts an inventory of significant assets,
including securities, and compare them with permanent records on an annual basis.
PROCEDURES
________________________________________________________________________
1. A detail fixed asset listing from the independent auditor will be obtained as of the
end of the fiscal year.
2. The assets listed will be accounted for and any additions and deletions noted.
3. Depreciation on these fixed assets will be posted to the general ledger and
reported in the monthly financial statements by the Finance Director.
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Policy No.: 2.15
Policy: Service Revenues and Unit Costs
Service Revenues and Unit Costs
POLICY
__________________________________________________________________________
The purpose of this policy is to insure the Agency annually analyze information on
service revenues and actual service delivery costs and unit costs on a per case and/or per
unit of service basis for each of its services to:
-Analyze operational effectiveness and efficiency;
-Monitor trends and current experiences and changes in costs;
-Contract, bill and charge fees for its services; and
-Budget for current fiscal cycle.
PROCEDURES
__________________________________________________________________________
1. The Finance Officer will enter the necessary information into the Cost Finding Spreadsheet. The
purpose of this spreadsheet is to capture the cost for each individual service provided based on the
amount of time, or Full Time Equivalent (FTE), that each person spends in the service.
2. The information entered includes: personnel and non personnel expenses; the time spent in each
service by individual; units of service expected to be provided using days of year open, hours per day
and number of FTE’s; units of service actually provided.
3. The spreadsheet will calculate the cost per unit of expected units to actual units based on hours of
service. The Finance Officer will review the difference between expected and actual costs with the
Executive Director and Program Director.
4. Each month the Finance Officer will review the grant ledger spreadsheets with the management
team to identify unusual expenses within each service and the amount of funding remaining in the
funding source for the fiscal year.
5. Each month the Finance Officer prepares and reviews with the Executive Director the Income
Statement Analysis (this is prepared with the other monthly Financial Statements) which identifies
fluctuations among revenues and expenses from month-to-month and year-to-year.
6. The information provided by this procedure is used in creating the Agency budget for the
following year.
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Policy No.: 2.16
Policy: Denial of Payment
POLICY
_________________________________________________________________________
The purpose of this policy is to determine the basis for any denial of coverage or payment under
insurance or contractual arrangements and follows up with timely appeals and communication with
the person served.
PROCEDURES
_________________________________________________________________________
1. When an insurance company sends the Agency an EOB (Explanation of Benefits) that gives the
reason for denial of coverage of a client, the Billing Specialist will review the client’s insurance
benefits and contact the insurance company
2. If denial is confirmed, the Agency will contact and bill the client for payment, if appropriate.
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Policy No.: 2.17
Policy: Finance Director
POLICY
_______________________________________________________________________
The purpose of this police is to ensure the Agency oversight and management of the
organization’s accounting system. The Agency requires that:
-A fiscal officer or business manager who is responsible for maintaining the financial accounts has
prior accounting and bookkeeping experience, and an accounting degree, business management
degree with concentration in accounting, M.B.A. degree or C.P.A. credential, as appropriate to the
size and complexity of the organization;
-All personnel who use the system are oriented to the accounting system and are retrained regarding
any changes; and
-Internal control systems are managed or reviewed by more than one person.
PROCEDURES
________________________________________________________________________
1. An applicant is interviewed by the Executive Director.
2. If qualifications as Finance Director are present in the applicant, a second interview is set up by
the Executive Director. Those present at the second interview will be the program directors, not the
Executive Director, and either the Auditor who performs the Agency’s annual audits or the Board
Treasurer, both of which are CPAs.
3. Once an applicant is chosen as the Finance Director, he/she will be trained on the policies and
procedures of the Agency and the Agency’s finances.
4. All reports, checks grant reimbursement requests, and State and Federal remittances prepared by
the Finance Director are reviewed by the Executive Director before processing or remitting.
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Human Resources
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Policy No.: 3.1
Policy: Affirmative Action
POLICY
_______________________________________________________________
The Affirmative Action Plan Policy will be a continuing and essential component of Family Services.
The Agency will provide written Affirmative Action Programs (AAP) where required for protected
groups in accordance with requirements and guidelines provided by the U.S. Office of Federal
Contract Compliance Programs (OFCCP).
The AAP will assess the participation rates for protected groups at all job levels and establish goals
where there is under representation.
PROCEDURES
_______________________________________________________________
This policy will be clearly communicated as part of the orientation process of all new employees and
in management meetings. All sources of recruitment will be informed of this policy. The AAP will
be updated annually and available for all employees of the Agency.
Supervisors are responsible for maintaining a discrimination-free work environment.
Management should be familiar with, and implement, all Affirmative Action policies and programs,
including any departmental Affirmative Action goals directed toward correcting imbalances in the
workforce mix. Management will assure that employee performance standards be evaluated on a
uniform basis, whether or not an employee is a member of a protected group; and supervisors will
base decisions upon the basic principles outlined in this policy.
All Family, Services employees share with the Agency the responsibility for mutual understanding,
support, and a spirit of cooperation along all relevant matters of diversity
REPORTING
_______________________________________________________________
Any question/issue regarding unlawful discrimination practices should be brought to the attention
of Human Resources, the Executive Director, or any member of the FSDC Management Team as
soon as possible. It is requested that concerns be submitted in writing. Depending upon the nature
of the issue, a member of FSDC’s leadership staff and/or Board will respond within in (5) business
days.
Any complaint generating from an external source (EEOC, etc.) will be reviewed with the Executive
Committee of the FSDC Board and appropriate outside council.
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Policy No.: 3.2
Policy: Diversity and Equal Employment
Approved by: Board of Directors v and Equal Employment
POLICY
It is the intent of Family Services, through its Equal Employment Opportunity Policy, to take
positive measures to ensure that each employee or applicant, regardless of race, color, religion, sex,
national origin, sexual orientation, age or handicap be accorded equal consideration and opportunity
with respect to all terms, conditions, and privileges of employment, including recruitment, selection,
placement and development.
Family Services wants our Agency to be a place that is a positive work environment for all of our
employees. The Agency strives for an environment characterized by respect for the individual where
cultural, ethnic, and lifestyle diversity is blended by teamwork into a harmonious workforce. Family
Services is committed to valuing differences in our workforce because the Agency believes that
diversity enriches and enhances our professional work environment.
This policy is intended to ensure the rights and dignity of each employee.
PROCEDURES
____________________________________________________________________________
Every employee has an opportunity for advancement based upon individual initiative, ability, and
performance. Family Services follows the spirit and letter of all applicable laws and does not
discriminate on the basis of race, color, religion, sex, national origin, sexual orientation, age, or
handicap.
Recruitment selection, transfers, promotions, compensation, education, training, recreation, and
social programs shall be administered within the objectives of this policy of nondiscrimination.
Reporting and Compliance:
All applicant and employee records will be maintained by the HR/Office Manager and will include:
applicant flow by race and gender (if available) and reason for non-selection applicants interviewed
and reason for non-employment; all new employees by job classifications, race, and gender; and
Promotion, resignation, dismissal or job elimination within the Agency by job classification, race and
gender.
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Policy No.: 3.3
Policy: Vacant Positions
Approved by: Board of Directors Positions
POLICY
___________________________________________________________________________
Refer to the Recruitment Policy within the Family Services, of Davidson County, Inc.
PROCEDURES
___________________________________________________________________________
Before the hiring supervisor or Program Director can recruit a candidate to fill either a new or
replacement position, approval must be obtained from the Executive Director. The Program
Director and Executive Director will review position responsibilities, qualifications, agency and/or
community need, and budgetary considerations. Once the position has been approved, the HR
Manager will be notified in order to begin the recruitment process.
Posting/Advertising a Vacant Position -- An announcement of applications being accepted is made
known by sending the notice to all sites for posting in a place where it can be seen by staff and
visitors. The notice should contain the vacant position, site (if applicable), contact person, posting
date, application deadline, brief description of duties/qualifications required and/or preferred.
Additional external recruitment sources may include ESC listings, local newspapers; college
placement offices, professional organizations, or job boards.
All Applications/Resumes Received: All applications received directly by a supervisor, should be
forwarded to the Personnel Office. The HR/Office Manager will ensure that candidate information
is maintained and that appropriate notifications have been sent, if applicable. Supervisors conducting
interviews are responsible for seeing that references are checked and specific documentation is
included with the applicant's materials.
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Policy No.: 3.4
Policy: Recruitment & Selection
Approved by: Board of Directors Recruitment & Selection
POLICY
____________________________________________________________________________
It is the policy of Family Services to be an equal opportunity employer and to hire individuals solely
upon the basis of their qualifications for the jobs for which they have applied. In pursuing this goal,
the agency will consider all qualified applicants regardless of their race, color, religion, sex, national
origin, age, or handicap.
Note: The conditions outlined in this policy apply to applicants for regular full-time, part-time,
contracting or temporary positions who are not currently employed by the Agency in another position. This policy will
be administered in accordance with State and Federal law.
PROCEDURES
____________________________________________________________________________
Requisition for Employment
Before a hiring supervisor or Program Director can recruit a candidate to fill a new and/or
replacement position, approval must be obtained from the Executive Director. The Program
Director and Executive Director will review position responsibilities, qualifications, agency and/or
community need, and budgetary considerations.
Once the position has been approved, the HR/Office Manager will be notified in order to begin the
recruitment process. The HR/Office Manager will work with the Program Director and/or
Executive Director to clarify position information and discuss recruitment options (e.g., contacting
agencies, placing ads, college recruiting). The HR/Office Manager, along with the Executive
Director, will ensure that the recruitment/selection process conforms to established Agency policy
and government regulations.
Under no circumstances will recruiting (e.g., contacting agencies, placing ads) be allowed by any
department without notification to the Personnel Office.
The Personnel Office should be immediately notified by the originating department if a requisition is
cancelled. All employment requisitions will have a close date for acceptance of applications. No
applications for a position may be accepted after the close date without the approval of the
requisitioning supervisor.
Promotion From Within
When a position becomes vacant within the Agency, all eligible employees are encouraged to apply
for the position through an internal posting. Prior to announcing the position outside the agency
and accepting applications, current employees interested in and eligible for the position will be
considered for promotion.
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Qualifications
Employment will be afforded to the applicant possessing the best qualifications for the job
requirements and within the scope of the EEO and Affirmative Action Policies. All applicants (both
internal and external) and applications on file will be evaluated for a vacant position, taking into
consideration, among other things, background, education, prior work experience, and any special
skills or qualifications. When all factors are equal, preference shall be given to current employees for
vacant positions. Any educational attainments, professional memberships or other professional
qualifications required for a position or claimed by an applicant will be verified at the discretion of
the Executive Director or his/her delegate.
Advertising Job Vacancies
Advertising and agency contacts will be considered and action taken to obtain resumes or
applications in the most effective manner. All advertisements for the Agency will contain the
statement "An Equal Opportunity Employer.” Advertisements for job vacancies must be kept on
file for a minimum of one year. Notification of a vacant position may be sent to service agencies, the
Employment Security Commission, newspapers, job boards, and/or other agencies who may
recommend applicants. Additional efforts may be taken to ensure that target area residents are
informed about vacant positions.
Applications
Applications for employment are accepted only when there is a position vacant and an effort to fill it
has been approved. When a vacancy exists, it will be announced and efforts to obtain qualified
applicants will be made in accordance with the Agency's Affirmative Action Plans and goals.
Interviewing
FSDC’s interviewing practice typically includes at least a 3-step process:
1. A candidate completes an initial phone screen with the hiring manager and/or designee
2. Candidate completes an on-site interview with the hiring manager
3. Candidate completes a group interview which includes a cross-section of staff members
from all units, including at least one management team member
4. Candidates may also meet individually with the Executive Director
Candidates are provided with a copy of the job posting/job description. FSDC uses a standard
behavior-based interviewing strategy. All questions are consistent and compliant with Title VII
guidelines.
References
Unrelated personal and/or work references will be required of persons interested in employment
with Family Services. Formal offers for employment will be extended only after three completed
reference forms have been attempted/completed and received. Written or verbal permission of the
applicant must be received before contact is made with a reference. Former employees must give
written permission before Family Service's will respond to reference requests.
Citizenship
The Immigration Reform and Control Act of 1986 requires that all employees hired after
November, 1986 verify their eligibility for employment in the United States by completing the Form
1-9: Employment Eligibility Verification. This document will be kept in the Personnel Office.
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Educational/Experience Requirements
Educational/experience requirements must be met for employment or advancement in professional
and paraprofessional capacities. Testing may be conducted for positions that require the use of
business machines or special skills.
Disclosure of Criminal Record
In all cases of application for employment by a person with a criminal record, the Executive
Director shall decide the fitness of each applicant on his/her individual merits. The following points
will be taken into account:
 Nature and seriousness of the offense
 Circumstances under which it occurred/length of time since occurrence
 Was the offense isolated or a repeated violation
 Age of the person when he/she committed the offense
 Social conditions which may have contributed to the offense
 Any evidence of rehabilitation
 Occurrence as relates to position
If it is determined that a recent conviction of a serious crime does not disqualify an applicant for
employment, the Executive Director will provide a written statement supporting the decision to be
entered into the applicant's personnel folder. A copy of this statement will be given to the proper
officials.
Bonding
If the position for which an applicant is selected requires the applicant to be bonded, the
eligibility for such bonding shall be a pre-condition for employment.
Reference Verification
All employment is subject to the receipt of acceptable references. Written or verbal permission of
the applicant must be received before contact is made with a reference. Former employees must give
written permission before the Agency will respond to reference requests. The following sources of
pre-employment references may be used:
1) Previous Employers
2) Personal Character References
Selection
A review and analysis of the application form, reference check, and the interview itself shall provide
sufficient information to assess and possibly predict how an applicant will fit into job, scope and
mission of the Agency. Selection will be based on this final evaluation of applicants, selecting, in
accordance with affirmative action, the best-qualified applicant.
Offer of Employment
A written offer of employment will be sent to the successful applicant setting forth the effective date
of the probationary appointment, compensation and any special conditions appropriate to the offer.
Drug Screening
Once an offer of employment has been extended, employment will be contingent upon successful
completion of a drug screening/test. The HR/Office Manager will be responsible for contacting the
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applicant and scheduling the drug test, which should be completed within
job offer.
24-72 hours of the
Background Checks
Offers of employment are also contingent upon successful completion of a background
check. All perspective employees of FSDC are required to complete a release form
authorizing FSDC to conduct a statewide and/or national criminal record check. Additionally, other
background checks (such as MVR, education, credentials) may be completed as appropriate. While a
negative report will not automatically withdraw a conditional offer, FSDC reserves the right to make
such decision as in the best interests of the agency.
On-Boarding Process
As part of the offer process, employees will be asked to sign an official letter of acceptance and
current job description. On the first day of employment, all new hires will meet with the HR/Office
Manager to complete/sign necessary forms and policies –including but not limited to I-9 forms,
benefits (if applicable), tax and direct deposit information, emergency contact information, at will
employment statement, and various policies including confidentiality, code of ethics and client
rights. Each new employee will complete an orientation process that includes training on how to
access FSDC’s policies and employee manual on-line. Once orientation is completed, a signed
orientation form is forwarded to the office manager and will be placed in the new employee’s file.
Orientation
Orientation begins at the time of the interview of job applicants. Once an employee has accepted an
offer of employment, the starting date is established. Complete orientation
requires a minimum of 16-20 hours: general agency orientation of approximately 8 hours and job
specific orientation of approximately 8-12 hours depending on nature of job requirements. See
attached orientation checklists; checklists must be completed and returned to the Human Resources
Manager within two weeks of the start date.
Official written offers of employment can only be made by the Executive Director (or
designee) and will only occur after the application requirements are in hand, including
resume, references and successful completion of pre-employment background check and drug
screen.
In the absence of a written contract, all employment relations between the Agency and
its employees shall be “at will” terminable at any time for any reason or no reason by either party with or without
advance notice. In no event shall the hiring of an employee be considered a contractual relationship between the employee
and the Agency for a definite period of time.
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Policy No.: 3.5
Policy: Employee Retention
Approved by: Board of Directors Employee Retention
POLICY
____________________________________________________________________________
At Family Services, people are our greatest resource. Therefore, we strive to not only recruit, but
also retain quality staff members and keep employee turnover to a minimum.
PROCEDURES
____________________________________________________________________________
The following components are part of FSDC’s retention practices. Pay adjustments will be based
on:
-performance; self and supervisor
-the number of years in employment with FSDC
-cost-of-living
Benefits:
Agency benefits are reviewed on an annual basis to ensure that FSDC continues to offer competitive
benefit options. Programs such as medical, dental, life and disability are provided as appropriate
(with board approval)
Performance Reviews and Feedback:
FSDC employees meet with their program manager and/or supervisor on a regular basis to discuss
issues such as performance, productivity and program needs/changes. Additionally, all FSDC
employees participate in an annual performance review process.
This written review includes goals, accomplishments and areas of improvement. Please see the
Annual Performance Appraisal policy for additional information
Job Descriptions:
Updated job descriptions are maintained for each active position at FSDC. Employees are given
copies of their individual job description upon hire. Job descriptions shall outline responsibilities as
well as location of services i.e. shelter, in-home services. All agency job descriptions are maintained
on-line and are accessible to all employees. Job descriptions are updated and revised as needed. A
copy of each employee’s job description is maintained in the personnel record.
Work Environment:
FSDC strives to maintain a physical work environment that is comfortable and safe. All employee’s
share this responsibility, although the office manager and/or Executive Director are responsible for
repairs, maintenance, contracts, etc. FSDC also promotes a positive work environment through its
“no tolerance” policies and practices regarding discrimination and harassment. Additionally, the
agency provides a written grievance policy which outlines an “open door” approach to dealing with
employee concerns and issues.
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Schedules/Workload:
Full-time employees of FSDC typically work a 37.5 hour work week. This provides flexible
scheduling options for most positions (*dependent upon agency need). All flexible schedules must
be approved by the Program Director and Executive Director and may be subject to change or
revision if agency need/demand dictates.
Supervisors and Program Directors work closely with employees to review productivity and
workload issues. FSDC maintains a policy on Workload Evaluation and Assignment.
Employee Satisfaction and Appreciation:
FSDC actively seeks ways to better understand employee needs and solicits feedback. The CQI
committee distributes an annual Employee Satisfaction survey and responses are submitted
anonymously. This survey is instrumental in helping the CQI committee determine employee and
agency needs/goals. A task force or committee may be formed if needed.
FSDC’s “Care Committee” was formed as a result of the above survey process. This committee
continues to serve as an active part of FSDC’s retention plan and sponsors or coordinates events
such as the staff appreciation luncheon and agency retreat.
Turnover/Demographic Statistics:
FSDC also tracks employee turnover and demographic information on an annual basis in order to
identify staffing trends and patterns, as well as opportunity for improvement.
Training/Continuing Education:
FSDC supports professional growth and development. In-service training is provided on a monthly
basis during agency-wide staff meetings. Additionally, employees are encouraged to seek out and
investigate professional training opportunities that meet both their professional development goals,
as well as the needs of the agency.
Communications/Meetings
There are a variety of communication methods utilized at FSDC. Agency-wide staff meetings held
monthly. Each unit provides an update and employees are encouraged to participate. Additionally,
unit/team meetings are regularly held, as well as individual supervision. FSDC’s management team
meets bi-weekly and the PQI committee meets quarterly. Minutes from all staff meetings are
distributed to staff via e-mail.
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Policy No.: 3.6
Policy: Staff Assessment & Strategic Planning
Approved by: Board of Directors & Strategic Planning
POLICY
________________________________________________________________________
Staffing needs may be identified through the following methods:
-Attrition
-Expansion of current services
-Addition of new services
PROCEDURES
________________________________________________________________________
Needs Assessment
Attrition: When an existing position becomes vacant, the Program Director will determine if the
position should be replaced. Criteria for assessment include work volume, client/service need, and
impact to the agency/staff. Based on this feedback, the Program Director and Executive Director
will determine how to proceed.
Expansion of Current Services: If work volume and/or community needs increase for existing
services, it may be necessary to add positions (not necessarily new programs or services). Criteria for
assessment include current work volume for existing staff, existing service level and/or projected
service level, and when appropriate – feedback from existing staff and community resources.
Addition of New Services: A request for FSDC to offer a new service may come from existing staff
members, clients, or the community. The feasibility of adding a new service will be reviewed by
FSDC’s PQI Committee, Management Team and Executive Director – and if necessary, the Board
of Directors.
If a new service is added, the Program Director and Executive Director will determine if additional
staff are required; necessary qualifications/experience; credentials, etc. Assessing staffing needs may
include the use of regular full-time or part-time staff, as well as independent contractors, temporary
employees or interns
Strategic Planning
Family Services’ Board of Director’s ultimately oversees strategic planning for the agency. However,
stakeholders may also include clients, staff, community resources and other service providers. While
the specific strategic planning process may vary, the overall goal/result is to
continue to provide meaningful, quality service to our clients. Therefore, the planning/review
process may include the following components:
-An identified community need for which Family Services may be an appropriate resources
-Review the feasibility of providing service in regards to agency philosophy standards, existing
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client services, staffing, funding, etc.
-Review additional resources that would be necessary to implement service – such as facility
needs, operational hours, administrative and/or technical support
-In regards to staffing – develop job description(s), determine position requirements and
qualifications required for consideration
-Develop recruitment plan/outline process
-Candidate selection – either through internal or external hiring process
-Implementation of service
Succession Planning
Succession planning is also a critical component of strategic planning. Grooming and preparing
qualified, existing employees for increased roles/responsibilities is critical to FSDC’s growth.
Program Directors are responsible for working with staff during supervision to assess professional
goals and to develop a plan to develop skills/abilities in those areas. Development may include
training, projects, or additional responsibilities as overseen by the program director.
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Policy No.: 3.7
Policy: Workload Evaluation & Assignment
Approved by: Board of Directors& Assignment
POLICY
______________________________________________________________________________
FSDC Management Team, in determining and reviewing the size of the workloads to be assigned,
will assess:
• The nature and difficulty of the problems encountered;
• The work and time required to serve each person or to complete each task; and
• Other responsibilities that may be assigned.
PROCEDURES
______________________________________________________________________________
Job descriptions will reflect an average caseload range for all applicable positions. The
Management Team responsible for each staff will assign and review caseloads with the following
considerations:
-Staff experience/education level
-Length of time with the agency
-Current caseload status, i.e. number, active vs. inactive, voluntary vs. court ordered,
severity of client needs
-Collateral responsibilities
-Management Team will document in supervision notes decisions made
regarding workload assignments.
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Policy No.: 3.8
Policy: Volunteer, Student & Intern Administration
Approved by: Board of Directors& Intern Administration
POLICY
____________________________________________________________________________
Family Services utilizes volunteers and interns for special projects and/or services that may require
or involve direct client contact. All volunteer and intern activities are closely supervised by a
member of FSDC’s management team, or designee. This policy outlines guidelines for those
volunteers and interns who typically have direct client contact.
PROCEDURES
____________________________________________________________________________
All interns or volunteer candidates must submit an application and schedule a personal interview
with the designated program supervisor before beginning an assignment.
Additionally, all candidates are expected to successfully complete a pre-employment background
check, drug screen, FSDC Confidentiality Agreement and agency orientation prior to beginning their
assignment.
Interns and volunteers will be closely supervised by their assigned program director. Depending
upon the experience, a mentor (other than the program director) may also be assigned to monitor
progress and provide feedback/guidance in providing provide service to clients.
If an intern or volunteer candidate is to have direct contact with clients, they will be provided with
written guidelines, which will also be shared with other individuals, such as academic advisors, as
appropriate. An intern or volunteer will have not have direct client contact without the approval of
the program director.
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Policy No.: 3.9
Policy: Use of Adjunct Personnel
POLICY
____________________________________________________________________________
The Agency defines adjunct personnel as independent contractors, temporaries, volunteers, interns
or any personnel performing assignments and/or projects who are not permanent employees of
FSDC.
PROCEDURES
____________________________________________________________________________
The Program Director or a designee will meet with all adjunct personnel prior to beginning a project
or assignment on behalf of FSDC. Additionally, adjunct personnel are expected to complete all
appropriate agency documents and/or contract requirements.
Adjunct personnel are expected to adhere to the all Agency Policies regarding Client Rights,
Confidentiality, Cultural Sensitivity and related workplace expectations (i.e., harassment, etc.).
Adjunct personnel will be assigned a supervisor in the area in which they wish to work and
performance will be monitored on a regular basis. Prior to beginning a project/and or assignment,
all personnel must furnish two references. The Agency also reserves the right to require a criminal
background check and drug screen on adjunct personnel before placement in a client service.
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Policy No.: 3.10
Policy: Personnel Records
POLICY
__________________________________________________________________________
Our agency is committed to ensuring the privacy of personal information maintained in the
personnel records. This policy serves as a guideline only in the collection, use, access, dissemination,
retention, and confidentiality of data maintained on applicants, employees, and volunteers. This
policy is applicable to all documentation retained by the agency on applicants, current or former
regular full-time, part-time, temporary and contract employees, or volunteers.
PROCEDURES
__________________________________________________________________________
The agency uses only ethical and lawful means to gather information about or from an applicant or
employee, and whenever reasonable, gathers it directly from the individual concerned. Devices such
as the polygraph or other truth verification methods are not used. Employee personnel files are
maintained as confidential records, locked and available only to authorized personnel. Documents to
be placed in an employee’s permanent record will be checked for accuracy and authenticity. The
personnel file is maintained for each employee to serve as the official record for all job related
personnel data about an employee. The personnel folder should contain the following documents:
-Employment Application and/or Resume
-Signed Offer Letter
-Performance Appraisals
-References
-Disciplinary Action Records
-Confidentiality Agreements
-Emergency Contact Form
-Job descriptions
-Credentialing (certification) forms including licensure
-Pre-employment drug screen, criminal records and Healthcare Registry check
-Training documentation and certificates of completion, including first aid, CPR, etc. as
appropriate to position.
An employee may examine his/her personnel file in the agency’s administrative office in the
presence of authorized personnel. An employee may not remove or destroy any material contained
in his/her file. Copies of documents retained in an employees personnel file may be obtained for
direct cost of reproduction.
Records Retention
Individual personnel files may be destroyed seven (7) calendar years after termination of
employment at the discretion of the Executive Director or the Board of Directors.
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Policy No.: 3.11
Policy: Employee Benefits
POLICY
___________________________________________________________________________
The greatest assets of any agency are its employees, their efforts and cooperation. Therefore, every
effort will be made to offer the most affordable, and comprehensive benefits programs to FSDC
staff.
PROCEDURES
___________________________________________________________________________
The benefits covered in this policy are applicable to eligible employees of Family Services.
Family Services reserves the right to design provisions and to add, eliminate, or in other ways modify
any discretionary benefits described herein where and when it is deemed in the agency’s best interest
to do so. Under most circumstances, there will be ample opportunity to provide employees with
advance notice of such modifications, and to consider the effect of the decision.
Family Services will annually review all benefit and compensation plans (including employee
compensation) to ensure that we are meeting legal and industry standards.
Retirement Plan: Employees are eligible to enroll when they reach 21 years of age. Upon hire, the
employee can pay into the plan and the employer will match by a
percentage as approved by the Board of Directors after one year of employment. For
details, see the Summary Plan Description pamphlet. Further explanations are available
through the Personnel Office.
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Policy No.: 3.12
Policy: Annual Performance Appraisal
POLICY
____________________________________________________________________________
This policy covers all employees of Family Services. It is the policy of Family Services to provide
annual written evaluations of employee work performance for the purpose of:
-Documenting and detailing employee completion of assigned objectives and accountabilities
and general job performance;
-Reviewing employee’s ability to meet needs of persons served – including awareness of
cultural and socioeconomic factors.
-Providing feedback to employees with respect to management assessment of their work and
progress within the agency;
-Highlighting achievements and/or deficiencies for the purpose of recognition or improvement;
-Identifying employee potential for additional responsibility or promotion;
-Establishing training and development needs;
-Providing a basis for salary action recommendations; and
-Supporting performance improvement planning or disciplinary action up to and including
termination.
PROCEDURES
__________________________________________________________________________
Process
The appraisal is a joint effort of the employee and supervisor. However, responsibility for initiating
and making the formal statement of appraisal lies with the employee’s immediate supervisor or the
person to whom the employee reports.
Before the appraisal, the supervisor and employee may select, jointly, any records to be reviewed.
The supervisor has the responsibility for completing the evaluation before meeting with the
employee. The employee should come to the appraisal with ideas about his/her
performance, be prepared to say what is positive and identify areas for improvement. It is essential
for the appraisal to include some plan for strengthening weaknesses that may be
causing performance to fall below accepted standards (if applicable).
Following the appraisal conference, the employee is given the opportunity to read and sign the
evaluation form. Any comments, objections, or recommendations made by the employee will be
noted on the form, added as an addendum, and become a permanent part thereof. A copy of the
signed document is given to the employee. Each appraisal and pertinent material is routed to the
Executive Director.
If the appraisal does not result in agreement between the employee and the supervisor, the employee
may file a written statement of disagreements within ten (10) working days from the appraisal date.
If the disagreement cannot be resolved by meeting with the Executive Director, the Grievance
Procedure may be used.
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Measurements/Standards
The Executive Director will work with each Program Manager to determine the goals and objectives
for his/her unit. However, while each unit may have different productivity standards and objectives
– all areas ultimately have the same agency-wide goals and expectations:
-Family Services of Davidson County Mission
-Agency-Wide Goals/Objectives
-Unit Objects/Goals
-Individual Goals/Objectives
-Support of Family Services core values/standards
Self-Appraisals
All staff will complete a yearly self-appraisal. The completed appraisal will be turned in
to their direct supervisor prior to the appraisal meeting.
Confidentiality of Performance Appraisals
All appraisals remain in the property of the agency and part of the personnel record of each
employee. They are not sent to another agency in lieu of a letter of reference.
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Policy No.: 3.13
Policy: Employee Grievances
POLICY
____________________________________________________________________________
A grievance is a claim or complaint based upon an event or condition which affects the
circumstances under which an employee works, which is allegedly caused by misinterpretation,
unfair application, or lack of established policy pertaining to employment or employment
conditions. A claim might involve alleged violations of the Agency's Personnel Policies and
Procedures or any grievance relating to conditions of employment. Family Services is committed to
providing proper disciplinary actions aimed at improving and/or correcting such grievances.
This policy applies to all employees of Family Services. Employees in probationary status shall be
afforded full access to the grievance procedures of this agency. However, in the event a
probationary employee is terminated in accordance with other provisions of the personnel policy,
he/she will not be afforded the procedures set herein.
PROCEDURES
___________________________________________________________________________
Each employee of Family Services shares responsibility for maintaining a safe and comfortable work
environment. Therefore, if a problem or issue arises, employees are expected to communicate these
concerns in a direct and prompt manner. Family Services promotes an “open door” approach and
provides the following communication avenues:
Step 1.
If possible, employees are encouraged to first talk with their immediate supervisor. Your
supervisor is most familiar with you and your job and is therefore, in the best position to assist you.
Your supervisor works closely with you, and is interested in seeing that you are treated fairly and
properly.
Step 2.
If you are uncomfortable approaching your supervisor, or if you do not feel that your supervisor can
help in resolving the matter, you can speak with either a member of the FSDC management team or
directly with the Executive Director, who has the ability to take your grievance to the Personnel
Committee if necessary. Prompt handling is essential and grievances will be given highest priority for
settlement. Employees agree to exhaust the agency's grievance procedure before seeking redress
from professional associations, other organizations, agencies, or individuals, or through judicial or
other actions. This procedure is an administrative process which moves through increasingly higher
administrative and accountability lines and all transactions shall be held in confidence by all parties
involved.
1. If the grievance cannot be resolved with the employee's direct supervisor, then the employee can
request a meeting with another member of Management Team within the next five (5) working days,
during normal working hours for oral presentation of the grievance. The employee and their
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member of Management shall make every effort to work out an equitable solution to the problem at
this meeting. The outcome will be documented on the “Report of Employee
Grievance” form and submitted to the executive director.
2. Within five (5) working days from the date of the conference, the appropriate supervisor or
program director will render a decision. The decision will be recorded on the form referred to in
step 1 above. If the decision is satisfactory to the employee, then it will be noted as such on the
form. If the decision is not satisfactory to the employee, then the he/she may proceed with the
grievance process.
3. If the decision reached is not satisfactory to the employee, an appeal may be made in writing
within ten (10) working days to the Executive Director. Within five (5) working days after the
Executive Director receives notice of appeal, he/she must set a place and time for oral presentation
of the grievance. The Executive Director shall hear testimony by the employee and the immediate
supervisor/program director.
4. The Executive Director shall render a decision and respond in writing to the concerned parties
within five (5) working days after the hearing.
5. If the decision reached by the Executive Director is not satisfactory to the employee, a final
appeal shall be submitted in writing to the Personnel Committee of Family Services of Davidson
County, Inc. Board of Directors within 14 working days for the purpose of hearing any pertinent
testimony from the concerned parties.
6. Within ten (10) working days, the Personnel Committee of Family Services of Davidson County,
Inc. Board of Directors shall hear testimony by the employee and the immediate
supervisor/program director.
7. Within seven (7) working days of such a hearing, the Personnel Committee of Family Services of
Davidson County, Inc. Board of Directors shall notify all concerned parties of their final decision.
8. Appeals to the Personnel Committee of Family Services of Davidson County, Inc. Board of
Directors shall be final and binding to all parties involved within this procedure.
9. The responsibility for compliance with this policy and procedure is assigned to the Executive
Director or his/her designee.
Documentation of Grievances:
FSDC maintains an accurate and complete record of each grievance filed as well as summary
information about the number, nature, and outcome of all grievances filed. Records of grievances
are kept separate and apart from other personnel records and files. Grievance records and files are
retained in accordance with state and federal laws governing retention and destruction of records.
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Policy No.: 3.14
Policy: Progressive Discipline
Progressive Discipline
POLICY
___________________________________________________________________________
Family Services is committed to the success of its employees. However, there may be times when
disciplinary action is required. The following outlines both the progressive disciplinary steps that
may be taken, and potential reasons for the corrective action.
This policy applies to all employees of Family Services of Davidson County, Inc.
PROCEDURES
___________________________________________________________________________
To insure that business is conducted properly and efficiently, employees are expected to meet certain
agency standards regarding attendance, conduct, work performance and other work rules and
regulations. If a problem should arise in one of these areas, the appropriate supervisor will address
the issue with the employee during supervision. Typically, this coaching/counseling process will
resolve the situation and result in developing a mutually effective solution. If however, the issue is
not resolved, or reoccurs, formal disciplinary action may be required. Typically, supervisors and
managers will follow the disciplinary process outlined below. However, there may be particular
situations in which the seriousness of the offense justifies the omission of one or more of the steps
in the procedure. Likewise, there may be times when the agency may decide to repeat a disciplinary
step.
Step One: Oral Reminder/Verbal Warning
This is the first step in the disciplinary process. Typically at this point the issue has already been
addressed during supervision, but has not yet been resolved. Therefore, it may have become
necessary for the supervisor to progress to a formal Oral Reminder and fully document the concern
- including a recap of previous discussions, expectations, and consequences if the desired outcome is
not met. Typically this warning will remain in effect for 3 months. However, the length of time may
be adjusted depending on the issue, as well as the level of progress being made by the employee.
Documentation of the incident will remain in the department file and will not be placed in the
employment file unless another disciplinary transaction occurs.
Step Two: Written Reminder/Warning
If the employee issue is not resolved as a result of the verbal warning, it may become necessary to
progress to a written reminder/warning. Additionally, if an employee does not sustain performance
improvement or is again in violation of Family Services of Davidson County, Inc. practices, rules or
standards of conduct, the employee will progress to a written warning. The supervisor will discuss
the situation with the employee, emphasizing the seriousness of the problem and the need for
immediate resolution. Following the conversation, the employee’s supervisor will write a memo
summarizing the issue; oral reminder process (Was there improvement? Was improvement
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sustained?); progression to written warning, expectations, length of time written warning is to be in
effect, consequences for failure to meet expectations. The
original Written Warning memo will go to the employee and a copy will be routed
to the Human Resources Dept. to be placed in the employment file (along with a
copy of the Oral Reminder).
* Timeframe for the Written Warning will be determined by the supervisor and the Executive
Director. If the written warning is for performance related issues, typically an employee will be given
3-6 months to meet and sustain improvement (note: the written warning period may be extended vs.
progressing to the next disciplinary step if the employee is making a sincere effort to resolve the
situation and improvement is being noted). However, if the written warning is for a nonperformance
issue (i.e., conduct, attendance) and does not require a significant amount of time to work towards
improvement, the written warning may be for a lesser timeframe.
During the written warning process, the supervisor and employee will meet biweekly
(usually during supervision) to review the employee’s progress. If the employee successfully
completes the action plan he/she will be removed from the written warning. The supervisor will
document the improvement and date of removal. The employee will be given the original document
and a copy will go to Human Resources for the employment file. However, if appropriate
improvement has not been achieved during the written warning process, the employee may progress
to the next step in the disciplinary process.
Step Three: Decision-Making Leave
If the employee’s performance does not improve within the Written Reminder
timeframe, or if the employee is again in violation of FSDC, Inc. practices, rules
or standards of conduct, they will be placed on Decision Making Leave. The
Decision Making Leave is the final step of Family Services of Davidson County,
Inc.’s disciplinary system.
Decision Making Leave is an unpaid, one-day disciplinary suspension. Employees on Decision
Making Leave will spend the following day away from work deciding whether to correct the
immediate problem and conform to all of the agency’s practices, rules and standards of conduct, or
to quit and terminate their employment with Family Services of Davidson County, Inc. If the
employee’s decision following the Decision Making Leave is to return to work and abide by Family
Services practices, rules and standards of conduct, the supervisor will write a letter to the employee
explaining the employee’s
commitment and the consequences of failing to meet this commitment. The employee will be
required to sign the letter to acknowledge receipt. A copy of the letter will be routed to the
Executive Director. A copy will be placed in the employee’s personnel file. The employee will be
allowed to return to work with the understanding that if a positive change does not occur, or if
another disciplinary problem occurs within a specified timeframe* they will be terminated (*The
Executive Director and Supervisor will determine an appropriate timeframe based details of the
incident, employee participation, and any previous patterns of improvement/sustainability). If the
employee is unwilling to make such a commitment, they may be terminated. If the employee meets
the expectations as outlined in the letter, they will be removed from disciplinary action and a memo
to that effect will be placed in their employment file.
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Exceptions to the Progressive Discipline Process: Occasionally incidents may occur that are so
egregious in nature that progressive discipline is not required. In that event, the Executive Director
may choose to issue a First and Final Warning, or progress directly to termination.
First and Final Warning: This may result when an employee has used poor judgment or decision
making skills that while not criminal in nature, do not meet FSDC’s expectations. Examples may
include (but are not limited to): inappropriate use of agency equipment, internet violation, offensive
remarks, failure to appropriately notify supervisor of incidents or absences, etc. Typically a first and
final warning does not require a timeframe for improvement. However, the incident may be
documented and if the same/similar incidents occur in the future, the employee may either be
placed on Decision Making Leave, or terminated.
Termination: If the employee commits any of the actions listed below, or any other action not
specified but similarly serious, the employee will be suspended without pay pending the investigation
of the situation. Following the investigation, the may be terminated without any previous
disciplinary action having been taken.
-Theft
-Falsification of agency records
-Failure to follow safety practices
-Conflict of interest
-Threat of, or the act of doing bodily harm
-Willful or negligent destruction of property
-Use and/or possession of illegal intoxicants, drugs or narcotics
-Neglect of duty
-Refusal to perform assigned work or to follow a direct order.
List of Disciplinary Actions
The agency will not attempt to list here all the types of conduct for which discipline, penalties, or
termination could result. Generally, employees must avoid conduct which is not in the best interests
of the agency or which adversely affects other employees or clients. All employees shall be notified
by letter of disciplinary action(s) taken against them by the agency. Employees will have the right to
conference with his/her immediate supervisor for a clarification of the action taken. Employees shall
be granted the opportunity to challenge any action through the Grievance Procedure as described in
the Personnel Policy.
Dismissal
Employment and compensation with Family Services of Davidson County, Inc. is
“at-will” in that an employee can be terminated with or without cause, and with or
without notice, at any time, at the option of either Family Services of Davidson
County, Inc. or the employee, except as otherwise provided by law. If the employee’s performance is
unsatisfactory due to lack of ability, failure to abide by FSDC, Inc. rules or failure to fulfill the
requirements of your job, the employee will be notified of the problem. If satisfactory change does
not occur, you may be dismissed. Some incidents may result in immediate dismissal.
Corporal Punishment and Discipline
Under no circumstances does Family Services permit corporal punishment in its
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programs. Any disciplinary measures employed with clients will meet the guidelines as put forth by
the State as well as acceptable professional practices. Any incidences of abuse of this policy will
result in immediate termination and/or
reporting to appropriate authorities.
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Policy No.: 3.15
Policy: Harassment
Latest Revision/Approval: February 27, 2014
Sexual Harassment
POLICY
__________________________________________________________________________
It is the policy of Family Services to maintain a work environment free from all forms of
discrimination, including harassment. Harassment is defined as any unwelcome contact that is based
on race, color, religion, sex (including pregnancy), sexual orientation, national origin, age, disability,
ancestry, marital status, political belief, military status, or retaliation, which includes opposing
participating in any compliant process at the Equal Employment Opportunity Commission (EEOC).
Harassing conduct in the workplace by supervisory or non-supervisory personnel is prohibited. All
complaints of harassment will be investigated promptly and, when found to have merit, will result in
disciplinary action up to, and including dismissal.
While each employee is responsible for conducting himself or herself in a fair and consistent manner
with respect to every other employee, it will be incumbent upon all supervisory personnel to ensure
that no employee is harassed or mistreated by any other employee.
Examples of Harassment
Examples of "harassment" covered by this policy, include, but are not limited to, bullying, offensive
language, jokes, or other physical, verbal, written, or pictorial conduct including sending graphic or
offensive materials through electronic and digital media relating to an individual's sex, race, religion,
national origin, age, disability, sexual orientation, or other factor protected by law that would make a
reasonable person experiencing such behavior to feel uncomfortable or interfere with the person's
work performance. Harassment can exist even if the offending person did not mean to be
offensive.
Prohibited Behavior
Harassment in any form, according to the EEOC becomes unlawful where:
1. Enduring the offensive conduct becomes a condition of continued employment, or
2. The conduct is severe or pervasive enough to create a work environment that a reasonable
person would consider intimidating, hostile, or abusive.
3. Anti-discrimination laws also prohibit harassment against individuals in retaliation for filing a
discrimination charge, testifying, or participating in any way in an investigation, proceeding, or
lawsuit under these laws; or opposing employment practices that they reasonably believe
discriminate against individuals, in violation of these laws.
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Definition of Sexual Harassment:
As defined by the Equal Employment Opportunity Commission’s regulations, unwelcome sexual
advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature
constitute sexual harassment when:
-Submission to such conduct is made either explicitly or implicitly a term or condition of an
individual’s employment,
-Submission to or rejection of such conduct by an individual is used as a basis for employment
decisions affecting such individual, or
-Such conduct has the purpose or effect of substantially interfering with an individual’s work
performance or creating an intimidating, hostile or offensive working environment.
The following actions constitute prohibited behavior as defined by EEOC regulations and are in
violation of this policy:
1. Unwelcome or unwanted sexual advances or propositions
2. Requests or demands for sexual favors accompanied by any implied or expressed promise of
preferential treatment or negative consequences concerning employment status.
3. Continued or repeated verbal abuse of a sexual nature.
4. Graphic or offensive verbal commentaries about an individual’s body.
5. Engaging in sexually oriented verbal or physical conduct, which interferes with work
performance and creates an intimidating, hostile or offensive work environment.
6. Display in the workplace of sexually suggestive objects or pictures.
PROCEDURES
___________________________________________________________________________
Reporting an Incident
FSDC is committed to providing a harassment free workplace and will treat any reported violation
of this policy with the utmost urgency. If an employee feels that they have been the victim of
harassment in the workplace, they should discuss their concerns with either their supervisor, a
member of the FSDC management team, or the Executive Director as soon as possible. All
concerns will be handled in a prompt, professional manner. Concerns regarding the Executive
Director should be made to the chair of the Personnel Committee of the Board or a member of the
Executive Committee of the Board of Directors. In addition, any employee with knowledge of
someone being harassed or violating the harassment policy is required to report it.
Confidentiality and Investigation Process
Confidentiality will be strictly maintained and never, under any circumstances, discussed with staff
members who are not directly involved. However, all reports of harassment must be investigated
(internally). Therefore it will be necessary for the Executive Director to be included in all
investigations and/or discussions that may take place. The Executive Director will determine which
(if any) individuals will be included in this process. If a violation of this policy concerns the
Executive Director, the chair of the Personnel Committee of the Board of Directors and/or a
member of the Executive Committee of the Board of Directors will conduct the investigation
and/or discussions that may take place.
Conclusion
Appropriate action will be taken based on the results of the internal investigation process
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(appropriate action may include suspension or disciplinary action up to, and including, termination
of employment). Again, findings will be held in the strictest confidence. However, if it is found that
an individual is in violation of this policy (and in effect, EEOC regulations) it may become necessary
to notify appropriate individuals/authorities.
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Policy No.: 3.16
Policy: Discontinuation of Employment
POLICY
_________________________________________________________________________
This policy applies to all full-time FSDC staff members:
PROCEDURES
_________________________________________________________________________
In the event that an individual’s employment is to be discontinued, the following procedures will be
followed:
Notice of Discontinuance
Family Services requests three (3) months notification for the Executive Director’s termination of
employment.
Positions which require qualification of graduate level study or which demand qualifications of five
(5) years or more of experience are requested one (1) month notice of intent to terminate.
Two (2) weeks notice of termination is requested for all other positions.
Final Pay
When appropriate notice as outlined above is provided, the employee shall receive a final paycheck,
which shall include:
 total salary due for days worked;
 payment for unused accumulated annual vacation leave days, and any required pay
adjustments to clear accounts between the employee and the agency, including but not
limited to insurance withholdings and Flexible
 Benefit Plan withholdings.
A written notice of an employee’s intent to terminate his/her employment is required. The letter of
termination should state the intent to resign and the date the employee wishes to be released from
active duty. The date should provide for as much work notice time as requested under Section A,
Notice of Discontinuance above.
Dismissal
When termination is contemplated because the appraisal indicates that a staff member’s
performance is not satisfactory in terms of the agency’s standards, the agency will assist the staff
member in improving his/her work and meeting standards. When standards are not met, the staff
member is advised of the dismissal and may granted notice as provided for in Section A, Notice of
Discontinuance.
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If the staff member is dismissed for malfeasance or official misconduct; s/he is relieved of his/her
duties immediately, and is not paid beyond the end of the day s/he is dismissed.
*Note: See Progressive Discipline Policy
Reduction in Force
Should a reduction in work force be required because of reorganization of the agency or a change in
the agency’s programs or funding sources, staff members will be informed of such possibility and
the reasons for it at the time such decisions become reasonably certain. A person whose position is
being eliminated may be offered any other position available for which s/he is qualified. There may
also be an opportunity for re-employment if a layoff is temporary.
The following factors in the order of their importance are considered when reduction in staff
becomes necessary.
-relative need of the particular position in the agency’s program;
-skills, capacities, and competence of the staff member in relation to the positions which are to
be considered;
-length of the staff member’s service in relation to the two (2) preceding points;
-regular employees are retained before any temporary, probationary, or part-time staff and will
be offered positions for which they qualify;
-where funding sources allow, the agency will provide two (2) weeks notice and pay. Upon
request, separating employees may be assisted in locating available positions in other
agencies.
Severance Duties
An employee leaving the agency should complete severance duties before receiving their final pay.
Such duties include appropriate dictation, reports and assisting in the transfer of duties to his/her
successor. Office keys and other equipment and supplies must be turned in.
Exit Interview
Prior to leaving their position at FSDC, employees are asked to voluntarily participate in an exit
interview aimed at understanding the nature of their decision to leave and giving opportunity for the
employee to offer constructive feedback. This interview is conducted by a member of Management
Team or the Shelter Coordinator.
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Policy No.: 3.17
Policy: Whistleblower Protection
Whistleblower Protection
Policy
It is the public policy of the State of North Carolina to encourage employees to notify an
appropriate government or law enforcement agency when they have reason to believe their
employer is violating a state or federal statute, or violating or not complying with a state or federal
rule or regulation.
A “whistleblower” is an employee who discloses information to a government or law enforcement
agency where the employee has reasonable cause to believe that the information discloses:
-A violation of a state or federal statute,
-A violation or noncompliance with a state or federal rule or regulation, or
-With reference to employee safety or health, unsafe working conditions or work practices in
the employee’s employment or place of employment.
Procedure
Family Services of Davidson County, Inc. will not make, adopt, or enforce any rule, regulation, or
policy preventing an employee from being a whistleblower. The Organization will not retaliate
against an employee who is a whistleblower.
Family Services of Davidson County, Inc. will not retaliate against an employee for refusing to
participate in an activity that would result in a violation of a state or federal statute, or a violation or
noncompliance with a state or federal rule or regulation, nor will the Organization retaliate against
an employee for having exercised his or her rights as a whistleblower in any former employment.
If you have information regarding possible violations of state or federal statutes, rules, call
the North Carolina State Attorney General’s Office at Telephone: 919-716-6400 or Fax:
919-716-6750. The Attorney General’s Office will refer your call to the appropriate government
authority for review and possible investigation.
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Policy No.: 3.18
Policy: Employee Conflict of Interest
Employee Conflict of Interest
Policy
Any kind of dual relationships between professional personnel and clients is strictly prohibited.
Procedures
Accepting payment or other consideration from another provider of services for referral of clients
or accepting payment for the referral of clients is strictly prohibited.
Steering or directing referrals to a private practice in which agency professional personnel,
consultants or the immediate family of personnel and consultants may be engaged is to be carefully
avoided.
In the event that a staff member leaves the agency to go into private practice direct referral of clients
to their private practice is strictly prohibited. All cases are either to be closed or transferred to
another agency staff member before the therapist's departure.
While names of former personnel in private practice may be included in referral choices given to
clients, direct referral of clients to former personnel in private practice is prohibited.
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Policy No.:3.19
Policy: Alcohol & Drug-Free Workplace
This document is only a summary of the agency official Alcohol/Drug-Free Workplace
Policy
The official copy is available to all employees for their review and should be consulted with respect
to any specific questions. Neither this summary, not the official policy, is intended to alter the
employment-at-will relationship of any employee, or to affect the agency’s right to manage its
workplace or discipline its employees, nor is it a guarantee of employment or of terms or conditions
of employment except as may be specifically stated therein. No contract of
employment, either express or implied, is intended or created by this summary or the policy.
Procedures
Family Services of Davidson County, Inc. (agency) is concerned about the adverse effects that drugs
and alcohol can have upon our employees’ safety and health. Alcohol abuse and the illegal use of
drugs lead to increased accidents and medical claims, and can lead to the destruction of an
employee’s health and adversely affect his/her family life.
Through its Substance Abuse Policy, the agency prohibits the possession, use, transfer, manufacture
or sale of alcohol, illegal drugs, or legal drugs without a valid prescription on agency property or
agency time. Any violation of this Policy may subject employees to immediate disciplinary action, up
to and including termination of employment. Employees who are identified as being substance
abusers may be referred for counseling and/or rehabilitation under terms of the policy at their sole
cost and expense. Applicants not passing the drug test will be denied employment.
Employees will not be permitted to work while under the influence of drugs or alcohol. Individuals
who appear to be unfit for duty may be subject to a medical evaluation, which may include drug or
alcohol testing. Refusal to comply with a fitness-for-duty evaluation may result in disciplinary action
up to and including discharge. Off-the-job illegal drug use which could adversely affect an
employee’s job performance or which could jeopardize the safety of other
employees, the public or agency facilities, or where such usage could jeopardize the security of
agency finances or business records, or where such usage adversely affects clients’ or the public’s
trust in the ability of the agency to carry out its responsibilities, will not be tolerated.
Employees who are convicted or arrested for off-the-job drug activity will be considered in violation
of this policy. Employees undergoing prescribed medical treatment with a controlled substance that
may affect the safe performance of their duties are required to report this treatment to their
supervisor through their personal physician.
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COUNSELING AND REHABILITATION
Family Services recognizes that alcoholism/drug abuse is a form of illness that is treatable in nature.
The agency shall not discriminate against employees based on the nature of their illness. No
employees shall have their job security threatened by their seeking of assistance for a substance
abuse problem. The same consideration for referral and treatment that is afforded to other
employees having non-drug/alcohol related illnesses shall extend to them. Every effort
shall be made to provide an early identification of a substance abuser, to work with and assist the
employee in seeking and obtaining treatment without undue delay.
Early identification of the substance abuse shall be based upon job performance and related criteria,
as well as resulting impairment on the job from the job activities. The supervisor of the employee
shall bring such information to the attention of the designated representative for further evaluation.
An employee who voluntarily seeks treatment for a substance abuse problem, which requires a leave
of absence for treatment, shall be granted such leave of absence and further shall be eligible for
benefits under the specifications of the existing
insurance policy. Nothing is this policy is construed to prohibit the agency from its responsibility to
maintain a safe and secure work environment for its employees or from invoking such disciplinary
actions as may be deemed appropriate for actions of misconduct by virtue of their having arisen out
of the use or abuse of alcohol or drugs or both.
TESTING OF APPLICANTS
All applicants who have been offered employment with the agency will be required to undergo a
drug-screening test as part of the hiring process. The agency will withdraw an offer of employment
made to any applicant whose test reveals the presence of illegal drugs or prescription drugs without a
valid prescription. Refusal to submit to an alcohol/drug screening will be considered a voluntary
resignation of employment. Reporting for duty or working with drugs present in the body or while
affected by alcohol will be handled as a disciplinary matter or by referral for counseling or
rehabilitation, as the agency determines. Drug testing may be required under the following
conditions:



When an employee is involved in an accident or incident.
When the agency has a reasonable cause and suspicion.
When the agency selects employees on a random basis for a drug-screening test.
At such time as the agency may decide to require all employees to be drug tested. As may be
required by federal or state law or regulations. When an employee has had a positive test and has
been referred for counseling or rehabilitation under this policy. As part of post-rehabilitation
random testing. Alcohol testing will be required under the following circumstances:



When an employee is involved in an accident or incident.
When the agency has reasonable cause or suspicion.
As may be required by federal or state law or regulations.
No employee will be requested to submit to a drug or alcohol-screening test unless specific
authorization for such has test has been granted by an agency official. The agency intends to utilize
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the most accurate and reliable testing method(s) available. Failure or refusal by an employee to
cooperate with the program or to submit to such a test when requested will be grounds for
disciplinary action, up to and including termination of employment.
CONFIDENTIALITY
All information concerning drug or alcohol testing results, medical examinations, or rehabilitation
and treatment of an individual employee will be treated as “confidential” and shared only with those
agency officials or other individuals on a valid need-to-know basis.
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Policy No.:3.20
Policy: Employment of Relatives
Employment of Relatives
Policy
Applications for employment from close family relatives will be considered with other applications
when vacancies occur. Restrictions in job placement will apply, however, to
prevent problems of supervision, safety, security, or morale. For purposes of this section,
your close family includes your spouse, your children, your siblings, your parents, your
grandparents, and your spouse's children, siblings, parents and grandparents. For the
purposes of this policy, “spouse” means those employees having a legal marital
relationship as well as employees involved in relationships, which in Family Services
judgment are characterized by permanence, duration, and stability normally associated
with marriage.
Scope
This policy applies to all staff and board of Family Services of Davidson County. Inc.
Procedure:
Close family will not be hired at Family Services of Davidson County, inc. without the prior
approval of the Executive Director.
Close relatives may not supervise the other nor may they work in the same department.
If the employees are unable to develop a workable solution, the Executive director of
Family Services of Davidson County, Inc. will decide which employee may be transferred
in such situations.
Should two present employees that work together or supervise each other enter into a
personal, non-work related relationship, one or both employees may have to be transferred.
Relatives will not be placed in positions where they work with or have access to sensitive
or confidential information regarding other close relatives, or if there is an actual or apparent
conflict of interest.
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Policy No.:3.21
Policy: Evaluation of Employment Data
Approved by: Board of Directors of Employment Data
Policy
Family Services of Davidson County, Inc. recognizes the contribution of cultural, ethnic, and gender
differences in the workplace. It is the goal of the agency to systemically communicate and enforce
this philosophy through the agencies policies and practices. In support of this goal, the HR/Office
Manager will track the following agency information and report results on an annual basis to the
CQI committee:
-Annual employment turnover rates
-Patterns or trends that may emerge in regards to turnover
-Patterns or trends that may emerge from feedback in the exit process
-Employee demographics (race, age, tenure, etc.) – for the purpose of understanding the
employee population of FSDC
The CQI committee and Executive Director will be responsible for making recommendations to
address issues/concerns, if applicable.
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Policy No.: 3.22
Policy: Outside Employment
Outside Employment
Policy
No employee may take an outside job, either for pay or as a donation of his or her personal time,
with a client or competitor of Family Services of Davidson County, Inc.; nor may they do work on
their own if it competes in any way with the services we provide our clients.
Procedure
If your financial situation requires you to hold a second job, part-time or full-time, or if you intend
to engage in a business enterprise of your own, we would like to know about it. Before accepting any
outside employment, discuss the matter with your supervisor. He or she will thoroughly discuss this
opportunity with you to make sure that it will not interfere with your job at Family Services of
Davidson County, Inc. nor pose a conflict of interest.
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Training and Supervision
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Policy No.: 4.1
Policy: Staff Orientation & Training
Approved by: Board of Directors Orientation & Training
POLICY
_______________________________________________________________
All new FSDC employees will receive an orientation to the program and the agency within 30
working days of their start date. Orientation will include, but not be limited to, a review of the
FSDC personnel policies and any applicable program specific policies and procedures.
PROCEDURES
_______________________________________________________________
Program Coordinators and office staff will be oriented to personnel policies and applicable program
policies and procedures by the Executive Director and/or the Office Manager. Topics covered and
dates of the orientation will be noted in the employee’s orientation checklist. The new employee and
the Executive Director will initial the orientation checklist at the time training is completed.
Program Coordinators will orient new direct care staff. Program Coordinators will review personnel
policies, agency policies and procedures, and program specific policies and procedures. Topics
covered and dates of the orientation will be noted on the employee orientation checklist. Program
coordinator and employee will initial the orientation checklist at the time training is completed.
Direct Care employees will receive approximately 60 hours orientation training as provided by the
Executive Director and the Program Directors. All employees will complete the orientation training
within 30 days of date of hire. When employees complete orientation training, dates of training and
topics covered will be noted on the employee’s orientation checklist. The employee and the trainer
will initial the orientation checklist.
Employees are required to attend at least 7 in-service training workshops each year. Monthly inservice trainings are provided on the 3rd Tuesday of each month.
All employees are encouraged to participate in any available education opportunities that will
enhance their skill level, knowledge, and ability to provide quality treatment for FSDC’s clients.
Expenses incurred in required training as well as optional training opportunities will be reimbursed
within the confines of the budget.
Direct Care Staff shall receive orientation and on-going training in all areas relevant to providing
quality care and treatment services, inclusive of but not limited to:
1. First Aid, cardio-pulmonary resuscitation, seizure management and the Heimlich maneuver
2. Client records & documentation
3. Standards of licensing facility and funding sources.
4. Treatment methodologies and goal planning
5. Therapeutic Crisis Intervention, as appropriate to position
6. Clients Rights
7. Confidentiality
8. Infectious Disease Transmission and Blood Pathogens
9. Program specific requirements
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Training for Crisis Intervention Staff consists of:
1. Information about the legal system, civil and criminal court procedures
2. Knowledge about dynamics of domestic violence and sexual assault.
3. Survivor sensitivity training
4. Cultural sensitivity training
5. Coordinating area services
6. Information on law enforcement procedures
7. Information on medical procedures
8. Permanent planning for homeless individuals
9. Responding to clients who need emergency mental health services
10. Supportive counseling
11. First Aid and Cardiopulmonary Resuscitation
12. Interviewing clients
13. Conducting needs assessments
14. Crisis Intervention Theory and Voluntary Service Model training
15. Accessing community resources
16. Shelter procedures
17. Safety planning
Successful completion of orientation training shall be competency based – based on written tests
and behavioral observations.
The agency shall post all announcements of educational and/or training opportunities for the
knowledge of all staff.
A record of all completed education and training activities shall be maintained in each employee's
personnel file.
Each employee providing direct care services to youth shall have, as a part of their personnel record,
a plan of training. This plan of training shall be co-signed by the Executive Director and Program
Director.
FSDC will maintain documentation of each employee’s orientation, in-service, and refresher training
for three years.
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Policy No.: 4.2
Policy: Staff Training Development & Supervision
Training Development & Supervision
POLICY
_______________________________________________________________
Family Services of Davidson of Davidson has a program that provides staff development, training
and supervision to help staff improve knowledge, skills and abilities, and increase the staff’s
sensitivity to the uniqueness of the various populations it serves. This is accomplished through a
number of ways, including orientation, supervision, performance evaluations, in-service training, and
attendance at workshops, seminars and professional meetings.
All agency staff members will receive on-going training related to his/her specific roles and
responsibilities. Those in supervisory positions must meet the criteria outlined by their specific
disciplines Licensure Board to provide clinical supervision.
Family Services’ employee development program shall include, but not be limited to, the following:
1. learning experiences which shall enhance employee’s ability to deliver client/family centered
service;
2. communication between employees, management and the Board of Directors;
3. regular evaluation of employees’ performance and development of plans to address areas
where improvement is needed.
PROCEDURES
_______________________________________________________________
Orientation
Orientation to the agency begins during interviewing of job applicants, in which duties of the
position, how the position fits into the agency’s services program, and the applicant’s ability to fill
the position are discussed. Following employment, there is more discussion of the agency’s
programs, policies, and employee benefits. Orientation continues during other staff development
efforts.
Orientation occurs in partnership between the Office/HR Manager and the Program Director under
whose supervision the new employee will work. The New Employee Orientation
Checklist sets forth the specific elements and time frame for orientation. This checklist is completed
within the first two weeks of employment, signed by those involved in orientation and maintained in
the employee’s personnel file.
Training
Staff shall be encouraged to take advantage of educational opportunities, to enhance current
training/skills and to add new learning as well as to present ideas for new program/practice areas.
During each annual performance review, each staff member will determine professional
development goals for the next year. Professional development monies can be used for a wide range
of activities. Employees should feel free to bring ideas forward to his/her supervisor throughout the
year.
In-Service Training is important to the quality of service and staff development so we have an
wide reaching program that includes time for the clinicians to meet (monthly staff meetings) to
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discuss the effectiveness of various theories and to stay updated on current theories and treatment
approaches.
Also a part of the ongoing in-service program is having various agencies in the community come to
address staff on resources in the community, training in client record keeping, and legal protocols
(such as: abuse reporting, “duty-to-warn”, court testimonies, etc.). Staff also receives training on
mandatory reporting of Child & Adult Protective Services issues (abuse, neglect and dependency)
and is kept up to date regarding the specifics of making reports in Davidson County. Other
mandatory reporting includes “duty-to-warn”, the commission of a felony and violent misdemeanor
(see High Risk Intervention). The clinical team also receives updates regarding the treatment of dual
diagnosis issues that are to address alcohol/drug use theories, treatment, relapse prevention and
signs/symptoms of abuse and withdrawal. Training also includes child and family development,
parent psycho-education programs, dealing with resistant clients/families and differing therapeutic
techniques that increase the likelihood of successful treatment outcomes.
Direct service staff will receive regular in-service training from curricula designed to improve skills
used for person-in-environment practice, assessment (including dual diagnosis issues), individual,
group, and family therapy, effective identification and intervention in situations of risk, use of
psychiatric services, accessing community resources, client advocacy, ethics, effective use of case
consultation and supervision, and legal parameters around agency practice. On a yearly basis,
credentialed staff is responsible for securing training for Ethical Practice in the human services field
that will outline North Carolina Statutes in the area of Mental Health.
Agency-wide staff meetings are held monthly. Staff meetings provide time for discussion and
clarification of items and areas of interest to employees; for group study of current philosophy,
theory, and practice; and to share information about related agencies and professional practices in
the community. Each meeting includes an in-service training followed by time for agency business.
All staff members are expected to attend. Programs may also have program-specific staff meetings.
The date, time, purpose and requirements depend upon the program to which the employee is
assigned.
Off Site Continuing Education opportunities are provided and encouraged by the agency.
During each annual review, each staff person will determine professional development goals for the
following year; including continuing education needs. Each professional staff member has a
specified monetary amount each year budgeted for continuing education. Staff is encouraged to use
this to obtain CEUs or contact hours to maintain their licensure. When it is in the best interest of
the agency to expand or improve services staff members may be sent for special training. Staff who
provides initial intake/assessment shall receive continuing education that addresses special needs
populations to ensure appropriate care. Workshops and expenditures are subject to approval by the
Director of Clinical Services and the Executive Director.
Retreats are scheduled for each division, as well as an agency wide retreat, to address stressors that
affect staff and their effectiveness with clients/families. Retreats focus on stress management, team
building, dealing with resistant and difficult clientele, improving communication and collaboration
both within the agency and with community resources.
Retreats also provided staff with new learning opportunities that help address client/family needs
that are being provided in our community and what services may be limited. These gatherings afford
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the staff the chance to share personal/professional experiences; skills and knowledge that enhance
each program’s focus, as well as rejuvenate staff.
Fees for Qualifying Standards
All staff of Family Services must meet specific levels of educational, experience, professional and/or
performance standards as set force in a job description established for the position.
These standards are the sole responsibility of the applicant seeking employment. Family
Services also expects applicants and staff to be active members in their professional organizations.
The expenses related thereto are the responsibility of the individual. In some instances, standards
above the minimal entry level are established by professional organizations, law, funding source, or
high grade level positions. Family Services encourages employees to qualify themselves for such
higher level standards.
Supervision
Each staff member has a supervisor. The purpose of supervision is as follows:
 To clarify Family Services of Davidson County, Inc. programs, policies, procedures, etc.;
 To monitor performance and to facilitate the supervisee’s efforts toward improved job
performance;
 To ensure appropriate clinical services to clients;
 To provide the administration with formal assessments of the supervisee’s performance as
compared to the agency’s expectations.
Each supervisor is responsible for monitoring the quality of the individual’s work. Supervisory
conferences are helped on a regular basis for the purpose of reviewing the overall work of the staff
person, specific skills, and overall management.
All clinicians’ cases are reviewed by the supervisor initially for the first month or so, and afterwards,
on an as needed basis as requested by the supervisor or clinician. Staff who is in need of supervision
that is not available by current supervisory staff, due to specialty licensure/certification, shall receive
assistance by the agency to locate an approved supervisor.
One hour of individual weekly supervision and case review is scheduled for each clinical staff
member with the Director of Clinical Services/designated clinical supervisor. It is possible to receive
clinical supervision from one supervisor and administrative supervision from another.
When basic professional licensing or certification, or professional education and experience, has
been obtained by the staff member, e.g. NASW, NCLPC, AAMFT Clinical
Membership, supervision may be reduced to biweekly as mutually agreeable to the Clinical
Director/designated clinical supervisor and the therapist. BSW/Bachelor level staff will also receive
one hour of supervision per week and will work toward the designation of Qualified
Professional (See agency personal manual’s classification of employees).
Case presentation shall follow a structure that includes;
 Client demographics
 Presenting problem
 Family history
 Work and/or School issues
 Treatment issues
 Medical diagnoses/procedures
 Substance Abuse issues
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 Domestic violence and/or traumatic events
 Current treatment difficulties and client progress
 Case coordination (both within and outside the agency)
Those cases that are deemed crisis oriented shall be scheduled for weekly supervision during the
crisis event. Other cases shall be presented at least quarterly. Cases that are likely to continue past
the target date for treatment will need to be presented to the Clinical Director/designated clinical
supervisor and a plan for continuation, further assessment/evaluation or referral is to be developed.
Crisis Cases and Questions - All staff members are encouraged to request time, as needed with a
member of the Management Team for input and discussion of any cases or questions about which
they have concerns. Staff shall have access to supervision during times of crisis via
 Regularly scheduled supervision sessions.
 Impromptu supervision sessions/request.
 Telephonic devises (fax, pager, cellular telephone)
*Refer to FPS policies regarding Intensive in-home services.
Student Training and Supervision - Students placed in the positions providing direct service have
at least an hour's supervision with an appropriate supervisor, as outlined by the college/university’s
criteria for supervisory experience, each week. A part of their supervision may be based on live
observation, either audio or video recordings or observations through a one-way mirror. In addition
they may do co-therapy with an experienced therapist during which the student's work can be closely
monitored.
Group Supervision will be held on a monthly basis and all clinical staff will be expected to attend.
Case presentations will be made as desired by the counselor when there is a need for suggestions on
working more effectively with a client or to demonstrate a successful intervention. Feedback will be
received from colleagues and clinical supervisors.
Documentation of supervision is documented in the client’s record. If the provider of services in
not a Qualified Professional the supervisor shall sign off on the supervisory note.
Each staff will receive performance evaluations on a regular basis in accordance with agency
personnel policies. The evaluation will address professional performance, skills, and growth of the
professional self and other agency standards of evaluation. A self-evaluation will be a part of this.
Due to the gravity of the work provided by agency staff the supervisor shall be responsible for
staying attentive to the supervisees’ physical, emotional and mental health needs. The supervisor
may recommend that the supervisee seek services (see Supervision Contract) that can address
medical and/or mental health needs and/or concerns. The supervisor may ask that a supervisee take
time off to help reduce stress levels that could be adversely affecting their work. Training may also
be recommended so as to provide an opportunity for the supervisee to increase their learning with
regards to the use of the professional self. Training may also provide for validation of knowledge
and experiences that may rejuvenate the supervisee so as to continue the focus of the programs
work.
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Policy No.: 4.3
Policy: Assurance of Staff Training for Special Modalities
Assurance of Staff Training for Special Modalities
POLICY
_______________________________________________________________
The agency ensures that only personnel who possess the specific specialized skills or training engage
in such treatment, and that they must be certified and verified of training in this special modality. In
addition, as with other services, on-going supervision will be provided to ensure continued quality
service delivery.
PROCEDURES
_______________________________________________________________
The agency ensures that only personnel who possess the specific specialized skills or training engage
in such treatment, and that they must be certified and verified of training in this special modality. In
addition, as with other services, on-going supervision will be provided to ensure continued quality
service delivery.
Clinical staff members do not engage in any treatment procedures, which are commonly viewed as
unconventional, coercive or controversial. Treatment that is deemed to cause adverse effects for the
client and/or family system shall be stopped immediately and the case reviewed with the Clinical
Director. The client and, if applicable, the parent/guardian will review the treatment goals and
determine the best course of treatment that is therapeutically appropriate and consistent with best
practice.
Staff use a variety of therapeutic methodologies in the counseling service that are client/familycentered, which may include but are not limited to: Structural family therapy,
Strategic family therapy, Bowenian family therapy, Gestalt Therapy, Child-centered play therapy,
Reality therapy, and Behavioral and insight oriented therapy. Depending on the needs of the client
and/or family, the following modalities of counseling are offered: conjoint, individual, family with or
without the identified client, parent-child, couple's group, individual adult group, and
child/youth/adolescent groups. The counseling services offered are supportive in nature, take
psychosocial contexts into consideration, and often provide basic psychoeducational components.
Any combinations of these methodologies and modalities are chosen to meet the client's needs
based on the diagnostic assessment and the treatment plans. Staff is understanding of their impact in
the client system and thus is aware of the use of the professional self. The use of the professional
self speaks to the staff member affecting the client system via modeling positive behaviors,
educating the client on constructive changes and advocating for future growth.
For specialized programs, such as Intensive Family Preservation Services, additional training and
certifications are required. IFPS staff is required to attend and be certified in providing intensive inhome therapy services. State-based trainings are provided for these certifications and proof of these
certifications from staff is kept in their staff/employee files.
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Policy No.: 4.4
Policy: Training Staff about Client Rights
Approved by: Board of Directors Staff about Client Rights
POLICY
_______________________________________________________________
All staff members who have regular client contact are to be aware of, and follow, appropriate
procedures for informing clients of their rights and responsibilities.
PROCEDURES
_______________________________________________________________
At the time of admission, or as soon as feasible (but no longer than 72 hours thereafter for 24 hour
programs or within 3 visits for day/night or periodic services), the client shall be informed of
his/her rights and responsibilities. This information shall be described in the FSDC's Your Rights as
a Client brochure, which shall be distributed at the time the client presents for services (typically by a
support staff member). A more complete explanation of the brochure shall be provided to the client
or legally responsible party by the FSDC staff member who completes the initial admission
assessment. Other applicable program-specific policies, procedures, regulations, rights, and
responsibilities shall be provided by other designated staff if the client enters any additional FSDC
Service Component(s).
The Agency will work to insure that clients who are disabled (i.e. visually impaired, mentally
disabled, etc.), functionally illiterate, or whose primary language is other than English, will be
informed of these rights and responsibilities. A copy of these rights will be posted in the reception
area at each location.
In each program component, the information provided to the client or legally responsible person
shall include:
 the rules that the client is expected to follow and possible penalties for violations of the
rules;
 the client's protection regarding disclosure of confidential information, as delineated in
G.S.122C-52 through G.S. 122C56;
 the procedure for obtaining a copy of the client's treatment/habilitation; and
 governing body policy regarding:
 fee assessment and collection practices for treatment/habilitation services;
 grievance procedures including the individual to contact and a description of the assistance
the client will be provided;
 suspension and expulsion from service; and
 search and seizure.
SUMMARY OF RIGHTS PROVIDED TO ALL FSDC CLIENTS
1. To be informed of their rights;
2. To be treated with dignity and respect, privacy, humane care and freedom from mental and
physical abuse, neglect and exploitation without prejudice of age, gender, creed, race,
ethnicity, religion or cultural background;
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3. To access crisis line and shelter services 24 hours a day/7 days a week
4. To access agency-based services Monday 8am-6:30pm, Tuesday – Thursday 8 am-7 pm, and
Friday 8 am-5 pm
5. To receive quality professional services delivered by staff who are professionally qualified
and supervised
6. To live as normally as possible while receiving care and treatment;
7. To know that information collected during assessment and treatment shall be limited to
what is deemed necessary for appropriate mental health services;
8. To receive age-appropriate treatment and access to medical care and habilitation, regardless
of age or degree of mental illness, developmental disability of substance abuse;
9. To have and participate in the development of a written, individualized
treatment/habilitation plan (including discussion of risks and benefits) within 30 days of
assessment;
10. To be informed in advance of the potential risks and alleged benefits of the FSDC treatment
choices;
11. To be informed of alternative treatment methods;
12. To receive the most appropriate treatment that is deemed the least restrictive and/or
intrusive;
13. To be assured that no confidential information acquired will be disclosed without consent
(unless as authorized by law);
14. To consent to or refuse any treatment offered including behavior management policies and
to understand the consequences of that decision;
15. To withdraw consent from treatment at any time except in court-ordered treatment or
certain emergency situations and to understand the consequences of their decision;
16. To exercise all civil rights unless adjudicated incompetent;
17. To have freedom from corporal punishment;
18. To have access to their treatment record, except when that information would be harmful to
the client's physical or mental well-being;
19. To not have any unauthorized publicity on, or use of, the client's treatment record (except as
authorized by law);
20. To review and discuss the fee for service (if applicable). To review and make suggestions on
the Agency's Service Policies and Procedures
21. To be assured that service delivery will not be influenced by any special contributions or gifts
made to the agency by clients
22. To take complaints to Agency Staff according to the published Client Grievance Policy To
contact and consult with a client advocate and/or the Governor's Advocacy council for
Persons with Disabilities. By contacting the NC Governor's Advocacy Council at:
North Carolina Governor's Advocacy Council for Persons with Disabilities
1314 Mail Service Center
Raleigh, NC 27699-1314
(919) 733-9250 (Voice/TTY)
(919) 733-9173 (FAX)
(800) 821-6922 (Toll free in state only)
(888) 268-5535 (Toll free TTY)
www.disabilityrightsnc.org
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This is the state-wide agency designated under federal and state law to protect and advocate the
rights of persons with disabilities.
CLIENT RESPONSIBILITIES
1. To respect the rights of other clients
2. To be on time for scheduled agency services
3. To be alcohol and drug free on the premises
4. To demonstrate safe, orderly, confidential and cooperative behavior
5. To not bring any weapons into the building
6. To pay fees for services according to the Agency Policy (if applicable)
7. To furnish pertinent personal and financial information as requested
8. To sign appropriate authorizations consistent with the treatment plan or partnership
agreement
OTHER
1. The Agency has the right and responsibility to determine the clients that it can appropriately
service within the limits of its mission, capacity, resources and expertise.
2. The Agency has the right to refuse or discontinue services when the clients' responsibilities
are not being met.
3. The Agency will make every effort to provide service satisfactorily in all respects and
welcomes any questions, suggestions, and inquiries.
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Policy No.: 4.5
Policy: Supervisor Qualifications
Qualifications
POLICY
_______________________________________________________________
Family Services of Davidson County ensures that staff receives supervision from a credentialed
supervisor. Credentialing is determined by the supervisor meeting criteria outlined by their specific
disciplines Licensure Board to provide supervision as well as the procedures set forth by this agency.
Supervision may also be provided by other clinical staff who has demonstrated competencies in the
mental health field that would signify them as “senior clinicians”. Staff who is in need of supervision
that is not available by current supervisory staff, due to specialty licensure/certification, shall receive
assistance by the agency to locate an approved supervisor.








PROCEDURES
_______________________________________________________________
Supervisor shall hold an advanced degree.
Supervisors must provide the agency with documentation i.e. certification or letter of
recommendation, that supports their expertise to provide supervision to staff human
services field.
Supervisors have documented supervisory experience of at least 2 years in the human
services field.
Supervisors are recredentialed with their specific disciplines Licensure Board as
recommended for supervisors (e.g. AAMFT Approved Supervisors- every five years).
Supervisors are to document specialized training with regards to providing supervision to
staff in the human services field that shall include evaluation, diagnosing and treatment of
the population served. Supervision perspectives should be strength based and ecological in
nature. Training should also include team building concepts as a way to ensure
comprehensive services both within the agency and with other resources in the community.
“Senior Clinicians” who provide supervision are to demonstrate supervisory abilities by
completion of formal educational experience that addresses assessment, diagnosing,
treatment planning and psychosocial factors that affect mental health.
“Senior Clinicians” are to document specialized training with regards to providing
supervision to staff in the human services field.
Supervisors shall support and enhance staff’s ability to perform their jobs by teaching and
modeling, as appropriate, technical knowledge and skills, work management and
communication skills, and conflict management skills.
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Facilities
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Policy No.: 5.1
Policy: Safe & Hygienic Work Environment Work Environment
POLICY
______________________________________________________________________________
Each facility will comply with Federal, State and local food sanitation and safety regulations
including facility accessibility, as well those related to the storage,
preparation, water temperatures and service of food and the health of food handlers, if
applicable. All areas to which children or clients have access will be maintained in a
safe and orderly manner, free of potential hazards. Staff will demonstrate safety
practices at all times.
PROCEDURES
______________________________________________________________________________
Food & Water
Food storage will follow the sanitation guidelines and the First In, First Out (FIFO)
method in inventory usage. Safe food handling practices will be maintained before, during, and after
preparation, including maintenance of correct food temperatures.
All facility water temperatures are to be maintained within the specified ranges as
determined by the Department of Health and Sanitation, if applicable by law.
Toxic Materials:
All potentially toxic substances must be stored out of children or clients reach and must
be in a locked cabinet. A specific room or closet for storage of toxic substances will be designated.
This room or closet must be securely locked. Any toxic or hazardous substances and/or materials
will be used only with proper ventilation.
Lighting and Emergency Lighting:
All classrooms, offices, hallway, and stairways will be well lighted. Each facility will be supplied with
an emergency lighting source. Emergency lighting source should be checked monthly.
Outlets and Electrical Cords:
ALL outlets will be securely covered with protective caps when not in use. When possible, outlets
will be fitted with hinge caps to allow covering of plug and outlet
when in use. Electrical cords will be securely plugged into outlet when in use. Cords will be
positioned in such a way to prevent unnecessary access. For example, cords should
not dangle and possibly cause child or client to pull equipment down.
Electrical cords must not be place under rugs, pillows, or other flammable material.
Extension cords are not to be used in any area accessible by clients or children.
Windows and Glass Doors:
Screens will be placed on all windows that open (when appropriate). All windows and glass doors
are constructed, adapted, or adjusted to prevent injury to children or clients.
Drapery or window covering cords are securely bed or fastened out of children's reach
to prevent strangulation. No blinds with lead will be permitted.
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Pathways:
ALL pathways and exit doors are to be kept clear of any debris or barriers.
Smoke Detector and Fire Extinguisher:
1. (See Crisis/Emergency Plan for more information)
Facility Maintenance
1. The Executive Director and/or Office Manager are responsible for oversight of
building maintenance issues
2. Routinely, vendor contracts and/or contacts will be reviewed and updated (i.e.,
housekeeping, lawn/landscaping, electrical, plumbing, heating and air, etc.)
3. Any equipment is to be stored appropriately when not in use
4. Equipment and Appliances (microwaves, coffee pots, oven, stove, etc.) are to only
be used by FSDC staff members. If repairs are required, those should be coordinated
with the Office Manager
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Policy No.: 5.2
Policy: Contagious Disease
Contagious Disease
POLICY
______________________________________________________________________________
Family Services is committed to providing all employees maximum safety by protecting
them from exposure to air and/or blood-borne pathogens. This policy applies to all
employees of the agency.
PROCEDURES
______________________________________________________________________________
A. Risk Assessment
Each program area shall evaluate its likelihood of exposure to airborne and/or bloodborne
pathogens. As well, program-specific routine and reasonably anticipated tasks and procedures will be
established to determine if and where there is actual or potential exposure to human blood, bodily
fluids, or other potentially infectious materials. If the nature of the risk or activity potentially results
in the employee having direct contact with blood or other body fluids to which universal precautions
apply, personal protective equipment and clothing shall be available and worn.
Risk for, prevention and control of HIV/AIDS, hepatitis, and TB and other contagious or
infectious diseases shall be regularly evaluated. Direct contact with persons having
such immuno-deficiencies will be reported to the Executive Director and medical advice
will be sought to determine appropriate treatment, as necessary.
Staff should make the Executive Director or his/her designee immediately aware if
suspected cases are identified. Staff will make arrangements for immediate transfer of
suspected cases to a health care facility for assessment, as necessary.
B. Precautions
Since the health status of potentially infectious materials is not always known,
precautions shall be used consistently. Such precautions shall include, but not be
limited to the following:
-Barrier precautions: All employees shall routinely use appropriate precautions to
prevent exposure when contact with blood or other body fluids from any human
source are anticipated. Gloves shall be worn for touching blood and body fluids,
mucous membranes, or the non-intact skin of all employees, volunteers, and clients
and for handling items or surfaces soiled with blood or body fluids.
-Hand washing: Hands and other skins surfaces shall be washed thoroughly with
soap and water immediately or as soon as feasible if contaminated with blood or
other body fluids following contact. Hands shall be washed immediately after gloves
or other personal protective equipment are removed and upon leaving the work
area.
-Protective clothing: Appropriate protective clothing shall be worn when the
employees have a potential for exposure to blood and other potentially infectious
materials. Type and characteristics will depend upon the materials and upon the
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task and degree of exposure anticipated.
-Containment: Appropriate containment of items that have been in contact with
blood or other bodily fluids will be available for use as necessary.
-Medical Records: Care will be taken to ensure proper documentation of any
exposure related to contagious and/or infectious diseases.
C. Employee Training
The Personnel Director is responsible for maintaining and implementing a current plan
for delivery to all training mandated by OSHA Final Standard for Occupational Exposure
to Blood-borne Pathogens. All employees shall participate in a training program at the
time of their initial employment and annually thereafter at no cost to them and during
working hours. Special attention will be given to HIV/AIDS, TB, and other infectious
diseases.
D. Visitors
All visitors must check in with the Receptionist upon arrival. It is the employee’s
responsibility to make certain that visitors in his/her department, whether employees or
not, are authorized to be there. In cases of doubt, s/he should ask visitors for
identification.
E. Medical Advice
Staff will seek medical advice to remain current regarding health regulations and
approved treatment.
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Policy No.: 5.3
Policy: Smoke-Free Environment
POLICY
______________________________________________________________________________
It is the responsibility of Family Services to provide and maintain a safe and healthy work
environment. Therefore, smoking is prohibited inside all agency facilities.
PROCEDURES
______________________________________________________________________________
This policy is applicable to all employees, volunteers, and clients on agency property.
Designated smoking areas are located outside of the upstairs and downstairs entrances. A
covered area and smoking urns are available.
Family Services may, at its discretion, designate additional smoking areas. Employees and
volunteers are expected to comply with this policy.
If desired, FSDC will assist those requesting information/referrals for smoking cessation
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Policy No.: 5.4
Policy: Conservation of Resources(equipment, energy, supplies, etc.)
Conservation
POLICY
It is the policy of Family Services of Davidson County, Inc. to reduce a negative impact on the
environment by recycling, disposing and/or utilizing resources in an environmentally responsible
manner.
PROCEDURES
The purpose of this policy to ensure that all employees contribute to effectively managing our
resources in order to save energy, conserve resources and improve the environment for all
staff.
The Office Manager in conjunction with the Executive Director and Program Directors is
responsible for educating all employees on this policy (*as well as related policies regarding
facility safety, hygienic work environment, contagious and infectious diseases, and bloodborne
pathogens).
Facilities
Family Services is a smoke-free environment (*see related policy)
Recycle bins are located in the upstairs break room and downstairs kitchen area. Staff
members are encouraged to use these receptacles to recycle plastic, paper and cardboard
items
Whenever available and cost-justified the following items shall be given preference when
purchasing decisions are made: Recycled content paper products, including but not limited to
tissues, office paper, toilet paper, water saving devices, items with auto-shut off or energy
saving options, low energy use lighting, locally sourced materials, and other related items.
Family Services will incorporate energy efficiency into the decision-making process during the
design and acquisition of facilities and equipment when cost effective. Additionally, using
products with longer documented life spans, less waste, and renewable materials will be a goal
in this process
Staff should make a member of the Management Team aware of any appliances and/or office
equipment that is not working properly. An appropriate assessment will be made whether to repair
or replace the item in question. All staff share the responsibility of taking care of agency equipment.
As a non-profit organization, we must manage all resources as wisely as possible.
A designated member of FSDC’s administrative staff is responsible for “locking up” each night.
This includes making sure that resources are secured (locked, put away, etc.) and that no equipment
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or unnecessary lights are left on overnight. However, all staff are responsible for sharing in this
practice and being vigilant and active in maintain a safe, energy efficient environment.
Disposing of Medications
FSDC does not house or retain prescription medications at our agency location. However,
shelter residents may have medications on site that require disposal upon the client’s
departure. In such cases, the Shelter Manager or Crisis Intervention Director will transport
drugs/prescriptions to Medical Ministries in Lexington, NC in order to be appropriately
incinerated.
Energy and Resource Efficiency
All employees shall turn off computers, monitors, printers, shredders and any other equipment
overnight or when not in use for more than 4 hours whenever possible. Hibernation options
should be utilized when equipment is not in use.
Office lighting shall be turned off at the end of each business day with the exception of
designated common areas.
The air ventilation system shall be balanced to ensure optimum efficiency.
Employees will be cognizant of resource waste and will promptly report such to the Office
Manager or Executive Director (i.e. leaking fixtures, unnecessary lighting etc).
Implementation
Products and practices generally accepted to be environmentally questionable or irresponsible
will be prohibited.
Any violation of this policy may subject the employee to disciplinary action under existing
personnel disciplinary procedure.
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Policy No.: 5.5
Policy: Facility Accessibility
Facility Accessibility
POLICY
______________________________________________________________________________
Family Services of Davidson County, Inc. strives to make services available and meaningful to
all clients.
PROCEDURES

FSDC’s facilities are centrally located in Davidson County and are easily accessible. The
agency does partner with Davidson County Transportation regarding services for eligible
clients (*Note: Neither the city of Lexington, nor Davidson County provide public
transportation – i.e., buses)

FSDC’s facility meets required standards regarding accommodating individuals with
physical disabilities. Entrances and hallways are wide and provide appropriate
wheelchair access. Reception areas, offices, conference rooms and restrooms also
comply with these standards.

Sidewalks are slopped and wheelchair accessible. The facility has two entrances (upstairs and
downstairs) in order for clients to avoid stairs, if necessary.

