Professional Practices

Family Service Association of San Antonio, Inc. Professional Practices

This Policy Applies to:

Date Written or Revised

ď ¸ Family Service Association of San Antonio, Inc. Name of Policy: Professional Practices Departments Affected:

January 2012 January 2013-Review Date Approved July 2013 Date Disseminated

All Family Service Departments and Projects

July 2013

TABLE OF CONTENTS Purpose Rights and Responsibilities De-escalation Practices Services to Minors Access and Eligibility Culturally Competent Practice Confidentiality and Privacy Protections Access to Case Records Case Record Reviews Procedures & Policies Participant Protections in Research Complaint and Grievance Procedures Ethical Conduct Protection of Health & Safety Emergency Preparedness Professional Practices Acknowledgement Form Case Review Confidentiality Form

1 2 2 3 4 6 6 11 23 31 35 37 39 40 42 43

PURPOSE Family Service Association of San Antonio, Inc. (Family Service) conducts its services with due regard to ethical and professional requirements, avoiding conflict of interest and protecting confidential information regarding persons served. Family Service is committed to providing quality services to individuals and families based upon profound respect for personal dignity, confidentiality, strong ethics and privacy. Employees, consultants and volunteers affirm their professional commitment by their signature acknowledging they have received, read, and understand the procedures on Professional Practices and that they will uphold and abide by all standards set forth in this document (Exhibit 1).

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RIGHTS AND RESPONSIBILITIES Family Service informs all persons served of their rights and responsibilities and provides sufficient information for them to make an informed choice about using the organization’s services. Client Rights and Responsibilities are posted in the reception area at each office location and are provided to each client in writing during their initial enrollment (per program specific policies and procedures) in agency services. Client Rights and Responsibilities are provided in both English and Spanish and are effectively and appropriately communicated to service recipients, including those with special needs.

Written rights and responsibilities include basic expectations, rights of participants, and information on how to lodge a complaint. A service provider is to be knowledgeable of, uphold and give full assistance to service recipients in exercising their rights. Prior to the initiation of services, each service recipient signs the “Service Recipient Bill of Rights and Responsibilities” (Exhibits 2 and 2a) and receives a copy.

DE-ESCALATION PRACTICES: During the event an individual(s) behavior should escalate into a crisis or dangerous situation and is exhibiting threatening behavior that could cause harm to oneself or others, agency personnel should follow the appropriate guidelines in de-escalating the situation to ensure the protection of the service recipients’ rights. Agency personnel should not attempt to restrain individual(s) in any way utilizing any restrictive behavior management techniques. Family Service also does not engage in any type or form of client searches. Guidelines are as follows: 1) Agency personnel utilize verbal de-escalation and conflict resolution skills; 2) Agency personnel contact the supervisor immediately and determine the most appropriate way to proceed; and 3) In extremely dangerous situations, agency personnel remove themselves from the danger and contact the appropriate authorities. The supervisor is then contacted immediately.

Supervisors are required to fill out an “incident/accident investigation report” within 24 hours, detailing the event to determine cause and means of preventing recurrences.

Corrective action is documented and followed up on by the supervisor. All incidents/accidents are reviewed and discussed by the management cabinet. The cabinet recommends any further action needed and submits all reports to the agency’s Vice President of Agency Services. If needed, the agency’s senior management team, including the President/CEO, reviews the investigation and guides further action, including informing the Board of Directors as warranted.

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SERVICES TO MINORS While Family Service respects the values of parental authority and family autonomy, it nevertheless recognizes that, in certain circumstances, children under the age of eighteen may be offered services without parental consent. The service provider always encourages the minor to obtain parental consent, and involves the parents in treatment as appropriate.

Services to Emancipated Minors: The agency may provide its services to minors without parental consent when the minor can be considered emancipated. A minor can be considered emancipated when 

he or she is legally married (A person under 18 cannot enter into an informal marriage); or



when the disabilities of minority have been removed by court order. A copy of the court order or marriage certificate is filed in the service record. These emancipated minors have full rights as adults.

Services to Un-emancipated Minors: Chapter 32.004 of the Texas Family Code states a child (under the age of 18) may consent to counseling for:   

suicide prevention; chemical addiction or dependency; or sexual, physical, or emotional abuse.

A licensed or certified physician, psychologist, counselor, or social worker having reasonable grounds to believe that a child has been sexually, physically, or emotionally abused, is contemplating suicide, or is suffering from a chemical or drug addiction or dependency may: 

counsel the child without the consent of the child’s parents or, if applicable, managing conservator or guardian;



with or without the consent of the child who is a client, advise the child’s parents or, if applicable, managing conservator or guardian of the treatments given to or needed by the child; and



rely on the written statement of the child containing the grounds on which the child has capacity to consent to the child’s own treatment under this section of law. This statement must be written and signed by the child and filed in the case record underneath the Informed Consent.