FSDC contracts with community resources to provide interpreters (if needed) for hearing
impaired and Spanish speaking clients.
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Policy No.: 5.6
Policy: Shelter Handicap Accessibility
Shelter Handicap Accessibility
POLICY
______________________________________________________________________________
Crisis Intervention Services provides assistance to all victims of domestic violence and sexual
assault regardless of any handicapping condition.
PROCEDURES
______________________________________________________________________________
-The Hattie Lee Burgess House is handicapped accessible. The facility maintains a ramp for
entrance into the building. All doorways are an appropriate width for wheel chairs. Handicapped
restroom facilities are provided. Counter space and kitchen appliances are located at an appropriate
height for wheelchairs.
-Clients who request advocacy services at our office locations have handicapped accessible
entrances and exits.
-Clients who are deaf can access agency services through the use of interpreters or by TDD
provided by the local telephone service, Crisis Ministry and through Services for the Deaf
and Hard of Hearing.
-All shelter residents need to be able to provide for their own care. Those who cannot
provide for their own care will be provided with case support services. All services will be
coordinated with Adult Protective Services of the Davidson County Department of Social
Services.
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Policy No.: 5.7
Policy: Facility Safety for Victims
Facility Safety for Victims
POLICY
______________________________________________________________________________
In order to ensure the safety of the named victims of the participant’s actions, Victim Follow-up is
conducted the Crisis Intervention Program.
.
PROCEDURES
______________________________________________________________________________
-AIP Program shall make good faith attempts, which shall be documented, to make
contact with the victim upon the participant’s enrollment in the program. This contact must include
information about the program and its limitations, victim confidentiality, and local resources for
victims. The program shall attempt, in collaboration with Crisis Intervention Unit Advocates, to
contact the victim when the program participant has begun the program, completed half of the
sessions, and at termination, unless the victim declines contact or is unable to be located.
-Program participants and persons who have been victimized by those participants
may receive direct services from the same agency. In those instances, the same
staff person or volunteer shall not provide services to both parties.
-All information about or from the victim shall be kept confidential from the program
participant, except with written permission from the victim.
-The program shall not schedule victim’s groups and abuser treatment groups to
occur simultaneously at the same facility.
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Policy No.: 5.8
Policy: Crisis Policy
Crisis Policy
POLICY
______________________________________________________________________________
A crisis is an event that can destroy or affect an entire organization. A crisis can affect
the very existence of our agency, an individual program, or the like. A crisis can
damage the agency's financial performance; harm the health and well-being of our
clients, student interns, volunteers, employees, or our neighbors in the community;
damage or destroy the public's basic trust or belief in our agency, our reputation and
image.
PROCEDURES
______________________________________________________________________________
The major goals of the crisis management plan are:
-To take whatever action necessary to protect the clients, staff, agency, or others
from harm.
-To correct, or rectify, in an open and forthright manner, any wrongdoing that was
caused by any actions or omissions of our student interns, volunteers, employees,
or others.
-To do whatever necessary to preserve the integrity and reputation of our agency by
damage control activities, assuming a posture of honesty and fairness.
-To be a "learning organization" and thereby make every effort to learn from our
mistakes; to possibly change a crisis to an opportunity; to offer forgiveness to those
who erred; and
-To develop or improve agency systems to help prevent mishaps in the future.
Crisis Management Team:
The Crisis Management Team (CMT) at Family Services is composed of agencies Management
Team (Executive Director, Finance Officer, Office Manager, Clinical Director, Crisis Intervention
Director and YCS Director)
Depending on the nature of the "crisis" other individuals may be included on the CMT.
Others may include our legal counsel, board chair, insurance agent, or others as
appropriate.
The CMT is responsible for developing a plan for responding appropriately in the midst
and aftermath of a crisis. The primary task of the CMT is to assume that prevention
measures have failed and the crisis is at hand. The team then develops responses to
the crisis situation that will enable the organization to minimize losses, restore mission-critical
functions in a timely fashion, to communicate with the media, and to protect the
overall viability of the organization.
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Establish a Command Post:
When an emergency or crisis occurs, a central location for assuming command, control,
and communication functions will be designated. The command site will most likely be
at the main office because of the availability of files, phones, faxes, copy machines, and
clerical help. The Executive Director, or her delegate, will determine the site of the
command post.
Crisis Stabilization
Ascertain the nature of the crisis, the extent of any injuries or other damages, and the
current status of the situation. If the crisis occurs in a remote location, the Executive
Director will establish a chain of command to initiate the agency's response to the
incident. The Executive Director, in conjunction with the CMT may delegate a member
of the team to go directly to the site to help implement the crisis plan.
The site director’s principal task is getting key players to focus their attention on
implementing the crisis plan before panic sets in. He or she must mobilize members of
the CMT, assign and clarify responsibilities, delegate tasks in order of priority, combat
negative thinking, refrain from dwelling on the cause of the crisis, and deal with the
impact of the crisis at hand.
Organize Information
Gathering and organizing information necessary to make critical decisions should be a
top priority. A link between the site of the emergency and the decision-makers in the
command post must be maintained. Information that will be required to manage the
crisis includes:
-What happened
-Who is involved: list names, and sequester staff and client files.
-Were there injuries? If so: Who was injured? What is their condition? Are they
being treated? Where? Have family members been notified?
-Were there fatalities? Who? Have next-of-kin been identified and notified?
-What is the extent of property damage? To the organization's property? To the
property of others?
-Is there an investigation in progress? What agency is investigating? Who is the
primary investigator?
-Who was supervising the activity? Is that individual still capable of exercising
leadership? Is he or she a client, student intern, volunteer, or employee?
-Are all of the participants accounted for? Was there a completed head count?
-What emergency assistance is on the scene? EMT? Fire Department? Police or
other law enforcement agencies?
-Are there special circumstances such as the presence of toxic materials or other
hazardous conditions associated with the emergency?
Maintain a Written Log During Crisis Operations:
A crisis may give rise to chaos. For this reason, the command post should keep a
chronological log of actions they take, when they take them, with whom they talk, and
whether the outcomes of these actions require follow-up. The log is so important that,
when possible, the responsibility for maintaining it should be assigned to one individual.
The individual keeping the log should time-code all entries. Such records can be
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valuable when debriefing after a crisis (drill or real) or when preparing to initiate or
respond to legal actions arising from the crisis. Remember that legal action against the
organization may be initiated months or years after the incident making the
contemporaneous log a valuable tool for reconstructing the organization's response
once it became aware of the emergency.
Protect, Direct and Support People:
When a crisis occurs, the crisis management team's top priority must be to protect the
individuals affected by the crisis situation, prevent injuries, provide first aid and medical
care to those who are injured, and offer emotional support and counseling to the people
affected. Putting people first is not only the humane, ethical response; in the long run it
facilitates the organization's return to its pre-crisis status.
Evacuation:
Evacuation instructions are located near the light switch in each office. Instructions
detail the evacuation plan for internal and external emergencies, i.e. fire, weather,
fumes, etc. Exit drills provide training for each staff member in executing the evacuation plan.
Every staff member should be aware of evacuation plans and be able to “guide” clients or other staff
members out of the building.
Designated Assembly Areas:
a)Greensboro Street Extension office: The basketball court and/or the van parking area
at the rear of the building.
b)Domestic Violence Shelter: west end of parking lot at the dumpster.
These areas will be used for evacuations where exiting the building is necessary.
Staff should be aware of evacuation plans/procedures when using other facilities,
i.e. churches, schools, hotels, etc.
Each program director or alternate will be responsible for a “head count”, starting with
their own staff and then assisting other program directors. Emergency personnel
should be notified of those staff members who are unaccounted for. FSDC should
develop a clear plan for those who are unaccounted for in case of an evacuation.
Once the building is evacuated no one is to be allowed back into the building until
emergency personnel give an all clear for reentering.
Designate zones to program directors for ensuring that equipment is turned off and files
are locked, etc, only if time permits.
Provide First-Aid and Initial Self Help:
Each staff member is responsible for calling 911 if an emergency is occurring in their
office and/or location. If the panic buttons are activated, there is an automatic call to
911. Please be aware that the panic buttons are audible alarms and will sound for the
entire building.
Each staff member will be trained in the use of a fire extinguisher. If you have not been
trained to use a fire extinguisher please see your direct supervisor.
Only those staff members who have been trained in administering first-aid are to
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provide initial first-aid care. Please see your direct supervisor if you have first-aid
certification, including CPR, or if you are interested in being certified.
First Aid supplies are located:
a) Greensboro Street Extension office: upstairs – mail room cabinet; downstairs –
kitchen cabinet
b) Hattie Lee Burgess Shelter: upstairs – medicine cabinet; downstairs – supply
cabinet
If a client has been injured at any of our offices or while participating in an FSDC
planned function, staff should refer the client to their primary care physician or to the
Health Department for medical follow-up. If the injury involves an open or closed head
injury, arrangements are to be made for medical follow-up. If a client refuses to seek
medical attention please have the client sign Denial of medical attention form. Place
the signed form in administrative mailbox for filing.
Staff Member in Crisis:
See FSDC Employee Manual (Harassment Policy, Standards of Conduct, Unpaid leave of
Absence, and Grievances).
Prevent Further Injury:
Preventing staff from reentering an unsafe building. Evacuation should be far enough away
from the building to assist management personnel from allowing staff back into the building.
See Evacuation.
Protocol for handling incidents away from the main office. The Crisis Line and/or the
use of FSDC issued cell telephones should be used for informing the office of a crisis.
The Crisis Line would inform the immediate supervisor (or follow a “calling tree” to
inform a member of the management team). If the incident occurred during regular
work hours/days, the staff member will contact their immediate supervisor or another
member of the management team. If an incident occurs away from the primary place of
operation, FSDC staff are to use appropriate measures to contain the problem and transport staff
and clients back to the primary place of operation. Training would be at the center of handling crises
away from the office.
If staff should detect problems with either hardware or software please contact direct
supervisor or the office manager. Management or administrative staff will contact
Stateside Data regarding protecting hardware and software or other computer
issues.
Recognize Stress and the Effects of Trauma:
Direct supervisors are to have regularly scheduled supervision with staff, to not only
detail work, but to check on the status of each employee. Staff who are dealing with
difficulties associated with their job responsibilities may be asked to schedule
appropriate time off or to scheduled needed training. Please refer to “Benefits” in the
Employee Manuel to address other concerns and/or options.
The response to a traumatic event, which may be experienced by FSDC staff, would be
addressed through Critical Incident Stress Debriefing (CISD). CISD will be provided
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through a contractual agreement with Family Service of the Piedmont.
Continued staff development/training can assist staff with the issue of stress. Our jobs
involve a great deal of stress and our policy of continued education, training, and staff
retreats will help address this issue.
It is recommended that FSDC consider an EAP for staff. If we are looking into other
health insurance carriers, an EAP that is tied into the health policy would be the least
expensive.
Financial, and other Personal support:
Current insurance coverage ensures that our agency will have the financial means to
operate in the case of a catastrophic event i.e. fire.
Protect and Maintain Resources:
Once people have been protected, the crisis management team should take steps to
minimize damage to the organization's tangible assets - real estate, equipment,
records, and financial resources.
Protect Facilities and Equipment
During an evacuation, organizations should take steps to limit damage to equipment
and records, and to make conditions safer for personnel entering the evacuated areas.
All electrical equipment, especially computers, should be turned off. This equipment
will suffer less damage from water when powered down, and the environment will be
safer for firefighters and other emergency response personnel who come into contact
with equipment. Water and fire resistant file cabinets should be closed (locked if
possible) to protect their contents as much as possible.
Access to areas affected by the emergency should be controlled to limit the possibilities
of looting and vandalism as well as to protect people who may not understand the
hazards they are approaching. Controlling access may require retaining the services of
a security firm to patrol the area and protect the property.
Maintain and Protect Vital Records
In many emergency situations, critical records may not be readily available, and the
organization's continued operations and survival may depend upon the manner in which
our crisis plan addresses the issue of vital records - including protection, access,
retrieval, and recovery. Records are vital if they:
-are needed to reconstruct an organization's activities;
-outline the organization's financial condition, debts, and receivables;
-document the organization's legal obligations such as contracts, ownership, and
other corporate affairs; or
-document unique features of the organization's service delivery.
For example, personnel records are vital because they contain staff and employee
information necessary for the notification tree and record commitments made to
employees.
The following approaches to protecting our vital records and ensuring the availability of critical
records in the aftermath of a crisis will be utilized:
-Designated and clearly labeled location for vital records.
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-Regular back-up computer files of vital records.
-Limit access, via locked drawers or special computer passwords, so that records
cannot be changed, destroyed, or otherwise manipulated.
-Surge protector on every computer.
-An inventory list that includes the specific names of critical files, their size, the media
used for storage (paper, computer disk, computer back up), their physical location,
storage equipment (file cabinet, computer drive, transfer case), and the consequences that loss of the
record would have on the organization.
-Copies of vital records and securely store the copies off-site.
-Arrange for evacuation of records to alternate facilities.
Protect Other Records as Appropriate
Family Services of Davidson County, Inc. has records that are not necessarily "vital" but
are clearly important to ongoing operations. Some of these important records may
become vital under certain circumstances. For example, if our agency is named in a
lawsuit, records such as consent forms, waivers, warnings, relevant medical history
documents, staff evaluations, and other paperwork will become vital to protecting our
legal interests. If an insurance claim is filed following a crisis, inventory, maintenance
records, blueprints, and insurance policies may prove the entitlement to recovery and
support the reimbursement owed. These documents will be stored in fireproof safes
and files.
Communicate with Stakeholders:
Our agency must be prepared to communicate about the crisis and the actions it has
taken to a defined internal audience, as well as an undefined external audience the
general public. Strategies for effective organizational (internal) communication as well
as public (external) communication during a crisis will be followed.
Communicate with Insiders
A critical component of our crisis plan is the strategy for communicating with people
inside the organization who will be assigned to implement the plan as well as others
directly affected by the plan. Many emergencies occur outside normal working hours.
As a result, we need to be able to contact essential personnel at home or wherever else
they may be. Under a calling tree, each supervisor is responsible for calling his or her
direct reports. The calling lists should include any alternative numbers, such as cellular
telephone numbers and pagers.
During a crisis it is imperative that our agency stay in touch with its principal
stakeholders and keep them informed about the nature of the crisis and the steps that
the organization is taking to cope. Our stakeholders include:
-clients and staff, whose concern is the personal safety of friends and continued
services;
-families, whose concern is the safety and present location of the family members;
-board members, whose concern is the adequacy of the crisis response and their
personal liability;
-affiliates/national organizations, which are concerned with their own response duties
and with assisting the organization resume operations;
-a vendors or suppliers, whose concern is the emergency's impact on current or
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future delivery of goods and services;
-retained professionals (for example, legal and insurance), whose concern is to
protect the nonprofit's interests.
-regulatory agencies, of which we are mandated reporters.
For instance, our insurance agent will need access to information necessary for filing a claim,
such as the cause of the crisis, nature of any damage or injury and the status (paid or
volunteer) of "involved" parties. A relative of a staff member may initially only be concerned
about whether their loved one has been accounted for and is safe.
Deliver Notifications of Serious Injury or Death
Organizational communication responsibilities may occasionally include delivering tragic
news. When an injury is serious or fatal, our agency is prepared to notify the next-ofkin.
Timely notification is important. It should occur as soon as possible after the injury
or fatality occurs.
The notification should include confirming the identity of the contact and his or her
relationship with the injured party, a brief description of the extent of the injuries (if
known) what is being done to treat the injuries, and the location where the injured party
is receiving medical treatment.
Personal contact can temper the impact of the crisis on the victim and the victim's
family, though it probably is not necessary for any of the other interested parties. Face-to-face
contact shows more compassion than a telephone call, and the person
delivering the message may be able to help the family cope with their trauma. Remember, however,
that the message should be limited to expressing genuine concern and should not include any
expression of responsibility for the tragic outcome.
At times, the next-of-kin notification will be made by a law enforcement agency or the
local coroner's office. When this occurs, our agency will follow up with our own contact,
express the agency's concern, and offer assistance and support to the injured parties
and their families.
Communicate with the Public
A single event is likely to affect a wide variety of people, and the Executive Director and
her delegates will determine how to strike a balance between full disclosure and no
disclosure, between candor and prudence. The spokesperson will focus on the
concerns relevant to the specific person or group receiving the information.
The following is a list of media organizations the agency will contact in preparing for
communications during a crisis.
Included in the list of printed media contacts is: The Dispatch (336) 249-3981, The Thomasville
Times (336) 472-9500, The Denton Orator (336) 859-3131, The Greensboro News and Record
(336) 373-7000, The High Point Enterprise (336) 888-3500, and The Winston-Salem Journal
(336) 727-7211.
Included in the list of Radio and Television Station Contacts is: WWGL-FM & WLXN- AM (336)
248-2716, WGHP-TV8 (336) 841-8888, WFMY- TV2 (336) 379-9369, and WXII-TV 12 (336)
721-9944.
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The Executive Director or her delegates will handle all media contact. The form of
communication strategy used to get our message to the public can include: a press
release, press conference, and/or a telephone interview. A prepared statement with the
facts, as the organization understands them, and the organization's official position; a
brief summary of the organization's history and our mission will provide background
information that members of the media may not know.
Debrief the Staff after the Media Communication
Family Services will provide information to its employees about the media plan including who is the spokesperson and what to do if contacted by a reporter. With
everyone's cooperation, we can control material used to prepare the story and provide
accurate, positive information. An organized effort will ensure that the crisis
communication is quick, accurate, thorough, and credible.
Restore Operations
Restoring our operations begins with assessing how much damage has been done to
critical functions. Irrespective of the nature of the crisis, the goal of recovery is to return
to pre-crisis status, as soon as possible.
Some crises, such as a tornado, may trigger an accidental release of a toxic or
otherwise hazardous substance, underground piping and utility lines may be no longer
attached and operational equipment may be destroyed. Under these circumstances,
restoring operations may involve recapturing, neutralizing, or at least containing the
spread of a toxic or otherwise hazardous substance.
After ascertaining the damage, we will determine whether outside expertise is
necessary to bring the operations back to normal (counselors, engineers, or certified
industrial engineers, an occupational physician, a toxicologist, or OSHA certified
hazardous materials technicians).
Identify Alternate Sites
If the emergency rendered our facilities unsafe, we will need to locate suitable facilities
for relocating our operations on a temporary or even a permanent basis. As part of our
planning process, we have developed alternate locations for our programs.
Limit Stress on People
In the aftermath of a crisis, staff or volunteers may be too eager to restore operations
and underestimate their own physical and emotional limits. The crisis management
team should carefully monitor staff activities to make certain that employees are not
overly stressed by trying to restore operations overnight. The crisis commander should
express appreciation for each person's commitment to the organization while explaining
the value of taking the time to follow the restoration schedule and not try to do too much
at once. If the extent of damage or nature of the emergency makes the restoration
schedule unrealistic, it should be adapted to meet the existing circumstances.
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Prepare for Litigation
The filing of a lawsuit begins a long, expensive process. The person or organization
responsible for an alleged injury must hire an attorney, file an answer to the complaint,
and make certain documents available for inspection and knowledgeable staff available
for interviews (known as depositions) before a court reporter. These defense costs may
amount to thousands of dollars and are generally incurred regardless of whether the
agency is ultimately found to be responsible for the injury. Appropriate insurance
coverage for our agency includes:
-General liability insurance, to cover general bodily injury and property damage claims;
-Automobile insurance, to cover bodily injury and property damage claims
-arising from the operation of a vehicle (both owned and non-owned);
-Directors' and officers' insurance to cover actual or alleged errors, misleading
statements, and neglect of duty claims against the governing board. Also coverage
for personnel issues.
-Professional liability insurance, to cover claims arising from the rendering or failure
to render professional services;
-An umbrella policy, to provide additional limits after an underlying coverage has
been exhausted.
-Business interruption policy, to cover losses if a program site is shut down as a
result of fire, flood, etc.
There are a number of things our organization will do to expedite payment for losses
covered by insurance, including:
-contacting our insurance agent as soon as possible;
-documenting our losses to satisfy insurer requirements. Documentation will include
before and after photographs of the damage;
-setting aside damaged equipment and supplies for inspection by insurance adjusters;
and cooperating with government authorities and insurance professionals.
Pay for the Damages and Injuries.
A crisis has occurred in the community and our agency has been affected. The
damage is done. Efforts are underway to restore operations. It is going to cost our
agency.
Two alternatives generally exist: using the organization's resources to pay for the loss
(retention of risk) or relying on a contractual agreement that requires someone or else
to pay for the loss (transfer of risk). The course of action we follow will be determined
by the nature of the crisis, our insurance coverage, and by our stated goal of "making
things right" when a crisis occurs. The CMT will decide on the proper course of action
to correct the situation.
Debrief Insiders and Update the Plan:
Maintain Continued Contact with Injured Staff
As noted before, trauma is not overcome overnight. Stress may affect a staff member's ability
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to concentrate, personal losses may be overwhelming, and individual's timely return to work,
decrease general anxiety, and reduce the amount of workers' compensation losses.
Maintain Continued Contact with the Media
Although the press is likely to lose interest in the crisis once the acute phase has
passed, it may be in our best interests to maintain contact with media organizations.
The organization can highlight its positive response to the situation, express remorse
for the loss, and keep the public informed about the progress of the restoration, any
new locations, and plans for the future. With the approval of legal counsel, the
organization may also want to inform. the community about any changes that have
been implemented to prevent such incidents in the future.
Maintain Contact with Stakeholders
Contact with the families of clients, student interns, volunteers, employees and other
interested parties is warranted. Who is contacted by whom, and the method used
(phone, letters, person-to-person, etc.) will be documented.
Investigate Causes
Without focusing on fault, an investigation should be conducted to determine the cause
of the crisis and evaluate relevant injuries (physical injury, property damage, lost
income, and damage to the organization's reputation). The crisis planning team should
convene to discuss and consider methods to avoid a recurrence. Was it caused by a
hazardous condition? Poor staff training or oversight? A criminal act? An
unpreventable natural disaster? An unpreventable economic or regulatory change? A
breakdown in the risk management program? A team, led by a member of the
management team, will conduct an internal investigation. The team will review any crisis
logs or documents created during the crisis, relevant operational policies and
procedures, as well as the crisis plan.
Team members will interview (and tape record or otherwise document the interview)
witnesses to an incident, affected parties (when they have recovered enough to
remember the incident), and other people, who may have relevant knowledge
concerning what happened and why.
They also may want to photograph or videotape the scene where the incident occurred
as soon as possible after it happened to document physical conditions that may have
contributed to the mishap.
Attorney/Client privilege – depending upon the nature of the crisis and the likelihood of
litigation, it may be appropriate to ask our outside legal counsel to serve as a post-crisis
"investigator". Conversations he has with staff during the weeks following the crisis may
be protected by the attorney/client privilege and any incident report documents
coordinated by the attorney may also be protected.
Not investigating is a dangerous, high-risk strategy. An investigation can yield
information and insights necessary to prevent future incidents. In addition, a thorough
investigation will strengthen overall agency management and support the preservation
of evidence that may be necessary at a trial
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Report and Remediate
Because the crisis incident, by definition, involved the possibility of catastrophic
consequences and threatened the viability of the agency, the review team's finding and
recommendations should be presented to the board of directors. The board should
participate in developing and adopting policies to control risks that threaten our
agency's viability.
The framework for the Crisis Management Policy and Plan was drawn from concepts and
excerpts from:
Northwood Children's Services, by James Yeager, President and CEO; Duluth, Minn.
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Policy No.: 5.9
Policy: Emergency Response
Response
POLICY
______________________________________________________________________________
The following plan addresses procedures to protect the health, welfare, safety and security of
all individuals involved in a crisis situation at Family Services of Davidson County, Inc. These
procedures are not intended to be all inclusive but are intended as guidelines in response to
Internal Crises i.e. fire, gas leak, medical emergency, violent client/employee or External Crises
i.e. weather or other natural disasters.
PROCEDURES
______________________________________________________________________________
Internal Crisis
Violent Individual Located inside Staff Office - The staff member has determined that
the situation within their office is not safe and has exhausted all appropriate attempts at
de-escalation.
Action: Push the panic button. This sets off an audible alarm.
Response: Response Team members check the keypad to identify the location of the
emergency and a member requests the Front Office to notify staff of the problem. The
security system will automatically call local authorities.
Action: Notification of staff on the intercom system using *48* and the following phrase:
“Attention all staff: Please meet Dr. Green in (state the panic button location).”
Response: All staff will immediately close & lock their office doors and remain inside
until an all clear is sounded with the exception of the Response Team. This is to ensure
the safety of staff as well as clients/visitors.
Action: Response Team responds to the panic location.
Response: The Response Team will assess the situation, formulate a plan and take
appropriate action.
Action: When the Response Team and/or the local authorities have determined that it is
safe for staff/clients to return to normal operations, an all clear announcement will be
made either over the intercom or via door to door notification by the designated
Response Team member.
Action: A follow-up report will be filed with the Executive Director.
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___________________________________________________________________________
Violent Individual Enters Lobby Area - Administrative Staff has determined that the
situation in the lobby is not safe.
Action: Push the panic button
Response: The security system will automatically call local authorities.
Action: Notification of staff on the intercom system using *48* and the following phrase:
“Attention all staff: Please meet Dr. Green in the conference room.”
Response: All staff will immediately close and lock their office doors and remain inside
until an all clear is sounded with the exception of the Response Team. This is to ensure
the safety of staff as well as clients/visitors.
Action: Response Team responds to the conference room.
Response: The Response Team will assess the situation, formulate a plan and take
appropriate action.
Action: When the Response Team and/or the local authorities have determined that it is
safe for staff/clients to return to normal operations, an all clear announcement will be
made either over the intercom or via door to door notification by the designated
Response Team member.
Action: A follow-up report will be filed with the Executive Director.
Fire/Gas Leak Located or Suspected in the Building - The staff has discovered or
suspects that there is a fire or gas leak.
Action: The person who locates the fire/suspected gas leak will announce over the
intercom using *48* and the following phrase: “Attention all staff: A fire (gas leak)
has been reported at (state the location). Please evacuate the building referring to
your evacuation plan immediately.”
Response: Any staff member located near the keypad should push the Auxiliary panic
button “A “for Fire or pull a Fire Pull. This will notify the Fire Dept.
Response: If there is a fire, the Response Team members closest to the location will
determine if the fire can be extinguished by staff. If so, an attempt will be made to do
so. Evacuation of other staff and clients will proceed as noted on the evacuation plan
next to each door. All staff will remain in their designated area until the all clear is given
to return to the building.
Response: In the event of a gas leak, all staff will evacuate the building, assisting
clients as necessary via the instructions on the evacuation plan located on the rear of
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each door. All staff will remain in their designated area until the all clear is given to
return to the building.
____________________________________________________________________________
Medical Emergency - Staff member or client appears to be in medical crisis.
Action: The staff member discovering an urgent medical need will immediately call
911. Then same staff will announce over the intercom using *48* and the following
phrase: “Attention all staff: There is a medical emergency in (state location).”
Response: The Response Team members or other staff trained in First Aid/CPR will
respond to the location and attempt to assist until EMT’s arrive.
External Crisis:
Weather Emergency
Action: In the event of a weather emergency the staff member who is aware of the
situation will notify the front desk and all other staff and clients by using feature *48*
and an appropriate statement.
Response: Staff and clients will follow weather safety procedures established by the
National Weather Service. Evacuation of staff and clients will proceed as noted on the
evacuation plan next to each door. All staff will remain in their designated area until the
all clear is given to return to normal operations.
Other External Emergencies - Depending upon the type of emergency, staff will be
notified as to the appropriate actions to take.
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Policy No.: 5.10
Policy: Vehicle/Driver Management
POLICY
______________________________________________________________________________
Employees of Family Services of Davidson County, Inc. who use personal vehicles for agency
business and/or client transportation.
PROCEDURES
______________________________________________________________________________
All employees are to be cognizant that their first responsibility while driving is the protection of
person and property. This can best be promoted by attending to the task of driving, obeying the
law, and driving defensively. For positions that include driving Family Services’ owned vehicles
for the transport of others, a copy of the employee’s driving record might be obtained.
Any *driving habits, violation of instructions for vehicle handling and passenger protection,
failure to drive defensively, or other conditions or occurrences which would indicate continued
threat to safety of persons or property shall be reason for release of any staff member from
positions requiring client transport.
*Due to safety concerns the use of a *cellular telephone is not permitted during the operation of
agency vehicles. Smoking and eating are not permitted in agency owned vehicles.
*Cellular telephones are to be used only by staff that is not operating the vehicle. If a staff
member, who is operating the vehicle, needs to use or answer a cellular telephone they must
first pull off the road and park.
Insurance
Each individual using their vehicle for work-related activities must carry responsibility for personal
liability (see A. 1).
Accident Report
All accidents involving Family Services’ staff while on duty will be reported immediately by
the employee or volunteer involved to the employee’s supervisor or to the Executive Director. A
verbal report will be given to the Executive Director, or in his/her absence, the Program
Director, as soon as possible followed by a detailed comprehensive written report.
Risk Management
Family Services of Davidson County requires that employees who regularly transport clients
complete a “Driver’s Agreement” form. The form should be signed and dated by both the
employee/driver and an authorized administrator and kept on file. The driver’s agreement
specifies company policy on issues such as valid driver’s license, maintaining financial
responsibility for personal vehicles, notification of management of significant changes in driving
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status, etc. Periodic reviews of MVR’s enable management to determine if a driver meets
company requirements as an authorized driver.
PROCEDURE:
The driver’s Motor Vehicle Record (MVR) may be checked to ensure that they remain
eligible to be insured by our current vehicle insurance carrier. Drivers who are no
longer eligible for coverage will either be reassigned to a non-driving position, or
available, or terminated.
Designated employees may be called upon to drive their personal vehicles on company
business. The following procedures have been adopted in order to minimize the
potential for losses arising out of claims involving vehicles that are not owned by the
agency but used on agency business.
Use of personal vehicles in conjunction with any activity that relates to company
business must be reviewed and approved by management.
All drivers of personal vehicles on company business must provide evidence that they
have auto liability insurance. A certificate of auto insurance must be obtained and
given to management upon hire and periodically, as requested.
In the event of an accident while driving a company vehicle or a personal auto for
company business, the driver is to follow these procedures:
 Take immediate action to prevent further damage of injury at the scene of the accident.
 Call the police. If someone is injured, request medical assistance. If fire is involved, request
Fire Dept. aid.
 Do not leave the vehicle unattended except in extreme emergency.
 Exchange “traffic accident exchange information” forms with other driver(s). Give
identifying information to the other party involved, but make no comments about
assuming responsibility.
 Secure names and addresses of all witnesses. Witnesses should be asked to
complete a Witness Information Card. If there are no witnesses, the name and
address of the first person to arrive at the scene should be obtained.
 Report the accident. The driver should call management immediately in the event of any
accident, regardless of how minor.
Post Accident Testing
All operators of vehicles are subject to testing when they are involved in a
“reportable accident.”
A reportable accident is defined as any accident which results in the death of a human
being or bodily injury to a person who, as a result of the injury, immediately receives
medical treatment away from the scene of the accident; or total damages to all property
aggregating $3,900.00 or more, based upon actual costs or reliable estimates. If
substance abuse test is conducted in any of the aforementioned situations, and the test
result is positive, the employee who tested positive will be assisted in seeing and
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obtaining treatment without undue delay. Nothing in this policy is construed to prohibit
the agency from its’ responsibility to maintain a safe and secure workplace for its
employees or from invoking such disciplinary actions as may be deemed appropriate for
actions or misconduct by virtue of their having arisen out of the use or abuse of alcohol
or drugs or both.
Driver Agreement Form
I may be asked to drive a company owned/leased vehicle or my personal vehicle in the course of
designated company business. I understand that I must maintain eligibility to drive as a condition of
my employment, and I agree to the following:
-To use seat belts/restraint devices for myself and passengers I may be transporting at all
times. In the event the passenger is a child, approved child restraining devices must also
be used as required by law.
-To retain a valid driver’s license for the type of vehicle to be operated, follow all license
restrictions, and keep the license(s) with me at all times while driving.
-To comply with all company operational rules as well as state and federal vehicle operation
laws. This includes any DOT requirements for CDL drivers, such as successful completion
on medical, drug and alcohol evaluations.
-To maintain the following minimum level of auto liability insurance, if I drive my personal
vehicle during the course of authorized company business: $100,000 each
person/$300,000 per accident for Bodily Injury, $50,000 Property Damage; or $100,000
combined single limit. I will provide a Certificate of Insurance upon hire and then at the
beginning of each new policy period.
-To notify management immediately if any of the following should occur:
-I receive a citation for driving under the influence of drugs or alcohol
-I receive a citation for any moving violation
-My driver’s license is suspended or revoked for any reason
-I am involved in a vehicle accident while on company business
-I fail to maintain required minimum limits of auto liability insurance during any period in
which I utilize my personal vehicle for company business.
-I will attend company provided or outside defensive driver training courses as instructed by
management.
_____________________________ __________________________
Driver Signature Date
_____________________________ __________________________
Manager or Administrator Date
Signature
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MVR Driver Consent Form
I acknowledge that the information contained in the company’s Fleet Management Program has
been reviewed with me, and a copy of the policy and driver rules have been furnished to me.
As a driver of a company vehicle, I understand that it is my responsibility to operate the vehicle
in a safe manner and to drive defensively to prevent injuries and property damage.
I also understand that my employer may periodically review my MVR to determine continued
eligibility to drive a company vehicle. In accordance with the Fair Credit Reporting Act, I have
been informed that a MVR may be periodically obtained on me for continued employment
purposes.
I acknowledge the receipt of the above disclosure and authorize my employer or its designated
agent to obtain a MVR report. This authorization is valid as long as I am an employee or
employee candidate and may only be rescinded in writing.
________________________________
Print – Employee’s Name
_________________________________ _____________________________
Driver’s License Number State Issued
_________________________________ _____________________________
Employee Signature Date
_______________________________ _____________________________
Reviewer’s Signature Date
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Policy No.: 5.11
Policy: Internet Use
Internet Use
Policy:
______________________________________________________________________________
Family Services of Davidson County provides Internet access to its employees to assist and
facilitate business communications. It is provided for legitimate business use in the course of
your assigned duties only. Inappropriate use may result in loss of access privileges and /or
disciplinary action.
Procedures:
______________________________________________________________________________
Family Services of Davidson County may monitor use of the Internet system or review the
contents of stored Internet records. Inappropriate use includes, but is not limited to:
1. Communications and uses not related to FSDC business.
2. Unauthorized attempts to access another's Internet account.
3. Transmission of sensitive or proprietary information to unauthorized persons or organizations.
4. Transmission of obscene, harassing or inappropriate messages.
5. Any illegal or unethical activity or any activity which could adversely affect Family Services
of Davidson County.
A critical concern is that nothing be transported from the World Wide Web, which might
contaminate and compromise our computer systems. All workstations with Internet access will
be provided with an internal virus scanning mechanism.
By using the Internet access provided, every employee agrees that he or she is aware of the
policy and that the Internet records may be read or monitored by authorized individuals.
Policy No.: 6.0
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Policy: Risk Management
Latest Revision/Approval: April 2013
Risk Management
POLICY
Family Services is committed to practicing effective risk management to protect the
safety, dignity, and legal rights of others as well as our human, financial, and intangible
assets. Family Services seeks to ensure the organization's continued ability to perform
its mission, grow and maintain good health and preserve its responsibility and
commitment to the community. This is accomplished through a continuing process of
evaluation and review of the various risks to which FSDC may be exposed. Because
Family Services has a responsibility to its stakeholders, maintaining the public trust is
essential for the organization's existence. By maintaining an effective risk management
program, the more confident the Board of Directors, senior management, staff, and
volunteers can be that the mission and operations will be achieved.
Information related to risk management will be distributed as considered appropriate to
board members, employees and volunteers, including, but not limited to posting on
agency bulletin of pertinent insurance information
PROCEDURES
______________________________________________________________________________
Purposes and Benefits of a Risk Management Program
Family Services needs a risk management program because:
-Risk management can help Family Services protect its stakeholders from harm,
-Risk management is a means for Family Services to examine the safety of its
Facilities, the fairness of its criteria for service delivery, the methods by which it
serves clients, the manner in which it trains paid and volunteer staff, and the quality
of the organization interaction with the public and
-It also provides a method for examining the degree to which the Board of Director's
fulfills its governance and legal responsibilities.
The number of claims and lawsuits filed against nonprofit organizations continues to
rise: In the past, nonprofit organizations were protected from litigation by the legal
defense known as charitable immunity. This type of defense has suffered in recent
years through numerous reversals in the courts. The courts have reasoned that since
non-profits have some degree of control over the activities of their paid and volunteer
staff, they are in the position to take precautions against injuries caused by them.
Nonprofits face litigation as a result of:
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-Violation of the state's charitable solicitation act
-Wrongful termination
-Defamation of character or invasion of privacy for inappropriate release of
confidential information on a client or volunteer
-Bodily injury
-Employment discrimination
-Breach of contract
Even in those cases where a nonprofit is likely to prevail, the time and money required
to defend an action may be considerable. Accidents, crises and adverse situations are
often preventable: Because risk management activities have the potential for identifying
areas within the organization that pose potential threats, the process of risk management offers a
means for minimizing the possible damage.
A risk management program can identify circumstances that could contribute to a crisis
in public confidence or result in negative publicity: Risk management actively works to
identify hazards that would diminish the public's confidence in the organization or generate negative
publicity.
A risk management program has the added potential to make the organization
attractive to competent board members. The presence of a risk management program
demonstrates to potential board members, and to the community at large, the organization's
commitment to maintaining its health and viability.
Goals
The goals of Family Services' risk management program are:
-Maintaining adequate internal controls in place to safeguard the organization's
financial assets;
-Maintaining the safety of the physical plants to protect its stakeholders from injury,
disability, and death;
-Maintaining adequate security and fire systems in place to monitor the security of
the physical environment;
-Providing adequate training for paid and volunteer staff in the areas of personal
safety measures, de-escalating conflict and handling emergencies, and handling
emergencies;
-Setting guidelines for providing services to children/families with infectious diseases
-Maintaining employment practice policies to minimize risk associated with:
Employee selection; Wrongful termination; Employment discrimination lawsuits
-Establishing a disaster recovery plan to minimize the loss of client, corporate
and financial data due to fires and environmental factors;
-Minimizing the risks of data/information integrity such as: computer viruses
access to client information by employees or those outside the agency; Unauthorized
use of computers to communicate with clients in an inappropriate capacity;
-Maintaining adequate property and liability insurance coverage
-Diversification of the revenue base to reduce reliance on a single source of
funding
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Assignment of Function
The risk management function is assigned to the Executive Director and the Executive Committee
of the Family Services Board of Directors. Senior management team members are also responsible
for developing and implementing the risk management program, as well as making
recommendations for its improvement.
However, in order to be successful, risk management must be a consciousness-raising
activity. Everyone must understand what risk management is about and what role each
person within the organization plays in promoting safety, reducing the likelihood of
accidents, and responding appropriately when precautions fail and an accident occurs.
Risk management should motivate everyone in the organization to consider the
consequences of their actions. Family Services’ CQI Committee plays a critical role in this process.
*CQI (Continuous Quality Improvement) is an internal oversight committee comprised of FSDC
management team members and staff representation from all units. An elected committee chair
(non-management team) is coordinates all meetings, which are held on at least a quarterly basis.
Minutes and reports for each meeting are maintained in a CQI binder, which resides with the
Program Chair. Committee participants typically serve a 2-year membership on this committee
(*with the exception of management staff) . * See also Policy Number 7.1 (PQI/CQI)
The Process
The risk management process is a continuous loop - The risk management process
covers four steps. These are (1) acknowledge and identify risk, (2) evaluate and
prioritize risk, (3) implement selected risk management techniques, and (4) monitor and
update the risk management program. Risk management is not a one-time activity.
As Family Services takes each step in the process, it logically leads to the next, until this process is
fully integrated into the life of the organization:
1. Acknowledge and Identify the Risk: What can go wrong? Consider:
-Operational-Loss of personnel through disability, death, retirement; Physical
Damage to its property and property of others; Consequential Losses; Criminal
Activity by staff, volunteer, director or a client; and Loss of Data
-Legal-Contractual liability, statutory liability, and tort liability
-Financial and Market-Financial loss due to investing or reliance on a single funding
source;
-Interest rate risks; and Banking risks;
-Political-Changes in rules, regulations and laws; and social action
-Programs-identify risks by program;
-Administrative operations-Physical office policies and procedures, employment
practices, computer equipment and data, and accounting and financial activities;
-Tools to identify risk
-Insurance applications
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-Internal documents - Employee manual, audits, written policies and procedures,
minutes, internal memos
-Financial statement and records
-Workflow-map out the workflow and processes used to deliver services
-Personal inspection of facilities
-Interviews-employees, volunteers, donors, clients, families and other service
providers
-Loss history-review incident reports
-Similar organizations
Function is assigned to member of management team Reporting to the Board of Directors
2. Evaluate and prioritize risks – frequency and severity
Assign high/ low probability and classify each risk by its frequency/severity grading:
Risks graded high frequency-high severity can be catastrophic to Family Services.
These risks should receive top priority. Family Services may best be served by
avoiding the risk or completely transferring it to another party.
Risks graded as low frequency-high severity - such as a large property loss, severe
auto accidents, or debilitating worker injuries can happen, and when they do they have
expensive consequences. Therefore, these risks should be shared and assigned the
next level of priority. Family Services can either insure against or retain a high
frequency-low severity risk (minor auto accidents, liability losses) so these risks are
rated as a moderate priority.
Low frequency-low severity risks - Family Services can retain the low priority risks, often
as part of an insurance policy deductible. Focus should be placed on the high priority risks that
might occur and could prove expensive, such as a wrongful termination complaint. In contrast, place
a low priority on those risks that are unlikely to occur or that involve an insignificant expense. After
establishing priorities, evaluate each risk and select the appropriate risk management technique.
3. Select and implement risk management techniques - develop a brief written plan
outlining how Family Services will manage its high priority risks. The plan should
address each of the principal risks identified and described the suggested strategy or
combination of strategies to be used. The four strategies are:
Avoidance - Family Services can decide not to offer a service or conduct an activity that
it considers too risky.
Modification - Family Services can change an activity so that the chance of harm
occurring and the impact of potential damage are within acceptable limits.
Retention - Retention is simply Family Services acceptance of all or part of a risk,
including preparing for the consequences. Retention is a sensible alterative for small
losses that will not unduly disrupt or affect Family Services' financial base.
Sharing - Sharing risks involves the full or partial transfer of an activity-or the financial
consequences.
4. Monitor and update the Risk Management Program - The Executive Director and
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Exec. Committee will review/revise the risk management program annually.
The Role of Insurance
The purpose of insurance is to share the financial responsibility for a loss. Because
insurance provides an important safety net, the Executive Director, Management Team and board
should be well versed in the role of insurance in Family Services' operations.
On an annual basis, the Executive Director and Management Team will meet with a representative
from the Agency’s insurance carrier. At this time, Agency insurance policies for property and
casualty, professional liability, director’s and officer’s
liability, workers’ compensation and any other coverage deemed appropriate will be
reviewed. The purpose of such review is to evaluate potential loss and liability and to
the extent considered feasible, reduce such loss and liability to an acceptable amount.
It may be necessary to rely on the expertise and the experience of insurance
professionals through work through the maze of insurance.
Based upon professional recommendations, Family Services has selected the following insurance
coverages:
Property Insurance - covers Family Services against damages to property such as
buildings, computers, furniture, documents and equipment.
Liability Insurance - protects Family Services against claims including litigation alleging
the agency's operations or actions that caused damage to another person or
organization. Included coverages are:
Professional Liability - Insurance will pay for damages because of any bodily injury,
property damage or personal injury caused by a professional incident
Automobile Liability - Insurance will pay for bodily injuries or property damages that
result from the ownership, maintenance, use of a covered vehicle and is caused by an
accident that happens while the insurance is in effect.
Directors' and Officers Insurance - Insurance will pay for (1) losses resulting from the
wrongful acts of Family Services and (2) losses resulting from allegations
including but not limited to false arrest, libel, slander, defamation of character, and
invasion of privacy.
Other coverage:
Employee dishonesty bond - Family Services carries employee dishonesty insurance.
This insurance pays for loss of or damage to, money, securities and other property that
results directly from employee dishonesty. This covers all employees, including those
handling cash and signing checks. Notwithstanding the insurance coverage, Family
Services, maintains a level of internal controls to minimize losses due to employee
dishonesty.
Workers Compensation:
The State of North Carolina requires all employers of three or more employees to carry workers
compensation insurance. Workers Compensation insurance applies to bodily injury by accident or
bodily injury by disease. Bodily injury includes resulting death. Family Services carries Workers
Compensation insurance through an insurance company authorized to do business in North
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Carolina. All employees are covered under this policy. The annual premium is based upon annual
payroll-and risk rates established by the Insurance Board of North Carolina.
Employees fall under two risk categories - the first category covers all clerical (support) staff and the
second category covers charitable organization (non-clerical) staff.
In conjunction with professional liability coverage, FSDC will provide and assume the
cost of legal assistance to personnel against whom claims are made related to lawful,
authorized actions taken in the course and scope of their employment, unless to do so
would represent a conflict of interest according to legal counsel. The Board of
Directors is provided a report on an annual basis that apprises them of Family Services
insurance coverage. This report highlights the type of coverage, the carrier, and the
amount of coverage. Paid and volunteer staffs are apprised of insurance coverage at
the time of orientation.
Security and Safety Procedures
It is the goal of Family Services to ensure the safety of its paid and volunteer staffs and
clients. The success of this policy depends on the alertness and personal commitment
of all parties as well as staff training. Training can ensure that the staff understands
how to avoid being placed in compromising situations. Family Services is also
committed to providing all staff maximum safety by protecting them from exposure to
blood-borne pathogens.
Family Services provides its staff members with training in the following areas:
-Staff members are oriented to the use of the security and fire systems in the various
facilities. Training includes - location of security and fire devices, use of these
devices, and procedures to follow in the case of fire and other emergencies. Staff is
trained to use the security devices if the need arises.
-Staff members are also trained in procedures to de-escalate conflict and handling
emergencies. Staff members are encouraged to report threats to their supervisors
and local law enforcement agencies if necessary. Any individual that commits an
act of violence or threatening behavior may be subject to criminal penalties.
-The Agency will provide the opportunity for training with regard to personal safety
measures and guidelines for providing services to children and families with
infectious diseases. (Refer to policy on Blood-borne Pathogens for more details.)
Staff members are instructed to take the following precautions relative to bloodborne
pathogens:
-Each program area shall evaluate its routine and reasonably anticipated tasks and
procedures to determine if and where there is actual or potential exposure to human
blood or other potentially infectious materials if the nature of the risk or activity
potentially results in the employee having direct contact with blood or other body
fluids to which universal precautions apply, personal protective equipment and
clothing shall be available and worn.
-Barrier precautions: all staff shall routinely use appropriate precaution to prevent
exposure when contact with blood or other body fluids from any human source is
anticipated. Gloves shall be worn for touching blood and body fluids, mucous
membranes, or the non-intact skin of all employees, volunteers, and clients and for
handling items or surfaces soiled with blood and body fluids.
-Hand washing: hands and other skin surfaces shall be washed thoroughly with soap
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and water immediately or as soon as feasible if contaminated with blood or other
body fluids following contact. Hands shall be washed immediately after gloves or
other personal protective equipment are removed and upon leaving the work area.
-Protective clothing: Appropriate protective clothing shall be mm Men the employees
have a potential for exposure to blood and other potentially infectious materials.
Type and characteristics will depend upon the materials and upon the task and
degree of exposure anticipated.
Family Services has installed fire detection systems at its facilities. When the systems
detect a fire danger, the systems will alert the occupants of the building of potential
danger and will also alert the central station. The central station in turn will notify the
fire department of the danger.
As soon as the system alerts the occupants of the building of the potential danger, all
staff members and clients will leave the building by using the fire escape plan that is
posted in each office. Designated staff members will ascertain that all rooms have
been vacated throughout the facility. No one should re-enter the building unless it has
been authorized as safe to do so.
Family Services has installed security systems at each location These systems serve
several purposes. They serve to protect the facilities from unauthorized entrance into
the building after-hours. If the system detects an unauthorized entrance, it notifies the
central station, which in turn notifies the police department. A police unit is dispatched
to investigate the unauthorized entrance. In order for the system to work at capacity,
everyone must understand what role each person within the organization plays in
protecting the security of the facility to minimize the likelihood of unauthorized entrance
in the buildings. Each staff person is asked to be cognizant of who is in the facility
after-hours and arm the system as needed. The last person to leave the facility is
assigned the responsibility of the arming the security system. On the other hand, the
first person to enter the facility is assigned the responsibility of disarming the system.
Only staff members that are authorized to enter their facility have been provide codes to
arm and disarm the security system. If a staff person has not been assigned a code,
that person is not authorized to enter the building unless accompanied by an authorized
staff person.
The systems also serve a safety purpose. The security systems in place have panic
buttons to use to alert others of impending danger with a client or visitor. The panic
buttons are strategically placed in each office (and carried by the Shelter staff) and are
used to alert others in the building of problems with a client or a visitor. If the panic
button is activated, the receptionist is alerted to the location of the problems and others
are dispatched to assist to de-escalate the disturbance. The panic button also alerts
the central station, which in turns notifies the police department and police unit is
dispatched to investigate. (See Crisis Plan for more information.)
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Use of Family Services Facilities By Others
The Executive Director must evaluate the extent of liability associated with contractual
relationships arising from the use of Family Services facilities by others.
From time to time, Family Service may be asked whether its facilities or portions of their
facilities are available for lease or short-term use for meetings or other similar functions.
In considering whether to allow this, senior management will consider the extent of
liability associated with this type of relationship. The Executive Director and Finance
Officer will review all proposed contracts, including leases and will consider the impact
of those relationships when determining the amount of liability coverage. The Agency
will also consider the potential financial impact of the contractual relationship including
but not limited to the risks related to participation in managed care contracts or
participation in a provider network. These types of transactions will be dealt with as
follows:
Short term use - Family Services will require the party using the facility to enter into an
agreement that: specifies the date and time of the function, number of people expected
at the function, level of compensation (if any), and an indemnification provision whereby the
contractor agrees to pay for specified losses (certificate of insurance from the
contractor or have the contractor add Family Services as an additional insured in their
applicable insurance policy). The agreement will also inform the user of the space that
it is their obligation to maintain the facility, supplies, and equipment in a manner that
reduces hazard to the persons served and/or liability to the organization.
Leases - The Facilities Committee of the Board of Directors must approve
arrangements of this nature. In considering a lease transaction, the committee must
evaluate the extent of liability associated with the contractual relationship of this nature.
The committee must also evaluate the contractor's ability to fulfill the responsibilities of
a lessee. If approved, the Finance Officer will enter into a contractual agreement with
the lessee that sets forth the terms of the lease. The agreement will also inform the
user of the space that it is their obligation to maintain the facility, supplies, and
equipment in a manner that reduces hazard to the persons served and/or liability to the
organization. The lessee must also provide a certificate of insurance whereby the
lessee agrees to pay for specified losses.
Fee For Service Provider
Family Services provides services to its clients using a sliding fee scale to make its
services available to a larger cross section of the general public. Family Services is a
fee-for-service provider. As such, it uses the following methods to be reimbursed for its
services:
-Third part reimbursement
-Direct billing
-Direct billing of sliding fee scale
-Managed care participation
The client's well being and care is Family Services' primary concern. In situations
wherein the client carries insurance, Family Services will:
-Request the client to complete an application form that includes any insurance
information.
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-Based upon information obtained from the above application and client interview,
the staff computes the per session fee either (1) insurance reimbursement and copay
or (2)the sliding fee scale, (3) grant/contract subsidy and informs the client of the fee.
-If services are covered by insurance, Family Services accepts a co-pay from the
client and files periodic claims with the insurance company for the remainder.
-Many times insurance company only cover a limited number of examinations. If this
is the case, Family Services will continue offering services to the clients based upon
assessed need. It is Family Services policy to provide clinical services to clients
regardless of their ability to pay for these services.
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Performance and Quality
Improvement
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Policy No.: 7.1
Policy: PQI/CQI
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. is committed to providing quality care and services
through its wide array of innovative programs to all individuals and families In Davidson County.
This is accomplished by maintaining a continuous quality improvement process which is a team
effort involving all employees of the Agency, Our governing Board community stakeholders and
clients. Diverse methods are used to foster involvement. Staff can participate through a range of
activities anywhere from surveys to committee membership. The quality improvement program at
Family Services attempts to foster strong collaboration and positive relationships toward the goal of
excellence.
PROCEDURES
_______________________________________________________________
Stakeholder Participation
As part of on-going quality improvement efforts, FSDC regularly solicits information from
stakeholders including: clients served, staff and volunteers, members of the Board of Directors,
community advocates/resources, and funders. At least every four years, FSDC will formally request
feedback from community resources through a survey designed to evaluate understanding of the
services available, ease of access, and satisfaction with services delivery. Ideas for program
development are also solicited.
Planning Processes
The planning process, both short and long-term, enables FSDC to review, evaluate, revise, and
develop policies and procedures that are consistent with the overall mission of the agency. Planning
takes place at multiple levels throughout the agency, including staff, volunteers, board, stakeholders,
and clients. The CQI Committee will serve as the central collection and processing point for this
information.
On a governance/organizational level, strategic plan development and maintenance is the
responsibility of the Family Services of Davidson County Board of Directors. A strategic planning
document is produced at minimum, once every four years. The short-term or on-going goals tend to
focus on the openness and adequate breadth of agency’s current services and the
hiring/retention/training realities for our staff. Long term goals focus more on operational
stability/sufficiency, revenue diversification and balancing of funding streams, and new program
implementation.
Since planning is fluid and on-going, FSDC Board and staff recognize that goals and plans may
change as the community needs change. Yet, the basic principle of the organization, to provide
quality, respectful care, will underlie all that we do.
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Internal Quality Monitoring
The risk management function is assigned to the Executive Director, with assistance from the FSDC
Management staff and the Executive Committee of the Board of Directors. This group is
responsible for developing and implementing the risk management program, as well as making
recommendations for its improvement. However, in order to be successful, risk management must
be a consciousness-raising activity. Everyone must understand what risk management is about and
what role each person within the organization plays in promoting safety, reducing the likelihood of
accidents, and responding appropriately when precautions fail and an accident occurs. Risk
management should motivate everyone in the organization to consider the consequences of their
actions.
The risk management process is a continuous loop. The risk management process covers four steps.
These are (1) acknowledge and identify risk, (2) evaluate and prioritize risk, (3) implement selected
risk management techniques, and (4) monitor and update the risk management program. Risk
management is not a one-time activity. As Family Services takes each step in the process, it logically
leads to the next, until this process is fully integrated into the life of the organization. Systems and
procedures regularly examined will include: service delivery processes and potential barriers, use of
restrictive interventions, training, retention, and supervision of staff, compliance with licensing and
funding requirements, and administrative operations including physical plant, computer equipment
and data, and accounting and financial activities.
Credentialing/Competency/Supervision Review
On a quarterly basis, professional/clinical supervision plans will be reviewed for staff who are not
credentialed. The CQI Committee will approve and sign off on any credentialing/competency
changes among professional/clinical staff.
Case Record Review
On a monthly basis, case record review will be conducted. The following actions will be conducted
during the monthly meeting:
Record Review -- Each record is reviewed twice (once after 30 days of opening, and at closing) for
monitoring the inclusion, timeliness, and order of case materials. Failure to be in compliance with
this review process results in correction notices issued to the staff member and others, according to
the lines of authority involved and the number of times non-compliance is determined per case.
Quality Assurance Review -- Each record (or a sampling) is reviewed 90 days after intake for quality
of assessment, planning, treatment, aftercare, etc. Open cases are subject to review, and are assessed
for measurable and definable work. Noncompliance results in follow-up by the immediate
supervisor if the case is not brought into compliance within two weeks of review, and quantitative
results are reported to management.
Outcomes Measurement
Outcome data are accumulated on an on-going basis. The outcomes are service specific and may be
based on pre and post-test scores on standardized instruments, Department of Juvenile Justice
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Tracking forms, and/or Client Self-Report forms. Each program will develop an outcome
measurement process and instruments to be used in conjunction with a “home-grown” client selfreport used across all programs. The Outcomes Sub-Committee of CQI will gather and review
outcome data and provide analysis for each program area.
Measures of Consumer Satisfaction
Consumer Satisfaction Survey data are collected on a monthly basis. On a randomly chosen day each
month, any client or community stakeholder that comes to the facility is asked to complete a
satisfaction survey. Surveys are also made available on the specified day to our in-home clients and
our shelter clients. Findings are resented in aggregate form to CQI by the Program Quality
Improvement Sub-Committee.
Feedback Mechanisms
Quarterly, findings documented by CQI will be presented to individual Program Directors and the
Executive Director. Information will be shared with the Agency Management Team in order to
problem solve to enhance and improve the quality of services to clients, and to improve employee
satisfaction. Quarterly updates will be provided to the governing Board and appropriate action will
be taken as needed including revisions of current policies and procedures or development of
additional policies and procedures.
On a yearly basis, CQI review the aggregate reports and action plans that were developed by each
CQI Sub-Committee. It will develop an overall agency summary and plan of action to address the
issues that were raised. This will serve as a tactical report and become a part of the agency’s annual
report. This information is distributed to staff and Board and is posted in the agency reception areas.
Information Management
FSDC ensures that all data collection processes provide consistent electronic data integrity. All
electronic client data will be stored centrally on secured network server providing staff access and
client confidentiality.
Staff members, outside partners, and consultants working on behalf of the Agency will be granted
access to the Information System according to job description, responsibilities, and on a “need-toknow” basis. The Agency requires staff and any others granted access to confidential data to
maintain and respect the privacy rights of those identified. Access to the computers is controlled
through the use of passwords.
All computers are protected by automatically updated virus protection and firewalls. FSDC
contracts with an outside technology company (Stateside Data) to provide IT support, including file
back-up and off-site storage.
This data will then be destroyed in accordance with contractual, regulatory, and Agency policy. As
appropriate, data will be reported and disseminated in clear and consistent formats.
Corrective Action
On a regular basis, through the CQI process, ideas and suggestions to improve services and
operating practices will be solicited. Actions will be presented and implemented through the proper
channels to build on strengths, determine the cause of problems/concerns and solutions to
eliminate/reduce them, monitor on-going effectiveness, and revise policies/procedures as
recommended.
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PROCESS:
At each quarterly CQI Team meeting, the following items will be included as part of each agenda:
issues related to work environment,
provision of services,
other quality improvement concerns
review of research safeguards
review of grievances, incidents, or accidents involving clients or staff
review of staff credentialing/competency changes
As appropriate, concerns will be documented as a part of the minutes of the meeting. Included in
the meetings will be a review of the client satisfaction surveys as they relate to the specific program.
Results of the surveys will also be documented in the minutes of the meeting.
The concerns documented in the minutes will be addressed with the Agency Executive Director by
the individual Program Directors. Information will be shared with the Agency Management Team
in order to problem solve to enhance and improve the quality of services to clients, and to improve
employee satisfaction.
Incident Reporting: Any incident (client and/or staff safety concern; DSS reports; medical events;
accidents – in short any unusual or “disruptive” event to client services) that occurs is to be
documented on the “Incident Report” form and given to the Program Manager as soon as possible.
This report is then forwarded to the CQI team member who is responsible for reporting
on/tracking incident report data.
Incident reports are reviewed at each CQI meeting. Outcomes are reviewed and any additional
opportunities for education or training are identified.
Quarterly updates will be provided to the governing Board and appropriate action will be taken as
needed including revisions of current policies and procedures or development of additional policies
and procedures.
Policy revisions or new policy implementations will be discussed at the next individual program
meeting and then relayed to the full staff at the next monthly staff meeting.
The clients and employees will be the beneficiaries of this process, as will be documented in the
client satisfaction surveys and annual employee surveys.
Summary of Teams Involved in CQI
The full CQI Committee will be structured as follows:
Board CQI Committee Members (Executive Committee or designee)
Management Team
Agency CQI Team Members
Program Quality Improvement Committee (as needed)
Work-Place Quality Improvement Committee (as needed)
Clients Rights Committee
Ad hoc committees as appropriate
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Duties of Committee
The CQI plan will utilize diverse methods of data collection in order to enlist information from the
people we serve, stakeholders, and personnel. The formal planning process will incorporate
statistical data, questionnaires and surveys, and other tracking techniques. The CQI teams will
aggregate and analyze information for the purpose of effective quality improvement.
Quality improvement is a multi-tiered process that is accomplished through focused committee
work. Client level reviews are built into the Utilization Review and Peer Record Review systems
of the agency. (Described in a separate document). A Program Quality Committee is established
to review each major program area. A Work-Place Quality Improvement Committee assesses
the capacity of the work atmosphere. A Clients Rights Committee will also function under the
auspices of the CQI team.
Overall CQI meeting & Tactical Report:
On a yearly basis, in January, the full CQI Committee will meet. The goal of this meeting is to
review the aggregate reports and action plans that were developed by each CQI Team and to then
develop an overall agency plan of action to address the issues that were raised. This will serve as a
tactical report.
The tactical report will be presented to the agency staff. The Executive Director will also present
this report to the full Board of Directors for later inclusion in strategic planning. The CQI notebook
of all committee work is kept in the CQI Chair’s office.
Ad hoc Committees/Employee Feedback:
FSDC conducts an employee satisfaction survey on an annual basis. Individual responses are
anonymous, but feedback is reviewed and rolled into an aggregate report that ultimately identifies
areas of strength and weakness for the organization.
Committees are then formed to address those areas that are seen as opportunities for improvement.
All employees are encouraged to participate on a committee.
Policy No.: 7.2
Policy: 90 Day Review
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POLICY
_______________________________________________________________
Clinical cases shall be reviewed every 90 days during the client’s treatment. This review shall
consider the appropriateness of services, progress towards treatment goals and need for more
intensive treatment, discharge and aftercare.
PROCEDURES
_______________________________________________________________
1. Administrative staff shall run reports each month identifying clients that will reach 90 days of
service during the month.
2. Each clinician shall receive a copy of the report for their caseload and the Clinical Director shall
receive the aggregate report.
3. Clinicians shall present each case on the report during regularly scheduled supervision. The case
shall be approved for one or more of the following:
· Continuation of services,
· Rewrite and/or make addition(s) to original treatment plan,
· Recommendation for more intensive service(s) or
· Discharge.
· Other
4. Any client without a face-to-face contact for one (1) month must be contacted to determine
ongoing need. The case may be placed on inactive status for six (6) months if the client, and/or
parent/guardian, made this request and it is deemed clinically appropriate. Cases must be closed if a
case remains on inactive status for twelve (12) consecutive months.
5. The type and frequency of case supervision will be consistent with the issues and needs of clients,
the frequency and intensity of services and the frequency of contact.
6. Cases that are deemed high risk i.e. victim of violence, self-harm risk, juvenile delinquency and/or
substance abuse issues, should be addressed in supervision with a review of safety planning for the
client and/or family on a more frequent bases.
7. Once the plan is agreed upon the Clinical Director shall document and sign the 90 day review
plan. This plan shall be placed in the chart adjacent to the original treatment plan.
8. Any changes will be developed in cooperation with the person served and his/her legal guardian.
9. If the case has been recommended for more intensive service(s) the clinician shall assist the client
in locating these service(s) either within this agency or the community.
Policy No.: 7.3
Policy: Utilization Review
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POLICY
_______________________________________________________________
Utilization Review is conducted in order to evaluate the services provided in terms of cost
effectiveness, necessity, and effective use of resources.
PROCEDURES
_______________________________________________________________
There are two Utilization Review processes. The first occurs within the first week of intake; the
second occurs 90 days from the point of intake. Both reviews consist of committees made up of
supervisors and professional staff who serve on a rotating basis. Each review has a different set of
forms to be completed and submitted to the Administrative Office.
A. All new intakes are subject to review. The case is assessed for risk status, the identified problem,
the modality of treatment, the projected length of treatment.
B. The second review occurs every 90 days from the point of intake until closure of the case. This
Committee meets monthly and assesses necessity for continued services, applicable reauthorizations, and projected length of treatment. The Utilization Review Form is completed at this
time.
Cases are chosen randomly by the Administration Department according to date of intake. For cases
subject to review, the UR Review Form should be completed by the clinician prior to the review.
The committee reviews the request for continued treatment and makes its recommendation. The
case is review to ensure continuity of assessment, treatment, progress notations and other materials
collected in the file.
The review forms are signed by each committee member and placed in the case record. For low risk
cases, this is the only required review. This does not mean that clinicians cannot discuss cases with
their supervisor, but they are not required to have additional documentation of a supervisor's review.
For Moderate Risk cases, the supervisor and the clinician should review the case after ' six weeks or
45 days. For High Risk Cases, the clinician and supervisor should review the cases weekly. And for
Extreme Risk Cases, the clinician and supervisor should review the case bi-weekly and discuss the
appropriateness of this case for treatment at Family Services if the score remains this high. Cases
reviewed by the clinician and supervisor should be documented on a supervisor's review sheet.
Policy No.: 7.4
Policy: Client Tracking & Outcomes
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POLICY
_______________________________________________________________
Family Services has a variety of mechanisms in place to monitor quality assurance and the
appropriateness and effectiveness of its services. The Agency recognizes the need to obtain input
from service recipients and such information will be solicited on an ongoing basis as a way of:
· Getting feedback from clients as to their satisfaction with the services delivered
· Assessing the impact and effectiveness of services delivered
· Determining new program needs
· Making adjustments in accessibility of services to meet consumer demands, e.g. location, hours of
service, intake process, etc.
· Agency governance
PROCEDURES
_______________________________________________________________
Statistical information such as referral source, client demographics, and services rendered and
referrals made are kept in the client record. Demographic and statistical information are put into
Therapist Helper (client tracking software) by one of the Administrative Assistants upon scheduling
of the initial appointment. Information in this database includes: client demographics, services
requested, services offered, services accepted, case disposition, referrals made, termination dates and
reasons. Therapist Helper can prepare a report analyzing this information on a quarterly basis for
review by the CQI committee as needed to supplement the direct service statistical outcomes report.
Care shall be taken to ensure the information is input and maintained in accordance with all HIPAA
standards and the Client Confidentiality Policy.
Staff shall have access to Therapist Helper through network and password use on a need-to-know
basis.
Statistical information is gathered on a monthly, quarterly, bi-annual, and annual basis. The Agency
documents client input and feedback on forms such as:
· Consumer Satisfaction Surveys
· Individual Program Surveys as determined by program staff
· Scale form for tracking client progress based on the client’s perception (Client’s Self-Report of
Progress)
· Client suggestion box located in the front agency waiting area
The Agency will solicit both formal and informal consumer feedback regarding agency services on
no less than a yearly basis. This feedback may take several forms including verbal interviews by staff,
by consumer satisfaction surveys distributed on a monthly basis at each location or by more
structured reviews to both current and former clients.
Consumer satisfaction surveys will be distributed in each location on a randomly selected date
during each month. Client satisfaction forms will be distributed in such a manner that client
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anonymity will be protected while still provided basic demographic information and program or
service area.
All clients complete evaluation forms at the beginning, during, and end of treatment. Evaluations are
used to weigh the appropriateness of rendered services, the degree to which client needs were met,
change in functional status (severity of concerns and coping skills), stability of life situation, and
health, welfare and safety.
Gaps in service delivery are discussed by the CQI teams. Where appropriate, each program or
service area will also use standardized instruments relevant to the client needs and service
expectations. The CQI teams and agency management are responsible for addressing gaps, service
duplication, and program performance.
The agency will share the findings of this information with the Board of Directors on a yearly basis
through the Tactical Report and with the Board and community through the Annual Report.
The Executive Director is responsible for directly initiating program improvement when services are
found not to be efficient, effective, or well-utilized.
Definitions:
Positive outcome is evaluated by:
· Client self-report “severity of concerns” scale, a 1-point reduction shows positive improvement.
· Client self-report “coping scale”, a 1-point increase shows positive improvement.
· Based on the Treatment Plan:
· Completion of 40-49% of the short-term treatment goals shows minimal success
· Completion of 50-60% of the short-term treatment goals shows moderate success
· Completion of greater than 60% of the short-term treatment goals shows significant
success
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Ethical Practice
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Policy No.: 8.1
Policy: Ethical Conduct
Ethical Conduct
POLICY
_______________________________________________________________
Family Services, Inc. conducts its behavioral health services with due regard to ethical and
professional requirements and protects confidentiality information regarding persons served.
Family Services has adopted the NASW (National Association of Social Workers) Code of Ethics
that is to be followed by all professional staff.
PROCEDURES
_______________________________________________________________
The Code of Ethics will be provided to each professional staff member at the time of employment.
Each professional staff will acknowledge receipt and agreement of the Code of Ethics and their
respective Codes of Conduct.
Code of Ethics:
Service:
 All persons being served will be informed and consent to services.
 All persons served will be informed and will participate in decisions about service, care,
and/or treatment.
 Persons served have the right to refuse participation in clinical studies and other research
 Persons served must provide informed consent to participate in clinical studies or other
research
 Confidentiality and privacy protection is followed in accordance to relevant statutes
 All persons served will be informed and acknowledge by consent to the definition and
limitations of confidentiality and private service delivery
 Supervision will be used to assure the integrity of decisions made about care and that they
are based solely on the diagnostic and treatment needs of the individual
 Supervision will serve as a means to monitor the relationship between use of service and
financial arrangements. This supervisory function will serve to protect consumers and to
insure that professional staff complies with policies regarding payment for service
 Persons served will be informed and consent to the procedure for establishing payment for
services
 Professional staff will not accept payment or other considerations from another provider of
services for referring applicants or persons served to that provider of services nor make
payment or other consideration for referral to the organization
 Persons served will be informed and acknowledge knowing how to file a grievance regarding
care and/or treatment
 Professional staff will inform and support persons served need to file grievances regarding
care and/or treatment
 Persons served will not be denied services regardless of ability to pay
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
Supervision will serve, as a mechanism for review of circumstances in which there is an
ethical and professional responsibility to provide service and/or care when payments
terminate
Ethical Practice:
1. All professional staff will be informed and acknowledge compliance with the agency’s Code
of Ethics.
2. All professional staff will be informed and acknowledge compliance with their respective
profession’s Code Ethics.
3. Supervision and in-service training will serve as a means to monitor compliance with agency
Code of Ethics and respective professional Code of Ethics.
4. Services are provided by professionals in such a way that promotes integrity in decision
making.
5. Persons served are informed and supported to participate in decisions regarding care and/or
treatment.
6. Services are provided by professional staff in such a way that supports freedom of choice for
consumers. Professional staff will communicate options and choices to consumers evident
by consumer’s participation in treatment planning and consent to treatment.
7. It is the practice of professional staff that Professional Responsibility is a priority over
personal interest.
8. When a client’s third-party benefits or payments end, FSDC staff, through consultation with
the Clinical Director or the Executive Director, will determine its ethical or professional
responsibility to provide services until appropriate arrangements are made.
9. Any kind of dual relationships between professional personnel and clients is strictly
prohibited.
10. Accepting payment or other consideration from another provider of services for referral of
clients or accepting payment for the referral of clients is strictly prohibited.
11. Steering or directing referrals to a private practice in which agency professional personnel,
consultants or the immediate family of personnel and consultants may be engaged is to be
carefully avoided.
12. In the event that a staff member leaves the agency to go into private practice direct referral
of clients to their private practice is strictly prohibited. All cases are either to be closed or
transferred to another agency staff member before the therapist's departure.
13. When referrals for ongoing services are necessary, referral sources may include former
personnel in private practice. However, FSDC does not engage in reimbursement for
referrals and/or use the referring process to generate business between FSDC and former
personnel.
When any conflict is present, priority is always given to the needs and rights of the client evident by
documentation and monitoring through supervision.
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Policy No.: 8.2
Policy: Culturally Competent Practice
Culturally Competent Practice
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. recognizes the importance that cultural, ethnic, and
gender differences make in service needs. FSDC recognizes the need to develop and maintain
services that are responsive to the needs of consumer populations from various cultural groups in
the community. Cultural competence will be evaluated before any agency hires. Additionally, cultural
competency training and education will be addressed with all agency personnel in agency staff
meetings, program meetings, and/or external training. The Agency regularly evaluates the services
provided and the needs of the community so that services can match service demands.
The following describes FSDC’s perspective on cultural competency and agency expectations
regarding assessment and interventions.
Ethnically and Racially Sensitive Social Work Practice
Sensitivity to human diversity is essential at Family Services of Davidson County, Inc.
Membership in an ethnic or racial group poses a special set of environmental circumstances.
The values and orientation of a particular group affect individual choices and pressures. FSDC staff
must understand and appreciate group differences so they will not impose inappropriate
expectations upon people culturally different from themselves. Nor should staff, based on their own
group membership, make stereotyped judgments about people. Additionally, members of a diverse
group may be subjected to prejudice, discrimination, and oppression solely because of their
membership in the group. Many times FSDC will be called upon to advocate on behalf of people
and groups who differ from those in the mainstream.
Gender-Sensitive Social Work Practice
Gender differences reflect another aspect of human diversity. Just as it is important for practitioners
to be ethnically and racially sensitive, so is it important for them to be sensitive to differences and
discrimination based on gender. Gender stereotypes have negative effects on both women and men.
The problem is that such stereotypes often limit alternatives. Although FSDC staff must be aware of
stereotypes imposed upon both men and women, they especially need to understand woman’s status
as an oppressed group.
Cross-Cultural Practice
Effective cross-cultural social work requires skills in several areas: attending, assessment, and
intervention. A culturally sensitive staff person should think about clients in terms of both group
strengths and limitations in addition to individual problems. In other words, you should be able to
use knowledge about clients’ racial or ethnic group in the assessment process. Simultaneously, you
must remember that membership in a particular ethnic group does not automatically explain a
person’s behavior. Another issue is recognizing one’s own cultural limitations and appreciating
cultural differences. Our own biases and anxieties when working with minorities can become a
problem. Anxiety or guilt can get in the way of being empathic. Moreover, we may tend to transfer
our reactions to situations to clients assuming they will react, feel, and think as we do. A willingness
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and eagerness to learn about a client’s culture will go a long way toward building better cross-cultural
relationships.
PROCEDURES
_______________________________________________________________
Strategies for Cross-Cultural Assessment
FSDC staff will use the following as strategies when doing assessments:
 Consider all clients as individuals first, as members of minority status next, and then as
members of a specific ethnic group. This will help prevent over-generalizing and making
erroneous assumptions.
 Ensure that assistance is provided for communication needs of the client, including
telephone amplification, sign language, translation needs, or other communication methods
as needed to meet the communication needs of all clients.
 Never assume that a person’s ethnic identity tells you anything about his or her cultural
values or patterns of behavior. Remember that within-culture differences are often
substantial and that two clients from the same culture may have vastly different life
experiences.
 Treat all “facts” you have ever heard or read about cultural values and traits as hypotheses,
to be tested anew with each client. Turn “facts” into questions.
 Remember that all minority groups in this society are at least bicultural. That is, they all live
in at least two cultures, their own and the majority culture. The conflicts involved in being
bicultural may override any specific cultural content. That is, the difficulty of surviving in a
bicultural environment may be of greater importance that the fact a person is from a
particular racial group.
 Remember that some aspects of a client’s cultural history, values, and life-style are relevant
to your work with the client. Others may be simply interesting to you as a professional. Do
not prejudge what areas are relevant.
Whenever possible, we should focus on the specific problems for which the client sought help
before getting into areas where the client the client can identify those factors which are important.
Identify strengths in the client’s cultural orientation. Help the client in identifying areas that create
social or psychological conflict related to biculturalism, and seek to reduce dissonance in those areas.
Be aware of your own attitude about cultural pluralism. Know whether you tend to promote
assimilation into the dominant society or whether you stress the maintenance of traditional cultural
beliefs and practices. Your own biases and perspectives are important, and can affect your work with
clients.
Engage your client actively in the process of learning what cultural content should be considered.
This means you must ask clearly about clients’ experiences, beliefs, and values.
Keep in mind that there are no substitutes for good clinical skills, empathy, caring, and a sense of
humor.
Strategies for Cross-Cultural Interventions
1. Maintain awareness that nonverbal communication probably constitutes more of the
communication in a counseling relationship with people of color than does the verbal
component.
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2. Ensure that on-going assistance is available to meet the communication needs of the client,
including telephone amplification, sign language, translation needs, or other communication
methods as needed to meet the communication needs of all clients.
3. Recognize that eye contact can be a problem for many ethnic groups.
4. Use both open-ended and closed-ended questions. They are almost universally acceptable.
5. Remember that reflection of feelings works with many cultures, but not with all (in many
cultures reaching for feelings should be used carefully and slowly).
6. Recall that paraphrasing generally is an acceptable technique in most cultures.
7. Use self-disclosure judiciously.
8. Give interpretations and advice in cultures expecting a directive helper.
9. Summarize from time to time.
10. Use confrontation appropriately and carefully with certain racial groups.
11. Remember that openness, authenticity, and genuineness are respected in all cultures.
Adapted from Introducing Generalist Practice: The Generalist Intervention Model
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Policy No.: 8.3
Policy: Productivity Expectations
Approved by: Board of Directors Expectations
POLICY
_______________________________________________________________
Family Services, Inc. has a rich history of quality service delivery. The Agency must be prepared to
respond quickly to changes in the financing and service demands placed on community-based, notfor-profit agencies.
In order to pursue the mission to put people first, the Agency must be managed efficiently.
Effective administrative procedures will help to maintain a healthy and viable organization in a
market-driven economy. Equal importance needs to be placed on both cost controls and the
provision of quality service to families so that funders will be assured that effective use is being
made of available and scarce resources. Otherwise, the opportunity to pursue the Agency’s mission
will be lost.
Measuring productivity can lead to greater efficiency and cost control. A clear idea of each clinician’s
productivity, leading to an awareness of overall staff capacity, facilitates projections for grant writing
and other planning strategies. It is a supervisory tool, tracking of individual worker productivity
establishes fairness and equity among employees and helps employees develop annual work plans
based upon established expectations.
The purpose of this statement is to clearly outline for all staff the clinical productivity expectations
and those activities, which qualify for any reductions of the amount of time effecting this
expectation.
PROCEDURES
_______________________________________________________________
EXPECTATION GUIDELINES:
Expectation Level is the minimum number of hours a clinician is expected to devote to direct
service. Each direct service provider is to spend a minimum of 24 hours per week (64%) in direct
service. Productivity will be documented on a monthly basis through completion of the
Family Services’ Monthly Stats form. This form is due to the Executive Director by the fifth
working day of the following month.
Supervisors will maintain productivity expectations as determined by consultation with the
Executive Director.
PROCEDURES REGARDING EXPECTATIONS:
 How the clinician performs in relation to expectations will be one factor considered when
evaluating eligibility for a salary increase and doing the annual performance appraisal.
 Progress toward achieving the annual expectation will be evaluated on at least a monthly
basis. Supervisors will work closely with persons demonstrating difficulty in maintaining
performance levels. The supervisor and clinician will identify the causes of lagging
production and develop a plan to correct the situation. Staff who consistently demonstrates
difficulty achieving expectation may be subject to disciplinary procedures including dismissal.
 In the case of severe illness or other personal tragedies resulting in the inability to achieve
annual expectation, the absent time will be factored in, the reason for failure to reach
expectations will be documented, and the person will not be subject to disciplinary
procedures due to the circumstances.
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
Those who consistently surpass the minimum expectation will be considered for additional
incentive recognition (as feasible and appropriate) which can be in the form of bonus,
conference support or desired activities.
INSTRUCTIONS FOR COMPLETING MONTHLY STATISTICAL WORKSHEET
See Monthly Stats. form and “Stats 101” document for directions and definitions.
REVIEW
Review of this procedure will occur annually by the management.
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Client Rights
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Policy No.: 9.1
Policy: Client Confidentiality
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. recognizes the ethical, professional, and legal
considerations for protecting the confidentiality of personal information about clients and their
families (“client information”). Information that personally identifies a client shall not disclose
outside the agency unless it is:
 With the client’s written permission
 With the written permission of the client’s representative authorized by law to consent to
release information
 Specifically required by statute, regulation, or judicial order
Within the agency, personally identifiable client information may be accessed by or disclosed to staff
only when required in order to provide client services. To reflect its commitment to appropriately
safeguard client privacy and confidentiality, and to demonstrate accountability to the community and
funding sources, the agency will make this policy available to staff, clients and the community at
large. A legal review will be conducted periodically to confirm that the policy conforms to applicable
law.
CAUTION REGARDING SCOPE OF POLICY: Highly specific federal rules apply to
information sought, received or disclosed about a client’s substance abuse diagnosis or treatment at
a drug or alcohol treatment facility covered by 42 U.S.C. 290dd-3. Violation of these rules could lead
to criminal penalties.
Although many of the principles and practices in this policy are completely consistent with those
rules, not all are, and due to the length, complexity and limited applicability of those rules, as a
practical matter they cannot be detailed in this policy. Therefore, this policy should be considered to
apply only to client information other than information sought or received from a drug or alcohol
facility about a client’s substance abuse diagnosis or treatment.
As guidance, this policy directs agency staff to (1) exercise extreme caution whenever they believe
they may be requesting, receiving, discussing or disclosing information about a client’s substance
abuse diagnosis or treatment provided at a drug or alcohol treatment facility, and (2) independently
confirm with the Director, and if necessary agency legal counsel, that their actions comply with
applicable federal rules governing such information.
PROCEDURES
_______________________________________________________________
The client’s honest disclosure of personal and family information is vital to the agency’s ability to
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deliver appropriate services. Candor and confidentiality are the cornerstones of the counseling
process.
The agency and its staff will respect client privacy and strive to safeguard the confidentiality of client
information obtained through the therapist-client relationship. This policy reflects the agency’s view
that each staff person has a fundamental responsibility to handle client information confidentially
and respectfully. At the same time, the agency acknowledges, and believes it is important for clients
to understand that absolute confidentiality is not an absolute right in all situations. In rare instances,
disclosure may be mandated by a court order (for example, in litigation), required by statute (for
example, when child or elder abuse is suspected), or necessary to protect the client or others in
accord with standards of good therapeutic practice (as in the case of suicidal or homicidal intent).
The agency also acknowledges that unique circumstances not directly contemplated by this policy
may arise, such as client emergencies or other exceptional situations falling outside this policy that
may warrant flexibility in interpreting this policy. All agency staff is expected to follow this policy to
honor client confidentiality, and when legal requirements, safety issues, or other circumstances
appear to conflict with this policy, staff are encouraged to immediately raise any questions or
concerns about interpreting the policy with the Director.
RECORDS: GENERAL STATEMENT
Sound records management in accord with industry standards is vital to providing quality service. It
protects privacy and confidentiality and is necessary to provide and plan for appropriate client
services. Additionally, it is critical in day-to-day management of the agency’s programs and for
internal and external accountability. Sound records management enables the agency to provide
statistics to agency contributors and purchasers of agency services regarding utilization and
community benefit of services the agency offers. Client records may include materials such as
written or electronic records, audio or video recordings, and photographs, identifying information
cards, or billing and accounting information. While tangible records are owned by the agency, the
client also has a continuing interest in the personal information such records contain.
The Board of Directors designates the Executive Director custodian of all agency records, and as
such empowers the Executive Director to act to the extent practicable and within the applicable
standard of care, to see that records are accurate, objective, specific, reliable, valid, timely, and
factual. As custodian, the Executive Director may delegate to Management Team staff the specific
authority to establish a records management system for the creation, maintenance, use, and
disclosure of client information.
CLIENT IDENTIFICATION
Legal, ethical, and regulatory standards, as well as client interest, determine what information will be
included in the record. The ability to retrieve and record client information is important to the
agency’s operations, and therefore, some mechanisms to identify client records are necessary. The
agency’s procedure to identify client records is intended to promote client confidentiality. At
present, a unique identifier code is just one means the agency uses to distinguish one individual’s
records from another’s, and with other mechanisms, enables accurate and efficient records
management.
REASON TO KEEP RECORDS
Agency records are maintained for many legal, business and client service reasons. Some purposes
require personally identifiable client information, while others may be accomplished using
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information stripped of personal identifiers, often compiled in aggregate form.
Aggregate information serves the agency’s professional needs, provides accountability, and aids in
planning. Some examples of the way the agency uses non-identifiable information compiled in
aggregate form include providing:
 Feedback vital to professional review and development, in turn helping to promote and
maintain quality services
 A basic tool in staff supervision, evaluation, and training to foster staff development and
improve client services
 Knowledge about the frequency and types of problems brought to the agency, enabling the
agency to identify gaps in needed services and tailor program offerings to meet the
community’s needs
 A source of information for service purchases, planning groups and agency contributors
 Important data for professional research
 Statistical information to enhance communication within the agency and externally to the
community.
RECEIVING CLIENT INFORMATION
CAUTION: Highly specific rules apply to information sought, received or disclosed about a client’s
substance abuse diagnosis or treatment at a drug or alcohol treatment facility covered by 42 U.S.C.
290dd-3. Because these rules are extremely detailed, they cannot be duplicated in this policy. This
policy should be considered to apply only to client information other than that concerning a client’s
substance abuse diagnosis or treatment at a drug or alcohol treatment facility. However, given that
violation of these rules could lead to criminal penalties, agency staff should exercise extreme caution
when requesting, receiving, discussing, or disclosing information about a client’s substance abuse
diagnosis or treatment at a drug or alcohol treatment facility, and should independently confer with
the Executive Director, and if necessary, agency legal counsel, that their actions comply with these
rules.
If the client has received services from other professional or social agencies and information from
these sources is deemed necessary to further the therapeutic process or to verify the client’s
psychosocial, medical or educational history, the agency will discuss with the clients what
information is needed, and from which “third party” sources. The client, or the client’s legal
representative authorized to consent to release this information, must give written permission to
enable the agency to obtain information from third parties. Agency forms are provided for this
purpose. If the third party provides client information under the condition that it not be disclosed to
the client but the client has asked to see it, the client should be referred to the original source to
secure the information directly. As with all client information in the agency’s possession, client
information received from third parties must be treated confidentially and should not be released
without appropriate authorization.
RELEASING INFORMATION
Unless required or authorized by law, no personally identifiable information about a client is to be
disclosed or released by the agency without the written permission of the client or the client’s legal
representative authorized to consent to release of this information. Agency forms are available for
this purpose.
The follow persons may sign Consent for Release Forms:
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




Competent adult clients
The client’s legally responsible person
An adjudicated adult when consent for release to his/her attorney
A minor child under the following conditions:
1. Pursuant to G.S. 90-21.5 when seeking services for abuse of controlled substance or
alcohol, or emotional disturbances
2. When married or divorced
3. When emancipated by a decree issued by a court of competent jurisdiction
4. When a member of the armed forces
Personal representative of a deceased client if the estate is being settled or next of kin of a
deceased client if the estate is not being settled
The release form should include specific information to be disclosed, to whom the client
information may be released, for what purpose, any time or other limitations on the authorization,
the consent effective and expiration date, the name of the person who will provide the confidential
information and a statement that the consent may be withdrawn at any time. If requested, a copy of
the signed form should be given to the client and the original placed in the case record. In
appropriate circumstances, the release form should be discussed with the client and if necessary,
read aloud by the staff member to provide opportunity for everyone, including clients who are
functionally illiterate or mentally impaired, to have a knowing understanding regarding the release.
There are exceptions to this general policy on client (or legal representative) consent. These include:
 If the therapist believes that the client is an imminent danger to self or others,
 The likelihood of the commitment of a felony or violent misdemeanor, the agency may
disclose information to law enforcement, any clearly threatened individual, and to others
who are authorized to help prevent such harm (for example, a physician),
 Depending on the instrument’s validity in the circumstances, the agency may be required to
disclose client information pursuant to “legal process” such as court order or subpoena,
 If the agency or anyone of its staff has a reasonable suspicion that a client is or may be the
victim or perpetrator of abuse or neglect of a child or dependent adult, a report of this
suspicion is to be made to the Department of Social Services,
 If the agency or anyone of its staff has a reasonable suspicion that a person has a
communicable disease,
 If an internal agency advocate has reasonable need for the information,
 When a client has left a 24-hour facility and appropriate individuals need to be notified,
 To a client’s attorney or attorney representing the state if client is facing court hearings,
 To the Department of Corrections if a client is or has been imprisoned,
 To a health care provider who is providing emergency services,
 To another mental health facility, provider of support services, secretary, physician, or other
individuals when necessary to coordinate appropriate and effective care,
 For the purposes of filing involuntary commitment or adjudication of incompetence,
 The agency’s attorney may need to see a client’s file because of legal proceedings, or
 For approved research and planning, audits, and statistical purposes.
FSDC shall give written notice to the client or the legally responsible person at the time of
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admission that disclosure may be made of pertinent information without his expressed consent in
accordance with G.S. 122C-52 through 122C-56. This notice shall be explained to the client or
legally responsible person as soon as possible. The giving of notice to the client or legally
responsible person shall be documented in the client record. The agency director, and/or
credentialed staff, shall be responsible for the disclosure of confidential information. Staff who has
not completed agency credentialing should seek direct supervision prior to release of confidential
information. Such delegation shall be in writing.
If records are subpoenaed or if information about an individual client is demanded by the courts,
public officials, investigative units or law enforcement bodies, the staff member should promptly
notify their supervisor, who is to promptly notify the Program Director and the Executive Director.
After considering the demand and any applicable policies or agency guidelines, the Executive
Director will determine whether to consult with legal counsel regarding the agency’s response to the
demand. The agency should always respond to the demand, even if it appears to be invalid, because
failure to respond can have adverse consequences including fines, program exclusion, and contempt
of court or other criminal charges. As discussed in Appendix I below, depending on the
circumstances and legal and ethical requirements, an appropriate response may range from resisting
the demand in court to complying with it.
CLIENT ACCESS TO RECORDS
Although client records are considered the agency’s property, the agency also acknowledges that the
client also has a fundamental, continuing interest in the confidential information contained in those
records. The agency will make its records available upon written request and under the following
safeguards:
 Upon written request on the “Request to Review Record” form, a client may inspect the
record in the presence of the therapist. The therapist is present during the inspection not
only to answer questions the client may have, but also to see that no part of the record is
altered, removed, or replaced. The inspection will take place only on agency premises. If the
therapist determines that the client should not have access to the record, the reason is
documented on the Client Access to Records form. Consultation with the therapist’s
supervisor is necessary, and must be documented on the form as well. The reason for refusal
of access is noted in the case record.
 If the therapist in their professional judgment determines that disclosure of records originally
obtained from a third party source could be harmful to the client or another person, or the
third party had a legitimate expectation that the information would not be disclosed to the
client without its permission, this information should not be disclosed, but the client is to be
informed that such third party information exists and who the client should contact directly
to obtain the information.
 Subject to the special rules for minors, when a case record contains information provided by
more than one client (as in family therapy), the complete case record may be made available
only upon written consent of all competent adult clients involved. If all do not consent, then
only entries made in the record that related to information received from consenting
individual(s) may be inspected, read, or otherwise disclosed.
 Records of counseling groups will be disclosed only with the written consent of all
individuals involved in the group. Records can be excised to include only information from
consenting clients.
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
Clients may take notes regarding their case records, but must separately request any copies of
the record, and such disclosure shall be governed by other provisions of this policy.
 The client must request in writing any amendment of information in the record that the
client believes is inaccurate. If the therapist agrees that the amendment should be made, the
amended information will be noted in the record, preserving the original incorrect entry in
order to maintain the integrity of the record. If the therapist disagrees with the client’s
requested amendment, both the client and the therapist may submit written statements
relating their respective positions, which is to be included in the record.
Clients have a right to insert a statement into their case record. If FSDC personnel insert a statement
in response, the client must be informed of this and given opportunity to review.
Client access to the case record will be documented on the “Client Access to Record” form. If the
client received copies of the record, this is also documented on the form. A charge for these copies
shall be established by the Finance Officer to cover the costs of copier, materials and supplies as
well as the staff time involved in making the requested copies. Such copies must be paid for at the
time they are delivered to the client. Each page shall be stamped “Client Copy.”
When a minor who is “unemancipated” (not married, not 18 years of age, not court order of
emancipation) requests access to his or her record, the staff member should determine whether the
minor client or the minor’s parent or guardian consented to the minor’s diagnosis and treatment.
Unless the minor is authorized to independently consent to the treatment (and therefore disclosure)
related to one of the conditions listed in N.C.G.S. 90-21.4 or 90-21.5, then the parent or guardian
should be contacted to obtain consent to disclose information to the minor. If the minor did
consent or is authorized by law to consent to treatment of such conditions independent of the
parent or guardian, access to the record should be allowed, unless the therapist believes such access
would be harmful as described below.
In some situations and after due deliberation in keeping with its professional obligation, the therapist
may conclude the reading the record would be harmful to the client and refuse the client permission
to examine the record. Concerns relative to harm for the client might include, but would not be
limited to, a client the therapist believes is not ready to handle the information in the record of a
client believed to be potentially suicidal or homicidal. This refusal must be reviewed and approved in
writing by the Clinical Director or Executive Director and documented in the client’s file. If the
client insists upon such access, the client has the right to demand that the agency send a copy of the
record to another qualified and credentialed professional in the clinical profession who is to review it
to determine whether disclosure would be harmful to the client. The client is responsible for the
costs of copying such records.
STAFF ACCESS TO CLIENT RECORDS
Records are accessible to agency employee on a strictly need-to-know basis, which may include the
following purposes:
 Assistance with the delivery of service to a client (i.e., supervision and consultation) and to
obtain payment.
 Administrative and internal accountability (administrative staff).
 Research (authorized research personnel).
 Re-accreditation or review by official monitors as required by funding or credentialing
bodies.
Access by staff, including clerical or treatment staff, must be for professional purposes only and in
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keeping with the applicable standard of care and the agency’s confidentiality practices. Board
members are not permitted access to personally identifiable client information without the client’s
(or legal representatives) written permission.
USE of RECORDS FOR RESEARCH, TRAINING, TEACHING AND PUBLIC RELATIONS
Case records may be used for research, training, teaching and public relations purposes without prior
consent only if they are thoroughly disguised by removing all identifying information and permission
is first obtained from the Program Director and the Executive Director. The Executive Director or
their designee is responsible for the release of any information to the news media. Only those clients
who agree and provide written consent will be quoted directly or photographed for public relations
purposes. FSDC prohibits involuntary participation in public performances and required or coerced
public statements.
USE OF RECORDS FOR THIRD PARTY CONTRACTS AND REVIEWING /
ACCREDITING BODIES
In those instances when the agency’s service to clients is to be audited or reviewed by third party
contractors, reviewers, or accrediting bodies, it will be the agency’s policy to encourage and assist
such examination by, whenever practical, furnishing aggregate data rather than personallyidentifiable client records. In those instances when client-identifying information is necessary, only
authorized participants in formal quality assurance activities may have access to this information.
Under a case-by-case payment contract referred by a third party, a summary of evaluation and
recommendation may be required for payment. This should be discussed with the client and written
permission secured before transmitting information to the third party payer.
LIMITATIONS TO CLIENT CONFIDENTIALITY
Legal Procedures: There is no statutory or court-made rule granting an absolute privilege of
confidentiality to the records of the agency. Therefore, despite the agency’s commitment to protect
the client’s right to confidentiality, records are subject to legal process and may have to be revealed
under court order. The agency and its professional staff are obligated to respond to an order of the
court requiring the giving of testimony or in the production of documents. If is the agency’s policy
that staff members normally would not appear in any court without a valid subpoena or direct order
from the judge; if the record is subpoenaed, to produce only those parts of the record requested by
the subpoena. For Licensed Clinical Social Workers and Licensed Marriage and Family Therapists,
communications with clients are protected by legal privilege of confidentiality pursuant to N.C.G.S.
Section 8-53.5 & .7. However, a court may override this privilege of confidentiality by ordering the
agency to produce records. In every case where staff or records are to appear in court, the Executive
Director or appropriate Program Director is to be informed in advance and the matter discussed.
After consideration of the issue, the applicable policies and guidelines, the Executive Director will
determine the need to consult with legal counsel regarding the agency’s response to such request.
Child Abuse and Neglect Situation: State law requires that any condition of such a nature as to
reasonably indicate abuse or neglect of a child will immediately be reported to the Department of
Social Services of the county of the residence of the child. This reporting takes precedence over any
confidentiality policy. It may be desirable to inform and involve the client in this reporting process
to the extent this is feasible according to the staff’s judgment. The Executive Director, Program
Director and/or immediate supervisor will be made aware of the details of each situation by the
completion of the Incident Report Form. This report will be presented to the members of CQI to
ensure procedural fidelity. The reporting of such instances or concerns will be documented in the
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case record. No more information that is necessary to protect the child’s safety should be reported.
Abuse, Neglect, or Exploited Disabled Adult: Anyone who has reason to believe that a disabled
adult need protective services has a duty to report that information to the Department of Social
Services where the disabled adult resides or is present. The Executive Director, Program Director
and/or immediate supervisor will be made aware of the details of each situation by the completion
of the Incident Report Form. This report will be presented to the members of CQI to ensure
procedural fidelity. The report of such instances/concerns will be documented in the case record.
Imminent Risk of Suicide and Homicide: If the client informs the therapist that he/she intends to
commit suicide, or if the therapist discerns this possibility without client verbalization, the therapist
is professionally obligated to take necessary steps to protect the individual, e.g., notification of
family, medical referral or hospitalization, if necessary. If the client is at imminent risk of committing
homicide, the police must be informed. In addition, if there is an identifiable threatened individual,
he or she should be informed after consultation with legal counsel when practical. Situations of
imminent risk to commit suicide or homicide are to be discussed fully with one’s supervisor, the
Program Director and the Executive Director. In addition, the reporting of such instances/concerns
will be documented in the case record. In accordance with N.C. Gen. Stat. 122C-55 staff may report
to authorities when a client has disclosed intent of imminent danger to the health or safety of
themselves or another individual or there is the likelihood of the commission of a felony or violent
misdemeanor.
SPECIAL CONSIDERATIONS
If agency staff, relatives, administration, and Board utilize agency services, the files in which these
records are kept will be marked confidential. Internal confidentiality will be insured and case
identification will be by number only. Under no circumstance will access to these records be allowed
except to worker, supervisor, or consultant.
Unemancipated minors may seek agency services. Every effort must be made to obtain parental
consent and involvement where appropriate; documentation of efforts should be included in the
client record. However, the agency may provide services without parental consent in accordance
with N.C. Gen. Stat. 90-21.1 and N.C. Gen. Stat. 90-21.5. This pertains to emergency services,
substance abuse and emotional disturbance. The minor seeking services must demonstrate an
understanding of the nature of the proposed treatment as well as its risk, benefits and alternatives.
Such services will be provided only with the ongoing supervision and monitoring of the Program
Director. Residential shelter will not be offered to
unemancipated minors unless accompanied by parent or guardian.
If the client is an unemancipated minor without permanent family ties and every effort has been
made to access a legal guardian as stated in governing statutes, then the existing policy regarding
release of information will be followed. If a guardian is available, then the guardian will sign the
release form allowing for exchange of information. Information regarding venereal disease,
pregnancy, drugs and alcohol, and emotional disturbance is not allowed to be released to the
guardian without permission of the minor.
The release of information will be read aloud by professional staff to clients who are functionally
illiterate. The client will sign the document acknowledging his/her understanding of said policy.
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The agency will not use clients in public performances, or in any photographs and/or videotapes for
public relations purposes without the written consent of the clients, or if the client in an
unemancipated minor, written consent of both the client and the client’s parent or guardian.
Any public statements by clients of gratitude for or appreciation of agency services will be strictly
voluntary, and will not be required, encouraged or coerced by the agency of any of its
representatives.
The agency requires that participation in research or follow-up studies will be completely voluntary,
and that the client’s agreement to participate or not participate will not affect services received. After
explanation of any benefits or risks of the proposed research or follow-up study, an informed
consent form is to be signed by the client or if the client is an unemancipated minor, written consent
of both the client and the client’s parent or guardian.
Research study directors must submit a “Human Subjects Review” document approved by an
official Human Subjects Review Committee prior to consideration of research activities; copies of all
consent forms and written research instruments to be used must also be submitted in advance.
Documentation shall be submitted to the Executive Director. The Executive Director is responsible
for taking the material before the Board for consideration and approval. Only research studies that
have been submitted the material and formally approved by the Board of Directors shall be allowed
to be conducted with agency clients, staff, volunteers, and/or on agency property.
OFFICE PROCEDURES
All case material, opened or closed, should be kept in locked files in a secure area and only those
persons described in Staff Access to Client Records should have access to them. When auditing,
contracting, or accrediting personnel are allowed access to client records, such individuals are
required to treat all files in a confidential manner. They are also required to sign a confidentiality
agreement prior to review of such records. No personal papers of clients should be accepted for
safekeeping or retained in case records. For closed records needing to be assessed, a sign-out system
exists to monitor record location at all times. Records, tape recordings, and videotapes are never to
be removed from the agency without administrative approval.
Therapists’ working notes will not be a part of the agency’s official record. The contents of notes
must be treated as confidential material until transferred to the permanent record.
Working notes will then be destroyed. Conjecture, surmise, assumption and personal impressions
should be labeled as such. Unprofessional editorializing is not properly a part of the record. All
closed cases will be monitored by the Program Director or supervisor for appropriate closure.
It is agency policy that all counseling records be destroyed seven (7) years case closure, or in the case
of a minor client whose case was closed prior to age eighteen (18), all counseling records will be
destroyed upon client reaching age twenty-four (24). There are special situations such as records
containing legal papers, historical data, contracts, and research projects where records may be
retained for a longer period, or where legally mandated. In the event of agency dissolution, the plan
for the disposition of records will be followed as required by applicable licensing and health
authorities. [Note: This period of record retention is not required by law, but is advised in order to
be prepared to defend against potential lawsuits by minor clients. For minors, the applicable statutes
of limitations do not begin to run until they turn eighteen]
All agency employees sign the Acknowledgment Form when presented with the agency Employee
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Manual, which contains the Confidentiality of Client Information Policy.
Computer systems discs and tapes are managed by the Office Manager. The network is safeguarded
by security measures and is only accessible by qualified agency personnel. Backup tapes are kept in a
locked fire-proof file cabinet to insure that client information is kept confidential.
When responding to requests for records, only copied documents will be provided. Original records
are not to leave the premises of the agency unless specifically ordered by a court, in transit between
different agency offices, or with the permission of the Program Director or Executive Director.
When records are in transit between different offices of the agency, they will be kept locked in the
glove box or trunk.
During the time that the case is active, the responsible agency employee is to maintain a record that
is kept up to date. All progress notes and summaries are to be placed in the client’s file within one
week from the time service is rendered.
RESPONDING to REQUEST for CONFIDENTIAL INFOMRATION
Subpoenas in General
Subpoenas are typically issued by attorneys, but may be issued by the clerk of court (or the
administrative tribunal handling the case), and in rare cases, by a judge. Because they are not “court
orders” and generally have not been scrutinized or authorized by a judge, there is some risk in
complying with a subpoena requesting confidential information. This includes subpoenas issued by a
district attorney in a criminal case. A subpoena (and a search warrant, for that matter) cannot simply
be ignored, however, as this could lead to being held in contempt of court.
When presented with a subpoena, the appropriately cautious response is to require the requesting
party to obtain and provide a copy of: (1) the client’s written consent to the disclosure; (2) the
written consent of someone with authority to consent on the client’s behalf if the client is
unavailable or not capable of consenting (such as the client’s attorney or legal guardian, or in the
case of an unemancipated minor, the client’s parent); (3) a court order, of (4) evidence of controlling
legal authority permitting or requiring disclosure. Without a court order or client consent, client
information should never be released directly to an attorney or mailed to the attorney’s office.
If the requesting attorney does not provide appropriate written authorization to disclose, the agency
is still free to ask the attorney who sent the subpoena to agree to allow the agency to submit the
documents directly to the court or administrative agency where the case is pending – ideally “under
seal” to protect the client’s confidentiality – for review by the judge to determine whether the
information should be revealed in the litigation. If the requesting attorney will not agree to this
alternative and does not provide one of the types of authority listed above, the agency will have to
go to court to “quash” the subpoena or face contempt of court charges.
Substance or Alcohol Abuse Information
When the client information requested may relate to substance abuse diagnosis or treatment
obtained at a drug or alcohol facility which is governed by 42 U.S.C. 290dd-3 (and related
regulations), the agency may not provide any information without very specific client consent or a
precisely-worded court order (issued only after a hearing conducted using fictitious names) that
follows the federal rules. The agency cannot even acknowledge to the requesting party whether it
possess any information about the person when substance abuse is involved. A proper response
would be: “Federal law prohibits the agency from disclosing any information about the individual
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named in the subpoena without their specific consent or a valid court order.”
Disclosure of HIV/AIDS Information
Request for information for client’s record containing HIV/AIDS related information must have
the client’s, and/or guardians’, signature and must specify that the HIV/AIDS information can be
released.
When to Demand a Court Order
The agency always is entitled to – and should – ask the requesting party to demonstrate its legal
authority to obtain client records; especially when a subpoena (1) demands records pertaining to
mental health, substance or alcohol abuse or treatment, peer review activities, or
HIV or AIDS, (2) demands more records that appears necessary to accomplish the stated purpose,
(3) is issued by someone the agency believes may not be entitled to the information, or (4) otherwise
appears unusual, the agency should insist on proper consent by the client. If the client does not
consent, the agency should then insist that the requesting party demonstrate the statutory authority
for the request. If that avenue also is unsatisfactory, the agency should ask the requesting party to
secure a court order. If the request appears to be invalid or otherwise problematic and no court
order is obtained, the agency (through its attorney) must go to court to “quash” the subpoena – or
face criminal contempt charges for failing to respond to a subpoena.
Order by Out-of-State Court
Out-of-state subpoena and court orders are invalid as authority to disclose client information unless
issued by a federal court having jurisdiction over North Carolina. Federal subpoenas may be valid if
the agency is within 100 miles of the issuing court.
Requests by Law Enforcement
If the request for information is from a law enforcement officer, the officer must show a valid court
order to obtain the information or must demonstrate that a statute or regulation authorizes the
release. Depending on how it is framed, a search warrant may not be sufficient to act as a court
order to permit access to a client’s confidential records. A warrant is typically issued by a magistrate,
not a judge, and does not contain the necessary findings of fact or conclusions of law concerning the
need for release found in a valid court order.
Requests by Governmental Agencies
If the agency receives a subpoena or other request from a governmental body for access to or
disclosure of client records, the agency should not presume that the request is authorized in the
absence of the client’s consent or a valid court order. Unless the agency is aware that the request is
authorized by law, the agency should ask to be provided a copy of the statute or regulation that
provides the purported authority. At the same time, it is prudent to avoid antagonizing the agency
making the request, because some government agencies (for example, those charged with
investigating possible Medicare or Medicaid fraud) have broad rights of access, and attempts to resist
granting a lawful request can have harsh consequences. Any question about whether a demand for
disclosure or access is appropriate should be directed to the Executive Director, and, as appropriate,
to the agency’s attorney.
When a Subpoena Commands Appearance
If a subpoena commands an employee/custodian of the agency to appear in court, the agency
should contact its attorney to determine if personal appearance may be excused by providing the
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court with certified copies of the records and an affidavit identifying the records and testifying to
their authenticity in compliance with North Carolina Rule of Civil Procedure 45 (c). This rule only
applies to custodians of hospital medical records, but most attorneys will excuse an
employee/custodian’s personal appearance in court based on compliance with this procedure. If the
employee/custodian’s appearance is not excused, the agency should contact an attorney. On pain of
criminal contempt charges for failure to appear, the agency should never ignore or fail to timely act
on a subpoena.
Requests for Research Purposes
If the request is for research purposes, the agency should only release information that does not
contain client-identifiable information. Otherwise, the researcher must show that the client’s consent
has been obtained, or that the request fits within a statutory exception.
Requests by Non-Custodial Parent
Unless the agency or the therapist has notice of a court order terminating parental rights or
otherwise limiting a parent’s rights, the non-custodial parent of an unemancipated minor client is
entitled to review, copy and authorize release of the minor’s information.
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Policy No.: 9.2
Policy: Clients Rights
Clients Rights
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. is committed to delivering quality, professional services to
individuals and families. Moreover, the Agency is committed to clearly communicating to clients
what the Agency believes are the rights and responsibilities of the client. A brochure outlining these
rights and responsibilities is to be given to all clients and staff.
Summary of Rights provided to all FSDC Clients:
1. To be informed of their rights;
2. To be treated with dignity and respect, privacy, humane care and freedom from mental and
physical abuse, neglect and exploitation without prejudice of age, gender, creed, race, ethnicity,
religion or cultural background;
3. To access crisis line and shelter services 24 hours a day/7 days a week
4. To access agency-based services Monday and Wednesday 8:30am-5:30pm, Tuesday – Thursday
8:30am-7 pm, and Friday 8:30 am-3 pm
5. To receive quality professional services delivered by staff who are professionally qualified and
supervised
6. To live as normally as possible while receiving care and treatment;
7. To know that information collected during assessment and treatment shall be limited to what is
deemed necessary for appropriate mental health services;
8. To receive age-appropriate treatment and access to medical care and habilitation, regardless of age
or degree of mental illness, developmental disability or substance abuse;
9. To have and participate in the development of a written individualized treatment/habilitation plan
(including discussion of risks and benefits) within 30 days of assessment;
10. To be informed in advance of the potential risks and alleged benefits of the FSDC treatment
choices;
11. To be informed of alternative treatment methods;
12. To receive the most appropriate treatment that is deemed the least restrictive and/or intrusive;
13. To be assured that no confidential information acquired will be disclosed without consent
(unless as authorized by law);
14. To consent to or refuse any treatment offered including behavior management policies and to
understand the consequences of that decision;
15. To withdraw consent from treatment at any time except in court-ordered treatment or certain
emergency situations and to understand the consequences of their decision;
16. To exercise all civil rights unless adjudicated incompetent
17. To have freedom from corporal punishment;
18. To have access to their treatment record, except when that information would be harmful to the
client's physical or mental well-being;
19. To not have any unauthorized publicity on, or use of, the client's treatment record (except as
authorized by law);
20. To review and discuss the fee for service (if applicable). To review and make suggestions on the
Agency's Service Policies and Procedures
21. To be assured that service delivery will not be influenced by any special contributions or gifts
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22. To take complaints to Agency Staff according to the published Client Grievance Policy
23. To contact and consult with a client advocate and/or the Governor's Advocacy council for
Persons with Disabilities. By contacting the NC Governor's Advocacy Council at:
2626 Glenwood Ave Ste 550
Raleigh, NC 27608
(888) 268-5535 (Voice/TTY)
(919) 856-2244 (FAX)
(877) 235-4210 (Toll free in state only)
(919) 856-2195
www.disabilityrightsnc.org
This is the state-wide agency designated under federal and state law to protect and advocate the
8. To sign appropriate authorizations consistent with the treatment plan or partnership agreement
OTHER
1. The Agency has the right and responsibility to determine if the clients can be appropriately
serviced within the limits of its mission, capacity, resources and expertise.
2. The Agency has the right to refuse or discontinue services when the clients' responsibilities are
not being met.
3. The Agency will make every effort to provide service satisfactorily in all respects and welcomes
any questions, suggestions, and inquiries.
PROCEDURES
_______________________________________________________________
A brochure outlining these rights and responsibilities is to be made available to all clients.
The Agency will work to ensure that clients who are disabled (i.e. visually impaired, mentally
informed of these rights and responsibilities.
A copy of these rights will be posted in the reception area at each location.
During the initial assessment staff will inquire whether the client understands their rights and
responsibilities and shall review the material with the client if requested (this shall be noted on the
Intake Assessment form).
Staff will review the Client Expectation letter to assist the client with their responsibilities while
seeking services at FSDC (this shall be noted on the Intake Assessment form).
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Policy No.: 9.3
Policy: Informing Clients of Rights
Informing Clients of Rights
POLICY
_______________________________________________________________
At the time of admission, or as soon as feasible as (but not longer than 72 hours thereafter for 24
hour programs or within 3 visits for day/night periodic services), the client shall be informed of
his/her rights and responsibilities.
PROCEDURES
_______________________________________________________________
This information shall be described in the FSDC's Your Rights as a Client brochure, which shall be
distributed at the time the client presents for services (typically by a support staff member).
A more complete explanation of the brochure shall be provided to the client or legally responsible
party by the FSDC staff member who completes the initial admission assessment.
Other applicable program-specific policies, procedures, regulations, rights, and responsibilities shall
be provided by other designated staff if the client enters any additional FSDC Service
Component(s).
The Agency will work to insure that clients who are disabled (i.e. visually impaired, mentally
informed of these rights and responsibilities.
A copy of these rights will be posted in the reception area at each location.
Confirmation of Informing Clients of Rights Responsibilities and Program Rules shall be marked as
required on the assessment form.
In each program component, the information provided to the client or legally responsible person
shall include:
 the rules that the client is expected to follow and possible penalties for violations of the
rules;
 the client's protection regarding disclosure of confidential information, as delineated in G.S.
122C-52 through G.S. 122C56;
 the procedure for obtaining a copy of the client's treatment/habilitation; and
 governing body policy regarding:
 fee assessment and collection practices for treatment/habilitation services;
 grievance procedures including the individual to contact and a description of the assistance
the client will be provided;
 suspension and expulsion from service; and
 search and seizure.
Summary of Rights provided to all FSDC Clients:
 To be informed of their rights
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




