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A child may not be counseled under these provisions if consent is prohibited by a court order.

A physician, psychologist, counselor, or social worker counseling a child under this section is not liable for damages except for damages resulting from the person’s negligence or willful misconduct.

A parent, or, if applicable, managing conservator or guardian, who has not consented to counseling treatment of the child is not obligated to compensate the agency for these services. Therefore, only the minor’s personal income is used to determine the fee.

Service providers carefully document in the record the rationale and need for proceeding after the first meeting without parental consent. Documentation is also provided concerning consultation with the supervisor and the Program Manager concerning the decision to proceed.

The advisability/practicality of involving the parents is continually reassessed and documented.

Once a minor’s situation is stabilized and he or she is no longer considered to be at risk, services are terminated unless parent(s) provide consent.

Release of Information on Minors: See Section on “Procedure for Release of Information,” item 7. Minors of any age are protected from disclosure of confidential information regarding their services when it is concluded by the therapist the parent requesting the information is not acting on behalf of the child or that the information released would be harmful to the child.

As specified in the section above, a licensed counselor or social worker may advise the parent/guardian/managing conservator of a consenting minor of the treatment given to or needed by the child.

ACCESS AND ELIGIBILITY: All Family Service programs have written material describing the service population and eligibility criteria. Written material includes policies and procedures disseminated to staff, the agency evaluation report disseminated to stakeholders, and brochures and outreach material disseminated to potential service recipients. If there are certain legal and/or governmental mandates that dictate service delivery, those conditions are published. Each year the staff and the Evaluation Committee of the Board of Directors review services and intended populations to ensure all are aligned with the agency mission. Services are focused on identifying the expressed needs and problems facing individuals and families served and engaging them in mutual efforts to achieve desired outcomes. In group and community intervention modalities, the focus is on identifying Professional Practices Updated January 2012

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the needs and problems of groups of community members to engage them in mutual efforts to achieve the desired outcomes of the group. Family Service retains the right to determine, from among applicants for its services, those it can serve appropriately within the limits of its mission, resources, and capacities. Each program determines the eligibility requirements for that service or service array. Family Service only accepts applicants whose expressed needs can be met through our services. For those we cannot serve, we make appropriate referrals to other community service providers.

Family Service does not discriminate against any applicant or service recipient based on race, color, religion, national origin, sex, sexual orientation, age, disability, or inability to pay for services.

During the intake process, Family Service staff conducts a screening with the potential service recipient to determine eligibility and the need for services. Within two weeks, the agency will inform the applicant as to whether services are available, will be delayed, or if other services are more appropriate. In emergency situations, services may begin immediately following the intake or an appropriate community referral will be made.

The Program Manager assigns intake duties for specific service areas. Intake workers must be knowledgeable about agency services and eligibility criteria. The intake worker makes the determination as to whether a client’s needs are congruent with the services the agency provides. If there is a lack of match between applicant needs and agency resources, the intake worker will offer to make a referral(s) to appropriate resource(s). If, in the intake worker’s opinion, the applicant’s needs would best be met through the services provided by a private practitioner or a for-profit resource, at least three must be suggested. The intake worker must make clear to the applicant that in providing a resource list, he or she is only imparting information and is not making an official recommendation, referral, or endorsement.

The applicant will be given a target time frame in which the requested services will begin. In those cases where the time delay is unacceptable, where another provider would be more appropriate, or additional services are needed through an active community network, Family Service will promptly provide the applicant with community referral information and/or link the individual directly with needed services. If an immediate opening is not available and the applicant wishes to wait for the service, he or she will be placed on a waiting list and given an estimate of the expected time before services will begin and how the initial service contact will be made. The applicant’s ability to pay is not a determining factor in placement on a waiting list for services. Family Service only maintains a waiting list for clients who have been provided with referral linkages to similar services providers and chose not to access those services but request to be placed on a waiting list. It is prohibited for the intake worker or any other person associated with the agency to accept any payment or reward in order to improve an applicant’s position on the waiting list or to provide immediate entry into a program. It is prohibited for an intake worker to give preferential treatment to board members, other service providers or consultants in the application process.

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CULTURALLY COMPETENT PRACTICE: Family Service is committed to the provision of culturally competent practice appropriate to each individual service recipient, and the intake worker when making assignments incorporates his/her knowledge of staff cultural competency. Family Service employs multi-lingual and multi-cultural staff that represents the population served. The agency provides cultural diversity training annually. Hearing-impaired callers are accommodated through accessing TTY Message Relay Texas. Voice mail as well as electronic mail is used to relay messages to staff. Clinicians are informed immediately of cancellations and rescheduled appointments. Family Service utilizes consultants to provide sign language when needed for direct services. Basic individual and family assessments include the consideration of race, ethnicity, religion and cultural background that may affect perception of the need/problem and any adjustments required in the service delivery as a result. Family Service utilizes internal resources and/ or arranges for outside resources for communicating the service needs of those individuals with special needs.

CONFIDENTIALITY AND PRIVACY PROTECTIONS Confidentiality is the cornerstone upon which the professional-client collaboration is built. It is the necessary prerequisite for a service recipient’s trust and confidence.

Family Service makes every reasonable effort to safeguard confidential information.

General Principles: 1.

Procedures related to privacy and confidentiality are derived from Family Service Association’s guidelines as published by the Severson National Information Center, the N.A.S.W. Code of Ethics as updated in 2008 and from the current standards for accreditation of the Alliance for Children and Families.

2.

Information provided by a service recipient to any agency service provider is covered by the agency-wide procedures on confidentiality.

3.

A person seeking service from Family Service comes to the agency rather than to a specific person. The agency, therefore, becomes the custodian of the information received and is responsible for its proper use.

4.

Agency personnel rely on agency procedures to provide adequate safeguards with regard to service recipient information, and agency procedures apply to each person who, in any way, deals with service recipient information.

5.

The service recipient is expected to be the primary source of information about himself or herself and about their families and their problems or needs. In the

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case of a minor child, the parent or legal guardian will be the primary source of information in conjunction with the child.

6.

Service recipients are to be informed that the agency keeps records concerning services received and are advised of their right to inspect those records for accuracy and to insert addenda if they so desire. The agency shall make provisions for inspection of the agency’s records concerning a service recipient’s service upon written request by the service recipient and with appropriate safeguards of all concerned.

7.

The service recipient’s written consent to the release of specific information is always required and blanket consents, either expressed or implied, are not acceptable.

Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA): Family Service ensures compliance with HIPAA regulations in safeguarding Protected Health Information (PHI) about a person that may identify them and that relates to their past, present, or future physical or mental health or condition and related health care services. Service recipients are to receive written notification upon intake regarding the Notice of Privacy rule (Exhibits 3 and 3a). Service recipients who receive services requiring an individual case file should confirm receipt by signing an acknowledgement form that they received a copy of their case file and that the original acknowledgement will be placed in their case file (Exhibits 4 and 4a). Service recipients that express that their rights have been violated are directed to the grievance procedures of the agency and followed accordingly.

Limitations on Confidentiality: The cornerstone of the professional-client collaboration is confidentiality and the right to privacy. Service recipients should feel assured that what they disclose will not be shared with persons or agencies not directly involved in the professional-client collaboration process. It is the policy of Family Service to safeguard information pertaining to our service recipients. We will not acknowledge that a certain person is a service recipient without proper authorization. However, there are certain exceptions to this policy: 1.

Legal Proceedings Family Service is subject to legal subpoenas. Subpoenas do not require a release of information but do require a response. Agency service providers who receive a Subpoena will want to protect service recipient interest and confidentiality while cooperating to the extent legally required and meeting all ethical obligations.

Subpoenas must be personally served to the person named. If addressed to the “Custodian of Record,” the Program Manager or designee may accept the Subpoena. The Court, an attorney, or a clerk of court may issue a Subpoena.

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Copies of case documentation provided may include only those documents produced by Family Service; not those received by, from, or through collateral sources. Names and personal information regarding other individuals not named on the subpoena are crossed out with a heavy marker and then copied again so the marked out information cannot be read. If the material requested is privileged or the subpoena is procedurally improper, the service provider has the right to object by filing written objections, requesting a protective order, or filing a motion to quash or modify the subpoena. These actions are to be taken only with the assistance and knowledge of the Program Manager.