To be treated with dignity and respect, privacy, humane care and freedom from mental and
physical abuse, neglect and exploitation without prejudice of age, gender, creed, race,
ethnicity, religion or cultural background
To access crisis line and shelter services 24 hours a day/7 days a week
To access agency-based services Monday and Wednesday 8:30am-5:30pm, Tuesday and
Thursday 8:30am-7 pm, and Friday 8:30am-3pm
To receive quality professional services delivered by staff who are professionally qualified
and supervised
To live as normally as possible while receiving care and treatment
To know that information collected during assessment and treatment shall be limited to
what is deemed necessary for appropriate mental health services
To receive age-appropriate treatment and access to medical care and habilitation, regardless
of age or degree of mental illness, developmental disability of substance abuse
To have and participate in the development of a written, individualized
treatment/habilitation plan (including discussion of risks and benefits) within 30 days of
assessment
To be informed in advance of the potential risks and alleged benefits of the FSDC treatment
choices
To be informed of alternative treatment methods
To receive the most appropriate treatment that is deemed the least restrictive and/or
intrusive
To be assured that no confidential information acquired will be disclosed without consent
(unless as authorized by law)
To consent to or refuse any treatment offered including behavior management policies and
to understand the consequences of that decision
To withdraw consent from treatment at any time except in court-ordered treatment or
certain emergency situations and to understand the consequences of their decision
To exercise all civil rights unless adjudicated incompetent
To have freedom from corporal punishment
To have access to their treatment record, except when that information would be harmful to
the client's physical or mental well-being
To not have any unauthorized publicity on, or use of, the client's treatment record (except as
authorized by law)
To review and discuss the fee for service (if applicable). To review and make suggestions on
the Agency's Service Policies and Procedures
To be assured that service delivery will not be influenced by any special contributions or gifts
To take complaints to Agency Staff according to the published Client Grievance Policy
To contact and consult with a client advocate and/or the Governor's Advocacy council for Persons
with Disabilities by contacting the NC Governor's Advocacy Council at:
1314 Mail Service Center
Raleigh, NC 27699-1314
(919) 733-9250 (Voice/TTY)
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(919) 733-9173 (FAX)
(800) 821-6922 (Toll free in state only) (888) 268-5535 (Toll free TTY)
http://www.disabilityrightsnc.org
This is the state-wide agency designated under federal and state law to protect and advocate for the
8. To sign appropriate authorizations consistent with the treatment plan or partnership
agreement
OTHER
 The Agency has the right and responsibility to determine the clients that it can appropriately
service within the limits of its mission, capacity, resources and expertise.
 The Agency has the right to refuse or discontinue services when the clients' responsibilities
are not being met.
 The Agency will make every effort to provide service satisfactorily in all respects and
welcomes any questions, suggestions, and inquiries.
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Policy No.: 9.4
Policy: Client's Rights Committee
POLICY
___________________________________________________________________
Family Services of Davidson County, Inc. shall retain ultimate responsibility for the assurance of
client rights. Family Services of Davidson County, Inc. shall establish a Committee to oversee
client's rights as part of the Continuous Quality Improvement (CQI) committee. Committee
members are not allowed to participate in review of incidents in which they were directly or
indirectly involved. The Family Services of Davidson County, Inc.'s established Client
Rights/Intervention Advisory Committee shall oversee the implementation of the following client
rights protection:
 compliance with G. S. 122C, Article 3;
 compliance with the provisions of Division publications Client Rights in Community Mental
Health, Developmental Disabilities and Substance Abuse Services APSM 95-2-and
Confidentiality Rules, APS.M 45.-l. adopted in accordance with G.S. 15OB-14 (c);
 compliance with all HIPAA standards; and
 establishment of a review procedure for any of the following which may be brought by a
client, client advocate, parent, legally responsible person, staff or others:
 client grievances;
 alleged violations of the rights of individuals or groups, including cases of alleged abuse,
neglect or exploitation;
 concerns regarding the use of restrictive procedures;
 failure to provide needed services that are available in Family Services of Davidson County,
Inc.; or
 instances of alleged or suspected abuse, neglect or exploitation of clients, which also must be
reported to Davidson County DSS.
Nothing herein stated shall be interpreted to preclude or usurp the statutory authority of a county
department of social services to conduct an investigation of abuse, neglect or exploitation or the
statutory authority of the Governor's Advocacy Council for Persons with Disabilities to conduct
investigations regarding alleged violations of client rights.
PROCEDURE
___________________________________________________________________
The Clients Rights Committee/ Intervention Advisory Committee shall:
1. have policy that governs its operation and requirements that:
2. access to client information shall be given only when necessary for committee members to
perform their duties; (B) committee members including Board members shall have access to
client records on a need to know basis only upon the written consent of the client or his
legally responsible person as specified in G.S. 122C-53(a); and (C) information in the client
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3.
4.
5.
6.
7.
record shall be treated as confidential information in accordance with G.S. 122C-52 through
122C-56;
receive specific training and orientation as to the charge of the committee and regarding
confidentiality, client’s rights, HIPAA, and general statutes contained in 122C.
be provided with copies of appropriate statutes and rules governing client rights and related
issues;
be provided, when available, with copies of literature about the use of a proposed
intervention and any alternatives;
meet, at minimum, on a quarterly basis and more often if needed, and
maintain minutes of each meeting; which shall not include client names.
Meetings will be conducted under Robert’s Rules of Order and only those with proper authority may
vote; decisions will be based on the majority decision. At each meeting, the committee will review
the implementation of clients’ rights procedures and consider patterns relating to their effectiveness.
The committee will review all reports of seclusion, restraint, ITO or other relevant procedures and
make regular reports to the Board of Directors regarding their use.
The Family Services of Davidson County, Inc. Client Rights Committee shall provide an annual
report of its activities. Clients shall not be identified by written or oral reports.
Current Clients Rights/Intervention Advisory Committee Members are:
Tim Tilley - Chair
Clinical Director
FSDC
PO Box 607
Lexington, NC 27293
Cynthia Fox- Therapist
CQI Chair
FSDC
PO Box 607
Lexington, NC 27293
Sherri Hill
CQI Staff representative
FSDC
PO Box 607
Lexington, NC 27293
Catherine Johnson- Crisis Intervention Director
FSDC
PO Box 607
Lexington, NC 27293
Meredith Martin- YCS Director
FSDC
PO Box 607
Lexington, NC 27293
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Paula Turlington – Board Chair or appointed Board member
SII Dry Kilns
sii_sales@siidrykilns.com
357-7146 (w)
Pam Parker – Board Secretary or appointed Board member
South Davidson HS Guidance Counselor
pparker@davidson.k12.nc.us
242-5700 (w)
Julia Toone- Interim Executive Director
FSDC
PO Box 607
Lexington, NC 27293
The Clients Rights/ Intervention Advisory Committee shall review grievances regarding incidents
which occur after the governing body of the agency has reviewed the incident and has had
opportunity to take action. Incidents of actual or alleged Client Rights violations, the facts of the
incident, and the action, if any, made by the contract agency shall be reported to the LME within 30
days of the initial report of the incident, and to the area board within 90 days of the initial report of
the incident.
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Policy No.: 9.5
Policy: Client Grievance
Grievance
POLICY
_______________________________________________________________
When a client/family has a compliant or grievance with regard to their treatment or any other
related activities, the most effective way to seek relief of or resolution to the problem is to discuss
the situation with the employee involved. Every effort will be made to resolve the issue at that point;
however, the client/family may not feel the complaint or grievance has been given sufficient
consideration or that the solution offered by the therapist is fair and equitable. This policy is
intended to secure the client’s right to have a grievance or complaint heard according to a standard
procedure.
PROCEDURES
_______________________________________________________________
The client should discuss a complaint or grievance with the employee involved. When the complaint
or grievance is considered solved here but of a serious nature, the employee should prepare a
“Report of Client/Family Grievance Conference” form and submit to their immediate supervisor/
program director. If the grievance cannot be resolved with the employee, then the client can request
a meeting with the employee and the appropriate supervisor/program director within the next five
(5) working days, during normal working hours for oral presentation of the grievance. The employee
and their supervisor/program director shall make every effort to work out an equitable solution to
the problem at this meeting.
Within five (5) working days from the date of the conference, the employee and the appropriate
supervisor/program director will render a decision. The decision will be recorded on the form
referred to in step 1 above. If the decision is satisfactory to the client/family, then it will be noted as
such on the form. If the decision is not satisfactory to the client/family, then the client/family may
proceed with the grievance process. If the decision reached by the supervisor/program director is
not satisfactory to the client/family, an appeal may be made in writing within ten (10) working days
to the Executive Director. Within five (5) working days after the Executive Director receives notice
of appeal, he/she must set a place and time for oral presentation of the grievance. The Executive
Director shall hear testimony by the employee, the immediate supervisor/program director and the
client/family. The Executive Director shall render a decision and respond in writing to the
concerned parties within five (5) working days after the hearing. If the decision reached by the
Executive Director is not satisfactory to the client/family, a final appeal shall be submitted in writing
to the Client’s Rights Committee of Family Services of Davidson County, Inc. within 14 working
days for the purpose of hearing any pertinent testimony from the client/family or other concerned
parties.
Within ten (10) working days, the Client’s Rights Committee of Family Services of Davidson
County, Inc. shall hear testimony by the employee, the immediate supervisor/program director and
the client/family. Within seven (7) working days of such a hearing, the Client’s Rights Committee of
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Family Services of Davidson County, Inc. shall notify all concerned parties of their final decision.
Appeals to the Client’s Rights Committee shall be final and binding to all parties involved within this
procedure.
Documentation of client/family grievance arising out of provision of services or out of failure by
the agency to provide services shall be reported to and reviewed by the Family Services of Davidson
County, Inc. Board of Directors.
A copy of this policy and procedure will be posted in the reception area of each
agency location as well as on the bulletin board in each location. A copy of this policy shall be
furnished to the client/family upon request.
A client/family may choose anyone to represent him/her at any step of these hearings. Such persons
may have access to any or all pertinent documents provided the consumer sign a waiver of
confidentiality. A client/family may request assistance from FSDC staff in writing their appeal. A
non-involved staff member will be assigned by the Executive Director to assist the client/family
with the written material. The responsibility for compliance with this policy and procedure is
assigned to the Executive Director or his/her designee.
Documentation of Grievances:
FSDC maintains an accurate and complete record of each grievance filed as well as summary
information about the number, nature, and outcome of all grievances filed. Records of grievances
are kept separate and apart from other client records and files. Grievance records and files are
retained in accordance with state and federal laws governing retention and destruction of records.
Grievances shall be documented in a Grievance log (Documentation of Grievance form) in
accordance with the following documentation procedures:
Oral Grievances
The Documentation of Grievance form/log shall include the following information for all oral
Grievances:
a. The date the oral Grievance was received and documented.
b. The name of the person taking the oral Grievance.
c. A summary of the nature of the Grievance, including the name of the Provider or other staff or
individual involved/named in the Grievance, if it involves a person.
d. Copies of written notices when extending the time frame for adjudicating oral
Grievances when FSDC initiates the extension.
e. The date of resolution, and summary of the resolution of the oral Grievance.
f. The name of the individual(s) resolving the oral Grievance. If the Grievance is regarding denial of
a request for an expedited resolution of an Appeal or involves clinical issues, the title and credentials
of the individual(s) who made the decision on the Grievance to demonstrate that they are individuals
who (1) were not involved in any previous level of review or decision-making and (2) are
professionals who have the appropriate clinical expertise.
g. The date the Client was notified of the Grievance resolution and how the
Client was notified (either orally or in writing).
h. If the Client was notified of the oral Grievance resolution in writing, copies of the written
Grievance Resolution Notice shall be maintained.
i. For oral Grievances not resolved within the required time frames, copies of Notice of Action
letters informing Clients that they may file an Appeal.
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j. Any other pertinent documentation needed to maintain a complete record of all oral Grievances
and to demonstrate that they were adjudicated according to the Contract provisions governing
Grievances.
Written Grievances
Using the same logging and tracking system as used for oral Grievances, FSDC shall keep the
following documentation on Grievances received in writing from
Clients:
a. The date the written Grievance was received.
b. The date and method of acknowledgment of the written Grievance (i.e., orally or in writing).
c. Copies of written notices when extending the time frame for adjudicating written Grievances
when FSDC initiates the extension.
d. The date of the resolution and summary of the resolution of the written
Grievance, this information may be documented in a written Grievance
Resolution Notice if the Client was informed of the Grievance decision in writing.
e. The name of the individual(s) resolving the written Grievance. If the Grievance is regarding denial
of a request for an expedited resolution of an Appeal or involves clinical issues, the title and
credentials of the individual(s) who made the decision on the Appeal to demonstrate that they are
individuals who (1) were not involved in any previous level of review or decision-making and (2) are
professionals who have the appropriate clinical expertise.
f. The date the Client was notified of the Grievance resolution and how the Client was notified
(orally or in writing).
g. If the Client was notified of the written Grievance resolution in writing, a copy of the written
Grievance Resolution Notice shall be maintained.
h. For written Grievances not resolved within the required time frames, copies of Notice of Action
letters informing Clients that they may file an Appeal.
i. Any other pertinent documentation needed to maintain a complete record of all written
Grievances and to demonstrate that they were adjudicated according to FSDC policy and
procedures.
The HR Director will maintain a tracking database for analysis using the information from the
attached Grievance Log-In Sheet.
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Policy No.: 9.6
Policy: Incident Reporting
Reporting
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. shall establish procedures for reporting all incidents,
unusual occurrences or medication errors regarding clients. A reportable incident or unusual
occurrence means any happening, which is not consistent with the routine operation of the facility
or the routine care of a client and that is likely to lead to adverse effects upon a client (incidents may
include but are not limited to accidents). Examples of such occurrences include (but are not limited
to): runaways, physical restraint, physical altercations between clients, adverse reactions to
medication, destruction of property, exposure to blood borne pathogens and any other condition
which adversely effects the delivery of services or potentially infringes upon the rights of clients.
NOTE: accidents involving FSDC employees should be reported in accordance with Davidson
County policy.
1.
2.
3.
4.
5.
6.
7.
8.
PROCEDURES
_______________________________________________________________
Any staff member directly involved in, or observing an incident, shall complete the FSDC
Incident Report Form (as appropriate based on level of incident). The completed form must
be presented to the employee’s immediate supervisor (or his/her designee) for review and
disposition within one working day of the incident.
The supervisor shall forward the form to the Program Director within one additional
working day. The Program Director will decide if and how the family should be notified.
The Program Director shall forward the form to the Executive Director who will review the
contents, involve other staff as deemed appropriate and seek corrective action in situations
when indicated.
The form will then be placed in a secure file as designated by the Executive Director.
If appropriate, a progress note describing the incident and the action taken should be
entered in the client’s clinical record; however, no reference should be made to the
completion of the Incident Report Form. The completion of this form is an administrative
matter and consequently should not be noted in the record.
If an incident report form involves a staff member other than the one completing the form,
that staff member will be advised by his/her supervisor. The staff member, if he/she so
desires, may file his/her own incident report.
All incident reports, up to and including fatalities, will be reviewed by the CQI committee
within the next quarter.
In the event of a fatality, reviews will take place by the CQI committee & the Management
Team within 48 hours following the submission of the report.
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Policy No.: 9.7
Policy: HIPAA Authorization
HIPAA Authorization
Purpose
The purpose of this policy is to specify requirements for authorization to disclose individually
identifiable health information and to develop a standard authorization form that must be used by
Family Services of Davidson County (FSDC).
FSDC agency shall not disclose, or be required to disclose, in individually identifiable format,
information about any individual without that individual’s explicit authorization, unless for
specifically enumerated purposes such as emergency treatment, public health, law enforcement,
audit/oversight purposes, or unless state or federal law allows specific disclosures.
POLICY
_______________________________________________________________
FSDC shall disclose individually identifying health information only upon authorization by the client
(or personal representative), unless state or federal law allows for specific exceptions. Authorizations
obtained or received for disclosure of individually identifiable health information must be consistent
with authorization requirements identified in this policy. An authorization permits, but does not
require, FSDC to disclose individually identifiable health information.
PROCEDURES
_______________________________________________________________
FSDC Standard Authorization
FSDC shall utilize a standard authorization form, “Consent for Release of Client
Information,” that contains the elements necessary to be considered a valid authorization. The
standard authorization form is written in plain and simple language that a client or personal
representative can easily read and understand. The standard authorization shall be made available in
languages understood by a substantial number of clients served by the agency. At a minimum, FSDC
shall ensure the standard authorization in Spanish translation is available. FSDC will coordinate with
the Division of Services for the Blind to provide access to authorization forms shall be available to
clients who are blind. Any alterations to the standard form must be prior approved by the FSDC
Privacy Officer (Executive Director).
Valid Authorization
The FSDC standard authorization form shall contain the core elements listed below. Any
authorization form received by FSDC from an agency/individual outside of FSDC shall be honored
only if it contains the following elements:
 A specific and meaningful description of the information to be used or disclosed;
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






The name or other specific identification of the person or class of persons authorized to
make the requested use or disclosure of the information;
The name or other specific identification of the person or class of persons to whom the use
or disclosure can be made;
A description of each purpose of the requested disclosure (the statement “at the request of
the client” is a sufficient description of the purpose when a client initiates the authorization
and does not, or elects not to, provide a statement of the purpose);
An expiration date or event that relates to the client or the purpose of the use or disclosure.
The following statements meet the requirements for an expiration date or an expiration
event if the appropriate conditions apply:
The statement “end of the research study” or similar language is sufficient if the
authorization is for use or disclosure of individually identifying health information for
research:
The statement “none” or similar language is sufficient if the authorization is for the agency
to use or disclose individually identifying health information for the creation and
maintenance of a research database or research repository; and
Signature of the client and the date of the signature. If a client’s personal representative signs
the authorization form, a description of the personal representative’s authority to act on
behalf of the client must also be provided.
In addition to the required elements, the authorization form must contain statements that inform
the client of the following:
 The client’s right to revoke the authorization, the exceptions to the right to revoke, and a
description of how the client may revoke the authorization;
 The consequences (as identified in the “Conditioning of Authorizations” section of this
policy) to the client for refusal to sign the authorization form; and
 The potential for information to be subject to redisclosure by the recipient and no longer
protected by state or federal law.
FSDC must provide a copy of the signed authorization to the client (or personal representative)
upon request.
Invalid Authorization
An authorization shall be considered invalid if the document has any of the following deficiencies:
 The expiration date has passed or the expiration event is known to have occurred;
 The authorization form is not completely filled out;
 The authorization form does not contain the core elements of a valid authorization;
 The authorization is known to have been revoked;
 Any information recorded on the authorization form is known to be false; or
 An authorization for psychotherapy notes is combined with a request for disclosure of
information other than psychotherapy notes.
Psychotherapy Notes
A separate authorization must be obtained for disclosure of the personal notes of a mental health
professional that are separated from the rest of a client’s record, except as follows:
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







Use by the originator of the psychotherapy notes for treatment purposes;
Use or disclosure by FSDC for its own training programs in which students, trainees or
practitioners in mental health learn under supervision to practice or improve their skills in
group, joint, family or individual counseling;
Use or disclosure by FSDC to defend itself in a legal action or other proceeding brought by a
client;
Investigations by the Secretary of the US Department of Health and Human Services;
Use or disclosure required by law;
Health oversight activities;
Coroners and Medical Examiners; or
Institution Review Board or Privacy Board approval for waiver of authorization for research
purposes.
Questions regarding the agency’s authority to disclose psychotherapy notes without a valid
authorization should be referred to the FSDC Privacy Officer (Executive Director).
Compound Authorization
An authorization for disclosure of individually identifiable health information shall not be combined
with any other written legal permission from the client (e.g., Consent for Treatment, Assignment of
Benefits); however, research studies that include treatment may combine authorizations for the same
research study, including consent to participate in the study.
An authorization for disclosure of psychotherapy notes may not be combined with any other
authorization; however, psychotherapy notes that are needed from more than one provider or are
disclosed to more than one recipient may be combined. Agencies may use a single authorization for
disclosure to multiple agencies involved in coordination of care. An authorization that specifies a
condition for the provision of treatment, payment, enrollment in a health plan or eligibility for
benefits may not be combined with any other authorization.
Conditioning of Authorization
The provision of treatment, payment, enrollment in a health plan or eligibility for benefits shall not
be conditioned on whether or not a client signs an authorization form, except as follows:
 The provision of research-related treatment can be conditioned on a client authorizing the
use or disclosure of individually identifiable health information for such research;
 Provision of health care solely for the purpose of creating individually identifiable health
information for disclosure to a third party (e.g., physical exam for life insurance); or
 Prior to enrollment in a health plan if authorization is for eligibility or enrollment
determinations and the authorization is not for disclosure of psychotherapy notes.
Signatures
Each authorization must be signed and dated by the client (or personal representative). If a client’s
personal representative signs the authorization form, a description of such authority to act for the
client must also be documented on the form. When minors are receiving treatment for alcohol or
substance abuse, based upon the consent of their personal representative, the minor and personal
representative must both sign the authorization. Should a client (or personal representative) be
unable to sign his/her name, an “x” or other mark/symbol is acceptable in place of a signature, as
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long as it is witnessed and documented, attesting to the validity of the signature.
Dates
Each authorization must state an expiration date or event, such as a specific time (e.g., January 1,
2003); a specific time period (e.g., one year from the date of signature); or an event directly relevant
to the client or the purpose of the disclosure (e.g., 60 days following discharge from the facility).
Unless revoked sooner by the client, an authorization will be valid for a period up to one year,
except for financial transactions, wherein the authorization shall be valid indefinitely. The expiration
date or event for each authorization must be acknowledged and actions taken on that authorization
must be consistent with such limitations.
Revocation of Authorization
The authorization must state that a client has the right to revoke the authorization at any time,
except to the extent that FSDC has already taken action based upon the authorization. FSDC
strongly recommends that clients be encouraged to sign a revocation statement that becomes a
permanent part of the record. Should a client refuse to sign a request for revocation, the verbal
revocation statement should be witnessed by a third-party and documentation of the request should
be placed in the client’s record. The authorization form must include instructions on how the client
may revoke an authorization.
Retention Period
Authorization forms in their client records must adhere to the retention period in the agency’s
retention and disposition schedule for client records.
Photocopy/Facsimile Authorizations
An original authorization form is preferred for disclosure of individually identifiable health
information; however, a clear and legible photocopy/facsimile is acceptable.
Contractor Authorizations
The authorization requirements contained in this policy also apply to contractors who perform a
service for or on behalf of FSDC. Such contractors are limited to those disclosures permitted in an
agreement with the agency. Contractors are responsible for ensuring these policy requirements are
enforced with any subcontractors they may use.
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Policy No.: 9.8
Policy: HIPAA Compliance
Purpose
The purpose of this policy is to set forth Family Services of Davidson County, Inc.’s (FSDC)
requirements for making reasonable efforts to limit the use and disclosure of individually identifiable
health information to that which is minimally necessary to support the intent of use or disclosure.
POLICY
_______________________________________________________________
FSDC must make reasonable efforts to limit individually identifiable health information to that
which is minimally necessary to accomplish the intended purpose for the use, disclosure, or request
for information.
The minimum necessary requirement applies to:
 Uses or disclosures for payment or health care operations;
 Uses or disclosures requiring the client to have an opportunity to agree or object;
 Uses or disclosures that are permitted without the client’s permission (except for those
required by law or specified otherwise in the FSDC Policy Manual); and
 Uses or disclosures by External Business Associates.
PROCEDURES
_______________________________________________________________
At FSDC, access to systems and/or files containing individually identifiable health information is
limited through access controls. These controls include:
Minimum Necessary within Agency
FSDC is required to identify persons or classes of persons in its workforce who need access to
individually identifiable health information and the categories of information to which access is
needed.
FSDC must develop and implement procedures that limit routine disclosures of individually
identifiable health information to the amount reasonably necessary to achieve the purpose of the
disclosure.
FSDC is required to develop criteria designed to limit individually identifiable health information to
the minimum necessary.
Minimum Necessary Outside Agency
FSDC will rely on a request for disclosure as being limited to the individually identifiable health
information that is minimally necessary, if:
 Disclosure is to a public official who represents that the request is for the minimum
necessary information;
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


The request is from another HIPAA covered health care component;
The request is from a professional in the agency’s own workforce or from a business
associate, and the professional represents that the request is for the minimum necessary
information; or
The requestor provides documentation that the disclosure is for research purposes.
The minimum necessary requirement does not apply to:
 Disclosures to or requests by a health care provider for treatment;
 Uses or disclosures made to a client to whom the information applies;
 Uses or disclosures authorized by the client (or the client’s personal representative);
 The Secretary of the United States Department of Health and Human
 Services for compliance enforcement;
 Uses or disclosures required by law; or
 Uses or disclosures required for compliance with the HIPAA Privacy Rule.
Implementation
The following protocols are in compliance with the HIPAA Privacy Rule and should be considered
when staff share individually identifiable health information in the performance of their job
responsibilities and when sharing individually identifiable health information with individuals outside
the agency.
When using individually identifiable health information within the agency, FSDC categorizes users
by their “need-to-know” in order to accomplish their job responsibilities and follows standard
protocol (criteria) that reasonably limits inappropriate access to individually identifiable health
information based on the following categories:
Standard Protocol for Uses of Individually Identifiable Health Information by FSDC’s own
Workforce
For uses of individually identifiable health information by its own workforce within FSDC, standard
protocol must:
 Identify the persons or groups of persons who need access to individually identifiable health
information to carry out their job functions;
 Identify the type of individually identifiable health information to which each person or
group needs access, as well as the conditions under which they need the access; and
 Make reasonable efforts to limit the access of its staff to only the information appropriate to
their job functions.
Standard Protocol for Disclosures of Individually Identifiable Health Information by an Agency’s
Own Workforce
For routine, recurring disclosures of individually identifiable health information by an agency’s own
workforce, standard protocol must:
 Identify the types of information to be disclosed;
 Identify the types of persons who would receive such information;
 Identify the conditions that would apply to such access; and
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
Develop reasonable criteria for disclosures to routinely hired types of business associates
(e.g., medical transcription).
For non-routine disclosures of individually identifiable health information by an agency’s own
 Develop reasonable measures to limit information to the minimum necessary to accomplish
the purpose of the disclosure; and
 Use these measures to review non-routine disclosures on an individual basis.
Standard Protocol for Making Requests for Individually Identifiable Health
Information by an Agency’s Own Workforce
For routine, recurring requests for individually identifiable health information by an agency’s own
 Describe what information is reasonably necessary for the purpose of the request; and
 Limit the request for individually identifiable health information to that information.
For all other requests for individually identifiable health information by an agency’s own workforce,
standard protocol must ensure that each request is reviewed by an agency staff member who has
authority to determine that the information requested is limited to what is reasonably necessary to
accomplish the purpose of the request.
Criteria must be developed that control both the request for, and the disclosure of, the entire client
record. Criteria must specifically justify why the entire client record is required. Exceptions to agency
criteria are prohibited without prior approval of the Executive Director.
Individuals or entities external to the agency that perform activities or functions on behalf of FSDC
as defined by the HIPAA Privacy Rule, are considered External Business Associates of FSDC. As
such, External Business Associates are required to comply with the Minimum Necessary
requirement as specified in the HIPAA Privacy Rule.
The minimum necessary policy is intended to make FSDC evaluate their current procedures and
enhance protections needed to limit unnecessary or inappropriate access to and disclosures of,
individually identifiable health information.
FSDC considers best practice for sharing individually identifiable health information is to always
limit such information to that which is necessary to accomplish the intended purposes of such use
or disclosure.
FSDC must limit their requests for individually identifiable health information to that which is
minimally necessary and reasonable.
No use, disclosure, or request for a complete client record is considered minimally necessary unless
specific justification is documented.
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Behavior Support and
Management
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Policy No.: 10.1
Policy: Use of Restrictive Interventions
Use of Restrictive Interventions
POLICY
______________________________________________________________________________
The goal of all FSDC treatment and habilitation shall be to provide services in the least restrictive,
most appropriate and effective manner. It is the policy of the FSDC to avoid the use of restrictive
interventions as defined in APSM 95-2, 01-01-92, whenever possible. Under no circumstances, shall
any member of FSDC staff use mechanical restraint, seclusion or isolation.
Restrictive interventions shall not be employed as a means of coercion, punishment or retaliation by
staff or for the convenience of staff or due to inadequacy of staffing. Restrictive interventions shall
not be used in a manner that causes harm or abuse. The use of any restrictive interventions will
comply with all federal, state and local legal and regulatory requirements. Any use of restrictive
interventions will comply with the guidelines of Non-violent Crisis Intervention from CPI (Crisis
Prevention Institute). Each staff member within the Juvenile Delinquency Program will be trained in
CPI and evidence maintained in their personnel file. A minimum of one staff member in each other
agency program will also be trained in CPI and evidence will be maintained in his/her personnel file.
Only those employees authorized and trained in the use of restrictive interventions will use them.
PROCEDURES
______________________________________________________________________________
_
Upon admission, there shall be a review of the client’s health history, comprehensive health
assessment, and an assessment of the potential need for restrictive behavior management
intervention. The assessment shall include pre-existing medical conditions, medications or any
disabilities and limitations that would put the client at risk in the event of restrictive intervention.
Clients, parents, and/or legal guardians will be given information, upon admission, about the
circumstances surrounding potential use of restrictive interventions as well as a copy of the FSDC
behavioral management policy. Consent will be valid for a period of 6 months. A Behavior
Management Contract will be explained to each parent/legal guardian. Each parent will sign the
Contract detailing the various techniques our staff might use in order to protect the youth. The
possible use of manual restraint will also be entered into the individualized service plan of each
client.
If it becomes necessary to restrain a violent or aggressive client to prevent him/her from harming
him/herself or others, FSDC employees shall use only that degree of force necessary to repel or
secure the client and which is permitted by FSDC policy. The degree of force that is necessary will
depend upon the individual characteristics of the client and the degree of aggressiveness displayed
by the client. When time permits, it is the FSDC policy to contact an appropriate law enforcement
agency to intervene to prevent the client from harming him/herself or others.
If a program component or contract agency finds it necessary to utilize restrictive interventions, the
staff involved and/or an immediate supervisor must notify the
Executive Director or designee of FSDC management, the treatment team and a person identified
by the client, if requested, as soon as possible but no more than 24 hours later.
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If, at any point, adverse side effects such as illness, severe emotional or physical distress or physical
damage are observed, behavior management intervention will be stopped immediately and the
Executive Director or designee will be notified.
Interventions that have been prohibited by statute or rule shall not be employed by FSDC. These
include:
 any intervention which would be considered corporal punishment under G. S. 122C-59;
 the contingent use of painful body contact;
 substances administered to induce painful bodily reactions, inclusive of Antabuse & Deproprovera;
 electric shock, excluding medically administered electroconvulsive therapy (the FSDC shall
not administer electroconvulsive therapy, however, clients may be referred for such
treatment at another facility);
 insulin shock;
 withholding nutrition, hydration and/or use of unpleasant tasting food;
 contingent application of any noxious substances which include, but are not limited to noise,
bad smells or splashing with water; and
 any potentially physically painful procedure, excluding prescribed injections, or stimulus,
which is administered to the client for the purpose of reducing the frequency or intensity of
a behavior;
 forced physical exercise;
 punitive work assignments;
 group punishment or punishment the client’s peers or program participants.
FSDC does not use seclusion or isolation as interventions with any client.
The following procedures shall only be employed when clinically or medically indicated as a method
of therapeutic treatment:



planned non-attention to specific undesirable behaviors when those behaviors are nonhealth threatening;
contingent deprivation of any basic necessity; or
other professionally acceptable behavior modification procedures that are not prohibited by
Rule .0102 of this Section or covered by Rule .0104 of this sect.
The use of restrictive interventions shall be limited to:
 emergency situations, in order to terminate a behavior or action in which a client is in
imminent danger of abuse or injury to self or other persons or when property damage is
occurring that poses imminent risk of danger of injury or harm to self or others.
 Emergency use of restrictive intervention will be limited to:
 Staff privileged to use the intervention based on experience and training.
 An agency employee privileged to administer emergency interventions may employ such
procedures for up to 15 minutes without further authorization.
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




Continued use of the intervention shall be authorized only by staff privileged to use the
restrictive intervention and based on clear and recent behavioral evidence that the
intervention is having a positive impact that requires continuation.
The responsible staff (with the necessary experience and training) will meet with and
conduct an assessment that includes the physical and psychological well-being of the client
and write a continuation authorization immediately after the time of the initial use of the
restrictive intervention.
If the responsible staff or a qualified professional is not immediately available to conduct an
assessment of the client, but concurs that the intervention is justified after discussion with
the facility employee, continuation of the intervention may be verbally authorized until an
on-site assessment of the client can be made. If authorizing staff is off-site, authorization will
only be for a period of up to 3 hours then a written order must be in place, written orders
for physical restraint or time-out is limited to four hours for adult clients; two hours for
children and adolescent clients ages nine to 17; or one hour for clients under the age of nine.
The original order shall only be renewed in accordance with these limits or up to a total of
24 hours.
Standing orders or PRN orders shall not be used to authorize the use of seclusion, physical
restraint or isolation timeout.
The legally responsible person of a minor client or an incompetent adult client will be
notified immediately in an instance of the use of restrictive interventions.
Time Out (defined as the removal of a client for a period of 30 minutes or more to a separate room
with a member of staff, that is not locked, and where there is continuous supervision) may be
utilized to control and/or modify maladaptive behavior of a client.
An initial attempt shall be made to obtain a voluntary exit by the client of the room where the
incident is occurring.
 A client may only be removed from group/activity under adult supervision.
 There shall be a FSDC staff in attendance with no other immediate responsibility than to
monitor the client who is placed in isolation time-out.
 There shall be continuous observation and verbal interaction with the client when
appropriate, and such observation shall be documented in the client record.
 The restrictive intervention shall be discontinued as soon as therapeutically appropriate but
in all cases immediately after the client gains behavioral control. If the client is unable to
gain behavioral control within the time frame specified in the authorization of the
intervention, a new authorization must be obtained for each additional 15 minute period.
Manual restraint may only be used to protect a client from physical injury to self or others.
 When a client is in physical restraint, staff will remain with the client continually.
 When a client is in restraint, she/he must be observed continually, to assure the
safety of the client.
Appropriate attention shall be made to the provision of regular meals, personal hygiene, and the use
of the toilet. Such attention and observation shall be documented in the client record.
The restrictive intervention shall be discontinued as soon as therapeutically appropriate but in all
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cases immediately after the client gains behavioral control.
If the client is unable to gain behavioral control within the time frame specified in the authorization
of the intervention, a new authorization must be obtained for each additional 15 minute period.
There shall be continuous assessments and monitoring of the client’s physical and psychological
well-being throughout the duration of the restrictive intervention by a staff present and trained in
restrictive intervention, and in CPR, for a minimum of 30 minutes following the termination of the
restrictive intervention.
Clients with reasonable foreseeable physical consequences to the use of restraint must be identified.
The Program Coordinator shall document any counter indications to the use of seclusion or restraint
that may include physical problems, unstable medical conditions (e.g. seizure disorders, cardiac
illness, pregnancy, metabolic illness, disorders of thermo-regulation, infection, etc.), medications (e.g.
neuroleptics), surgeries or psychological reasons such as a history of physical or sexual abuse. The
Program Coordinator shall identify and document alternative or modified emergency procedures, if
needed.
A health status check will be conducted immediately prior to the use of a restraint.
The health status check shall include observation of the client’s breathing.
Health status checks shall be conducted during and immediately following the use of a restraint. The
post-restraint health status check shall include assessment of the client’s:
 Circulation
 range of motion in the extremities
 vital signs
 physical and psychological status and comfort
If at any time, physical consequences are present, a physician must be contacted to monitor the
client for the remainder of the intervention and at any future use.
The restrictive intervention shall be considered a planned intervention and shall be included in the
client's treatment/habilitation plan whenever it is used:
1. more than four times, or for more than 40 hours, in a calendar month;
2. in a single episode in which the original order is renewed for up to a total of 24 hours in
accordance with the limit specified in Item (E) of Subparagraph (e)(10) of this Rule; or
3. as a measure of therapeutic treatment designed to reduce dangerous, aggressive, selfinjurious or undesirable behaviors.
When a restrictive intervention is used as a planned intervention, facility policy shall specify:
 the requirement that a consent or approval shall be considered valid for no more than six
months and that the decision to continue the specific intervention shall be based on clear
and recent behavioral;
 evidence that the intervention is having a positive impact and continues to be needed;
 prior to the initiation or continued use of any planned intervention, the following written
notifications are necessary:
1. consents and approvals shall be obtained and documented in the client record:
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2. approval of the plan by the responsible professional and the treatment and habilitation
team, if applicable, shall be based on an assessment of the client and a review of the
documentation required by Subparagraph (e)(9) and (e)(14) of this Rule if applicable;
3. consent of the client or legally responsible person, after participation in treatment
planning and after the specific intervention and the reason for it have been explained in
accordance with 10A NCAC 27D .0201;
4. notification of an advocate/client rights representative that the specific intervention has
been planned for the client and the rationale for utilization of the intervention; and
5. physician approval, after an initial medical examination, when the plan includes a specific
intervention with reasonably foreseeable physical consequences. In such cases, periodic
planned monitoring by a physician shall be incorporated into the plan.
Within 30 days of initiation of the use of a planned intervention, the PQI established in accordance
with Rule .0106 of this Section, by majority vote, may recommend approval or disapproval of the
plan or may abstain from making a recommendation. Within any time during the use of a planned
intervention, if requested, the PQI shall be given the opportunity to review the
treatment/habilitation plan; if any of the persons or committees specified in Subparagraphs (h)(2) or
(h)(3) of this Rule do not approve the initial use or continued use of a planned intervention, the
intervention shall not be initiated or continued. Appeals regarding the resolution of any
disagreement over the use of the planned intervention shall be handled in accordance with
governing body policy; and
T10A 27E .0100 North Carolina Administrative Code 12
Documentation in the client record regarding the use of a planned intervention shall indicate:
1. Description and frequency of debriefing with the client, legally responsible person, if
applicable, and staff if determined to be clinically necessary. Debriefing shall be conducted as
to the level of cognitive functioning of the client;
2. Bi-monthly evaluation of the planned by the responsible professional who approved the
planned intervention; and
3. Review, at least monthly, by the treatment/habilitation team that approved the planned
intervention.
Following the use of any restrictive interventions, staff will conduct debriefing and planning with the
client and responsible party at the appropriate level of cognitive functioning to ensure the client
understands. Debriefing will include discussions of the elimination or reduction of the probability of
future use of restrictive interventions.
If a client requests voluntary restrictive intervention, all applicable procedures must be followed.
If a client refuses restrictive interventions, staff will assess danger and implement procedures for
suspension/expulsion, as appropriate. Client and responsible party (as appropriate) will be notified
that a meeting between client, FSDC staff, and responsible party will be required prior to readmission.
Clients will be informed that due process for disagreements over the use of restrictive interventions
will follow FSDC’s grievance policy/procedures. In the event a client has not maintained their copy,
additional copies of this policy will be provided.
Documentation of each occurrence of restrictive intervention will be maintained in a Restrictive
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Intervention Log. Documentation will include:
 name of the client;
 name of the responsible professional;
 date of each intervention;
 time of each intervention;
 type of intervention; duration of each intervention; reason for use of the intervention;
 positive and less restrictive alternatives that were used or that were considered but not used
and why those alternatives were not used;
 debriefing and planning conducted with the client, legally responsible person, if applicable,
and staff to eliminate or reduce the probability of the future use of restrictive interventions;
and
 negative effects of the restrictive intervention, if any, on the physical and psychological wellbeing of the client.
Documentation will include the signature and title of the staff member who initiated, and of the
employee who further authorized the use of the intervention. A Restrictive Intervention Report
Form QM04 will be completed for any use of restrictive interventions within 24 hours. This report
will be reviewed by the Program Director and forwarded to the CQI Committee for review.
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Clinical Services
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Policy No.: 11.1
Policy: Service Eligibility
Eligibility
POLICY
_______________________________________________________________
FSDC shall provide appropriate service(s) to each client that seeks treatment/remedy. This is
ensured by our staff collecting necessary initial contact information to verify need. Once it is
determined that the client’s(s’) request is consistent with services offered, a comprehensive
assessment, provided by a credentialed employee, is scheduled. If services requested are not
available, staff will inform the client and provide referral(s) to the appropriate agency/provider.
PROCEDURES
_______________________________________________________________
Services shall be available to:
 Davidson County residents,
 children who attend Davidson County, Lexington City, Thomasville City Schools,
 individuals who live in surrounding counties and are referred by their insurance company or
Local Management Entity(Cardinal Innovation Healthcare Solutions- Medicaid clients).
Each client is assessed by a Qualified Professional to determine need. The mental health assessment
includes demographic information, family history, symptom history, current symptomatology
(including substance abuse), history of psychiatric/substance abuse treatment, mental status exam,
and diagnosis. Once the assessment is completed the client(s) may be assigned to the following
program(s) based on need and meeting criteria.
Family Empowerment Program- Referrals to this program may be in house or from the community.
Referral must meet 3 of the following 5 criteria:
1. Previous involvement with Department of Social Services or at risk for current involvement
2. Head of household is not a high school graduate
3. Family income is at or below the poverty level
4. Single parent home
5. Parent(s) do not have full time year round employment.
Youth and Community Services – Client must be a school-aged child (7-17 years old) with behavior
problems that causes difficulties within the school system or at home i.e. school suspension or
oppositional at home/school. Main focus of treatment is family and group therapy. Complete intake
process and set up with Intake Specialist with Juvenile Delinquency Team. Also, Juvenile Court
Counselor may submit, by fax, referral form for services. Appointment is scheduled on Therapist
Helper and a copy is given to Intake Specialist. A copy is also filed in Intake Folder under date of
appointment. Once assessment is completed client will be assigned to the After-school Treatment
Program, Structured Day Treatment Program, or to a therapist for individual, group or family
therapy. An appointment is then scheduled. The counseling is FREE.
After-School Treatment Program – Client meets 7 – 17 age guideline and is demonstrating behaviors
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that
could mean Juvenile Court involvement if left unchecked. Information is taken regarding the client
and
submitted to Youth and Community Services (YCS). An assessment is scheduled with a team
member of
YCS. Client is then assigned to the program if deemed appropriate.
Structured Day Treatment Program - Client meets 7 – 17 age guideline and is currently adjudicated
and/or on probation for a juvenile offense. Information is taken regarding the client and submitted
to Youth and Community Services (YCS). An assessment is scheduled with a team member of YCS.
Client is then assigned to the program if deemed appropriate.
Intensive Family Preservation Services (IFPS) - IFP services are funded and organized through two
major sources, the Juvenile Crime Prevention Council (JCPC) and Medicaid. The JCPC is also
referred to as the Division of Juvenile Justice. Medicaid funding comes through the Local
Management Entity provider named Cardinal Innovation Healthcare Solutions (CIHS). IFP services
provided through the JCPC and Medicaid are listed below based on their routes of referral and their
modes of service.
JCPC IFPS: Family Services will accept referrals, by phone and fax, from the Division of Juvenile
Justice for the Intensive Family Preservation Services program. Referrals will be Level II and III
youth who have not succeeded at less-intensive forms of treatment, are at risk of out-of-home
placement, are capable of benefiting from family therapy, have support systems in place, and who
will not place the community at unacceptable risk. Youth, under the age of 17, may be referred
before or following YDC commitment after consultation with and approval from the Division of
Juvenile Justice, the Judge, the Assessment Center, and the Treatment Team. An intake/assessment
session, at Family Services or at the Youth Development Center, will be scheduled with the youth
and family as soon as possible following the referral. This assessment performed by Family Services
will serve as program admission, will assess the appropriateness of the referral, and will evaluate the
youth, family, and community network available to make an intensive commitment to the work of
the program. Once the intake session is complete, the Intensive Family Preservation Therapist(s)
and Clinical Director will review the assessment in order to accept or deny the referral, along with
making recommendations for further mental health treatment and/or further coordination of care
services. Family Services will notify the family and the referring court counselor about the outcome
of the initial assessment.
Medicaid IFPS: Family Services will accept referrals, by phone and fax, from CIHS for the Intensive
Family Preservation Services program. Referrals will be youth under the age of 17 who have not
succeeded at less intensive forms of treatment, are at risk of out-of-home placement, are capable of
benefiting from family therapy, have support systems in place, and who will not place the
community at unacceptable risk. This assessment performed by Family Services will serve as
program admission, will assess the appropriateness of the referral, and will evaluate the youth,
family, and community network available to make an intensive commitment to the work of the
program. Once the intake session is complete, the Intensive Family Preservation Therapist(s) and
Clinical Director will review the assessment in order to accept or deny the referral, along with
making recommendations for further mental health treatment and/or further coordination of care
services. Family Services will notify the family and the referring court counselor about the outcome
of the initial assessment.
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FVP, SA, or DV - This counseling is FREE to clients who are victims of domestic violence or
sexual assault. Complete Therapist Helper intake process and scheduled assessment with Intake
Specialist or with the Family Violence Prevention therapist. Once assessment is completed case is
assigned to Family Violence Prevention therapist.
Insurance/Medicaid - Client may elect to use personal insurance to cover the cost of mental health
counseling. Client contacts FSDC for an initial assessment. FSDC staff determines if client’s
coverage is accepted by this agency. If a contract exists, the client is scheduled with the therapist
covered under the plan for an initial assessment. If there is not an active contract with the insurance
company, the client is scheduled with the Intake Specialist. The client is asked to bring a copy of
insurance card and authorization number to first appointment. During the initial assessment,
administrative staff will verify coverage by contacting the insurance company and completing the
“Insurance Questions Form”. This information is given to the Intake Specialist who addresses the
coverage with the client. This may also include referral(s) to other covered providers in their plan. If
FSDC is covered under the client’s plan the client may need to call their insurance company to
request an authorization for services. The client is given opportunity to speak with their insurance
company in a confidential setting to secure authorization. After completion of the assessment, the
client is scheduled with a therapist according to plan/authorization.
Sliding Scale Fee – If client(s) indicate they cannot afford to pay, have no insurance, or do not fit
under a grant, they can be set up under a sliding scale fee. This is based on client’s income and
number of people in the household, use the Sliding Scale Form. Once a fee is determined the client
is informed of the cost of services. Complete Therapist Helper intake process and schedule
assessment with Intake Specialist. Hattie Lee Burgess House – Women and children fleeing
domestic violence or sexual assault or at-risk are eligible. Put client in contact with a Court Advocate
or the Shelter Coordinator.
HMO/INSURNACE PANELS:
Aetna Behavioral Health, LLC (HMO & EAP)
Blue Cross & Blue Shield
Carolina Behavioral Health Alliances (CBHA)
Ceridian (EAP & HMO contract)
Cigna Health Care (HMO & EAP)
CoreSource
Coventry Health Care
GEHA
Integrated Behavioral Health
Magellan Behavioral Health (HMO & EAP)
MedCost
Medicaid
NC Health Choice
NC Teachers & State Employees Plan
Primary Physician Care
Pyramid Life
TriCare
UMR
ValueOptions (HMO & EAP)
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EAP PROVIDER GROUPS:
ACI Enterprises
American Behavioral EAP
Compsych
First Advantage
McLaughlin Young Employee Services
Warren Shapell
Vasquez Management Consultants-VMC
Wausau Benefits
Policy No.: 11.2
Policy: Person & Family Centered Assessment
Approved by: Board of Directors Family Centered Assessment
POLICY
_______________________________________________________________
The agency conducts comprehensive, strength-based, and culturally sensitive psychosocial
assessments on each person who is considered a client, either in case treatment or case management
capacities. Each intake assessment shall be conducted by a Qualified Professional skilled in
providing an initial psychosocial assessment. The client and family are considered primary sources of
information during the client and/or family assessment. Further case information is gathered from
the referral sources and all other workers involved (e.g., assigned Department of Social Services
Social Worker, Community Supports, assigned Court Counselor at the Division of Juvenile Justice,
etc.). Assessments are completed and filed appropriately within 7 to 10 days of completion.
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PROCEDURES
_______________________________________________________________
A screening at request for service identifies the direction of assignment and shall include:
 Caller’s identifying information (name and date of birth)
 Current Residence (including contact number(s)
 Risk (danger to self or others, Child or Adult Protective Services issues and domestic
violence concerns)
 Substance abuse issues
 Emergency contact(s) (as appropriate)
 Guardianship status
 Medicaid or other types of public assistance
 Identified problem(s) that shall include risk level of severity/urgency
 Previous treatment with the agency or other providers
 And appropriateness for agency services
Intakes shall be scheduled as follows;
 Emergency/Crisis- immediate referral to the on-call therapist.
 Urgent- services offered within 24 hours.
 Emergent- services offered within 3 business days.
 Routine- services offered within 7 - 10 business days.
Initial assessments are scheduled for 75 minutes due to the comprehensive nature of the contact.
During the initial assessment it may be determined that other assessments (i.e., substance abuse
assessment) are needed to clarify the specific therapeutic need. Complicated cases may take up to
three (3) contacts to complete the initial assessment.
The initial assessment is designed to evaluate client/family needs and goals for treatment and will
review the risks and benefits associated with the recommended services. This begins the
development process of the client’s treatment/service plan, and the criterion for discharge is
discussed. The treatment goals, plans and criteria for discharge are developed with client/family
input and are agreed upon by those involved in the intake process (i.e., client, family members,
guardians, clinicians). Clients and family members are asked to fully participate in their intake,
treatment planning, and discharge criterion development. Clients, referred to the agency from other
providers, must complete the initial assessment with FSDC. Assessments provided by another
agency/provider will be review for ancillary information so as to expedite mental health services but
shall not be a substitute for FSDC’s initial assessment.
Qualified staff may incorporate assessment tools to assist with the establishment of diagnosis(es)
and treatment recommendations. Assessment tools include the Substance Abuse Subtle Screening
Inventory (SASSI), Beck Inventories for depression and anxiety (BDI & BAI), ADHD Rating Scale
–IV (school and home versions). Staff may request the use of other assessment tools. These tools
must first be reviewed by the Clinical Director prior to use.
Once the request for service is determined to be appropriate and has been assigned, all assessments
on persons becoming clients are conducted in a comprehensive manner. Information is gathered
from the client and/or parent/guardian. This includes information about past/current treatment
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services (within and outside the agency). Within the assessment, there is an evaluation of the
individual, couple, or the family, the resources of the existing support system (related to the
problem), psychosocial problems undermining family stability (that shall include addictive
behaviors), recognition of strengths/needs of the caregiving family, educational/vocational
problems, housing or income concerns, the need for referral, family relationships, legal status of
minors, full mental status evaluation as well as risk status (High, Medium and Low).
Co-occurring issues, such as substance abuse, medical and/or existing mental health diagnoses are
considered prior to the development of the diagnostic impression. The DSM IV and DSM IV-TR
are used to determine this initial diagnosis and subsequent treatment plan.
FSDC staff shall be aware of clients that are in need of protective services during the initial
assessment and ensure that information gather during the interview will enhance client safety (see
High Risk Intervention and Client Confidentiality Policies).
Based on the age of the client, the type of problem, or where health is relevant to the service under
consideration, information about a person's health is gathered. An assessment of the person's need
for health-related services may include the need for laboratory testing and/or other diagnostic
procedures as ordered by the client’s primary care physician or another medical specialist, and an
evaluation for medication or other appropriate referrals is also part of the assessment. The FSDC
employee recommending lab work or other outside testing is responsible for follow-up with the
client and/or healthcare provider. These recommendations should be documented in the client file.
Initial paperwork completed shall include consent granting permission to seek emergency healthcare.
The assessment also includes pertinent biographical data: other names of family members, ages,
marital, medical, and psychiatric histories (including seizure history, medications and disability),
employment (that shall include financial status/stressors) and family histories. Legal, trauma, and
substance abuse histories (including family history of use and treatment) are included as well as
religious, racial, and ethnic background (identifying any related issues resulting in special treatment
needs). Also included is emergency contact information including the name, address, and phone
number of a contact in case of sudden illness or accident and the name, address, and phone number
of the client’s primary care physician.
Issues of gender, age, developmental stage and other special population criteria are considered
during the assessment to ensure the client is scheduled with the therapist with the competencies that
complement the population referred.
Substance abuse is also a focus of the initial assessment. Details regarding current and/or past use
along with age of 1st use and last date of use are collected (see initial assessment form). The
assessment may also include the recommendation for further evaluation that includes the Substance
Abuse Subtle Screening Inventory (SASSI). The assessment will also determine dual diagnosis issues.
Recommendations for substance abuse treatment will be consistent with American Society of
Addiction Medicine (ASAM) criteria.
Should the clinician determine (up to and after the first two client interviews) that the case warrants
either short term or long-term service, the service is indicated as such and documented in the case
record.
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Indicators of risk status, frequency of treatment updates, and reassessment dates determine this
information.
These cases are reviewed in Utilization Review to determine longevity and to ensure more frequent
staffing.
If necessary, the case may be further reviewed by the Clinical Director.
Assessments and diagnoses will be reviewed and revised, as necessary, at least once per quarter (See
Client
Records Directive Policy and Case Advisory- 90 day review).
While these assessment components address the general population of clients, there may be program
specific criteria that are used instead of/in addition to any of the above.
Should the assessment include needs for (or a specialized need) a service presented by a person with
a disability, assessment will additionally include the following: (Interpretive services are available by
arrangement).