Subpoena Protocol:  The Family Service employee named in the Subpoena, a Program Manager or the designated employee will review and sign the Subpoena at the time that it is delivered to the office location by the Court or Attorney designated person.  The Family Service employee named in the Subpoena, a Program Manager or the designated employee that received and signed for the Subpoena will:  Review the subpoena and deliver it to the employee addressed in the subpoena or to the Program Manager of the employee’s Program.  If a subpoena is delivered in the name of a former employee of the Agency and the Agency is not the entity subpoenaed, the Agency does not accept the subpoena, instructing the official of serving the subpoena that the individual named is no longer an employee of the Agency.  The employee receiving the Subpoena documents in the client’s chart/file that a subpoena has been received.  If a subpoena is received with a timeline of compliance less than 24 hours, the individual staff members subpoenaed would comply with the attendance requirement, but inform the court that they were not given sufficient time, (at least 24 hours) to comply with the document request but will comply with the document request within sufficient time.  The employee addressed in the Subpoena will review the Subpoena to determine if:  Only the chart was subpoenaed  Only the employee was subpoenaed  Employee and chart/file was subpoenaed 

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If only the employee was subpoenaed, the employee will contact the Court identified on the Subpoena to confirm attendance. The employee will document in the client’s chart/file if the employee is authorized by the Court to be on standby during the Court date. The chart/file will not be copied and sent to the Court.

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

   

2.

If only the chart/file is subpoenaed, the employee will:  Review the chart/file and remove any loose papers that are not part of the Agency’s approved forms  Request that the Program Manager (program specific), or designated person; such as but not limited to receptionist, program assistant, therapists, etc, make copies of the chart/file.  The specific Program Manager according to the programs where the subpoena employee is assigned will review the copies of the chart/file to ensure that information copied is in compliance with HIPPA, PHI, and Agency policies.  Consult with the Psychologist or designated person if a psychological test has been administered (if applicable).

If the chart and the staff are subpoenaed, the employee contacts the Court to confirm attendance and prepares the chart/file according to chart/file review and copying procedures; a fee for copies may be applicable.

A progress note is written to the client’s chart/file.

If the Court, Attorney or designated person informs that the Family Service employee attendance is no longer required, then the employee will write a progress note in the original chart/file.

If the Family Service staff attends court, then the employee will write a progress note to the client’s original chart/file, indicating the outcome of the Court proceedings. The original chart/file is filed with the active chart/files or closed charts/files depending on the chart/file status when the Subpoena was originally received.

Suspicion of Abuse or Neglect of Children and Disabled or Elderly Adults Family Service is fully committed to reporting child abuse or neglect of children and abuse, neglect and exploitation of disabled or elderly adults, and to complying with legal mandates in this area. All staff, volunteers and consultants are made aware of what behaviors are included under abuse, neglect and exploitation and the reporting requirements as they appear in the Texas Family Code of West’s Texas Statutes and Codes (Exhibit 5) regarding children, and in TDPRS Adult Protective Services procedures (Exhibit 6).

Applicable sections from Texas law are posted in work areas of each of the Agency’s offices and should be consulted as often as necessary.

Reporting requires only suspicion, not confirmation. This reporting is documented in the case record and an incident/accident report is completed and given to the Human Resources Coordinator and the Agency’s respective Director and Program Manager is informed, with a notification to the Vice President of Agency Services if needed. The Human Resources department keeps this

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information on file separately. When the service provider receives the final report, it is filed in the case record.

Suspicion of abuse or neglect of children reported within 48 hours to the Texas Department of Family and Protective Services reporting line, 1-800252-5400 or via their web-based reporting system www.txabusehotline.org .

Suspicion of abuse, neglect or exploitation of elderly or disabled adults must be reported immediately to the Texas Department of Family and Protective Services reporting line, 1-800-252-5400 with the followings exceptions: For adults in nursing homes, call 1-800-458-9858; for adults in facilities for the mentally retarded, call 1-800-647-7418. Adult abuse can also be reported via the DFPS web-based reporting system www.txabusehotline.org.

There is a penalty of being charged with a Class B misdemeanor for failure to report suspicion of child abuse and neglect and possible disciplinary action by Family Service for knowingly failing to report as required.

3.

Potentially Suicidal/Homicidal/Dangerous Service Recipients Taking precedence over confidentiality concerns are situations in which a service provider judges that a service recipient is a danger to herself/himself or others.

It is the policy of Family Service to report potentially life-threatening situations to whoever is in a position to intervene responsibly. For emergencies where violence against self or others is imminent, the service provider should call the San Antonio Police Department at 911 or SAPD’s Crisis Intervention Team at (210) 223-7233. Confidential information may be given without consent in these situations.

“Duty to Warn” has been left to the discretion of the therapist by the Texas Supreme Court, 1999 in Thapar v. Zezulka, 994 SW2d 635. The legislature has chosen to closely guard a patient’s communications with their therapist. As such, when a therapist learns from their client that the person may be dangerous to themselves or others, they nevertheless do not have an affirmative duty to warn a third party of that danger. It clearly falls within the therapist’s professional discretion as to warn the appropriate medical or law enforcement entity.

4.

Services to Sex Offenders Sex Offenders receiving services are required to sign a “Waiver of Confidentiality for Sex Offender Service” (Exhibits 7 and 7a).

5.

Services to Un-emancipated Minors Giving Consent For Treatment In cases where a minor has given consent for treatment as specified under “Services to Minors,” the law allows the licensed counselor or social worker, with or without consent of the child who is a client, to advise the child’s parents,

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managing conservator, or guardian of the treatment given to or needed by the child.

ACCESS TO CASE RECORDS: Case Records: Purpose, Content and Security The agency maintains case records for the following purposes: 1.

To provide a source of information to render appropriates services to the service recipient.

2.

To protect the organization and comply with legal regulations.

3.

To provide a basis for supervision of staff and for enhancement and evaluation of staff skills and quality of service.

4.

To provide a source of information to purchasers of service, planning groups and the community at large.

5.

To provide data for professional research; to study demographic and other data concerning the service recipients served; to provide aggregate information to the community about the problems brought to the agency and the kinds of services received by consumers.

6.

To assemble aggregate information for purposes of professional needs, accountability, communication and planning, both to the community and within the agency.

Contents of Case Records: 1.

The basic information contained in the case records includes:

2.

a.

Biographical, demographic or other identifying information

b.

Presenting problem(s)

c.

Assessment

d.

Service Plan

e.

Documentation of ongoing services

Depending on the type of service being provided by the agency, the above is supplemented by:

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a.

Psychological/medical/psychosocial evaluations.

b.

Legal documents including court reports, guardianship documents, birth or marriage certificates, divorce decrees and any court order related to the services provided.

c.

Financial data used to set fees and collect demographic statistics.

d.

Services provided through referral.

3.

Records are kept up-to-date from intake to case closing through regular progress notes, periodic summaries and documented consultation/supervisory sessions.

4.

All intakes, progress notes and closing summaries are typed or legibly written.

5.

All entries in records are specific, factual, concise and pertinent to the case.

6.

As appropriate, follow-up and aftercare services are thoroughly documented with client notification of the process for engaging or re-engaging in additional agency services.

7.

At closing, or at least annually, the supervisor examines case records and expunges material unrelated to the problem(s), service process or the service recipient-agency relationship.

8.

All record entries are signed and dated by the person providing the service.

9.

All entries must be in blue or black permanent ink and be legible to any reader.

No whiteout or scratch outs may be used which obliterate an error. Draw a single line through the error, write “error�, initial and date.

10.

All record entries are signed and dated by the person providing the service. All signatures must be absolutely legible to any reader.

11.

In addition to the information which the agency requires in the case record, service providers have the option of maintaining working notes which may contain process data on the interview and/or impressions which can be used by them for supervisory or planning purposes and case consultation. These notes are kept in locked filing cabinets for easy accessibility while maintaining record security. The notes should not be made part of the case record and are to be destroyed when the case is closed.

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11.

Process material on interviews and other detailed material maintained by students for their own learning purposes, should be treated like the working notes of staff and should be destroyed at the time the case is closed or at the time the student leaves the agency, whichever occurs first.

Procedures for Receiving Information: 1.

To the extent possible, the service recipient is to be informed: a.

Of the purpose and intended use of any information;

b.

That the service recipient may refuse or is not legally required to supply the information;

c.

Of any known consequences arising from supplying or not supplying information; and,

d.

Of the identity of other persons or entities authorized by law to have access to the information.

2.

Information requested from the service recipient should be limited to data that directly impacts the purpose of the service recipient’s relationship to the agency.

We request collateral information only as deemed reasonably necessary and with the consent of the person served. This empowers the service recipient to take more responsibility for determining services and protects their freedom to choose the services they want to receive. The “Authorization to Release and Request Information” must be completed (Exhibits 8 and 8a).

3.

Informed consent begins with the service recipient’s initial contact with the agency. a.

Only general information regarding the nature of the problem is obtained, along with identifying information, during telephone intake.

b.

The Informed Consent is signed prior to initiation of services at the first visit. This describes limitations upon confidentiality and mandatory reporting (Exhibits 9 and 9a).

c.

The Informed Consent is provided in the service recipient’s primary language or is read to persons who are blind or unable to read.

d.

Deaf persons may authorize a third person as translator if the agency does not have a staff person skilled in sign language.

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4.

Personal papers belonging to the service recipient should generally not be accepted for safekeeping or retained in service records. Personal papers will be retained as part of the record, only when pertinent to the work on the case.

5.

Information received from other sources in reference to a service recipient is not shared with the service recipient without a release of information from the original source.