Explore relationship of disability to developmental period at onset as well as impact of
disability on current and future life stages. This will be achieved through completion of a
genogram and/or life span review.
Assess functioning specifically as it pertains to leisure activities, work history, education,
housing, mobility, supervision needed and activities of daily living.
Assess roles, support, and inclusion of their family system with client, by developing an EcoMap/Genogram/Family Map, and strengthen with further referrals for the client as
indicated (i.e., support groups, volunteer activity, financial counseling, etc.).
Therapy, or referral, will be provided as diagnosis(es) indicate.
Clients with special needs will be assessed for the service type or complexity of service needed and
referred out as appropriate. The agency does not perform assessments that address the need for
present or planned use of assistive technology nor corrective prosthetic devices; however, a client’s
special needs are considered in the assessment.
Clients in need of services to understand and resolve conflicts resulting from a restricted or sheltered
lifestyle will be referred for educational services through Cardinal Innovations Healthcare Solutions.
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Policy No.: 11.3
Policy: Person & Family Centered Intake
Approved by: Board of Directors & Family Centered Intake
POLICY
_______________________________________________________________
At the initial intake or consultation meeting, a screening for the person's need for services takes
place, and the potential client(s) is (are) informed whether the Agency's service will be available, will
be delayed, or if another service is more appropriate. When the client is a minor these issues will be
discussed with the parent/guardian.
PROCEDURES
_______________________________________________________________
The Agency retains the right to determine, among its applicants for services, those it can serve
appropriately, within the limits of its resources, contractual obligations, capacities and mission. The
agency provides counseling services for families, adults and children. We also provide emergency
counseling for victims, and their families, of trauma, domestic violence, abuse, and neglect. FSDC
provides services to children at risk for being adjudicated delinquent by the Juvenile Court system
and their families. Substance abuse services are available to those at-risk for or eligible for a
substance abuse diagnosis requiring periodic outpatient services. Employee assistance counseling is
available for employees who have EAP services with companies that have contracted with FSDC.
FSDC also provides counseling to children, adults, couples, and families with problems of personal,
interpersonal, marital and/or social adjustment problems, mental disorders, and other clinically
significant behavioral and psychological syndromes associated with impairment of functioning. Inhome counseling can be provided to referrals that meet the criteria for this service (See Eligibility
Criteria).
Because the screening process is not a single portal entry, other programs serve clients and they refer
to their own criteria.
When the needs of the client are better met elsewhere, referrals are made to other community
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resources or within the agency to other programs.
When the client is a minor, the parent/guardian shall provide consent for treatment and be involved
in the intake process. (See Client Confidentiality Policy for exclusions to this standard.)
Staff who provide initial intake/assessment evaluations shall receive continuing education and
ongoing supervision that addresses special needs populations to ensure appropriate care.
Should a caller present to the staff person taking the intake with a need out of the agency scope or
one which cannot be met in a timely fashion, they are provided several resources to address their
need, which could include being placed on a waiting list.
Family Services receives referrals from a variety of sources such as: court, EAP providers, personal
referrals, schools, police, community support agencies, and other sources.
The client-centered approach is used to provide entry into the FSDC Intake system. Each caller will
be advised of the intake process. Confidential information for entry into the system will be
completed on Therapist Helper (software system for tracking, scheduling and billing). The staff
person will briefly discuss fees, third party payments, etc. The administrative office obtains a brief
description of client's problem and schedules the initial appointment with the Intake Specialist (Inhome cases are assigned to the In-Home Coordinator). Once the assessment is complete, it will be
determined if the client is appropriate for services. If the case is deemed inappropriate, the client
will be referred to another resource or to the Clinical Director for disposition.
An approved licensed clinician must respond to Employee Assistance Program referral within 24
hours.
The status of all referrals will be assessed as an Emergency/Crisis (immediate referral to on-call
therapist), Urgent (services offered within 24 hours), Emergent (services offered within 3 business
days), or within normal agency standards (within 2 weeks) as presented by the call.
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Policy No.: 11.4
Policy: Person & Family Centered Intervention
POLICY
_______________________________________________________________
By the third session, the initial assessment is completed, including risk factors. The treatment plan
has been developed with the client and/or parent/guardian. The treatment plant outlines the agreed
upon clinical goals and defines the benefits, alternatives, and risks of services. Established target
date(s) for completion are set and the client and/or parent/guardian signs off on the plan, which
indicates the client’s involvement in the process and their ownership of the outcome goals. The
treatment plan will be reviewed periodically with the client to ensure that goals are being met or
whether outcome goals are in need of clarification or revision. Client attendance and date of
progress note is written on the Blue sheet called the Index of Attendance. Continuing progress notes
are recorded in the client record tracking the treatment. Upon completion of treatment, a
discharge/discontinuation summary is completed with ongoing needs and aftercare addressed. At
the time of assessment, treatment planning and discharge staff is to be sensitive to socio-cultural
issues, lifestyle choices, and complexities of the family system that will impact the effectiveness of
treatment.
PROCEDURES
_______________________________________________________________
The Admission Assessment should include the following:
Demographics,
Presenting problem,
Background of the problem,
Relationship HX/ family relationships/ Genogram,
Medical history,
Educational History,
Current behavior/mental status exam,
Strengths and supports (including involvement of other community agencies),
Chemical use (including current, past history and family history),
Psychosocial/environmental problems/ecomap,
Legal evolvement,
Risk assessment,
Diagnosis (including dual diagnosis issues).
The Treatment Plan includes the following:
Demographics,
Patient strengths,
Diagnosis (including dual diagnosis issues),
Problems/needs to be addressed,
Long term and short term goals,
Therapeutic interventions,
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Treatment modalities,
Treatment approaches,
Prognosis (if appropriate/optional),
Discharge criteria/aftercare plan
Treatment plans shall be developed in a direct response to assessed needs of the identified client.
Treatment recommendation(s) shall ensure the most appropriate and least restrictive or intrusive
service necessary to alleviate the client and/or family’s mental health needs. The plan will assist the
client in understanding their diagnosis(es) and educating the client and parent/guardian, if
applicable, regarding the symptoms associated with the(se) diagnosis(es). The treatment plan will
establish goals that aid the client in managing their illness and provide strategies for the development
of skills to help the client function more successfully in their environment. The plan shall also assist
clients and their families in the use of natural support systems and provide referrals to structured
support programs when applicable (see Case Coordination and Management).
Client and/or parent/guardian will be involved in the development of a treatment service plan as
well as the subsequent review and/or change of the plan. The client and/or parent/guardian are
informed of treatment options, including staff that shall be responsible for the treatment/service,
and how current treatment may impact the client and the family system.
Treatment focus will have an emphasis on strengthening the family system that may include other
services offered both within the agency and community. Services could include psychoeducational
group offered to the family as well as other support groups in the community. During the
development of the treatment plan and throughout treatment, staff shall keep the client and/or
parent/guardian up-to-date regarding other treatment options that can best achieve the agreed upon
goals. When the client is a minor, disclosure of treatment shall be with the minor’s consent. (See
Client Confidentiality Policy for conditions that require the minor’s authorization).
Goals shall be established that are target driven and measurable. The goals shall include short and
long term objectives that are consistent with desired outcomes. Treatment will follow strength-based
protocol with emphasis on family systems and brief solution models of intervention. The
responsible staff will sign off on goals of the treatment plan to demonstrate responsibility.
When the client meets the criteria for more intensive services (i.e. victim of violence/abuse, selfharm), the treatment plan will include safety planning that addresses these needs and may include,
but is not limited to, prevention of harm (suicide prevention plan or victim safety plan), shelter and
access to other services within the agency and community. Clients that meet these criteria for more
enhanced services shall be evaluated for psychiatry services (see Psychiatric Services).
When the client served is a minor in the custody of the Department of Social Services (DSS), the
authorized social worker will be involved in the development of the treatment service plan. The plan
will establish goals consistent with the DSS plan (i.e., family reunification, adoption, other foster care
placement, or independent living). Treatment will focus on assisting the client’s acceptance of the
department recommendations as well as addressing family system issues that may cause distress or
exacerbate current mental health diagnosis(es). Clinical staff shall provide clinical information that
can assist the DSS with the continuation of placement which shall include family reunification,
foster care, or other options. Staff shall support the involvement of the biological parent/family
unless detrimental to the client.
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The treatment service plan is automatically rewritten at annual review. However, clinical staff is to
review the treatment service plan quarterly with the client and/or parent/guardian. Complicated
cases that are identified as needing urgent or crisis care shall be reviewed with the Clinical Director
or direct clinical supervisor immediately and followed up weekly until issue(s) is resolved. Those
meeting the criteria for substance abuse treatment shall have the treatment plan reviewed in the first
30 days of treatment.
Treatment that is deemed to cause adverse effects for the client and/or family system shall be
stopped immediately and the case reviewed with the Clinical Director. The client and, if applicable,
the parent/guardian will review the treatment goals and determine the best course of treatment that
is therapeutically appropriate and consistent with best practice.
The Progress Note should always address or relate back to the treatment plan and the following
information should be included:
 How the client presented.
 What was addressed/ what was the problem being treated?
 What interventions were being used that related to the problem?
 Follow up to previous intervention.
 Evaluation of the client’s progress.
 Recommendations for next session based on evaluation.
The Discharge Summary should include the following:
1. Final diagnosis(es),
2. Reason for admission,
3. Findings and treatment received,
4. Aftercare plan to include follow up, referrals, and recommendations.
Discharge/discontinuation should occur as a planned and orderly mutual process between client
and/or parent/guardian and clinician. Discharge indicates that a chart has been closed with no
continued services. Discontinuation is closing one service and referring an active client to another
service within the agency. Hold is keeping the case open for a period of time, no longer than six (6)
months, to accommodate special circumstances that may be interrupting services (i.e.,
hospitalization and/or illness).
Policy No.: 11.5
Policy: Family Involvement & Participation
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POLICY
_______________________________________________________________
It is the policy of Family Services of Davidson County, Inc. to support the appropriate involvement
of the families of clients in the development, implementation, and review of treatment, habilitation,
and rehabilitation services and to ensure client and family participation in the therapeutic goal
planning process and development of discharge criteria.
FSDC recognizes that the implementation of a policy supporting family involvement requires the
balancing of a family’s need for information and legal rights to access that information with the legal
and human rights of the clients, including the right to confidentiality.
PROCEDURES
_______________________________________________________________
FSDC holds that the laws governing the release and sharing of information are preeminent.
Therefore, information regarding clients can be shared with family members only as provided for
under relevant statutes. Provided that relevant statutes are followed, it is incumbent upon the clinical
staff of FSDC to assist in determining appropriate therapeutic roles for family members. Such roles
will vary with regards to intensity dependent upon such factors as the age, type and level of
disability, and competency of clients.
Nothing in this policy shall be construed so as to imply that it abridges a family’s rights to:
 Seek contemporaneous treatment for the family system or other individual members;
 Pursue legal avenues regarding commitment, guardianship, or competency;
 Provide information to clinical staff to be used for planning for client services.
In family therapy cases, the client and/or legally responsible person will participate in setting content
goals.
Any exception must be approved by the Clinical Director or Executive Director and documented on
the Intervention/Goal Plan form above the primary therapist’s signature. Unless an exception has
been documented, the therapist’s signature indicates client and/or legally responsible person’s
participation has occurred.
Policy No.: 11.6
Policy: Continuity of Care & Case Assignment
Continuity of Care & Case Assignment
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. recognizes the importance of the relationship between a
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client and a staff member. Therefore, care will be taken to ensure that clients are assigned to the
most appropriate staff person at initial intake and at any point of transfer that may become
necessary.
1.
2.
3.
4.
5.
6.
7.
PROCEDURES
_______________________________________________________________
Assignment of cases will be handled by the Administrative Staff with assistance from the
Clinical Director when appropriate. Effort is made to assign each case to a Family Therapist
who has a specialty or interest in that population or issue.
The Clinical Director will review caseloads on a regular basis to ensure appropriate levels of
care based on the need for extra attention in high-risk cases, the need for balance between
clients/families at beginning stages of work, clients/families moving toward termination,
and clients/families presenting different levels of need. As appropriate, the Clinical Director
may adjust caseloads.
In the event that a client’s(s’) needs change, a case transfer can be completed. The Client
Transfer form is completed outlining the current situation and plan for transfer. This is
presented to the Clinical Director and the case is reassigned. The re-assignment will be
based on the needs of the clients and on the skills and availability of staff. The Clinical
Director shall ensure there is limited interruption of service during the transfer process.
If, due to the client’s(s’) changing needs, services are best provided elsewhere the staff will
assist with the transfer of the case to another agency/provider. This shall be done by
securing consent for release so information may be shared to expedite the transfer and
follow up so as to ensure the transfer was completed and services offered are appropriate.
The Clinical Director will work with the assigned staff to help ensure this process is timely
and the client does not experience a lengthy disruption in service. This process will be
reviewed during regularly scheduled supervision.
Clients requesting a transfer due to issues of therapist/client interaction that is deemed
nonproductive will be reviewed by the Clinical Director. Decisions regarding this type of
request will made with consideration of the treatment offered, availability of other staff and
what is believed to be clinical appropriate. The agency may involve other community
agencies/providers to meet the request of the client.
All transfers shall be noted in the case file and Administrative staff shall be informed.
In the case of prolonged absence, resignation or termination of employment the Clinical
Director will meet with the assigned staff to determine the most appropriate staff and/or
program for transfer of services. If the staff is unavailable the Clinical Director reviews the
case to make this determination. The client and, if applicable, the parent/guardian will be
notified of the changes in personnel and/or program assignment. The client and/or
parent/guardian will be given options for services with our agency and/or other agencies in
the community. This shall take place within 72 hours of the interruption in services.
Special Note:
The Intensive Family Preservation Therapist(s) will complete the assessment for youth referred to
our Intensive In-home service. The Family Empowerment Social Worker schedules intakes for
those families ordered through court due to truancy and/or Department of Social Services
involvement. The appropriate in-home staff will contact the referral within 24 to 48 hours to
complete the assessment and provide on-going counseling services.
Due to the special nature of in-home counseling, case assignment is based on the following criteria:
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

The client must meet standards for the specific program requested.
The client(s) must reside in the county of Davidson. Client(s) served must not pose an
obvious risk of violence to the professional providing the service.
Case assignment also is based on availability, as only one master’s level and one bachelor’s level staff
are employed in the program. In-home cases that are part of the Intensive Family Preservation
Services (IFPS), because of the intensity of the treatment provided, are not to exceed 4 active cases
per week. This smaller caseload takes into account that staff members spend more time in the
home, have travel requirements, and work with high-risk families.
Policy No.: 11.7
Policy: Case Coordination & Management
Approved by: Board of Directors Coordination & Management
POLICY
_______________________________________________________________
It is the responsibility of Family Services of Davidson County, Inc. to assume case coordination in
situations in which it is appropriate in order to meet the needs of the client. This shall be done
when:
 Services provided by other agencies address the needs of the client that are not within the
scope of services provided by this agency.
 Services provided by other agencies enhance the services provided by Family Services of
Davidson County, Inc. to address the client’s needs.
 The client is a minor and coordination is necessary to ensure appropriate treatment and/or
services. This could include the school system(s), Department of Social Services and
Juvenile Court system.
PROCEDURES
_______________________________________________________________
Case coordination shall be investigated, addressed, and administered (when appropriate):
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 At first contact (either phone or face-to-face) with client and/or parent/guardian.
 At development and reassessment of treatment plan.
 As emerging needs of the client are recognized.
 When deemed necessary.
Clients and/or parent/guardian shall sign appropriate releases (when necessary) before case
coordination begins. Case coordination shall be documented:
 In the development of the treatment plan.
 In the case notes (when presented during direct service).
 On the Clinical Contact Log.
 On all appropriate releases.
Ongoing communication shall exist between this agency and providers of other coordinated services
on all open cases. Communication (either spoken or written) shall be documented in the case notes
and/or Clinical Contact Log. The level of communication shall be established on a case-by-case
basis as deemed necessary. The agency shall inform clients and/or parent/guardian of other
providers of services not offered by the agency. The agency shall also coordinate efforts with other
providers to enhance services provided by this agency in order to meet the needs of the client. These
efforts shall be conducted via telephone, e-mail, letter, or in person. The client and/or
parent/guardian shall be advised of all appropriate releases to coordinate such efforts.
It is also the agency’s responsibility to periodically reassess the service plan with any other
cooperating service provider. The agency shall maintain ongoing communication, whether written or
oral, with such provider’s regarding status, level of functioning, termination, referrals, or emerging
needs of the client.
Reassessment dates and communication level shall be determined on a case-by-case study as deemed
necessary.
Policy No.: 11.8
Policy: Discharge, Discontinuation & Aftercare
Discharge, Discontinuation & Aftercare
POLICY
_______________________________________________________________
Development of the discharge criteria is initiated during the initial contact with the agency. The
criterion for discharge is addressed with the client and/or parent/guardian and is documented in the
treatment service plan that is signed by client and/or parent/guardian. Success of treatment shall be
that the client reaches 60% of the short term objectives.
Discontinuation of services may occur when services are no longer appropriate for the client; the
client fails to comply with treatment guidelines, the client refuses to take responsibility for treatment,
the client no longer meets the eligibility criteria, or the client is no longer ordered by the Court
and/or the Department of Social Services to comply with treatment.
Aftercare shall make certain that the client is referred back and/or reports to the referring source (if
appropriate) and/or their Primary Care Physician or pediatrician. The discharge summary will
outline recommendations and/or other referrals, evaluation, testing and/or treatment that may be
needed for the client.
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Staff shall coordinate with other agencies/providers that were involved during discharge to ensure
case continuity.
As with the initial assessment and intervention planning the discharge/discontinuation and aftercare
is developed by a Qualified Professional.
If judged necessary the Clinical Director/designated clinical supervisor shall review the
discharge/discontinuation and aftercare plan.
Staff shall follow up with appropriate court personnel if the client completing services was court
ordered for treatment. If applicable, contact with Probation and Parole or a report to the court will
be completed and submitted for adults who were court ordered for treatment. Juvenile Court
Counselors shall receive a Client Progress Report for juveniles completing court ordered treatment.
All reports will review the client’s progress, continued needs and recommendations. An every other
monthly meeting is scheduled with the Juvenile Court Counselors to review these cases and to
review treatment and recommendations.
PROCEDURES
_______________________________________________________________
Discharge:
1. During the initial assessment the client and/or parent/guardian reports the goal(s) that they wish
to achieve and indicators of success.
2. The treatment service plan is developed to address the goal(s) and to set the discharge criteria.
This plan is signed by the client and/or parent/guardian.
3. During treatment the discharge criteria will be reviewed periodically to ensure progress and/or to
be aware of the changing needs of the client.
4. Discharge shall occur when;
 60% of short term objectives are met,
 client and/or parent/guardian and staff agree that treatment has been successful,
 due to client need staff recommends treatment that is not provided by this agency,
 the client and/or parent/guardian indicates that they are no longer in need of treatment and
the staff substantiates that there are no safety concerns,
 Court ordered treatment has been completed either by Court mandate or documentation of
completion.
5. A discharge summary is completed within 15 days after discharge that outlines:
 First and last dates of contact
 Date of discharge
 Final Diagnosis(es)
 Findings and treatment provide
 Condition of the client at time of discharge
 Aftercare plan- that includes referral back and/or reports to referring source, PCP or
pediatrician.
 Recommendations regarding other referrals, evaluations, testing and/or treatment.
Discontinuation:
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1. Client and/or parent/guardian will be given a client’s right and responsibilities brochure and staff
will review rights/responsibilities that outline discontinuation of services during the initial
assessment.
2. During treatment the staff may review reasons for discontinuation of services if client fails to
comply with client responsibilities.
3. Discontinuation of services may occur if;
 Client fails to comply with client responsibilities, i.e. does not attend scheduled sessions and
doesn’t observe treatment plan recommendations.
 Client no longer meets the eligibility criteria for services.
 Is delinquent in paying for services.
4. If discontinuation of service is recommended the staff shall address with the client and/or
parent/guardian other resources and/or referrals that could meet the needs of the client. Services
shall be available to the client until an appropriate plan can be developed so as to ensure continuity
of care. Staff is to expedite this process by providing contact information for providers or direct the
client and/or parent/guardian to contact their insurance company or Cardinal Innovations
Healthcare Solutions (Medicaid consumers) for local providers. Staff shall document plan in a
progress note and/or in the aftercare plan. If the client is a current patient of the psychiatrist, a
certified letter shall be sent explaining the termination of medical services and directing the client to
their PCP.
Aftercare:
1. Every client and/or parent guardian shall have a documented aftercare plan (if applicable) to
ensure continuity of care.
2. Staff shall contact referring sources (if applicable) to address discharge and recommendation(s)
for continued services.
3. Staff will refer the client back to their PCP or pediatrician with a follow up from the staff member
either by telephone and/or letter outlining services provided and other recommendation(s).
4. When deemed appropriate the aftercare plan shall outline the need for further evaluation, testing
and/or treatment. The staff shall provide the client and/or parent guardian with at least 2 resources
that could provide the needed services(s) and assist with appointment if requested by the other
agency/provider receiving the case.
5. Staff shall secure consent for release by the client and/or parent/guardian for follow up with the
referral agency/provider so as to expedite other needed services.
6. Staff will contact the agency/provider (if applicable) receiving the case to make certain the client
and/or parent/guardian has followed up with the recommendation(s) of the aftercare plan.
7. If the aftercare recommendation(s) is concerning a minor or dependent adult and the staff deem
that the aftercare plan is necessary for continued safety of the client. The Department of Social
Services Child/Adult Protective Service shall be contacted if there is failure to follow through on the
aftercare plan.
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Policy No.: 11.9
Policy: Intensive Services for Victims of Abuse or Neglect
Services for Victims of Abuse or Neglect
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. recognizes that abuse and neglect perpetrated against
children and adults frequently occurs in conjunction with mental illness and chemical dependency.
The Agency utilizes interventions to specifically address occurrences of abuse and neglect upon the
primary person served where a parent or other persons in the household has a problem with mental
illness or chemical dependency. FSDC recognizes that this population is in need of more intensive
services over a longer period of time. Crisis planning shall be done with input of the client and/or
parent guardian.
PROCEDURES
_______________________________________________________________
Agency staff works with the client and/or parent/guardian and in conjunction with the Agency’s
Crisis Intervention unit who can provide advocacy, which includes protection plans, and shelter for
up to six weeks, for victims of domestic violence. Staff is to work closely with the Department of
Social Services to ensure quality and timely mental health services for minors with open Child
Protective Services (CPS) reports. Staff shall have appropriate releases signed to ensure collaborative
efforts and participate in treatment team planning meetings to make certain necessary services are
being provided and/or make recommendations for more enhanced services. Cases involving CPS
are to be reviewed in regularly scheduled clinical supervision, examined during monthly utilization
reviews. Clinical staff is to coordinate with Crisis Intervention staff for mental health clients who are
adult victims of domestic violence. This shall be accomplished by participating in the Crisis
Intervention staff meetings and regularly scheduled supervision. Agency staff can refer a perpetrator
of domestic violence to the Agency’s twenty-six week Abuser Intervention Program.
To ensure a broader scope of intensive services, the Agency works in collaboration with the
following:
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




area law enforcement and courts,
Path of Hope,
Daymark Recovery Services,
Cardinal Innovations Healthcare Solutions, and
Davidson County Department of Social Services
Adult clients who are diagnosed with drug and alcohol disorders that need medical detoxification
and/or more enhanced substance abuse treatment are referred to Cardinal Innovations Healthcare
Solutions or the client’s insurance company to assist with appropriate program referrals.
To enhance service delivery for this population the case plan is flexible and provides for extension
of services, as need indicates.
Policy No.: 11.10
Policy: High-Risk Interventions
High-Risk Interventions
POLICY
_______________________________________________________________
The following sections address areas to which particular attention is paid during the assessment
process.
Special procedures are outlined for these areas.
PROCEDURES
_______________________________________________________________
CLIENTS AT SUICIDE RISK
Definition
Verbal intent – any verbal acknowledgement by a client of a plan to hurt or kill him/herself. The
client has the desire, a plan, and the means to cause harm.
Nonverbal intent - a report by client or significant other of self-destructive behavior; e.g., driving
under the influence, fighting with a violent spouse, heavy use of medication or alcohol.
Indirect intent - Information suggests conditions are ripe for suicide; e.g., significant depression,
significant withdrawal, failure to handle necessary life tasks.
Degree of Risk
Determine if imminent or chronic.
Review history of suicidal attempts, family suicide attempts, significant depression, and
hospitalizations.
Evaluate current risk factors; e.g., recent loss, divorce, loss of job, medical problems, and financial
problems.
PROCEDURE
Interaction with client: Establish rapport, assess the risk, formulate a plan, discuss options, refer or
reschedule.
Involvement with others: Contact physician, contact family, notifies Clinical Director. If necessary,
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contact Cardinal Innovations Healthcare Solutions (CIHS) and request response by the Mobile
Crisis Unit. Call 911 and request response from law enforcement and/or ambulance.
Contracts: Try to establish verbal or written no-suicide contract with client, either permanent or
short-term (until next session, until tomorrow). Contract with family for continued care and/or
hospitalization.
Documentation: Record all pertinent details including impressions, action taken, plans.
Ongoing Assessment and Follow-up: If rescheduled, assess suicidal risk each time. Keep appropriate
contact with family or other professionals.
CLIENTS AT HOMICIDE/VIOLENCE RISK
Verbal intent - any verbal acknowledgement by a client of a plan to hurt or kill another person. The
client
has the desire, a plan, and the means to cause harm to another.
Nonverbal intent - Behavior manifested by physical force, which has caused or may cause harm.
Indirect intent - Information suggests conditions are ripe for violence; e.g., significant anger or
depression, preoccupation with being victimized or taking revenge.
Degree of Risk
Determine if imminent.
Review history of violence (against others or self) that includes; family violence, hospitalizations,
significant mood alterations.
Evaluate current risk factors; e.g., marital conflict, family conflict, divorce, loss of job, medical or
financial problems.
PROCEDURE
Interaction with client: Establish rapport, assess the risk, formulate a plan, and discuss options. Try
to defuse the situation. Use proper care.
Involvement with others: Contact family, notify Clinical Director, contact intended victim to ensure
“duty-to-warn” laws (N.C. Gen Stat. 122C-55) are followed. If necessary, contact CIHS and request
response by the Mobile Crisis Unit. Call 911 and request response from law enforcement and/or
ambulance.
In accordance with N.C. Gen. Stat. 122C-55 staff may report to authorities when a client has
disclosed intent of imminent danger to the health or safety of themselves or another individual or
there is the likelihood of the commission of a felony or violent misdemeanor.
Contracts: Try to establish verbal or written no-violence contract with client, either permanent or
short-term. Contract with family for continued care and/or hospitalization.
Ongoing Assessment and Follow-up: If rescheduled, assess violence risk each time. Keep
appropriate contact with family or other professionals.
CLIENTS CONSIDERED PSYCHOTIC (OR PREPSYCHOTIC)
Definition
Client is presenting behavior(s) indicating that the client has lost touch with reality; e.g., delusions,
hallucinations, severely irrational judgment, bizarre actions.
There are reports from reliable sources of client's loss of touch with reality.
Degree of Pathology
Assess degree of pathology.
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Risk of Suicidal or Homicidal/Violent Behavior.
Assess suicidal and/or homicidal risk.
PROCEDURES
Interaction with client: Establish rapport, assess the needs, formulate a plan, discuss options, and
facilitate a referral to a more appropriate resource.
Involvement with others: Contact personal physician, psychiatrist or CIHS, as appropriate.
Contact family. Notify Clinical Director. If necessary, contact CIHS and request response by the
Mobile Crisis Unit. Call 911 and request response from law enforcement and/or ambulance.
Contracts: Try to establish verbal or written agreement with client to seek and cooperate with help;
not to attempt suicide; not to be violent. Contract with family for continued care and/or
hospitalization.
Ongoing Assessment and Follow-up: Keep appropriate contact with family or other professionals.
PROCEDURES FOR EMERGENCY HOSPITALIZATION (VOLUNTARY &
INVOLUNTARY)
Ask client for permission to involve the person they live with, i.e. spouse, parent, family member, or
friend in helping to get the service they need whether it involves voluntary or involuntary
commitment.
If voluntary, therapist should discuss referral resources taking into account the client’s financial
resources, including insurance. If the client is without resources, he/she should be referred to CIHS
Access and request response from the Mobile Crisis Unit or North Carolina Access center, as they
are the portal of entry for state facilities. If client has financial resources, the therapist should
facilitate admission to a hospital of the client’s choice.
If involuntary, therapist should engage and encourage the client’s family, significant other, or friend
to make the commitment through the Magistrate’s office. The therapist may need to accompany
them to the Magistrate’s office.
If client has no one to assist him/her in securing the help needed and he/she refuses to follow
through with recommended treatment, the therapist may call law enforcement to ensure the client’s
safety. The therapist would then go to the Magistrate’s office to file the involuntary commitment
petition. The therapist should notify their supervisor and, in turn the executive director about such
action.
PROCEDURE
You may petition for involuntary commitment if you have a client, residents relative, neighbor, etc.
who you feel meets the criteria for involuntary commitment, which are:
A. Mentally ill and dangerous to self or others -or- mentally retarded and, because of an
accompanying Behavior disorder, dangerous to others.
OR
B. A substance abuser and dangerous to self or others.
If you have knowledge of an individual who meets the above criteria, the following options are
available to you:
Whenever possible, contact the Local Management Entity (CIHS) Access center for the Mobile
Crisis Unit. This service is provided 24 hours per day 365 days per year for clients in the 5 county
catchment areas who meet the criteria for services i.e. Medicaid/Medicare and/or who meet the
North Carolina target population services definitions.
If staff contacted CIHS Access and were advised to petition or if staff felt immediate action was
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needed, staff or anyone having knowledge of the facts (can be hearsay/does not have to have
witnessed the behavior) can go to the magistrate's office in Thomasville or Lexington and petition
for involuntary commitment (this procedure will be explained further).
In certain select cases when staff believe an individual is mentally ill and dangerous to self or others
or mentally retarded and, because of an accompanying behavior disorder, dangerous to others AND- in need of immediate hospitalization to prevent harm to himself or others, staff may seek a
Special Emergency Involuntary Hospitalization by transporting the client directly to Lexington
Medical Center (LMC) or Thomasville Medical Center emergency room. (TMC). The staff member
is also to follow “duty-to-warn” procedure that includes contacting the intended victim(s).
In serious emergencies in which staff considers an individual to be extremely dangerous to others,
the most logical action is to call the police or the sheriff's department (in the county). Law
enforcement can then transport the individual to LMC or TMC under the special emergency
procedure, or staff may elect to press charges against the person and let the courts decide if the
individual was competent at the time of the criminal act.
The staff member is also to follow “duty-to-warn” procedure that includes contacting the intended
victim(s).
The process for petitioning for involuntary commitment is as follows:
 Anyone having knowledge of the facts may go to the magistrate's office and request to
petition for involuntary commitment.
 The magistrate will request that staff provide factual information to the best of their
knowledge that supports the belief that the individual is in need of involuntary commitment.
The magistrate will decide based on that information whether to accept or deny the petition.
If the magistrate accepts the petition, he/she will issue a custody order and instruct law enforcement
officer to go pick up the individual (this must be done within 24 hours of the time of the petition or
the entire process must be repeated) and transport the individual to LMC or TMC to be examined
by a physician.
The examining physician has 4 options:
1. Determine that the individual does not meet the criteria for involuntary commitment and
release him/her -- the police will then return client home.
2. Determine that the individual meets the criteria for outpatient commitment (OPC) and
advise him/her they will be notified of a hearing date, and release client. Police will take
client home.
3. Determine that the individual meets the criteria for substance abuse commitment (SAC) and
then:
(1) place client in the hospital or another treatment facility for treatment, or
(2) release client and advise that he/she will be notified of hearing date.
4. Determine that the individual meets the criteria for inpatient commitment (IPC) and
hospitalize client.
Special Notes:
A second physician who has the same options as outlined above must examine any person who is
involuntarily hospitalized.
Any person who is found to meet the criteria for any of the 4 involuntary commitments (OPC, SAC,
IPC, or
Special) by the examining physician(s) must have a District Court Hearing within 10 days of the
petition.
The judge has the same options as those identified for the examining physician.
At any time during a hospitalization that the attending physician no longer feels the patient meets
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the criteria for inpatient commitment; he/she must release the patient or encourage the patient to
sign in voluntarily.
If the judge at the hearing agrees with the involuntary commitment, an inpatient-committed
individual may be committed for up to 90 days, an outpatient committed individual may be
committed for up to 90 days, and a substance abuse committed individual may be committed for up
to 180 days.
SUSPECTED CHILD ABUSE, NEGLECT and/or DEPENDENCY
In the event of information being received by the agency of an incident of suspected child abuse,
neglect and/or dependency, a report of the incident will be filed as soon as possible with the
appropriate county office of the Department of Social Services. Whenever possible, the individual(s)
who provide the agency with the information related to the suspected child abuse, neglect and/or
dependency should be informed of the agency's legal obligation to report such incidents to the
Department of Social Services.
If the agency receives information that a child is in immediate danger of abuse, staff will direct those
providing the information the process for making a Child Protective Services report and assist them
in contacting the Department of Social Services. If there is evidence that the report has merit and
the individual sharing the concern refuses to contact Department of Social Services, staff will take
on the responsibility for the report. Law Enforcement will be informed if the abuse is perpetrated
by non-care giving adult.
SUSPECTED ELDER ABUSE, NEGLECT and/or DEPENDENCY
In the event of information being received by the agency of an incident of suspected elder abuse,
neglect and/or dependency, a report of the incident will be filed as soon as possible with the
appropriate county office of the Department of Social Services. Whenever possible, the individual(s)
who provide the agency with the information related to the suspected elder abuse, neglect and/or
dependency should be informed of the agency's legal obligation to report such incidents to the
Department of Social Services.
If the agency receives information that an elder is in immediate danger of abuse, stall will direct
those providing the information the process for making a Adult Protective Services report and assist
them in contacting the Department of Social Services. If there is evidence that the report has merit
and the individual sharing the concern refuses to contact Department of Social Services, staff will
take on the responsibility for the report. Law Enforcement will be informed if the abuse is
perpetrated by non-care giving adult.
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Policy No.: 11.11
Policy: Collaborative Activities
Collaborative Activities
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. recognizes the importance of collaborative efforts
designed to promote well-being, prevent future difficulties, and increase the receptivity of the
community to respond to human need.
PROCEDURES
_______________________________________________________________
In this on-going effort, Family Services participates in the following:
1. Community education activities designed to increase awareness about human need in our
community and services available within the agency and broader community. We do this at
community festivals, church meetings, schools, and civic groups.
2. Agency staff are given time to participate on a variety of inter-agency councils, boards, and task
forces in the community and state, including, but not limited to the:
 Davidson County Child Fatality Task Force
 Davidson County Child Protection Team
 Work-First Welfare Reform Planning Committee
 Domestic Violence Task Force
 NC-Providers of Abuser Treatment
 NC Best Practices Task Force on Abuser Intervention
 NC Association of Marriage and Family Therapists
 Davidson County Education Foundation
 West Davidson-West Community Development Corporation Board
 Davidson County Mental Health Services Advisory Board
 Davidson County Juvenile Crime Prevention Council
 Davidson County Health Department Home Health Advisory Board
Policy No.: 11.12
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Policy: Credentialing
POLICY
___________________________________________________________
To ensure the highest quality of services to clients, all staff must be fully credentialed and
demonstrate competencies required by the specific population served, or they must be supervised by
a staff member who is fully credentialed.
PROCEDURES
_______________________________________________________________
Credentialing is the process of the review of the employee’s competencies that include education,
training and experience to evaluate that employee’s ability to adequately provide services with a
specific population. Initial credentialing will be completed at the time of hire by the immediate
supervisor and from that point updated as the employee receives other certification/licensure and
increases knowledge, experience, skills and abilities.
An employee who does not meet the criteria for a “Qualified Professional” (see below) shall abide
by the following guidelines:
 Complete a supervision contract with the Clinical Director/designated clinical supervisor
that outlines criteria for QP status.
 Attend weekly supervision sessions and present cases via case presentation, audio/video or
live supervision.
 Present cases during clinical group supervision (1X/month) while working towards QP
status.
 Attend training as requested by the Clinical Director/designated clinical supervisor.
 Document direct service time and submit to the Clinical Director/designated clinical
supervisor.
Employees who provide any form of counseling services shall be or shall be working towards the
classification of a “Qualified Professional” as identified in the NC Administrative rule (10A NACA
28A. 0102 &.10A NACA 27G. 0104). A) QP means an individual who: holds license, provisional
license, certificate, registration or permit issued by the governing board regulating a human services
profession, except a registered nurse who is licensed to practice in the State of North Carolina by
the North Carolina Board of Nursing who also has four years of full-time accumulated experience
with Mental health or Substance abuse population; or B) a graduate of a college/university with a
Master’s degree in a human service field and one (1) year of full-time, post graduate degree
accumulated Mental Health experience with the population served or a substance abuse professional
who has one (1) year of full-time, post graduate degree accumulated supervised experience in
alcoholism and drug abuse counseling; or C) a graduate of a college/university with a bachelor’s
degree in a human service field and has two (2) years fulltime, post bachelor’s degree accumulated
Mental Health or Substance abuse experience with the population served, or a substance abuse
professional who has two (2) years of full-time, post bachelor’s degree accumulated supervised
experience in alcoholism and drug abuse counseling; or D) a graduate of a college/university with a
bachelor’s degree in a field other than human services and has four (4) years of full-time, postbachelor’s degree accumulated Mental Health or Substance abuse experience with the population
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served, or a substance abuse professional who has four (4) years of full-time, post-bachelor’s degree
accumulated supervised experience in alcoholism and drug abuse counseling.
Employee supervision attendance will be maintained in each Program Director’s supervision files.
All professional staff will receive an agency orientation period prior to providing services. The
training will include the agency’s philosophy, policies and procedures confidentiality rules, and client
rights. Due to the unique qualities of in-home services staff shall not provide in-home services
independently without first meeting QP criteria.
Credentialing/Privileging forms are approved by the CQI committee and maintained in employee
personnel file.
Policy No.: 11.14
Policy: Psychiatric Services
Approved by: Board of Directors Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides psychiatric services through its contracts with
Jane Hoonhout (psychiatric nurse) and R Lance Waycaster, M.D. (supervising physician). These
contracts provide services that are responsible for evaluation of complicated mental health cases that
include physiological concerns such as disease control or other types of organicity and medication
management. We also use Cardinal Innovations Healthcare Solutions (CIHS) Access in emergency
situations which could include; mobile crisis, consumer safety and authorization for inpatient care.
In addition we work with private insurance companies if there is a need for inpatient or emergency
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care.
PROCEDURES
_______________________________________________________________
Clinical staff review complicated mental health, medical or co-occurring substance abuse cases with
the Clinical Director to determine appropriateness of psychiatric referral.
Staff shall refer clients for psychiatric services when:
 the client has been diagnosed with a disorder that is best treated with both process therapy
and medication management,
 staff is concerned about the possibility of organicity as the cause for a mental illness,
 there are complications due to diagnosis of a physiological disorder that is affecting mental
health treatment,
 co-occurring issues are identified,
 there is uncertainty about diagnoses and/or direction of treatment,
 the client requests this service and is deemed appropriate
The client is asked to sign the Psychiatric Service Letter to begin services with the psychiatric
nurse/psychiatrist.
The responsible therapist completes the Psychiatric Evaluation Request form that outlines
symptoms, diagnosis (es) and the reason for referral. This is presented to the psychiatrist/psychiatric
nurse prior to the evaluations.
Upon completion of the psychiatric evaluation the client is informed of the recommendations for
psychiatric care that may include medication management. The client is given details regarding the
medication(s) prescribed, which shall include benefits, risks and alternatives, and signs the Contract
for Controlled Substance Prescriptions (if applicable).
The psychiatrist/psychiatric nurse shall document in the case record (Medication Form):
 name of client,
 pharmacy,
 allergies,
 date of prescription,
 type of medication(s)
 dosage,
 how to administer and/or special conditions/instructions,
 number dispensed,
 refill(s),
 other notations.
The psychiatric/psychiatric nurse shall also document missed, unscheduled and/or rescheduled
appointments in the case record.
The psychiatrist/psychiatric nurse continue to follow each client in order to manage the
medication(s) prescribed. Each visit is documented in the case record and shall include:
 Effectiveness of the medication(s),
 Side effects,
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Changes in health and/or disease management,
Therapeutic issues addressed while in treatment at FSDC, and
Referrals and/or recommendations for medical tests.
Therapists whose client(s) are seen by the psychiatrist/psychiatric nurse, provide reports during
Rounds, which is scheduled the day medication management is provided.
Medications are not kept on FSDC premises. The psychiatrist/psychiatric nurse write prescription(s)
for the client to fill with their pharmacy.
Due to the possible complications of substance abuse and the use of prescription medications,
clients who are being treated for substance abuse issues are to practice abstinence during their
treatment with the psychiatrist/psychiatric nurse. Failure to be in compliance i.e. positive UDS,
could mean discharge from psychiatric services (See Psychiatric Services Letter).
The psychiatrist/psychiatric nurse is responsible for staying informed of current medication
formularies that address the approval and abuse potential for psychotropic medications. A
PDR is provided by the agency.
The agency does not personally administer medications and thus does not have medical waste.
Policy No.: 11.15
Policy: Fees
Fees
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. is a fee for service agency that has established fee
standards for services. Clients are informed of these standards during the initial contact with the
agency and at the time of their initial assessment. The client is given details regarding; fees, payment
schedule, past due accounts and charges for late cancellations and missed appointments. Details
regarding suspension of services due to failure to pay are addressed with each client.
FSDC will not withhold services due to the client’s inability to pay.
PROCEDURES
_______________________________________________________________
Administrative staff informs potential client at the time of initial contact of the fees that are
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customary for the services requested. During the initial visit the client is presented with a Welcome
letter that outlines services and the fees associated with our agency, as well as payment schedule, late
cancellation and/or missed appointment fees and suspension of services.
Fees for services are as follows:
AIP Intake
Court Appearance ($110.00 per hour)
Court Preparation ($50.00 per hour)
Family Psychotherapy-L
Family Psychotherapy/without IP-L
Family Therapy w/o IP
Family Therapy with IP
Group Psychotherapy, Multiple Family grp
Group Psychotherapy, Non-Multiple group
Intensive In-Home Services
Interactive Complexity Add-On
Intervention group
OV Estab. Pt. Moderate 15 min.
OV Estab. Pt. Severe 25 min.
OV New Pt. Severe-Phys time apprx 60 min
Psychiatric Diag. Eval. w/Med. Svc
Psychiatric Diagnostic Evaluation
Psychological Testing
Psychotherapy 16-37 minutes
Psychotherapy 38-52 minutes
Psychotherapy 53 + minutes
Record Copy
Report/Record Preparation ($50.00 per
hour)