Procedures for Release of Information: 1.

Within the agency, service recipient information is provided in accordance with the procedures in this document on Staff Access to Case records. Internal request for case information or material should be specific and addressed to the staff person responsible for the case.

2.

General legal advice or formal counsel may be sought when special or unusual information about an individual served is requested by courts, attorneys representing their service recipients or spouses, public officials and investigative or law enforcement bodies. This is especially true when disclosure might threaten the rights of persons served or when Family Service might incur liability specific to the individual instance or case.

3.

Interpretation of a vague or ambiguous law or regulation shall be resolved in favor of non-disclosure and confidentiality to protect the service recipient’s privacy.

4.

No information is released without the service recipient’s authorization except as described in the section “Limitations of Confidentiality”. The “Authorization to Release and Request Information” is completed and filed.

5.

When deemed necessary, legal counsel is utilized if service recipient rights are in danger of being violated, if service providers are subpoenaed for testimony that might be to the disadvantage of the service recipient, or whenever the agency feels there is a need to reconcile our procedures with current laws.

6.

A minor receiving substance abuse or chemical dependency services is considered to be in legal control of information regarding these services and must execute an authorization to divulge the confidential information. For all other services, a minor child of any age may not execute an authorization to divulge confidential information.

7.

The Texas Supreme Court, in Abrams v. Jones, Tex. Lexis 80, 43 Tex. Supreme Court Journal 1064 (July 6, 2000) reconfirmed an earlier decision for social workers and therapists, that it trusts the good faith professional discretion of the therapist, as to when disclosure of certain mental health records could be harmful

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to a minor. Further, the Court reconfirmed the importance of the trust between patient (service recipient) and therapist, and a person’s expectation of confidentiality, so much so that children could claim the privilege of confidentiality, even against a parent. The Court noted that while parents normally had a right to their children’s mental health records, that right was not unfettered. The Court concluded that a mental health professional is not required to provide access to a child’s confidential records if a parent who requests them is not acting “on behalf of” the child. Examples included a parent accused of sexually molesting a child or parents embroiled in a divorce or other suit affecting the parent/child relationship. In this particular case, the child was 11 years old.

The court did not specify a particular age where this is effective and it is therefore in reference to minor children of all ages.

In this instance, the counselor documents their decision in the record that they do not feel the parent is acting on behalf of the child and why. This is then reviewed with the Clinical Supervisor who notes concurrence in the record. If there is no concurrence, the President/Chief Executive Officer will review the record and make the final decision with the outcome documented in the case record.

8.

Case files should not be made physically available to persons, agencies, or institutions outside the agency. The agency maintains the right to determine what information it will share with an inquiring party. Only management staff, as the custodian of records for the agency, may release information.

9.

The service recipient will be fully informed of the nature of the inquiring agency’s request. Written consent to release information must be received before material is communicated to any other party.

10.

When referring service recipients from one service to another within the agency, the referring staff member should involve the service recipient in determining what specific information should be disclosed.

11.

To release information, the service recipient, parent of a minor child, or legal guardian must complete and sign the Authorization to Release/Request Information. All blanks must be completed. The time limit on the authorization should not exceed the time reasonably expected to release the information.

12.

If a report is requested by another agency, the Family Service program to which the request is made should include only information relevant to its own service(s).

13.

Social Security numbers identify service recipients, and therefore are to be treated with the same confidentiality as is the service recipient’s name. Materials containing identification of the service recipient through use of their social

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security number should not leave the agency without the service recipient’s current written consent and that consent should be made part of the record.

14.

All requests for release of information on closed cases must be presented in writing and be accompanied by a signed release from the service recipient. Such requests should be addressed to the appropriate Program Manager who will approve and process the request. Faxed requests and releases are not accepted.

15.

Whenever case records are still available, and the staff person last active on a closed case is still on the agency staff, the Program Manager should designate this person to respond to the request.

16.

Responses to appropriate requests for information on closed cases may be written or verbal and a notation about the request and response must be made in the case record.

17.

When the service recipient is endangered, or may be harmful to others, the service provider confers with the immediate supervisor and plans the best approach for disclosure.

18.

In instances where disclosure is requested for a particularly vulnerable service recipient, Family Service takes a protective role with regard to the release of information about the person served. Vulnerable service recipients might include those who are challenged by mental retardation, functional illiteracy, or children without permanent family ties or legal guardian. Service providers must make note of any particular vulnerability of the service recipient on the Authorization to Release Information and refer the case to the Program Manager. In those instances, the Program Manager reviews the authorization and the specific information requested. Approval to release/not release is documented in the case record.

Staff Access to Case records: 1.

Staff access to case records is on a need-to-know basis. The case record is available only to agency service providers who have a need to work with the record. In addition to the direct service provider, this includes supervisory staff, support staff, data processing staff, business office staff and agency management.

2.

All staff having access to case records are required to treat service recipient information as confidential and are prohibited from sharing case information with anyone other than authorized personnel.

3.

Whenever a case is presented to service provider groups, it is edited to delete identifying information.

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4.

Staff is prohibited from removing case records from agency premises without prior administrative approval. Files transported from agency approved file rooms to other locations must be transported in a secure, confidential file lock box for transporting files to court, case file reviews, monitoring reviews, etc.

5.

Staff is prohibited from discussing service recipient information where any other person can overhear such discussion.

6.

Requests for case record material should always go directly to the person to whom the case is assigned.

7.

Case records are maintained in each of the office sites in a room not open to the public and designated “file room”. Case records are kept in locked, fireproof file cabinets and are removed from their location only when in actual use. An exception to this occurs only when records are waiting typing by support staff or in mail cubicles awaiting pick-up for work that day. This location must also be in an area where only agency staff enter and be kept locked during non-working hours. No case record may be kept in service providers’ offices or in work areas overnight.

8.

Staff removing a record from a file cabinet must complete an out card so the record may be located at any time. If a record cannot be located, this is reported to the appropriate Program Manager.

Procedures for Client Case record Examination: 1.

Service recipients have the right to examine the agency’s record concerning their service. This examination takes place on agency premises. a.

Record examination should be viewed as part of the service process.

The service recipient reviews his or her case record in the presence of the direct service worker most closely involved in the provision of service.

b.

Service recipients must submit the request to examine the record in writing by completing the Request for Record Review (Exhibits 10 and 10a).

c.

In the case of group, conjoint or family service records, the service recipient must have the consent of all parties involved in the service if the total record is to be examined. Consent must be obtained in writing.

Without such consent, the service provider will disclose only that portion of the record pertaining solely to the service recipient requesting examination. This protects the confidentiality of other individuals referred to in the content of the record.

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2.

The service recipient can challenge the accuracy of the record and insert his or her own statement. Insertion of a statement by a service recipient into his or her case record does not constitute agency agreement and such statements added to the case record shall be clearly identified as such. Further statements by service providers in reference to the service recipient’s inserted comments must be done only with their knowledge. Service recipients may not remove material contained in the record concerning their service.

3.

No information received from professional sources outside the agency can be shared with the service recipient or released. Requests for release of this information should be referred directly to the outside source with the service recipient’s written consent to release information. If the agency’s assigned direct service provider is no longer with the agency, the supervisor is responsible for the referral.

4.

Service recipients should be discouraged from duplicating case material, but may take notes on their records.

6.

a.

If a service recipient insists on photocopying the records, the agency shall require a release of the agency’s obligation to ensure confidentiality (Exhibits 10 and 10a).

b.

Service recipients are charged $1.00 per page for the first 25 pages and fifty cents ($.50) per page thereafter for photocopying.

The agency reserves the right to deny access to a service recipient’s record. There may be a rare instance where the President/Chief Executive Officer may formally deny a service recipient access to their record based on perceived harm to that person. Circumstances under which it might be considered harmful for a person served to review his/her own record might include information that might trigger the person to express suicidal intentions or cause harm to another person. The President/Chief Executive Officer may seek independent professional counsel to assist in making the decision. The service recipient may request a duly qualified professional to review his or her record on their behalf. The duly qualified professional must sign a written statement that he or she will not reveal information believed to be harmful to the person served without a prior mutual, signed agreement with the agency.

Protection of Case Material: All staff is provided an orientation to the agency’s procedures regarding confidentiality of case material at the time they are hired. The immediate supervisor generally accomplishes this.

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1.

All case material, when not in use, should be kept in the appropriate files and only those persons working directly with cases should have access. Support staff, volunteers, consultants and students are bound by the same principles of confidentiality as employees of the agency.

2.

Case records may be used for studying and teaching purposes outside the agency only if they are thoroughly disguised by removing all identifying information, and permission is first obtained from the appropriate Program Manager.

Audio Taping and Video Taping: 1.

Tape recording and video taping of services being provided may serve several important functions: a. It may assist in the therapeutic or educational process by making it possible for service recipients and service providers to review jointly what has taken place and plan for next steps in the process. b. The staff may find review of the material useful for their own understanding of the situation, for supervisory and consultation purposes, or for individual learning. c. Audio or video taped material is useful to service providers and legitimate researchers for study, teaching, research and community education purposes.

2.