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





60.00
27.50
12.50
110.00
110.00
27.50
27.50
35.00
35.00
260.00
30.00
25.00
75.00
95.00
175.00
225.00
120.00
45.00
55.00
110.00
110.00
5.00
50.00
FSDC deems that 45-50 minutes equals a clinical hour.
Reproduction of client records .10 per page
Clients receiving grant-funded services are not charged.
Clients will pay for services in advance of each session.
Client may pay with cash, check, Debit/credit card or money order.
Clients paying with check are informed of or our insufficient funds penalty that shall include
the client paying with cash or money order for all future services.
Clients with Mental Health coverage through their insurance carrier are expected to utilize
their benefits and assign such benefits to FSDC. Fee subsidies will not be provided to clients
using their insurance benefits for services.
Clients are informed of their responsibility for meeting their deductible as set by their
insurance carrier.
Clients that accumulate a past due balance equivalent to three (3) sessions may have services
suspended pending payment in full of the balance.
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Suspension of services will be determined by:
1. The client’s mental health concerns/needs and the level of care needed to ensure safety of
the client and others.
2. The availability of other resources in the community.
3. Previous financial debt owed to the agency.
Prior to suspension of services the case must be reviewed by the Clinical and/or Executive
Directors. Once services have been suspended FSDC shall make certain that the client has referral(s)
and/or recommendations to assist with their locating other services.
If the client meets the following criteria there may fees adjustments and/or waivers.
 Client lives or works in Davidson County.
 Client has financial hardship due to unusual debt or income level.
 Client is without means to pay for needed Mental Health/Crisis services.
 Client meets criteria for grant funded services (see Eligibility policy).
 In the event of a Division of Juvenile Justice referral, client fee will be filed with private
insurance or submitted to Division of Juvenile Justice as part of the JCPC funding program.
Policy No.: 6.1
Policy: Client Records Directive
Records Directive
POLICY
_______________________________________________________________
The client record is the property of Family Services of Davidson County, Inc. The agency has a legal
responsibility to maintain the confidentiality of the contents of the record and a duty to have
established procedures/directives for maintenance of the client records. All types of record
information, regardless of the form in which the information is kept, or located, are protected by any
state or federal confidentiality regulations.
PROCEDURES
_______________________________________________________________
Storage and Accessibility of Clinical Records
In order to ensure confidentiality of all client records, it is necessary to have client records
maintained in centralized, locked areas. Records are not to be kept in clinician offices overnight.
Administrative Office
All records should be returned to the Records File Room each day by 5:00 p.m., or at the end of the
clinician’s scheduled workday.
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Hattie Lee Burgess House
All records should be maintained in the File Room, under lock, unless in use by an agency/shelter
employee
Transporting of Client Records
Records may be removed from the facility property only with the following safeguards:
 Records shall be transported between programs by program staff only. Efforts shall be made
to ensure that the records are packaged securely.
 Records transported by motor vehicle shall be secured in a locked compartment, i.e., trunk
of car.
Records will only be removed from the property when absolutely necessary, including when it is not
feasible to copy records or portions of records to transport to local healthcare providers for
appropriate treatment, autopsy, response to subpoena, or audit by authorized person/entity.
Without exception, the record will remain in the direct physical care of an FSDC employee. The
record will be reviewed by the Administrative Department upon its return to FSDC to confirm no
unauthorized documentation, defacement or tampering has occurred.
DEPARTMENT AND STAFFING
The Records File Room is organized so that efficiency, accountability, and tracking of client records
are maintained. The Administrative Department has the responsibility for reviewing current client
records for required content and authentication, for inclusion of appropriate legal documents, for
integration into a single record, and for tracking completion of the record at the time of or
immediately following termination of services.
The Records File Room is under the direction of the Office Manager. The Office
Manager is responsible for maintaining the client record system at the agency’s administrative office,
as well as working with the Administrative Assistants to insure that activities necessary for
accessibility, accountability and confidentiality of client records is maintained at all locations. These
activities include filing, retrieving, dispatching and monitoring so that client information is directly
accessible to the clinicians caring for the client.
Requests (written, oral, and countersigned) from outside parties for the release of confidential
information in closed records will be in accordance with Family Services of Davidson County, Inc.
policies and can be received and processed by the Office Manager or clinician. If the clinician is no
longer with the agency, final authorization of records to be sent is required by Clinical Director. This
should be noted on the Disclosure of Information Form.
MAINTENANCE OF RECORDS
An integrated client record is to be maintained for each client. All significant clinical information is
to be in the client’s record in sufficient detail to enable the clinician to give effective continuing care
to the client, as well as to enable him/her to determine, at a future date, what the client’s condition
was at the specific time and what treatment was provided. Records are also maintained in order to
give a consultant enough detail to give an opinion after his/her examination of the client and the
record. A client’s record is written in such a way as to enable another practitioner to know what has
been done in the client’s behalf and to know his/her response to treatment in the event that this
clinician is required to assume the care of the consumer. Corrections shall be made only by the
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individual who recorded the entry. One single thin line shall be drawn through the error or
inaccurate entry, making certain the original entry is still legible. The corrected entry should be
recorded legibly above or near the original entry. The date of the correction and initials of the
recorder shall be entered. An explanation as to the type of documentation error shall be included
whenever the reason for the correction is unclear (e.g. “wrong consumer record”, “transcription
error”). Whenever omitted words cannot be inserted in the appropriate place above the record entry,
the information should be made after the last entry in the record. Never “squeeze” additional
information into the area where the entry should have been recorded. Correcting fluid or tape shall
not be used for correction of errors.
Electronic corrections are governed by the same standard and the correction shall be electronically
signed and dated, and the text shall not be deleted.
Symbols and abbreviations are used only if they are generally understood. Symbols and
abbreviations are not used when recording diagnoses. (See Glossary of Terms and
Policy/Procedures for Abbreviations in the Client Record).
An equally important reason for client record maintenance is the need to demonstrate accountability
for client services to funding and regulatory agencies, including Council on Accreditation, and
private insurance companies. In the absence of timely and adequate documentation in client records,
requests for reimbursement cannot reasonably be generated. When client billings do occur, and
client record documentation is not present, paybacks may result. These paybacks to funding sources
will originate with the program providing the unsubstantiated client service, and may lead to
restricted client service program-wide. Further, a continued failure to document client services
(treatment plans, progress notes, etc.) may result in the discontinuation of Family Services of
Davidson County, Inc. as a reimbursable agency.
Documentation requirements and timelines vary according to the nature and the purpose of each
program. Definitive requirements for the completion of documentation of outpatient services are
established. A criterion of timelines is essential for adequate and accurate record.
All entries in the client’s record are to be typed or legibly handwritten, dated, authenticated by the
signature and highest degree of the individual making the entry, pertinent and concise. No pencil
entries are acceptable, only black or blue ink or typewritten. Post-It Notes, telephone messages, and
small bits of paper are NOT acceptable as part of a client record.
Adhesive forms must be attached to plain paper to be included in file. Information should be
documented as a Progress Note. ONLY direct service/clinical staff credentialed as a “qualified
professional” can make documentation in the client record.
If a client is receiving more than one service at FSDC, those staff providing each service will
document in separate sections. If a client returns within 12 months of case closure, the previous
documentation will be maintained in a separate section of the case file. If required, the diagnosis is
recorded in the standard nomenclature as provided in the Diagnostic and Statistical Manual of
Mental Disorders Fourth Edition Revised (DSM-IV-TR), current edition published by the American
Psychiatric Association. Note- Diagnostic and Statistical Manual of Mental Disorders Fifth Edition
(DSM-V) shall be adopted as the required diagnostic manual beginning on or before October 1,
2014.
Maintenance Procedures
At the time of client checkout after the initial visit, the clinician should turn in all completed case
record paperwork along with the Billing Form to the Administrative Assistant. After receipt is
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written, the Administrative Assistant will enter information into the client tracking system. The
Administrative Assistant will create the case record file.
The Administrative Assistant is responsible for maintaining and filing the material in the proper
order within a client record (open or closed) that is housed at each location.
Materials to be filed in a record should have the case name clearly identified and should be placed in
the designated area in the Records File Room. Material within a client record should be in the
following order:
Left Side – Section I- PROFILE, EVALUATION, CORRESPONENCE
Client Self Report Form
Format Sheet-I
Intake Information/Face Sheet
Contact HIPAA Form
Consent for Interventions/Treatment
Release of Information
Request to Review File
Discharge Summary
Admission Assessment/History
Medical reports/labs
LOCUS/CALOCUS
Walmyr/SASSI Assessment
YCS Contracts
Psychiatric- Evaluations/Progress Notes/Medication form
Court Orders
Correspondence
Sliding Scale Fee Form
Other Client Information
1. Youth Questionnaire
2. NCALLIES Tracking Form
3. Miscellaneous
Right Side Section II- INTERVENTION
Format Sheet- Section II
Index of Attendance
Service Order
Diagnostic Report Form
Intervention/Goal Plan/Service Plan
90 Day Review
Transfer Form
Progress Notes
Client Creative Work
Middle (if applicable) – FINANCIAL
Format Sheet – Section III
Billing Sheets
EAP Paperwork
Authorization Sheet
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Client Insurance Verification Letter
Client Insurance Information Form
Insurance Card (copy)
Fee Waiver/Adjustment Form
Miscellaneous
Transferring a Case
Once a case is opened, should it be transferred from one clinician to another, it is not considered
transferred until a Transfer Summary Progress Note is completed. The client tracking information
must be edited to reflect the transfer.
Closing a Record
Closing a record consists of the following steps:
1. Editing of the client tracking information to reflect closure information.
2. Completion of progress notes and signing of all entries.
3. Completion of the Discharge Summary. Completed case materials should be turned in to the
appropriate QA committee for the following month’s record review
When in compliance, the record will be filed as Closed.
Record Sign-out
The Records File Room maintains a check-out system. Only that clinician assigned to a client,
another qualified professional with professional reason, a member of the billing staff and/or a
member of Management Team may sign out a record, which consists of:
1. Locating the record (open or closed)
2. Signing out the record by completing the sign-out guide and inserting it in place of the
record.
3. Signing in the record upon its return and removing the sign-out guide.
All records must be returned to the Records File Room for re-filing by the end of the day.
Electronic records (Therapist Helper/Therascribe) are held to the same requirements for access. A
unique password is required to access both of these databases.
Disclosure of HIV/AIDS Information
Request for disclosure received by the agency, and appropriately authorized by the client, must
specify that HIV/AIDS information can be released.
Disclosure of Substance Abuse Information
Whenever a client’s record contains substance abuse-related information and a request for
information is received, the consent for release of information, which the client signs, must specify
that the substance abuse information can be released.
Documentation of Disclosure of Information
Identification of information, which is disclosed by the clinical staff or Records File
Room staff, will be documented in the record on the Clinical Contact Log form.
Any disclosure of client information shall include the consent form, the date the information was
released, what information was released, and the signature of the employee releasing the
information. If information is released without written consent, the reason this consent could not be
obtained shall be documented in the client’s record.
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Collaborative information shared (with appropriate consents) as part of a client’s ongoing treatment
should be reflected in the Progress Notes and/or in the Clinical Contact Log form.
All written information, which is released, must be stamped: “Confidential Information.
Re-disclosure Prohibited Unless Proper Authorization Is Obtained.” Information received from
other sources (organizations, outside professional, etc.) shall not be released under a Request for
Disclosure.
Correspondence in the Client Record
Correspondence from other human service agencies/hospitals will be filed within the client record
and is not the property of Family Services of Davidson County, Inc. and shall not be released. It is
only utilized as a reference for client care.
Faxing Client Information
Client information will only be faxed in emergencies, and only to providers, due to confidential
concerns. The following procedure will be followed:
1. Consent must be obtained from the client to fax the information.
2. Ensure faxed documentation is being received in a confidential location/area.
3. Facsimile Transmittal- Confidentiality Notice Sheet must accompany faxes containing
confidential client information.
4. Never fax highly secured information, such as HIV/AIDS, substance abuse or adoption
placement information.
If record information is accidentally faxed to the wrong number, file an incident report immediately
with the Office Manager. Additionally, fax a request to the erroneous number asking the recipient to
destroy the faxed materials.
Emailing Client Information
Information should only be emailed when absolutely necessary. No identifying information, such as
name, date of birth, gender, age, and race shall be used when emailing information. However,
recipients of emailed information must have client authorized Disclosure of Releases filed in the
client record. Initials may be used rather than client names in all email documentation. All emails of
a professional nature should have a disclosure notice indicating the information is confidential and
should be protected.
TIMETABLE FOR RECORDS MAINTENANCE
Listed below are the requirements for completing tasks/documentation for information to be
included in the record of clients receiving services at any location of Family Services of Davidson
County, Inc.
 Completed Face Sheet- 1st Contact
 Consent for Treatment- 1st Session
 Fee/Insurance information- 1st Session
 Risk Status- 1st Session
 Completed Intake Summary- 2nd session
 Utilization Review/Quality Assurance Normally, within thirty days of first session Every 90
days until Closure. Based on 20% of files randomly selected for Utilization Review. All files
are administratively reviewed at discharge.
 Program Specific Admissions- within first 2 sessions or 30 days
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Initial Treatment Plan- 3rd session or 30 days
Progress Notes Completed- 24-48 hours based on service and location
All other case documentation Within 30 days after initial session
Case Record Review 90 days from Intake Date and every 90 days from Intake until
Closure/Discharge
Revise (rewrite) Treatment Plan Once per year
Closure Documentation Within 15 days of closure/discharge date. Note- Division of
Juvenile Justice referrals must have closure/discharge within 7 days of last visit.
NCALLIES (Division of Juvenile Justice referrals) tracking completed at referral, 1st contact
and at discharge.
Administrative Record Review Within 15 days of completion of closure
Policy No.: 6.2
Policy: Storage & Destruction of Client Records
Approved by: Board of Directors& Destruction of Client Records
POLICY
_______________________________________________________________
The purpose of this policy is to address storage and/or destruction of inactive client records and
provide directions for such.
PROCEDURES
_______________________________________________________________
Inactive client records (hard copy) with a closure date of less than seven years will be stored in a
secure, locked area (*may or may not include off-site storage of hard copy files). Note:
Inactive client records are also maintained electronically and daily back-ups are stored in a locked,
fire-proof cabinet. Inactive client records (hard copy) with more than seven years may continue to
be stored, or possibly destroyed (*unless program regulations require otherwise). Destruction of
such records is the responsibility of the Office Manager. Intakes (requests for services that have not
been made into a case) forms can be destroyed within a three year period as well as the Face Sheet.
For client records that meet the age criteria, pull the appropriate record. Staff pulling such records
should exercise caution when gathering records to be destroyed and protect client confidentiality.
Client records will be destroyed by means of shredding. In the event of agency dissolution, client
records will either be maintained, stored, or disposed of in a legally compliant manner as directed by
the Executive Director and FSDC Board of Directors.
237 | P a g e
238 | P a g e
Substance Abuse
239 | P a g e
Crisis Intervention Services
Domestic Violence and Sexual Assault
Programming and Services
240 | P a g e
Policy No.: 14
Policy: Crisis Intervention Service Philosophy
POLICY
_______________________________________________________________
Crisis Intervention Services are provided under the Voluntary Services Model, which is a strengthbased empowerment approach to providing survivor services.
In addition, Crisis Intervention staff utilizes the Crisis Intervention Theory which is a logical
approach of providing intervention to produce quick and constructive change for survivors whose
problems are short term. Crisis Intervention Theory has been established as an effective modality
for crisis hotlines, walk-in centers, and crisis clinics provides immediate support
Ultimately, empowering clients while promoting client safety is our program’s goal..
PROCEDURES
_______________________________________________________________
Survivors are provided comprehensive services including:
9. 24/7 Crisis Hotline- focuses on specific and time-limited treatment goals, clarifying and
assessing the client’s source of stress, assisting clients in developing problem-solving
mechanism functioning and exploring resources, providing emotional support for crisis line
clients.
10. Shelter - A safe temporary residence available 24 hours a day, 7 days a week for female
domestic violence and sexual assault survivors and their minor children.
11. Counseling – Free counseling services, treatment and support groups
12. Hospital Accompaniment – provided for domestic violence or sexual assault victims who
need medical intervention. Staff and volunteers are on-call to respond 24 hours a day at the
hospital to provide support, information and referrals, and clothing.
13. Law Enforcement and Court Advocacy – provides assistance with Protective Orders,
warrants, legal referrals and court accompaniment.
14. Case Management – provides information and referrals to other community agencies, goal
setting, and limited financial assistance.
15. Community Education – Programs regarding domestic violence and sexual assault for
schools, civic and church groups, and community agencies.
16. Training– Education and information to individuals wishing to volunteer and to
professionals who work with domestic violence and sexual assault survivors
All Crisis Intervention Services are voluntary and provided free of charge.
COA Standards: DV 6 and SH4
Policy No.: 14
Policy: Community Partnerships
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. facilitates on-going relationship efforts with local service
providers that promote a collaborated community response for domestic violence, sexual assault,
and trafficking victims.
PROCEDURES
_______________________________________________________________
New Department of Social Services Child Welfare Workers and Lexington Police Department
employees tour our agency and shelter to promote referrals
Hosts Child Protective Services child and family team meetings to collaborate efforts on shared
cases when necessary
Distribute brochures and business cards to area medical offices and hospitals
Provide free-of-charge trainings to area agencies on domestic violence and sexual assault dynamics.
Trainings have been provided to law enforcement, health department, hospital, early childhood
intervention, community college, school personnel, department of social services and EMS
employees.
Weekly case collaboration is held during Crisis Intervention team meetings.
Maintain annual Memorandums of Understanding with local service providers that promote
coordinated efforts.
Collaborate with Child Protective Services social workers if they are involved with our client’s
children provided that we receive a signed release of information from the parent.
Coordinate referrals to Legal Aid of NC and host monthly legal aid clinics
Coordinate hosting support groups various community agencies including the hospital and
community college
Host trainings for mental health professionals
Engage in community collaboration efforts for Sexual Assault and Domestic Violence Awareness
Month
COA Standards: DV 7.01-7.03
Policy No.: 14
Policy: Community Access to Services
POLICY
_______________________________________________________________
Crisis Intervention Staff conduct community outreach efforts and work to reduce barriers to
accessing services in order to ensure that survivors are aware of our available services and can access
services when needed.
PROCEDURES
_______________________________________________________________
Program staff conducts monthly presentations and trainings to local community groups including,
civic clubs, religious organizations, educational institutions, and human services organizations.
Information regarding services and access to such services is provided.
An advocate has a weekly presence in civil court where potential clients are approached and given
information about our services.
Brochures and business cards are given to local agencies, hospitals and doctor’s offices advertising
our services.
New Lexington Police Department Law Enforcement Officers tour our facility and are given
information on how to make referrals.
Information about Crisis Intervention Services is placed our agency’s website, Facebook page, and
provided in the agency’s e-newsletter
Crisis Intervention Staff participate in community events such as health and agency fairs, and
National Night Out where information is distributed.
Crisis Intervention Staff initiate various awareness events throughout the year to enhance
community knowledge of services provided and to increase client access to services. Events include:
Community Domestic Violence Peace Vigil, The Silent Witness Campaign, Wear Teal: National
Sexual Assault Awareness Day of Action, and various other agency fundraising events.
Crisis Intervention Staff collaborate with various human service organizations in the community to
facilitate access to service and to minimize barriers that may prevent individual from seeking or
obtaining services.
COA Standards: DV 1.01,DV1.03,SH1
Policy No.: 14
Policy: Client Access to Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides 24-hour Crisis Intervention services for
domestic violence and sexual assault emergencies.
PROCEDURES
_______________________________________________________________
Trained Shelter Managers/Crisis Line staff operates the crisis line, which is housed at the family
violence shelter, the Hattie Lee Burgess House.
Trained staff are available to provide 24-hour Crisis Line services, including:
 Safety screening
 Crisis counseling
 Safety planning
 Shelter admission
 Information and referral
Hospital emergency room after-hours advocacy services are provided to victims of domestic
violence and sexual assault, by trained staff member that is on-call.
The Crisis Line and the On-Call Advocate can be accessed by dialing (336) 243-1934.
COA Standards: DV 1.02
Policy No.: 14
Policy: Access to Services for Secondary Victims
POLICY
_______________________________________________________________
Family Services provides crisis intervention services to all victims of domestic violence or sexual
assault incidents including secondary victims (non-offending family members or significant others).
PROCEDURES
_______________________________________________________________
Secondary victims are eligible for the same services as primary victims. This includes: advocacy,
safety planning, the crisis line, support group, counseling and shelter.
These services will be provided free of charge.
Policy No.: 14
Policy: Advocacy & Support Services
COA Standards: DV 8.01 -8.10, SH 9.01- 9.07
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides victims with a range of supportive services that
promote client empowerment, independence and living violence free.
PROCEDURES
_______________________________________________________________
All Crisis Intervention Services are voluntary.
All Crisis Intervention Services are provided in a manner that supports culturally sensitive practice.
All Crisis Intervention Unit clients are involved in the development of their clinical treatment and
case management plans
Clients are encouraged to develop supportive networks from individuals, family members and
community supports that will assist them in maintaining their safety and promote their wellbeing.
Housing Assistance
 Clients desiring to separate from their abusive partners are offered assistance in locating safe
emergency and long-term housing, which includes the agency’s transitional housing program
 Agency advocates help clients explore temporary safe housing options such as family and
friends, our shelter or rental property.
 Resource files on available housing options are housed at the shelter.
 Agency advocates can write priority letters to the local housing authority agencies on behalf of
family violence victims.
 Shelter residents who do not have transportation are offered assistance in getting to housing
authority appointments.
 If tenant problems arise as the result of family violence issues, agency advocates can refer clients
to Legal Aid Services for legal representation.
Legal Services
 FSDC staff work closely with Legal Aid of North Carolina to arrange for court representation
during 50-B hearings.
 FSDC host divorce and custody clinics for clients. These clinics are lead by Legal Aid of North
Carolina.
 Advocates assist clients in obtaining domestic violence protective orders, criminal warrants and
nonconsensual contact orders.
 Advocates provide victims with general information about the court system to help victims
know their legal rights.
COA Standards: DV8.01-8.10, SH 9.01-9.07

Advocates collaborate services with local law enforcement agencies and the court system to
encourage more positive case outcomes.
Employment Support
 If applicable, shelter residents are asked to work on employment goals while residing at the
shelter.
 Typical referrals for employment services are made to: The Employment Security Commission,
Job Link, various temporary employment agencies, Davidson County Community College and
Vocational Rehabilitation.
 For qualifying residents who need immediate economic assistance, referrals are made to the
Davidson County Department of Social Services’ Work First program.
Educational Support
 During weekly case management sessions issues of budgeting are addressed
 Periodic financial empowerment seminars are held using the All State Financial Empowerment
curriculum
 Information about accessing public assistance is given during case management planning
services
 Resources regarding community resources are available
 If needed, advocacy staff can provide transportation to public assistance appointments
Group Support
 Support group is based on a psycho-educational format. Various topics are discussed during this
group. (Communication, Domestic Violence Dynamics, Community Agency Awareness,
Improving Self Esteem and Health Information). Some topics are generated by the group
facilitators, other topics are based on surveying participants.
 Group services are voluntary
 Free babysitting is offered during group
 Empowering group participants to become survivors is the goal of group. Group facilitators
work to create a positive atmosphere where participants can feel safe, network with other
survivors, share their experiences and gain education in areas related to their experience.
 The group is an open format for survivors of domestic violence.
Child Care
 Referrals for child care subsidies are made to the Davidson County Department of Social
Services.
 Referrals for Day Care location are made to Child Care Connections.
Medical Assistance
 Referrals for emergency medical care are made to area hospitals.
 Referrals for routine medical care are made to Davidson County Medical Ministries or the
Davidson County Health Department.
 Referrals for sexual assault examinations are made to the SANE program at Thomasville
Medical Center.
Transportation Assistance
 Referrals for transportation services for qualifying clients are made to Davidson County
Transportation.
Mental Health Services
 Mental health referrals are made in-house to our agencies clinical division or to Daymark
Recovery Services.
 Substance Abuse referrals are made to Daymark Recovery Services.
Financial Assistance
 Family Services has some limited financial assistance for qualifying family violence victims to
assist them in relocation to violence free living.
 Other referrals for financial assistance are made to: The Davidson County Department of Social
Services, the Salvation Army, Thomasville Cooperative Ministries, Crisis Ministries of Davidson
County, Community Action and His Laboring Few Ministries
Support Networks
 Building support systems are routinely discussed during support group, counseling and case
management/planning sessions.
 Shelter residents are encouraged to include safe friends and family members in their case
planning sessions at the shelter.
 Safe family members and friends are allowed to visit shelter residents with prior approval from
the Shelter Coordinator or Crisis Intervention Director.
Counseling services
 Clinical Services are provided to family violence victim’s free of charge unless the client has
insurance to cover the fee.
 The theoretical framework for clinical services is strength-based and comes from a systems
perspective.
 Clinical services are delivered in a nondiscriminatory manner to promote healing and
empowerment of victims.
 If a client continues in therapy, a treatment plan will be developed by the 3rd session and
updated during the 90-day review and annually.
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Counseling Services – Non Shelter Residents
Clinical services for Family Violence clients are provided by appointment only.
Clients can call or come into the office to request this service.
Intake appointments are scheduled within a two week time period.
Emergency intake sessions are available each workday for those clients who need immediate
intervention.
Counseling Services – Shelter Residents
Shelter residents are required to attend a one-time clinical assessment with our Shelter Therapist
within 5 business days of their shelter admission.
Clinical services are offered at the shelter to avoid transportation obstacles.
Any other follow-up services for counseling are provided on a voluntary basis.
Policy No.: 14
Policy: Crisis Client Assessment
POLICY
_______________________________________________________________
Survivors participate in a comprehensive, individualized, strengths-based, culturally responsive
assessment that identifies strengths, needs, and risk factors. All assessments are conducted by
trained professionals.
PROCEDURES
_______________________________________________________________
All staff conducting case management is professionally trained and participates in on-going training
and development.
Information gathered during the initial intake is reviewed during case planning and any concerns
mentioned during the initial screening are addressed.
Assessments are completed by the Shelter Coordinator.
Follow-up case management occurs weekly during a mutually agreed upon time between the
survivor and the Shelter Coordinator.
The following is addressed in assessments and planning sessions:
1. Confidentiality
2. Understand the client’s presenting concerns
3. Address and identify and challenges, safety concerns or emotional needs of the survivor and
her children
4. Support the survivor in creating goals
5. Identify a plan for housing
6. Identify a plan for obtaining employment (if needed)
7. Provide the survivor with resources to support him/her in achieving her agreed upon goals
Policy No.: 14
Policy: Crisis Client Screening
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc.’s Crisis Intervention Unit efficiently screens all crisis line
and walk-in referrals to identify the client’s needs as well as promote appropriate referrals for
services.
PROCEDURES
_______________________________________________________________
All clients are asked about their presenting issue.
All clients are asked about the type of help they are seeking or how they would like assistance in
resolving their current situation.
A risk assessment is conducted to see if the client needs immediate emergency help.
Service recommendations are made based upon the presenting issue.
Safety planning information that includes our services (obtaining 50-B, information on shelter,
information on our crisis line and area referrals) are routinely given out when a client initiates crisis
intervention services.
If our agency is not able to provide a service that has been requested, additional outside agency
referral information is given. Assistance with making that referral is provided if needed.
COA Standards: DV 2.01 – 2.03
Policy No.: 14
Policy: Rights of Shelter Residents
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc respects the rights and dignity of all shelter residents.
Rules are created to promote safety and respect and are cultural sensitivity.
PROCEDURES
_____________________________________________________________________
Shelter residents are informed of the shelter rules and expectations upon arrival at the shelter.
All Crisis staff is trained in confidentiality and the importance of protecting the confidentiality of all
clients accessing services.
The use of services beyond the provision of shelter is voluntary and is not required as a condition of
stay.
All residents are given a copy of the shelter rules, client’s rights and expectations, grievance
procedure, and agency confidentiality policy during the resident’s intake.
During weekly case planning sessions, clients are asked about their adjustment to the shelter and any
difficulties they may be experiencing.
Shelter residents can use the shelter address to receive mail. Crisis staff does not open residents’
mail at any time. If a resident has left the shelter and provided a forwarding address then staff will
forward the mail. Otherwise, uncollected mail will be returned to sender.
COA Standards: DV 12.01-12.02, SH 5.01-5.07
Policy No.: 14
Policy: Expelling Shelter Residents
POLICY
_______________________________________________________________
Family Services of Davidson County designs rules to provide a safe and respectful atmosphere for
all shelter residents and staff.
PROCEDURES
_______________________________________________________________
While every effort is made to support shelter residents and provide safe housing, the following could
result in immediate dismissal from the shelter:
1. Violent or threatening behavior toward staff, residents, or a child
2. Consuming alcohol or drugs on shelter property
3. Possession of a weapon on shelter premises
4. A resident’s abuser is invited to the shelter
5. Using the shelter under false pretenses
If a resident is asked to leave the shelter, reasonable efforts will be made by staff to locate alternative
housing. If a resident calls to return to shelter and fits agency criteria for shelter services, she can be
readmitted.
In cases when a resident disagrees with the dismissal decision, residents are instructed to follow the
agency’s client grievance procedures.
All residents are given a copy of the shelter rules, client’s rights and expectations, grievance
procedure, and agency confidentially policy during the resident’s intake.
COA Standards: SH 2.01-2.06
Policy No.: 14
Policy: Shelter Intake and Assessments
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides survivors with an initial intake and needs
assessment services within 24 hours of a shelter admission or within the next business day.
PROCEDURES
_______________________________________________________________
Any obstacles to confidentiality are disclosed during the assessment period. This includes reporting
to Child Protective Services or homicidal/suicidal concerns
All FSDC staff are qualified and trained in conducting assessment services.
Assessment information gathered is based upon the client’s presenting issue and is gathered only to
promote the client’s safety and wellbeing.
During the admission session, staff conducts an initial interview with the client and completes
admission paperwork. Paperwork completed includes the following:
1.
Face Sheet
2.
Homeless Verification Form
3.
Staff Checklist for Verification of Homelessness Form
4.
Inventory Checklist / Fire Safety Ladder
5.
Waiver for Hattie Lee Burgess Home
6.
FSDC Residency Agreement Contract
7.
Five-day Evaluation Agreement and Departure Date Form
8.
Approved Visitor List
9.
Shelter Rules Violations
10.
Medication & Locker Policy
11.
Confidentiality Form
12.
Permission for Recreation Form
This intake assessment will be provided to residents within 24 hours of their shelter admission.
During the intake assessment, brief social history information is gathered including:
1. client and family members demographics
2. health and medication
3. any emergency medical needs
4. any emergency legal needs
5. housing information
6. prior issues surrounding family violence.
Within the next business day, residents are asked to meet with our Shelter Coordinator for additional
case planning and on-going risk assessment in order to best meet the needs of the client and to
address any concerns for which the client may have.
Within 5 business days, shelter residents are asked to meet with the Crisis Intervention Therapist for
a clinical assessment. Clinical services are provided at the shelter for the convenience of residents.
The following is explored during the assessment: client demographics, immediate physical and
emotional needs/concerns, health concerns, family history of violence, medical and mental health
information/history, and survivor safety concerns. Depending on the information reported, referrals
and recommendations will be made of additional support and /or treatment if needed or requested
by the survivor.
Any other follow-up services for counseling are provided on a voluntary basis.
If a client continues in therapy, a treatment plan will be developed by the 3rd session and updated as
needed, and during a 90 day and annual review process.
Services are offered regardless of an individual or family’s ability to pay and, if the shelter is full or
services are limited to a specific population, the survivor will be referred to other services.
Policy No.: 14
Policy: Client Accessibility
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. works to minimize clients’ barriers to accessing Crisis
Intervention Services.
PROCEDURES
_______________________________________________________________
Handicapped accessible facilities are provided at the shelter and main office location.
Interpreting services are offered for Non-English speaking and deaf clients.
Shelter is provided to adolescent, male children with no age maximum when a mother is seeking
services.
Individualized case management services for shelter residents is provided to address any necessary
accommodations or special needs.
Policy No.: 14
Policy: Shelter Special Populations
POLICY
_______________________________________________________________
The Hattie Lee Burgess House provides services to special population clients. It is the intention that
services are inclusive and accessible to all people.
PROCEDURES
_______________________________________________________________
Clients with Disabilities
The Hattie Lee Burgess House complies with the Americans with Disabilities Act (ADA) and to
make reasonable accommodations to persons with disabilities upon request (unless it would clearly
be an undue financial burden on the agency to do so).
The shelter is handicapped accessible. The facility maintains a ramp for entrance into the building.
All doorways are an appropriate width for wheel chairs. Handicapped restroom facilities are
provided. Counter space and kitchen appliances are located at an appropriate height for
wheelchairs.
Clients who are deaf can access agency services through the use of interpreters, RELAY or email
services.
All shelter residents need to be able to provide for their own care.
Personal care assistants can
accompany or provide care to persons with a disability, upon request, while the individual receives
services. However, it must be verified with the client that the individual providing personal care is
not the batterer or assailant. The personal care assistant must sign the agency confidentiality
agreement and a statement of nondisclosure regarding the location of the shelter.
Those who cannot provide for their own care will be provided with case support services. All
services will be coordinated with Adult Protective Services of the Davidson County Department of
Social Services.
It is the agency’s intention to allow service animals to accompany their owner while the person with
a disability receives services. When the client is seeking safe housing at the Hattie Lee Burgess
shelter, staff will request documentation verifying that the service animal has a current rabies
vaccination, when possible. The client is responsible for the care of the service animal at all times.
COA Standards: DV 13.01, 13.06
Adolescent Males
Male adolescent males are housed with their mothers in the basement bedrooms of the shelter.
Mothers are responsible for supervising all minor children at all times.
Adult Males
Adult male survivors have access to all crisis intervention services including, counseling, advocacy,
safety planning and temporary safe housing. When a adult male calls for safe housing, the Shelter
Coordinator will be contacted to coordinate hotel accommodations.
Temporary safe housing will be provided at the following location:
Highway 8 Motel
1631 Cotton Grove Rd
Lexington NC 27292
Phone 336-357-6444
All counseling and support services will be provided at the shelter or FSDC main office location,
depending on the needs of the client.
COA Standards: DV 13.01, 13.06
Policy No.: 14
Policy: Shelter Safety and Security
POLICY
_______________________________________________________________
Family Services provides all residents and staff of The Hattie Lee Burgess House with a secure
facility and utilizes appropriate emergency procedures in order to protect resident and staff.
PROCEDURES
_______________________________________________________________
In case of an emergency of any type, 911 will be contacted immediately and the appropriate service
requested.
FSDC has taken steps to provide security that includes the following safety measures:
1.
bulletproof siding and windows
2.
burglar alarm system
3.
smoke alarms and fire extinguishers
4.
fire evacuation plans (fire safety ladders where needed)
5.
inclement weather plans (tornado, hurricane, etc.)
6.
video surveillance on all four sides of the building
7.
portable emergency panic button
8.
all doors can be opened from the inside.
All Crisis Intervention staff is trained on all of the above-named procedures.
COA Standards: DV 11 and SH 8
Policy No.: 14
Policy: Shelter Room Assignment
POLICY
_______________________________________________________________
Families residing in the shelter are maintained as a unit and individual shelter residents are given
single rooms.
PROCEDURES
_______________________________________________________________
Shelter families are each assigned individual rooms.
Rooms are provided for families with infants and families with multiple children.
If bed space will not accommodate an entire family group in one room, families are assigned
adjoining bedrooms.
All bedrooms are clean, comfortable and functional, with working equipment in all bedrooms.
When determining room assignments and groups, shelter staff considers the needs of each resident.
Policy No.: 14
Policy: Recreation Consent
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc obtains parental consent for minor residents to participate
in recreational activities.
PROCEDURES
_______________________________________________________________
Adult shelter residents sign waiver forms for their children to play on recreational equipment.
Minor shelter residents are provided recreational activities with their parents only. FSDC does not
engage children and youth in recreational/athletic activities.
Policy No.: 14
Policy: Promoting Child Well-Being
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. promotes child well-being through the provision of
various services.
PROCEDURES
_______________________________________________________________
Recreation
FSDC does not provide coordinated recreational activities for children living at the shelter. Mothers
are responsible for any engagement in coordinated recreational or athletic activities.
Family Services provides all residents of the Hattie Lee Burgess House with safe and age-appropriate
recreational activities including:
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Two areas have been identified for children’s recreation: the backyard play area and the indoor
playroom.
There is a play area in the backyard, which is gated. The play equipment is safe and wellmaintained.
There is also a playroom in the living room area. The playroom is equipped with ageappropriate toys, games, and books. There is a television, DVD, and age-appropriate movies
available for the children’s enjoyment.
Children must be supervised in these areas at all times.
The shelter also has other recreational items for our residents. These items include: television,
games, crossword puzzles, books, and magazines.
The shelter coordinates with various organizations in town regarding community events and
activities for which residents may choose to participate
Family Services admits child and adolescent males along with their mothers who are experiencing
any form of family violence. Male adolescent residents will be housed in the basement bedrooms of
the shelter. A motion detector will be armed at 10:30 PM and disarmed at 6:00 am in order to
provide for the protection of all shelter residents.
The Crisis Intervention Unit has a therapist on staff that provides specialized services to child
victims of violence. A therapeutic playroom exists at both the shelter and main office locations.
When necessary, referrals to other service providers are made on behalf of children residing the
shelter.
Mothers are responsible for supervising all minor children at all times.
Positive Parenting
1. Family Services provides parenting classes at our main office location.
2. Parenting seminars are also provided by the agency’s child therapist at the shelter for residents
when requested.
3. Family Services doesn’t allow corporal punishment of children at our shelter. Residents are
informed of this policy at shelter admission and are given a copy of the shelter rules, which
includes this policy. Residents are encouraged to use other age-appropriate discipline
techniques, including time-out and restriction of privileges. Failure to comply with this policy
could result in dismissal from the shelter facility.
Education
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Minor shelter residents are to be enrolled in school within three business days after shelter
admissions.
For those children who it is safe for them to remain in the school system they were enrolled in
prior to coming into shelter, parents are encouraged to continue that enrollment.
If safety issues arise with the previous school, shelter residents are encouraged to enroll their
children in the shelter’s school district.
Family Services Shelter Staff provide assistance in enrolling the children in our local school
district.
If it is in the child’s best interest to remain in their prior school system but the child’s parent can
not transport them from the shelter to the school, Family Services Staff will advocate for the
prior school system to transport the child under the McKinney-Vento Homeless Assistance Act.
FSDC provides school supplies to our shelter residents.
Policy No.: 14
Policy: Case Closing
POLICY
_______________________________________________________________
Shelter discharge planning begins at intake and last for the duration of residents’ stays.
PROCEDURES
_______________________________________________________________
Exiting information is provided at intake.
Clients begin formally talking about discharge planning during weekly case management/goal
planning sessions.
Clients are expected to leave their room and surroundings in proper order and complete all
necessary paperwork.
Upon leaving the shelter, residents are asked to complete an exit survey wherein they rate the quality
of services received, give future contact information and indicate their willingness to be contacted,
and give information on their unmet needs.
Residents are given information and are encouraged to participate in other services provided by our
agency.
If the shelter resident is asked to leave the program, reasonable effort is made by Crisis staff to assist
the survivor with locating appropriate services. Survivors leaving the shelter are still eligible to
receive advocacy and counseling services. In addition, survivors being asked to leave the shelter will
be reconsidered for readmission if they meet the eligibility requirements in the future.
Collaborative partners are notified when a survivors ends services if the survivor gives written
consent or disclosure takes place with the Department of Social Services when there is an open
Child Protective Services report and confidentiality is secondary to the child’s safety.
Contracts with Public Authorities
Family Services of Davidson County, Inc. does not have a relevant contract with a public authority.
COA Standards: DV 15.01 - 15.04
Policy No.: 14
Policy: Record Keeping
Latest Revision / Approval: October 2013
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. staff maintains advocacy/shelter files with essential
information.
PROCEDURES
_______________________________________________________________
Case files are housed under double lock at the Hattie Lee Burgess Home. .
Survivor file information and documentation is limited to only essential information, which typically
includes a brief description of the presenting problem and the services the agency provided.
Shelter files are not medical records. They are not released outside the agency.
COA Standards: DV 17
Policy No.: 14
Policy: Aftercare & Follow-up
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. assists shelter residents in developing an aftercare plan
and provides shelter residents with follow-up services
PROCEDURES
_______________________________________________________________
Aftercare planning occurs several weeks before discharge at the shelter during weekly case
planning/goal setting sessions.
1. After care planning involves collaboration between the shelter resident and agency staff
2. After care plans emphasize safety planning, support systems and the utilization of area
resources.
3. When necessary, shelter staff assists residents in arranging for community services needed
after discharge.
4. Upon discharge from the shelter, clients give consent to be contacted in the future by our
agency.
5. When soliciting telephone contact with a former resident, crisis intervention staff always asks
the question, “Is it safe to talk?” in case the abuser is present. If the victim replies “no,”
then the staff will terminate the conversation.
6. Due to the likelihood that a victim’s perpetrator may find mailings from the agency, this
method of follow-up is only used when requested or approved by the victim.
7. Clients are always reminded that the Crisis Line and office telephone numbers are available
to them anytime they need follow-up services.
8. With all client contacts, clients are asked about any ongoing safety concerns, and safetyplanning information is offered regardless if the client chooses to leave their partner or
return to their partner.
9. Shelter staff attempt to obtain information about the client’s adjustment to new living
arrangements, and offer problem-solving information during these follow-up contacts.
10. Clients are encouraged to participate in support group and clinical services.
COA Standards: DV 16.01 – 16.04 and SH 12.01-12.07
Policy No.: 14
Policy: Involvement of Perpetrators
POLICY
_______________________________________________________________
Family Services strives to protect the safety and well-being of survivors and their children, therefore
Perpetrators are not involved in services provided to survivors.
PROCEDURES
_______________________________________________________________
Family Services of Davidson County does not provide victim services to known perpetrators of
family violence including couples counseling and advocacy. However, when necessary or requested
by the survivor, safety planning may address perpetrator involvement.
If a victim remains with their abusive partner, the victim is still provided with safety planning
information.
Abuser Intervention Program Services
Abuser Intervention Program services (AIP) are offered at the agency’s main office location weekly.
During this time, AIP program staff monitors and manages AIP program participants to ensure the
safety of any victims receiving services at the agency during the time of group.
Family Services staff members providing victim services are educated and informed about AIP
group services and unless it is an emergency, do not schedule follow-up appointments with victims
at the main office during the time that AIP group is offered.
Crisis Intervention Staff provide follow-up services to all victims whose perpetrator is enrolled in
AIP group services. Special precautions are taken when contacting victims to ensure that victim
safety is the top priority.
COA Standards: DV 3.01, ASE 6.04
Policy No.: 14
Policy: Crisis Personnel Qualifications
POLICY
_______________________________________________________________
All Crisis Intervention Staff possess appropriate education, experience, and training for the position
held.
PROCEDURES
_______________________________________________________________
Crisis Intervention Director


The Crisis Intervention Director has at least a bachelor’s degree in social work or other human
service degree.
The Crisis Intervention Director must have at least two years’ work experience in domestic
violence and sexual assault, supervision, and/or residential facilities.
The Crisis Intervention Director receives biweekly supervision from the Agency Executive Director.
The Family Violence Prevention Therapist



The Family Violence/Shelter Therapist has a master’s degree in social work or related counseling
field.
This position must possess or be working towards clinical licensure.
This position must also have at least two years’ prior experience in treating persons who have
experienced victimization and trauma.
This position must have experience in working with clients in a group setting. This includes
experience facilitating support and/or treatment groups, understanding group dynamics,
encouraging group participation with activities and understand psycho-educational format of
conducting group.
This position will receive weekly administrative supervision from the Crisis Intervention Director
and clinical supervision from the Clinical Director.
COA Standards: DV 18.01,18.03 SH 13.01-13.07
Advocate
Advocates have a bachelor degree in social work or a related field and two years’ experience in
working with family violence victims, case management, the legal system, and community resources.
This position must have experience in working with clients in a group setting. This includes:
experience facilitating support and/or treatment groups, understanding group dynamics,
encouraging group participation with activities and understand psycho-educational format of
conducting group.
This position receives weekly supervision from the Crisis Intervention Director.
Shelter Coordinator
The Shelter Coordinator has at least a high school diploma and at least two years’ experience
working with domestic violence and sexual assault victims, persons in crisis, and/or residential
facilities.
This position receives weekly supervision from the Crisis Intervention Director.
Part-time Shelter Managers
All shelter managers have a high school diploma and at least two years of experience in working with
persons in crisis and/or residential facilities.
Shelter managers will receive weekly supervision from the Crisis Intervention Director and the
Shelter Coordinator.
COA Standards: DV 18.01,18.03 SH 13.01-13.07
Policy No.: 14
Policy: Crisis Administrative Personnel
POLICY
_______________________________________________________________
The program Director for the Crisis Intervention Unit holds an appropriate level of experience for
providing direct services in a shelter and for advocacy clients.
PROCEDURES
_______________________________________________________________
The Crisis Intervention Director has at least a bachelor’s degree in social work or other human
service degree.
At least two years’ work experience in the field of domestic violence and sexual assault, supervision,
and/or residential facilities is required.
Policy No.: 14
Policy: Crisis Staff Competencies
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc.’s staff is appropriately trained and competent to perform
Crisis Intervention Unit duties as well as appropriate back-up and supervision plans for emergency
situations.
PROCEDURES
_______________________________________________________________
All Crisis Intervention Staff are cross trained to perform most duties from advocacy, crisis line
procedures to shelter operations.
Training for Crisis Intervention Staff consists of:
20. Survivor sensitivity training
31. Crisis Intervention Theory and Voluntary Service Model training
33. Shelter procedures
34. Safety planning
Depending on the Crisis Intervention Staff’s skill level and related work experience, the orientation
period can last a minimum of 20 hours or longer.
During orientation, Crisis Line staff spends at least two hours with both the Crisis Intervention
Director and Shelter Coordinator. The remaining orientation period is spent under the supervision
of the Shelter Coordinator and includes role play, shadowing, and working with other experienced
staff.
COA Standards: DV 18.02 – 18.04, CR10.01-10.03
Crisis Line staff have a specified set of skills to master before working a Crisis Line shift without
any other staff present.
After the training period has ended, the Crisis Intervention Director and Shelter Coordinator holds a
consultation with each new staff to determine their level of comfort in working independently.
During difficult calls, all Crisis Line staff always has direct 24-hour access to supervision and
debriefing by the Shelter Coordinator, Crisis Intervention Director or Clinical Director.
Child Development Knowledge
All Crisis Intervention Staff posses’ basic knowledge about child development and most
have direct experience in working with children.

Crisis Intervention Staff attend trainings specific to issues of the effects of witnessing
domestic violence on children and interventions for child trauma victims.


All staff are trained on reporting procedures to Child Protective Services.
Staff model and encourage alternatives to corporal punishment to shelter residents with
children.

COA Standards: DV 18.02 – 18.04, CR10.01-10.03
Policy No.: 14
Policy: Crisis Staff Workloads
POLICY
_______________________________________________________________
The program Director for the Crisis Intervention Unit is responsible for ensuring staff caseloads are
appropriate.
PROCEDURES
_______________________________________________________________
Employee workloads support the achievement of positive outcomes for survivors, are regularly
reviewed, and are based on an assessment of the following:
a. the qualifications, competencies, and experience of the provider, including the level of
supervision needed;
b. the work and time required to accomplish assigned tasks and job responsibilities; and
c. service volume, accounting for assessed level of needs of new and current survivors and referrals
Crisis Hotline Polices
Policy No.: 15
Policy: Crisis Line Service Definition
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. Family Services provides a 24-hour Crisis Line number
available to its consumers and the citizens of Davidson County, N.C. for the purposes of having
immediate access to services including: crisis stabilization, advocacy and support services,
information and referral services to community resources as well as a general assessment of the
client’s needs.
The goal of the crisis line is to:
1. Identify and assess the client’s presenting issue/crisis
2. Provide intervention and stabilization
3. Work with the caller to develop an action plan
4. Work with the caller to develop a safety plan as needed
5. Make referrals to appropriate resources
6. Follow-up with each caller within 24 hours, when appropriate
Policy No.: 15
Policy: Crisis Line Service Philosophy
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. crisis line service philosophy is based upon Crisis
Intervention theory.
PROCEDURES
_______________________________________________________________
Crisis Intervention Theory is a logical theoretical approach because the goal of this intervention is to
produce quick and constructive change for clients whose problems are short term.
Crisis Line workers utilize this model by:
 Focusing on specific and time-limited treatment goals
 Clarifying and assessing the client’s source of stress.
 Assisting clients in developing problem-solving mechanism functioning and exploring resources
 Providing emotional support for crisis line clients
 Crisis Intervention Theory has been established as an effective modality for crisis hotlines, walkin centers, and crisis clinics
COA Standards: CRI 4
Policy No.: 15
Policy: Crisis Line Quality of Service
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides quality assurance for crisis line calls on an ongoing basis.
PROCEDURES
_______________________________________________________________
All crisis line calls are documented on an identified log.
For any call where there is imminent danger, a supervisor is contacted during the intervention (if
needed) or as soon the intervention has concluded.
For calls that do not meet the standards of imminent danger; however, the client’s risks are high, the
supervisor is contacted during the intervention (if needed) or as soon the intervention has
concluded.
Documentation from crisis line calls are reviewed the next business day to monitor staff’s
intervention appropriateness and proficiency as well as to identify potential areas of needed training.
Supervisors monitor the crisis line staff’s proficiency of task to determine the level at which they can
work independently and to determine what additional support/training is needed.
All paperwork on crisis line calls is reviewed by a supervisor on the next business day.
Data generated from crisis line calls is evaluated on a monthly basis and information regarding
statistics in shared in community collaborative meetings.
PQI reviews outcome measures and incident reports generated from crisis line staff on a quarterly
basis.
Phone and resource lists are kept up-to-date and evaluated regularly by the Shelter Coordinator with
the assistance of Crisis Line staff.
COA Standards: CRI 3
Policy No.: 15
Policy: Crisis Line Access to Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides a 24-hour Crisis Line number available to its
consumers and the citizens of Davidson County, N.C. for the purposes of having immediate access
to services including: crisis stabilization, advocacy and support services, information and referral
services to community resources as well as a general assessment of the client’s needs.
PROCEDURES
_______________________________________________________________
The number (336) 243-1934 has been designated as our 24-hour Crisis line and this number is
always answered by trained staff and volunteers.
Advertising of this number occurs in:
 local telephone directories
 local newspapers
 agency handouts, business cards and brochures
 national and statewide domestic violence and sexual assault directories
Family Services of Davidson County, Inc.’s clients are given this number for emergency access to
services.
During professional trainings and community presentations, local law enforcement agencies, human
service agencies, medical providers and civic and church groups are given information on accessing
our crisis line services
Crisis line workers assess client’s presenting issues and offer information and referrals based on the
client’s presenting issues and needs.
The Crisis Line staff can respond to emergency situations such as: shelter and advocacy requests, the
need to involve emergency/lifesaving services (911, law enforcement) as well as mental health crisis
situations.
Spanish-speaking calls are handled through relaying the telephone number to a contract interpreter,
referring the caller to the national hotline, or by making a 3 way call with a certified interpreter.
Deaf speaking clients can utilize our services through the Relay service.
Although the crisis line was initially developed as a domestic violence and sexual assault crisis line,
Family Services of Davidson County, Inc. has expanded this service to include mental health and
community resource services for FSDC clients.
COA Standards: CRI 1.0-1.02
Policy No.: 15
Policy: Crisis Line Screening & Assessment
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides clients with immediate access to screening and
assessment services through our 24-hour crisis line. During this process clients’ urgency of needs is
determined and responded to appropriately.
PROCEDURES
_______________________________________________________________
Crisis line staff is available to respond to calls 24-hours a day.
When a client requests a specific service, crisis line staff informs the caller if our agency provides
that service. For those clients’ whose service request is not provided by the agency, immediate
referrals for accessing that service are given.
A crisis line calls are answered and responded to in a prompt/immediate manner.
An on-going rapid risk assessment is conducted during the call in a culturally responsive manner to
determine risk of imminent danger, potentially lethality to self or others, current emotional status
and needs, current resources and support systems, and identifying client coping mechanisms.
If crisis line staff feels immediate danger exists or if that is communicated by the caller, an
immediate lethality assessment is conducted using the agency’s Lethality Assessment document.
Crisis line staff employs the least restrictive interventions unless imminent danger is present.
If appropriate, follow-up is provided within a 24-hour time period.
COA Standards: CRI 2.01-2.04,6.01
Policy No.: 15
Policy: Crisis Line Information & Referral
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides immediate referral services for appropriate
community resources and documents service gaps and duplications.
PROCEDURES
_______________________________________________________________
Crisis line callers are immediately provided with the referral information on the service they have
requested.
The Crisis Line office has easily accessible listings of telephone numbers to community agencies
posted on the wall above the crisis line.
The Crisis Line office keeps a more detailed list of community resources in the resource file by the
phone, including telephone numbers, addresses, description of services, fee structure, languages
offered and contact persons.
When clients request domestic violence services for programs in this state and out of state, staff is
able to access that information from directories available in the Crisis Line office.
Crisis Line staff may also access the Internet if a resource cannot be easily be accessed through our
program files.
Phone and resource lists are checked for accuracy once a year by Crisis Line staff.
FSDC prints a resource guide for clients who need multiple services.
Information about the use of the crisis line is provided in our annual “State of the Agency” report.
When the shelter is full, staff assists callers in locating alternative safe housing.
Policy No.: 15
Policy: Crisis Line Training and Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides a 24-hour Crisis Line, equipped to handle
emergency situations which is operated by trained Crisis Intervention staff.
PROCEDURES
_______________________________________________________________
The Crisis line is always answered by a trained staff member or volunteer.
Training for crisis line employees consist of:
3. Victim sensitivity training
14. Crisis Intervention Theory and Voluntary Services Model
All Crisis Intervention Staff complete a minimum of 20 hours of training prior to having
responsibility for answering the hotline. In addition, all staff complete a 60 day employment
probationary period where additional training is provided under the supervision of the Shelter
Coordinator and Director of Crisis Intervention Services. .
Probationary period training consists of an introduction to Agency and Crisis Intervention Unit
policy and procedures, shadowing other trained staff, and instruction from the Crisis Intervention
Unit Director.
Daily supervision as well as 24-hour emergency supervision is always provided to all Crisis Line
staff.
COA Standards: CR10.03.
Throughout the year, quarterly training is provided on domestic violence and sexual assault issues,
community resources, and interventions in crisis situations.
Other updates in services delivery are provided during weekly supervision and through assignments
of reading materials during scheduled work shifts.
In order to handle multiple emergency situations, our crisis line has a two-phone line capacity.
Call waiting is also available on the Crisis Line when both lines are in service. Pushing the “feature”
button on the phone and dialing 71 can access call waiting.
Our Crisis Line phones have features such as hold and transfer buttons to manage more than one
incoming phone call at a time. When more than one call is in process, Crisis Line staff will need to
prioritize the calls in terms of emergency need.
Crisis Line staff will need to state to the less urgent call, “Although your call is extremely important
to me, I have an emergency call in process on the other line. I think I can complete that call in (fillin amount) minutes. Is there a safe number that I may call you back at or would you prefer to call
me back after (fill-in amount) minutes?”
During normal business hours, Crisis Line staff may also access assistance in managing incoming
calls from other Crisis Intervention Unit Staff.
COA Standards: CR10.03.
Policy No.: 15
Policy: Crisis Line Personnel Supervision
POLICY
_______________________________________________________________
All crisis line staff receives sufficient orientation, training and supervision to perform their assigned
work duties.
PROCEDURES
_______________________________________________________________
Crisis Line staff must satisfactory complete an orientation period (minimum of 20 hours) prior to
working independently on the crisis line.
Training for crisis line staff continues past the orientation process.
Quarterly trainings are held at the shelter that address issues such as cultural sensitivity, staff
burnout, accessing community resources, interview techniques, emergency procedures,
confidentially, substance abuse and disclosure, etc.
Employees receive immediate supervision as needed for debriefing purposes, upholding agency
policies and needed follow-up procedures.
Documentation from crisis line calls are reviewed the next business day to monitor staff’s
intervention appropriateness and proficiency as well as to identify potential areas of needed training.
Supervisors monitor the crisis line staff’s proficiency of task to determine the level at which they can
work independently and to determine what additional support/training is needed.
As crisis line staff typically works an extended shift, 12 hours – 35 hours, job responsibilities can be
accomplished within that time period. If necessary, extra provisions can be made with the program
supervisor to complete all duties.
If the volume of calls exceeds the crisis line workers capabilities, advocates and on-call therapist can
be utilized to handle incoming calls during normal business hours and supervisors and on-call
advocates can be utilized during afterhours.
Policy No.: 15
Policy: Crisis Line Personnel
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc.’s staff is appropriately selected, trained, supervised and
competent to perform the duties on an emergency crisis line before allowed to work independently.
PROCEDURES
_______________________________________________________________
Crisis Line Staff
FSDC attempts to hire crisis line workers who have prior experience dealing with crisis lines or
problem management. Staff is selected based on the presence of qualities such as maturity,
judgment and the ability to react in a crisis.
Depending on the Crisis Intervention Staff’s skill level and related work experience, the orientation
period lasts a minimum of 20 hours.
During orientation, Crisis Line staff spends at least two hours with both the Crisis Intervention
Director and Shelter Coordinator. The remaining orientation period is spent under the supervision
of the Shelter Coordinator and includes role play, shadowing, and working with other experienced
staff.
Crisis Line staff have a specified set of skills to master before working a Crisis Line shift without
any other staff present. These skills include assessment skills, de-escalation techniques, supportive
counseling, show proficiency in knowledge about area resources, working with special population
clients and self-care.
Crisis Line staff have a specified set of skills to master before working a Crisis Line shift without any
other staff present. Crisis line workers also need to have knowledge of reporting procedures as it
relates to child abuse/neglect and felony criminal behavior.
FSDC staff must sign a copy of our confidentiality policy before beginning work. Issues of
confidentiality are stressed during the orientation period.
During the orientation period, FSDC staff must show proficiency in completing agency
documentation.
FSDC crisis line staff must understand the back-up/supervision plan in terms of when and how to
contact a supervisor as well as when to access emergency personnel.
After the training period has ended, the Crisis Intervention Director and Shelter Coordinator hold a
consultation with each new staff to determine their level of comfort in working independently.
On-going training is provided to all Crisis Intervention Staff.
During difficult calls, all Crisis Line staff always has direct 24-hour access to supervision and
debriefing by the Shelter Coordinator, Crisis Intervention Director or Clinical Director.
Crisis Line Supervisors
Crisis line supervisors have at least a master’s degree in social work or a related field and are
available 24/7 to support staff and assist with program operation.
Policy No.: 15
Policy: Crisis Line Access and Handling Multiple Calls
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. provides a 24-hour Crisis Line that is equipped to receive
all incoming calls for service.
PROCEDURES
_______________________________________________________________
Trained staff persons are available to answer the crisis line 24 hours a day, seven days a week.
When the Crisis Line number, 243-1934, is busy, the Crisis Line business number of 243-1628
serves as a rollover line to the Crisis Line.
Call waiting is also available on the Crisis Line when both lines are in service.
Pushing the “feature” button on the phone and dialing 71 can access call waiting.
Our Crisis Line phones have features such as hold and transfer buttons to manage more than one
incoming phone call at a time.
When more than one call is in process, Crisis Line staff will need to prioritize the calls in terms of
emergency need.
Crisis Line staff will need to state to the less urgent call, “Although your call is extremely important
to me, I have an emergency call in process on the other line. I think I can complete that call in (fillin amount) minutes. Is there a safe number that I may call you back at or would you prefer to call
me back after (fill-in amount) minutes?”
During normal business hours, Crisis Line staff may also access assistance in managing incoming
calls from other Crisis Intervention Unit Staff.
If it is necessary to dispatch emergency help (fire, rescue, EMS, law enforcement) on behalf of a
crisis line caller, crisis line staff can do so from another phone or another line. This will avoid
having to disconnect the client’s call.
Policy No.: 15
Policy: Crisis Hotline and Support Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. has a 24-hour Crisis Line number available to survivors
that provides immediate support, intervention and information and referral.
PROCEDURES
_______________________________________________________________
The number (336) 243-1934 has been designated as our 24-hour Crisis line.
This number is always answered by trained staff and volunteers.
Advertising of this number occurs in:

local telephone directories

local newspapers

agency handouts, business cards and brochures

national and statewide domestic violence and sexual assault directories
Family Services of Davidson County, Inc.’s clients are given this number for emergency access to
services.
During professional trainings and community presentations, local law enforcement agencies, human
service agencies, medical providers and civic and church groups are given information on accessing
our crisis line services
Crisis line workers assess client’s presenting issues. They offer referrals based on the client’s
presenting issues and needs.
The Crisis Line staff can respond to emergency situations such as: shelter request, the need to
involve emergency/lifesaving services (911, law enforcement) as well as mental health crisis
situations
Through this line, clients can get immediate access to shelter and on-call advocacy services
The crisis line phone has the capacity to handle 2 incoming calls as well as call waiting on the line.
These telephone capabilities can be used to handle multiple incoming calls as well as dispatch
emergency help if needed.
Resources
The Crisis Line office has easily accessible listings of telephone numbers to community agencies
posted on the wall above the crisis line.
The Crisis Line office keeps a more detailed list of community resources in the resource file by the
phone, including telephone numbers, addresses, description of services and contact persons.
When clients request Crisis Intervention services for programs in this state and out of state, staff is
able to access that information from directories available in the Crisis Line office.
Crisis Line staff may also access the Internet if a resource cannot be easily be accessed through our
program files.
Phone and resource lists are checked for accuracy once a year by Crisis Line staff.
Collaboration with Emergency Officials
The Crisis Intervention Director solicits annual Memorandum of Understanding (MOU) from the
following area agencies:
 Area Law Enforcement Agencies
 Local Hospitals
 Department of Social Services
 Local mental health organizations including substance abuse service providers
 Local and National Human Trafficking Organizations
 District Attorney’s Office and Legal Aid of North Carolina
 Surrounding domestic and sexual violence service providers
The MOUs outline each party’s responsibility in:
 Procedures for responding to emergency situations
 Providing information and referral services
 Collaborating services
Policy No.: 15
Policy: Crisis Intervention and Response Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc.’s staff responds immediately and appropriately to
individuals in crisis situations.
PROCEDURES
_______________________________________________________________
Family Services of Davidson County, Inc. crisis line staff is available 24-hours a day.
Crisis Line staff respond immediately and:
1.
2.
3.
4.
5.
6.
Identify and assess the client’s presenting issue/crisis
Provide intervention and stabilization
Work with the caller to develop an action plan
Work with the caller to develop a safety plan as needed
Make referrals to appropriate resources
Follow-up with each caller within 24 hours, when appropriate
Crisis personnel are available on-call by telephone 24 hours a day, on a walk-in basis during normal
business hours, and by referral.
The agency maintains an on-call advocate and therapist schedule to address emergency mental
health and advocacy situations.
Any emergency intervention by crisis line, advocacy or clinical staff is reviewed by a supervisor
(Executive Director, Crisis Intervention Director or the Clinical Director) within a 24-hour period.
For domestic and sexual violence related emergencies additional safety measures are taken to appropriately support the
survivor.
1. Staff quickly assesses domestic violence callers for lethality by questioning the caller about
the presence of weapons, degree of any injury received and current location of the
perpetrator of the violence.
2. Emergency demographic data such as caller’s name, address and phone number is gathered.
3. Domestic violence and sexual assault victims who are in imminent danger are kept on the
crisis line while staff contacts law enforcement on a separate telephone line.
4. If a caller contacts our crisis line wanting information about the shelter and it is obvious to
staff that the caller’s abuser is present in the room, the caller is encouraged to go to a
telephone that is separate from their abuser. These callers are additionally questioned for
their need to have law enforcement present.
5. Sexual assault victims who contact the crisis line after a very recent attack are encouraged to
seek medical attention from the local emergency room.
Staff document all crisis line calls. This documentation includes: date of contact, type of contact,
client demographic data, the client’s presenting problem and service rendered by staff.
Mental Health
See Screening and Assessment (CRI 2.01 – 2.04) policy
Medical Crisis
Crisis Line staff are not trained to handle most medical emergencies. If the caller contacting the
Crisis Line is requesting medical service the following actions will be taken.
Staff will ask if there are any other family members present with the caller who can take them to an
appropriate medical provider (emergency room, doctor’s office, etc.).
If the caller is alone and is need of immediate medical attention, staff will gather identifying
information such as the client’s name, address and telephone number. Staff will then contact 911 on
a separate telephone line and dispatch an ambulance to the caller. Staff will remain on the line with
the caller until the ambulance arrives.
Follow-up services are provided within 24 hours, when appropriate.
Policy No.: 15
Policy: Community Connections and Coordination
POLICY
_______________________________________________________________
In order to encourage collaborative efforts on behalf of our crisis line clientele, FSDC maintains
yearly Memorandums of Understandings (MOU) with local human services and emergency agencies.
PROCEDURES
_______________________________________________________________
The Crisis Intervention Director solicits annual Memorandum of Understanding (MOU) from the
following area agencies:
 Area Law Enforcement Agencies
 Local Hospitals
 Department of Social Services
 Local mental health organizations including substance abuse service providers
 Local and National Human Trafficking Organizations
 District Attorney’s Office and Legal Aid of North Carolina
 Surrounding domestic and sexual violence service providers
The MOUs outline each party’s responsibility in:
 Procedures for responding to emergency situations
 Providing information and referral services
 Collaborating services
An up-to-date list of community social service organizations is maintained.
Abuser Intervention Program Polices
Policy No.: 16
Policy: AIP Service Definition
POLICY
_______________________________________________________________
The Abuser Intervention Program (AIP) provides psycho-educational groups to adult men perpetrators
of intimate partner violence. This program addresses issues of abuse and control used in relationships.
AIP is certified by the North Carolina Council for Women and Domestic Violence Commission.
_______________________________________________________________
1. Program participants can come through four primary sources:
a) Self-referrals
b) Criminal and civil court orders
c) Local probation and parole
d) Other human service agencies such as the Davidson County Department of Social
Services.
2. Program participants have reported to engage in, or the court system or another human service
agency has found that they have engaged in, acts of domestic violence.
3. Participants must not have any pending domestic violence court actions in the court system when
they are beginning group, nor may they have any pending domestic violence court actions filed
against them while they are participating in group.
4. All participants participate in an intake session. During this session they are assessed for:
a) Social and family history
b) Medical health history
c) Relationship history
d) History of violent, controlling or abusive behavior
e) History of past criminal behavior
f) Lethality
g) Cognitive and social abilities.
5. Individual treatment is not provided as an alternative to group unless gender or language barriers
prohibit the client from group participation.
6. When it is determined that a client is not appropriate for the AIP group setting (due to homicidal,
suicidal or active substance issues), a client is referred for psychiatric or substance abuse services.
See High Risk Intervention Policy. Once medical clearance is received, the client is re-admitted
back into the AIP group.
Policy No.: 16
Policy: AIP Service Philosophy
POLICY
_______________________________________________________________
The Abuser Intervention Program (AIP) is conducted in a psycho-educational group format to address
issues of power and control used in relationships, and to promote personal responsibility and positive
change.
PROCEDURES
_______________________________________________________________
1. Intervention is provided in a group setting unless same gender, age, geographic or language
restrictions apply.
2. Groups are composed of two facilitators, one male and one female.
3. Group materials include the Duluth Model - Domestic Abuse Intervention Program (DAIP)
4. Groups identify and process the following:
a) all forms of physical, economic, sexual and verbal abuse and violence
b) the impact of domestic violence on victims, adults, children, and the perpetrator
c) emphasis on personal responsibility of the batterer for his/her usage of violence
d) identification of personal, societal and cultural values and beliefs that support the use of
violence and oppression
e) alternatives to violent and controlling behaviors
f) identification of healthy relationships
g) promotion of accountability
h) the identification of behavioral, emotional and physical triggers that occur prior to a
violent episode.
COA Standards: CSE 4
Policy No.: 16
Policy: AIP Provision of Group Services
POLICY
_______________________________________________________________
AIP groups are conducted in a manner to promote personal change while respecting client diversity
and different values.
PROCEDURES
_______________________________________________________________
1. The goal of the Abuser Intervention Program is threefold:
 to hold the abuser accountable for prior acts of violence
 to promote relationships of equality
 to teach skills to deal with interpersonal conflict.
2. Group Facilitators promote personal change through various techniques including:
 modeling appropriate behaviors and boundaries
 utilizing time outs
 assisting clients in developing positive action plans to use during future
disagreements with their partner
 examining prior use of violence by the client
 recognizing behavior triggers and prior inappropriate actions taken.
3. Group participants are treated with respect. Group facilitators model appropriate respect
behaviors during groups.
4. Varied value systems in regards to personal beliefs are accepted in group, except for value
systems that support the use of power and control issues in relationships.
5. When clients verbalize negative value systems in regards to power and control issues,
facilitators challenge those belief systems in a therapeutic manner.
6. Complex family interactions are incorporated and respected in our AIP program; however, they
can never be used as a means of:

Placing the blame for group participant’s abusive actions on others or as the causality of
client’s anger

Treating violence as a mutual process between victims and perpetrators
7. The Abuser Intervention Program (AIP) is a psycho-educational program for perpetrators of
family violence that focuses on taking accountability for past violent actions. Prior
victimization cannot be reviewed as causality for abusive actions. If the AIP participant has
a prior history of victimization and they would like to receive services for their past trauma,
staff would recommend the client for individual therapy. Most likely this referral would
occur after group has taken place. FSDC staff would explain that individual therapy could
not be used in place of our court-ordered AIP.
8. It is the policy of this program to be mindful of the safety and rights of the victims and the
perpetrators while participating in the program. The Abuser Intervention Program will
follow the policies and procedures of Informed Consent and Client’s Rights as defined by FSDC.
9. Participants will have the doctrine of informed consent and client’s rights explained to them
in the beginning of intake and willfully sign the Consent for Evaluation/Treatment and Right to
Refuse Treatment.
Policy No.: 16
Policy: AIP Personnel- Information and Referral
POLICY
_______________________________________________________________
The Abuser Intervention Program (AIP) staff’ are appropriately trained and supervised to provide
information and referral services.
PROCEDURES
_______________________________________________________________
1. Prior to facilitating group, AIP staff has basic knowledge about domestic violence, the service
population, community referrals and the Duluth model.
2. AIP group facilitators receive ongoing training on:
a.
Service needs of AIP participants
b.
Domestic Violence dynamics
c.
Agency procedures for making referrals and giving our information on
community resources
d.
Intake/interviewing techniques
e.
Handling emergencies
f.
Enacting the agency’s High Risk Intervention Policy
g.
Disclosure laws in case of abuse
3. AIP staff are supervised by a program coordinator and program director, both of which have a
background in:
a.
working with domestic violence populations
b.
facilitating groups
c.
providing intake and assessments
d.
providing appropriate information and referral services
e.
agency policy governing the delivery of needed services
Policy No.: 16
Policy: AIP Personnel- Education and Support
POLICY
_______________________________________________________________
The Abuser Intervention Program (AIP) staff is qualified and has the support necessary to facilitate
psycho-educational groups.
PROCEDURES
_______________________________________________________________
1. AIP facilitators are studied in group dynamics.
2. Facilitators understand how to engage group members and encourage active participation.
3. Facilitators understand the concept of advocating for domestic violence victims.
4. Facilitators can identify the symptoms of mental illness and substance abuse and intervene when
needed.
5. Facilitators are able to lead group discussions on areas of power and control, nonviolent
behaviors, value systems and family stressors.
6. Supervision is provided by a program coordinator with the support of that program director that
is able to show competencies in all of the above areas as well as assist staff in their roles as
facilitators.
7. Group census are kept to a maximum of 16 persons to support a manageable group, where all
parties have the opportunity to participate and facilitators can accomplish group task.
8. The program coordinator monitors the group census in order to support facilitators in their role.
COA Standards: CSE 8.01-8.03
Policy No.: 16
Policy: AIP Access to Services
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. utilizes multiple strategies to provide community outreach and
identify clients for The Abuser Intervention Program (AIP).
PROCEDURES
_______________________________________________________________
1. Program participants can come through four primary sources:
a) Self-referrals
b) Criminal and civil court orders
c) Local probation and parole
d) Other human service agencies such as the Davidson County Department of Social
Services and Davidson County Probation and Parole.
2. The Crisis Intervention staff provides information about our AIP to any persons calling to selfrefer themselves to this service.
3. FSDC advocates have a weekly presence in civil court to take down contact information on
persons ordered to our services.
4. The AIP Program Coordinator has weekly contact with area Probation Officers to facilitate the
client enrollment process.
5. Community outreach presentations and professional trainings are regularly held that promote our
AIP services.
6. Family Services Abuser Intervention Program has been certified by the North Carolina Council
for Women. Contact information on our agency appears in publications by the Council for
Women that promote North Carolina approved programs.
COA Standards: CSE 1.01
Policy No.: 16
Policy: AIP Education and Group Services
POLICY
_______________________________________________________________
The Abuser Intervention Program (AIP) is conducted in a psycho-educational group format where
personal growth, well-being and the prevention of intimate partner and family violence is supported.
PROCEDURES
_______________________________________________________________
Group Focus
1. Group participants have experienced the recent crisis of participating in acts of intimate partner
violence, with the majority of clients being court-ordered.
2. All participants are asked to use alternatives to violence and take accountability for their previous
use of power and control tactics.
3. In addressing using alternatives to violence, AIP participants are asked to identify action plans
including alternative behaviors/techniques and support systems that will assist them in becoming
violence free.
4. Participants are asked to identify prior emotional triggers that were present leading up to their
violent incident. Additionally, they are asked to identify negative responses to their abusive
behavior and the impact those behaviors have on their pattern/spouses and their family.
5. FSDC does not work from the theoretical framework that domestic violence is the direct cause of
poor anger management; however, stress management techniques are covered during the group
sessions. Participants are encouraged and are given alternatives to managing their daily stresses.
6. Group participants are asked to explore their value systems that supported their use of violence
and to consider the impact of those values on family functioning.
7. The purpose of the group is future focused and strengths based. Instead of evoking shame for
past actions, facilitators encourage participants to respond constructively to their relationships.
Group Setting
1.
2.
3.
Group participants are encouraged to participate in discussions with respect and support
being the top priority.
Group facilitators model respectful communication, negotiation, the sharing of power and
appropriate responses to group input.
The scheduling of group is done with respect to participant’s work commitments. When a
client works a swing shift, or is involved in long distance travel, they are given the option of
entering into a work contract. This prolongs the amount of time it may take them to
complete group; however, it accommodates varying work schedules. If our AIP time
completely conflicts with a participant’s work schedule, they are given referrals to other
programs with varying schedules.
Group Activities
1. Homework and in class assignments are part of the group curriculum. Participants are
encouraged to share these assignments during group discussions. Facilitators lead
discussions where group participants give feedback and suggestions on the assignments.
2. Group rules are developed to encourage respect, support and confidentiality.
Policy No.: 16
Policy: AIP Personnel- Training and Education
POLICY
_______________________________________________________________
Abuser Intervention Program (AIP) staff have the necessary educational qualifications and receive
sufficient training to facilitate psycho-educational groups.
PROCEDURES
_______________________________________________________________
Group Facilitators
1. AIP group facilitators have a minimum of a bachelor’s degree in social work or a related field and
experience in working with families in crisis in a group setting.
2. AIP group facilitators show proficiency in the following fields: group dynamics, family
functioning, working with collaborative partners, working with resistant populations,
understanding the dynamics and impact of family violence.
Program Director
1.
The program director has a minimum of a master’s degree in social work, counseling or a related
field.
2.
The program director has at least two years’ experience in supervising staff.
3.
The program director has at least two years’ experience in facilitating psycho-educational groups.
Training
1.
AIP staff receive training on:
a.
best-practice strategies in responding to domestic violence offenders
b.
ecological perspective – as it relates to family violence dynamics (poverty, social
history)
c.
Crisis Intervention Theory and Voluntary Service Model
d.
Domestic violence advocacy issues in the criminal and civil justice system
e.
Assessing individuals for intensive services (as it relates to mental health and substance
abuse issues)
Workloads
1. AIP groups are limited to 16 persons.
2. No more than 3 intakes are scheduled at a time
3. The program coordinator monitors group census and develops plans for organizing a waitlist to
enter group.
4. Supervision topics address issues of workload, task accomplishments, timeframes and job
responsibilities.
Policy No.: 16
Policy: AIP Information and Referral Services
POLICY
_______________________________________________________________
Information and referral services are a continuous process throughout the Abuser Intervention
Program.
PROCEDURES
_______________________________________________________________
1. Information and referrals on available community resources are given at intake if unmet needs are
identified.
2. The agency maintains up to date resource guides on area referrals. Contact information (agency
name, telephone number, address, eligibility criteria, service fees, languages spoken and services
offered) is verified on an annual basis.
3.
AIP staff is available to provide advocacy services in assisting clients in accessing these services
while participants are enrolled in our program.
4. In crisis situations, staff is available to provide emergency intervention both in-house and through
outside sources. During emergency interventions (hospitalization, law enforcement, and
substance abuse treatment) AIP staff connects program participants to more intensive services.
Reference: High Risk Intervention Policy
Policy No.: 16
Policy: AIP Screening and Intake
POLICY
_______________________________________________________________
Program participants will be screened during an initial intake to determine group appropriateness
before admission in the AIP.
PROCEDURES
_______________________________________________________________

Clients who are referred to our agency are asked to schedule an intake appointment within a
month of receiving their case dispositions.

Clients are scheduled for an intake within a two week time period.

Clients who do not comply with enrollment and intake process are referred back to the court
system.

During the intake session, FSDC staff explains the program’s requirements and staff assess
the client’s group appropriateness including risk of harming self or others, substance
abuse/dependency, and the ability to participate in a group setting.

FSDC staff explains all AIP participation forms, after which each participant will give
consent by signing each form.
a. Consent for Evaluation/Treatment and Right to Refuse Treatment
b. Consent for Release of Information
c. Contract for Participation

Each participant will answer the questions on the FSDC Abuser Intervention Program Intake
Form.

Only the Crisis Intervention Director or other authorized personnel can make modifications
to the Contract for Participation for individual participants.

At the end of the intake process the staff will make recommendations to the client for other
assessments and/or treatments if needed, and an Intake Screening Summary shall be completed.

If another mode of treatment is deemed more appropriate than our program or if another
mode of treatment is needed prior to beginning our program, intake staff give referrals for
area services.

Within a week of completing the intake process, AIP clients are assigned a time to begin
group. Most clients begin group within a two-week period.

If the AIP group census is full (16 clients), clients who complete the intake process are
placed on a wait list. They are notified by mail of the next available start date.

Court personnel are informed of the client’s participation in intake and enrollment dates of
group.

All client appointments including the intake and regular group sessions are documented in
the client’s file.
Keeping Up Program Policies
(Juvenile Justice Day Services)
Policy No.: 17.2
Policy: Engagement & Assessment
Engagement & Assessment
POLICY
_______________________________________________________________
Family Services of Davidson County, Inc. responds to referrals in a timely and appropriate manner.
PROCEDURES
_______________________________________________________________
Referral sources for the YCS unit come from: Juvenile Court Counselors, school system
employees, area human services personnel, parents of the juvenile and other social service providers,
etc.
1. When a referral comes in directly from a child’s guardian, an intake appointment is
scheduled at the time the guardian initiates contact with the agency.
2. Referrals that are faxed in from an outside source (Physicians, the School System, and
Juvenile Court Counselors) are responded to within a 24 hour (next business day) time
frame.
3. If FSDC staff is unable to reach the referral’s guardian after three attempts by telephone, a
letter is sent requesting that they contact our agency to schedule an intake appointment.
4. For court-involved youth whose guardians do not follow through with accessing the court
ordered services, information is given to the court counselor regarding their noncompliance.
5. At the first point of contact with the client’s guardian, routine questions are asked in regards
to the need for an emergency assessment.
6. If it is deemed that the client is in need of an emergency assessment, arrangements are made
to see that client within the same day of the referral.
7. If it is deemed that our agency cannot provide the service being requested by the client then
referrals to other area service providers are given.
COA Standard: JJD 1.01
Policy No.: 17.3
Policy: Assessments
Assessments
POLICY
_______________________________________________________________
Admission of a client to a YCS program involves a family assessment and is completed in
accordance with the overall agency policy as it relates to the admission of clients using the YCS
Initial Assessment tool.
1.
2.
3.
4.
5.
6.
7.
8.
9.
PROCEDURES
_______________________________________________________________
Once a youth has been referred to Keeping Up, the KU social workers will contact the
family within 2 business days to schedule an assessment. This assessment can generally be
accommodated within 5 business days of the initial contact, if not in the same day.
The assessment will be conducted by one of the two social workers who will use the
standard YCS Initial Assessment tool to assess the potential participant for major mental
health issues, unmet basic needs, and problem behaviors that resulted in the suspension or
categorize the student as at-risk.
KU staff make every effort to ensure that assessments are conducted in a responsive manner
that includes attention to age, developmental level, gender, language, culture, race, ethnicity,
religion, geographic location, sexual orientation, and trauma history.
Appropriateness for admission to the program will be determined at the end of the
assessment.
Potential reasons for a referral not to be accepted into the program are space availability,
mental health issues that require immediate help such as active suicidal or homicidal
intentions, aggressive behaviors that would warrant a more structured setting and any other
diagnosis that could potentially cause harm to the youth, other students or staff in the
program.
If the student is assessed as inappropriate for services the social worker will arrange for a
referral to appropriate services.
Should the student be assessed as appropriate for services, a start date will be discussed with
the family.
The family and student will also be asked to sign a program agreement at the time of
assessment informing them of program guidelines and requirements.
Students can start as early as the same afternoon of their initial assessment. KU social
workers will follow up with all referring agencies within 10 days of the receipt of the referral
to inform the referring agency of the student's status with regards to participation in the
program.
COA Standards: JJD 1.02-1.06
Policy No.: 17.4
Policy: Further Evaluation
Assessments
POLICY
_______________________________________________________________
Throughout the course of treatment clients may be exposed to various measures to obtain
information about a client’s specific condition and its clinical significance. These measures may also
be used at various times to measure a client’s position on the continuum of improvement. Clinicians
using these devices will obtain training, interagency or otherwise, in regards to the administration,
scoring, and interpretation of data obtained from these measures.
PROCEDURES
_______________________________________________________________
Currently the measures utilized by the Youth and Community Services include but are not limited to
the following:









Child Behavior Checklist
Generalized Contentment Scales
Index of Peer Relations
Index of Family Relations
Index of Parental Attitudes
SASSI Substance Abuse Subtle Screening Inventory
Global Assessment of Functioning (GAF) of the DSM-IV
The WALMYR Scale of Family Functioning
Client Self-Report of Progress
Results of these tests are reviewed by supervisory staff in individual and group supervision. If the
need for further assessment occurs, YCS clients may be referred to other appropriate professionals.
COA Standard: JJD 1.04
Policy No.: 17.5
Policy: Service Planning & Monitoring Timeframes
POLICY
_______________________________________________________________
YCS staff develop individual service plans with participating youth and their families. These plans
are the basis for the delivery of services. Service planning is completed in a timely manner by
qualified staff. If urgent risks are identified expedited service planning is required.
PROCEDURES
_______________________________________________________________
During a participant's initial assessment, the social workers will begin to guide the youth in setting
specific goals for himself or herself that he or she will address throughout his or her participation in
Keeping Up.
1. Youth will develop an individual service plan with the support of the social worker, his or
her parents and any other relevant personnel that addresses his or her specific needs and
goals. The individual service plan may include:
 The clients’ goals in participating in YCS services and the expected timeframes for
completion.
 Specific services to be provided and the identified staff persons providing those services.
 Any identified unmet service needs and a plan for locating those services outside the
agency.
 Collaborative partners involved in the treatment of the client and the type and frequency
of communication with those partners.
 Established target date(s) for completion are set and the client and/or parent/guardian
signs off on the plan, which indicates the client’s involvement in the process and their
ownership of the outcome goals.
2. Staff will work to address these goals during group treatment, individual sessions with
participants, and through the parent group. These goals will also be discussed during the
follow-up social work services that each student will receive once he or she returns to his or
her school.
3. YCS staff review the individual service plan at least quarterly with the client and/or
parent/guardian.
4. Complicated cases that are identified as needing urgent or crisis care shall be reviewed with
the YCS Director immediately and followed up weekly until the issue(s) is resolved.
5. The client and family members are involved in service planning and case conferences.
6. Treatment plans require the signature of the youth and their parent and/or legal guardian.
7. Family members are encouraged to attend family therapy sessions where the client’s
treatment plan is discussed.
8. Family members are weekly advised of the client’s progress in meeting his/her goals through
a variety of contact types which may include but are not limited to: phone calls from YCS
Social Workers, therapy sessions, treatment team meetings with other service providers and
COA Standards: JJD 2.0 – 2.07
during informal daily contacts when parent comes to pick their children up from our
program.
9. YCS staff offer ways that the agency can assist the family in meeting their goals and how we
monitor client/family progress.
10. Expectations of the court including consequences if the desired outcomes are not met
(Noncompliance with attendance, positive drug screens, etc.) are reviewed with clients and
their guardians throughout treatment.
Policy No.: 17.7
Policy: Collaboration & Coordination
POLICY
_______________________________________________________________
In order to promote client advocacy, appropriate referrals, best practice service delivery, and a
coordinated effort, YCS staff participate in ongoing collaborative efforts with community partners
1.
2.
3.
4.
5.
6.
7.
8.
PROCEDURES
_______________________________________________________________
Weekly collateral contact is held with Juvenile Court counselors, DSS social workers, school
system personnel, parents and other involved community partners to share case updates.
YCS staff has a weekly presence in Juvenile Court to answer the court’s questions about
clients’ response to treatment and available resources, as well as to make recommendations
on case dispositions.
Quarterly collaborative meetings are held with Juvenile Justice Personnel. During this time,
joint cases may be discussed.
YCS maintains lists, brochures, and contact information for additional community programs
and resources that might provide additional support to clients. YCS staff can advocate for
additional supports for clients via their relationships with partner agencies and service
providers.
YCS staff are available to provide client outreach presentations to community civic groups,
churches and organizations. YCS staff maintain a presence at community events in order to
educate others about the services that are provided at FSDC.
YCS is available to give professional trainings on at-risk youth populations and available
resources.
YCS recruits volunteers to support its Circles Program. These volunteers are trained to work
with people experiencing poverty and work as mentors, child care providers, and meal
providers at weekly community meetings. Clients are encouraged to appropriately support
agency services as well through pro-social volunteering opportunities.
All sharing of information is conducted within HIPPA guidelines and FSDC policy. Releases
of Information are completed on all case-related collaborating partners during the intake
process.
Policy No.: 17.8
Policy: Family Involvement
POLICY
_______________________________________________________________
In order to provide for positive case outcomes and strengthen internal supports, family involvement
is required for all YCS clients.
1.
2.
3.
4.
5.
6.
7.
PROCEDURES
_______________________________________________________________
Admission of a client to a YCS program will involve a complete family assessment.
Parents or legal guardians must be present during the initial intake session to sign necessary
paperwork and to participate in the family assessment.
Treatment plans are developed with and signed by the legal guardian or parent.
Weekly contact is held with legal guardians or parents of YCS clients in order to
communicate the client’s response to treatment, changes in the family structure and future
scheduling of services.
A weekly Parent Group is held for all current Keeping Up Program participants. During this
support group topics such as: understanding and appropriately responding to a child’s
behaviors, accessing resources, improving communication, family boundaries and
strengthening relationships are explored.
In order to promote parental involvement in treatment, transportation vouchers may be
provided in the event they are needed.
See the organizational service philosophy for more information about the high value of
family involvement that FSDC has for all services.
Policy No.: 17.10
Policy: Educational Program
POLICY
_______________________________________________________________
It is the goal of Family Services of Davidson County, Inc. to provide the best quality care for each
client. For those youth in our educational component of the Keeping Up Program (KU), each child
has an individualized service plan and educational plan. The educational plan is coordinated to
maximize the impact on the youth’s educational and treatment goals.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
PROCEDURES
_______________________________________________________________
Our KU educational component uses approved curricula provided by the Davidson County
Schools including a computer based Program called Edgenuity. The program allows
suspended students the opportunity to earn classroom credits. The student’s home school
defines what the appropriate curriculum is for the student and the case liaison makes
arrangements to provide the needed instructional tools to help the student “keep up” with
requirements while he or she is in the KU program. For most students this involves using
the Edgenuity website or a home bound educational plan through the Exceptional
Children’s Department of Davidson County Schools. If a student is transferring into
Davidson County schools and does not have a current educational plan as defined by a
home base school, the case liaison uses Common Core instructional material for the
student’s grade level as an interim educational plan.
The Keeping Up program operates between the hours of 1:00 pm - 5:00 pm, Monday
through Thursday.
All of the staff of the Keeping Up will be qualified to provide the educational and
therapeutic services we offer to families and the youth.
Some of the youth we serve in the KU program are in an out of home placement at the time
of admission. Those youth will be provided with an educational plan, as appropriate, that is
integrated with his/her therapeutic treatment plan.
Those youth who are not long-term suspended but receive services from our department
and/or agency are enrolled in their local school district and/or encouraged to stay in school.
Our case liaison (educational personnel) and social workers work closely with local school
professionals. Upon reintegration to the school system by the youth, our case liaison
provides consultation in that referral process.
When a young person is given the label “E.C.” we coordinate with the school to provide
homebound services either on-site at FSDC or at the youth’s home.
The case liaison will implement the educational plan and integrate the educational goals and
activities with the overall therapeutic program.
Case Liaison and social workers will provide the youth with recreational, athletic and social
activities, where appropriate, within the individual needs and abilities of each youth.
The Case Liaison will obtain school records promptly upon admission and provide up-todate records to the new school once the student transfers elsewhere.
Students in the Keeping Up Program receive 3 seat hours of educational time per day. These
hours will transfer once the student is able to reintegrate back into a traditional school
setting.
12. The Case Liaison has a minimum of a bachelor’s degree (Education Preferred) and
experience working with high-risk youth.
13. The ratio to students and instructors is 12 to 1
Policy No.: 17.13
Policy: Maintaining Safety & Security
POLICY
_______________________________________________________________
It is the goal of Family Services of Davidson County, Inc. to provide a safe, secure and nurturing
environment where all YCS clients and Staff are protected from harm.
PROCEDURES
_______________________________________________________________
Client Supervision
 Ratios during classroom is 1 staff for every 12 clients; for group treatment there is always 2
staff present.
 During outside recreation time, a minimum of two staff persons will be present to
adequately supervise clients as well as effectively deal with any emergency situations that
arise.
 Ratios during field trips are 1 staff for every 3 clients.
Attendance
 In order to account for all clients in group activities, daily attendance is monitored.
 Clients and their parents/legal guardian are notified of attendance requirements during the
intake process.
 Failure to comply with the attendance requirements could result in program expulsion.
Entering and Exiting monitored
 YCS clients are not allowed to enter or exit our facility without the accompaniment of staff,
their parent/legal guardian or other responsible party.
Outside Activities
 Parents sign permission slips for their children to participate in recreational/community
reintegration activities outside of FSDC’s campus.
 If the client’s behavior prohibits him/her from participating in recreational activities, a
supervised on-campus alternative is provided.
Incident Reports
 An incident report is completed on any noncompliance or safety issue.
 These reports are reviewed during PQI meetings.
COA Standards: JJD 9.0 – 9.02, 9.05-9.06
Policy No.: 17.14
Policy: Search & Seizure
Search & Seizure
POLICY
_______________________________________________________________
Each client shall be free from unwarranted invasion of privacy. Search and seizure shall take place
under approved conditions and in the manner specified by the FSDC Board of Directors.
1.
2.
3.
4.
5.
PROCEDURES
_______________________________________________________________
If there is reasonable information to believe that a client may be in possession of a
dangerous weapon or object that could sustain harm, or is in possession of an illegal
substance the following steps will be taken to ensure client & staff safety:
 Verbal inquiries will be made to assess the lethality of the situation first.
 If the client refuses to admit to having the object, the staff will continue to monitor
client closely for safety of self and others.
If it is determined that there is an unsafe/unlawful object in the client’s possession then this
will follow:
 If the client can safely turn over the object to staff, staff will turn the object over to the
appropriate authority i.e. parent/ guardian/ court counselor. If this object is unlawful i.e.
gun, knife etc., the police and the probation officer (if applicable) will be notified.
 If the client refuses to let staff have the object, then based upon the lethality potential of
the object, immediate plans for client removal will take place. This can include the
notification of parent or police. Means of transportation from the program to the client’s
home will be determined by staff based on level of danger to self or others.
 If the client threatens others with an object, the staff will make every effort to isolate the
client from other clients, contact authorities immediately, and try to ensure safety of
clients and staff. If a client begins to attack a client or staff person, then staff may
physically intervene to protect the life of self or others.
 If it is necessary to search the client’s possessions, two FSDC staff will be present for the
search. Written documentation of any item seized will be witnessed by both staff
members and the client, if client is willing. Otherwise, documentation will include that
client was unwilling to sign.
 Any illegal items seized will be turned over to the appropriate law enforcement agency.
 Inappropriate items will be secured in a locked cabinet until they can be destroyed or
returned, as appropriate.
FSDC staff will not conduct physical searches of a client’s person. Law enforcement will be
contacted if this becomes necessary.
When either a search or seizure is conducted, there shall be a notification to the immediate
supervisor of that program and/or a member of the management team immediately. This
notification to a supervisor will also be entered into the client’s record.
Every search or seizure shall be documented. Documentation shall include:
(1) scope of search;
(2) reason for search;
(3) procedures followed in the search;
(4) a description of any property seized; and
(5) an account of the disposition of seized property.
6. When either a search or seizure is conducted, the legally responsible person of a minor client
or an incompetent adult client will be notified immediately. This notification will also be
entered into the client’s record.
Policy No.: 17.15
Policy: Transition & Aftercare
Search & Seizure
POLICY
_______________________________________________________________
In order to promote a positive community reintegration, Youth and Community Services Staff, their
clients and the clients’ families work jointly in establishing transition and aftercare planning.
1.
2.
3.
4.
5.
6.
7.
PROCEDURES
_______________________________________________________________
Social Work and Education after care planning begins at the intake/screening process.
Eventual case outcomes are developed by all involved parties during the development of the
Individual Service Plan.
Individual Service Plans are reviewed every 90 days to determine the client’s progress in
meeting their goals.
Involved community partners have input in determining the progress the client is making in
reaching his/her ISP goals.
Aftercare planning involves an assessment of the client’s strengths and needs in living
responsibly in the community.
Aftercare planning also involves identifying community resources for unmet needs.
Social work staff provides advocacy services to ensure clients are able to access additional
services once they are discharged.
Policy No.: 17.16
Policy: Case Closing & Follow-up
Search & Seizure
POLICY
_______________________________________________________________
Case closing is a planned, orderly process that involves follow-up services, assessment after care
planning.
1.
2.
3.
4.
5.
6.
PROCEDURES
_______________________________________________________________
After a client completes the Keeping Up Program, social work follow-up services are
provided for a six month period.
Prior to closing a YCS case, the client’s case will be reviewed at the next staffing by the
entire team.
All YCS paperwork, including a discharge summary, is completed on all cases.
Prior to discharge, clients and their families are given an aftercare plan that identifies
community resources and contact information on accessing those services. FSDC staff also
ensure clients know they can be contacted for continued support past termination.
For any court involved youth, YCS staff will provide the Department of Public Safety Staff
(Juvenile Court Counselors) with a discharge notification which included an assessment of
any unmet needs, the degree to which goals were or were not achieved and reasons for
success or failure.
See Educational Procedures for educational case closing and follow up procedures.
Intensive Family Preservation Services and Family
Empowerment Program Policies
(Family Preservation Services)
Policy No.:
Policy:
POLICY
_______________________________________________________________
In-Homes Services provide Intensive Individual and Family Therapy and Case Management for
residents of Davidson County to create a positive impact in their lives. In-Home Family Therapy
provides Family Therapists who work collaboratively to provide in-home counseling and
comprehensive case management services to ensure safety for the client, family, and community.
This service is also offered as a preventive measure to interrupt out-of- home placement and as a
service for those clients returning from out of home placement.
The staff works with families to increase positive family interaction and awareness of developmental
needs of all family members, builds upon individual strengths, works to enhance parenting skills and
addresses issues that affect and impact their emotional health and well-being.
Case management also assists the family in identifying community resources that can help to
maintain positive changes. Specifically, these families have children that are at risk for abuse and
neglect or present problems and issues that, left unresolved, would inhibit the children from success
in their home, at school, and within the greater community. Services are devised to be strengthsbased and solution oriented by providing the tools, techniques and resources to resolve the pressing
issues that precipitated the need for in-home case management or intensive in-home family
preservation therapy.
In-home staff shall stay alert to the changing needs of families by attending training/workshops that
address the stressors that affect families and their environment. Trainings shall include theoretical
and treatment techniques, communication, conflict resolution, parent training and the impact of
violence on the family system (See Staff Training, Development and Supervision Policy).
PROCEDURES
_______________________________________________________________
The Master level Intensive Family Preservation Therapist (Intensive Family Preservation Services –
IFPS), Bachelor level case manager (Family Empowerment Program – FEP), and the Master level
YCS Unit Director comprise the in-home Family Preservation services team and maintain strict
adherence to the professional code of ethics that govern their academic disciplines.
Referrals:
 The Intensive Family Preservation Therapist receives referrals for IFPS through the Juvenile
Crime Prevention Council (JCPC). The JCPC is also referred to as the Department of Public
Safety – Division of Juvenile Justice (DPSDJJ).
 The Bachelor level case manager (Family Empowerment Program – FEP) receives referrals
through DJJ, Truancy Court, Davidson County Schools, or through individual
COA Standards: FPS 1, FPS 2, FPS 3, FPS 4, FPS 6, FPS 7, FPS 9, FPS 10, FPS 11
referrals/recommendations (including other Family Services of Davidson County service
providers).
Initial Session:
 The Intensive Family Preservation Therapist(s) contacts the family to schedule the initial
intake or consult session within 24-48 hours and the FEP case manager contacts the family
to schedule the initial intake or consult session within 72 hours of receiving the original
referral.
 If the family is not reachable, the IFPS Therapist or the FEP Case Manager immediately
notifies the referral source.
 The Parent/Guardian is given details regarding in-home counseling and/or case
management that are designed to benefit the family’s needs and ensure in-home services are
the most appropriate modality of treatment.
 The initial session or consultation meeting includes a comprehensive, strengths-based, and
culturally sensitive intake assessment, which concludes with agreed upon goals for treatment
by the client, family, and treatment provider.
 The following occurs during the initial session:
1. Consent(s) for Release of Information as well as Consent for Release of Information to
the local management entity, Cardinal Innovations, is/are obtained as indicated.
2. Consent for Interventions/Treatment is obtained from the parent/guardian/client,
which shall include consents to see the client in other appropriate settings (i.e., daycare,
school, detention facility, workplace, etc.).
3. Parent/guardian and client (if applicable) are provided written information related to
“client rights” and a verbal explanation of In-Home services.
4. Comprehensive information is obtained during the initial intake assessment such as:
demographic, social, family, medical, legal, and mental health histories; information
about other community agencies involved currently or in the past; current issues of
concern; current goals the client/family would like to address; strengths, interests, and
supports of the client/family; and any self-reported identifying factors or characteristics
such as cultural, racial, ethnic, religious, spiritual, or etc.
5. Other assessments may be recommended as deemed necessary to address dual diagnoses
and/or other mental health issues.
6. Client is informed that there are no fees for service and location of treatment is in the
clients’ home.
7. An appointment is scheduled to review the treatment plan and begin the first treatment
session in which minimally the client and the parent(s) or legal guardian must be present,
although all family members are encouraged (as appropriate) to participate if so desired,
including youth, adults, extended family, etc.
8. The initial assessment is completed and documented in the client record within 24 hours
of the initial intake or consult session. At that time the family is notified of when they
can expect to begin services and approximate/projected length of services. If services are
not immediately available, the IFPS Therapist or FEP Case Manager will recommend
intermediate services such as parent education, alternative suspension program (if
suspended or at risk of suspension) or social work services if applicable (in the case of
IFPS).

9. Client and family are informed they may be contacted by administrative staff of the
agency who will contact the client family to identify how the family is functioning up to
one year after assessment.
10. The client and family are considered primary sources of information at the intake
session. Further case information is gathered from the referral sources and all other
workers involved (e.g., assigned Department of Social Services Social Worker,
Community Supports, assigned Court Counselor at the Department of Juvenile Justice,
etc.).
Once assigned for in-home services the staff shall continue to assess the needs of the client
system that will determine eligibility as well as the need for other FSDC and/or community
services. This includes the continuous evaluation of the appropriateness of in-home services – if
at any point the client is determined as needing a higher level of care a treatment team meeting is
held to include the court counselor (if applicable) to identify an appropriate service. They are
then assisted with connecting to the appropriate service or resource (such as individual therapy,
family therapy, crisis services, etc.)
Case Management:
 Treatment providers (IFP therapists, FEP social worker) are required to meet for supervision
with the YCS Unit Director on a weekly or bi-weekly basis to discuss cases and their
progression. The IFPS Therapist and the Social worker meet weekly (as needed) to staff shared
cases.
 The in-home providers also meet as a team with the YCS Unit Director at least once a month to
discuss their current caseloads, progression of cases, and any needs of the client/family and/or
supervision needs of the therapist/social worker. The YCS Unit Director maintains case notes
for each treatment provider and for each client/family served to document the progression of
each case at every weekly or bi-weekly supervision meeting.
 Due to many of the clients referred to in-home counseling and case management being made by
the Department of Juvenile Justice, the Intensive Family Preservation Therapist and/or FEP
social worker shall keep referral resources informed of the assessment, treatment, and discharge
of clients. The staff at FSDC is to have consistent contact with community resources so as to
ensure continuity of care, including monthly treatment team meetings for the IFPS Therapist
and general program updates during monthly DJJ/FSDC collaborative meetings as well as
distributing printed materials to promote Family Preservation Services.
Treatment sessions:
 At the first in-home session, the Walmyr Indexes of Family Relations and of Parental
Attitudes are completed. A treatment plan based upon diagnosis is developed with
measurable, client-centered goals for therapy and/or case management. The treatment plan
is dynamic to the ever changing needs of the client/family and developed with the client’s
input and signed during the first treatment session.
 The treatment plan includes the client system’s request for services in their environment.
The treatment plan is reviewed with the client/family after its creation, throughout
treatment, and at the outset of treatment.
 IFP services are based on individual and family therapy models that are evidenced-based and
designed to meet the needs of each family. Overall treatment may last for approximately 16
weeks, depending on the needs of the child and family and based on the recommendations


for ongoing treatment discussed at IFPS team meetings (keeping with what is the most
appropriate, least intrusive service that can be provided).
FEP services and treatment is based on a brief solution focused model for 8 sessions;
however, Evidenced Based Practice will be the focus of service delivery. Cases that extend
beyond the initial 8 weeks will be reviewed with the YCS Unit Director and a plan that may
include continued in-home services and/or other services within the agency will be
addressed.
If a client is in need of services not provided by FSDC, the In-home staff will assist with
referral(s) and ensure that the client does not experience an interruption in services.
Treatment goals:
 Sessions are conducted weekly and may be Family, Individual and/or Conjoint treatment
modalities.
 The course of treatment includes therapeutic and educational components, which may include
developing a genogram and/or eco-map to assess for systemic familial patterns of functioning
and current support systems.
 The main treatment goal is to help the client and his/her family system to identify solutions that
are sustainable and self-reliant.
 Other treatment goals may include but are not limited to: resource connection, life skills training;
education about parenting in a positive manner, appropriate discipline, best child rearing
practices, and how to manage your household; learning about positive communication patterns
and dynamic interactional patterns; learning and applying positive coping skills; and accessing
other community supports and teaching/encouraging collaboration with familial, peer or
community supports.
 Other treatment components may include advocacy on clients’ behalf and crisis intervention
services. The therapist and case manager maintain accurate and current records on clients as
required by the agency and funding sources.
 The established criterion for determining success is for a client to attain 60% of the treatment
goals at time of discharge.
 Evaluation of client progress is obtained from weekly supervision, the admission assessment,
post-evaluation of the Walmyr Indexes, attendance, progress notes, discharge summary, client
evaluation of services, monthly utilization review, and monthly and/or quarterly reports to the
FSDC Executive Director, and funding sources.
 The client is also notified of expectations/potential consequences of noncompliance with the
service plan during time of creation.
 Prior to discharge the Treatment Plan and completion criteria are reviewed with the client,
including percentage of goals successfully completed. An after care plan is developed, including
short and long term goals to maintain progress and community/resource connections.
 If needed, IFPS Therapist/FEP Case Manager assists client in setting up additional services or in
advocating on client’s behalf to other service providers.
 Once a client has completed the program the IFPS Therapist/ FEP Case Manager provides a
termination report to the funding source (DJJ) with an update on successful/unsuccessful
completion and any further recommendations.
 After hour emergency are handled by FSDC Crisis response line (24/7/365) or the FSDC
therapist on call.
Training:
 Staff will address training needs during regularly scheduled supervision and at each annual
review.
 Staff shall participate in staff training as outline by Staff Training, Development and
Supervision Policy.
 Staff will attend training that addresses the following topics:
 Child and family development.
 Domestic Violence.
 Assessment and treatment in the home.
 Systems theory.
 Ethics/Mental Health law.
 Effective Case Management.
 Staff may request training in other areas of interest and this request shall be made to the
YCS Unit Director.
Circles for Davidson Policies
(Counseling and Support Services)
Policy No.:
Policy: Circles Screening & Intake
POLICY
_______________________________________________________________
Program participants will be screened during an initial intake to determine group appropriateness
before admission to Circles for Davidson.









PROCEDURES
_______________________________________________________________
Clients who are referred to our agency are asked to schedule an intake appointment within a
month of receiving the referral.
Clients are scheduled for an intake within a two week time period.
During the intake session, FSDC staff explain the program’s requirements and staff assess
the client’s group appropriateness
FSDC staff explains all Circles participation forms, after which each participant will give
consent by signing each form.
a. Consent to take part in the Circles Program (document provided by DOL to allow data collection
for their Young Parents Demonstration (YPD))
b. Contact HIPAA form
c. Consent for Release of Information
d. Consent to be recorded for photographed
Each participant will answer the questions on the YPD Intake Form and the Client SelfReport.
If another mode of treatment is deemed more appropriate than our program or if another
mode of treatment is needed prior to beginning our program, intake staff give referrals for
area services.
Within a week of completing the intake process, Circles clients are invited to join the Circles
Community Meeting. Because Circle Leader Training is a closed group, if Circle Leader
Training has already started or is full, clients who complete the intake process are placed on
a wait list. They are notified by phone of the next available start date. They are able to
participate in the larger Circles Community Meeting each week until the Circle Leader
Training is available.
If applicable, court personnel are informed of the client’s participation in intake and
enrollment dates of group.
All client appointments including the intake, regular group sessions, and phone follow-up are
documented in the client’s file.

Family Services of Davidson County Policy Manual Revised October 2003

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