The service recipient and service provider discuss at length the agency’s request for taping and such taping is done only with the service recipient’s signed authorization (Exhibits 11 and 11a).

3.

Written consent from each service recipient or group member is required when group sessions are audio or video taped. All service recipients have the right to review such material and to have all or part of it destroyed upon request at any time.

4.

No taped material is to be retained in any form beyond the termination of the case or group sessions unless specific permission is granted by the service recipient. In that case, a written document is prepared specifically for that purpose and signed by the service recipient after he or she has once more been given an opportunity to review the material and have portions deleted or disguised.

Observation of Service Recipient Sessions: Observation of service recipient sessions is a useful teaching and study device for interns and service providers. Such observation may take place only with the knowledge and written consent of the service recipient(s) involved (Exhibit 12 and 12a).

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Public Relations: At all times the rights of service recipients, program participants and service providers must be respected, especially the right of privacy.

1.

Photographs of individuals or groups are often helpful for agency programs, promotions and community education. A written media release from the service recipient or parent/guardian is required before photographs can be taken (Exhibits 13 and 13a).

2.

Occasionally it can be helpful for service recipients to be interviewed or observed for public relations purposes including newspaper, magazine and broadcast stories. This requires the permission of the service recipients and following a careful explanation of the purpose of such interview or observation. Such interviews or observations can be done with or without preserving the anonymity of the service recipient. This decision is made by the service recipient in consultation with the service provider, and consent is given on the Media Release.

3.

Participation in public events against the wishes of the person served or without the written informed consent of that person or, in the case of a minor, both the minor and the parent/guardian is prohibited. Requirement or encouragement of public statements which express gratitude to the agency or using photographs or video of the service recipient for public relations without proper consent is prohibited.

Use of Undisguised Case Material for Agency Promotion/Publicity: Undisguised case material and direct participation of service recipients in interpreting agency services (i.e., press interviews, audio tape and TV interviews) should ensure the use of the following procedures: 1.

The service recipient is to be advised how the material is to be used and the nature of his/her participation. Written consent on the Media Release is to be obtained and made part of the case record.

2.

Consideration is given to the potentially negative as well as the positive effects that such personalized publicity may have on the service recipient and on other persons who may need or desire the services of the agency.

Utilization Review/Funder Auditing: 1.

Internal utilization and quality assurance procedures will adhere to the agency confidentiality policy.

2.

Third party funders/contractors seeking access to case records will have reviewers who are bound to confidentiality standards by their own professional ethics and

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agency policies. These parties may examine records pertinent only to their specific contract or purposes.

3.

Service recipients receiving services covered by contracts are made aware through the Informed Consent that their record may be reviewed for quality assurance and contract compliance purposes.

4.

In situations where service recipients voluntarily wish to provide information to third parties, the agency should evaluate the purpose and legitimacy of the third party’s request. Responses should be limited only to the specific information requested.

5.

Records will be made available to auditors from funding or accrediting bodies.

Independent consultants may have similar access for purposes of program evaluation when deemed appropriate by the President/Chief Executive Officer. If possible, the identity of the service recipient should be concealed.

Destruction of Case Records: 1.

Adults’ case records will be kept for seven (7) years after the closing date.

2.

Children’s case records will be kept seven (7) years, however, for children involved in the CPS system their records are kept seven (7) years beyond the age of majority, eighteen (18) years. The President/Chief Executive Officer will consider exceptions if there is a legitimate reason for extending or decreasing the storage time period.

3.

The Director of Contracts and Scalability, or his/her designee, is responsible for annual identification of case records due for destruction. Program Managers or their designee(s) are responsible for reviewing and authorizing their destruction.

Case Storage and Destruction processes are scheduled annually in January.

4.

The Director of Contracts and Scalability, or his/her designee is responsible for supervising record destruction. Records are destroyed by means of a professional shredding service.

5.

The Director of Contracts and Scalability maintains a list of cases/date destroyed.

Loss of a Case File or Case File Materials In the event that a Case File is lost or material from a Case File is lost, the following steps must be taken.

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1. A thorough search of Case Files and Office sites must be conducted to determine if the Case File or Case Material is truly missing.

2. If the Case File or Case Material is determined to be missing, an Incident Form must be completed denoting the Case File lost or the Case Material that is lost within 24 hours. The Complaint/Incident/Grievance Log on the U drive must be updated. Copies of the Incident Form must be submitted to the appropriate Program Manager, the Vice President of Agency Services and the Vice President of Quality, Contracts & Systems within the 24 time period.

3. The Client must be notified through personal contact and informed of the items missing from their case file or the loss of the case file. The client must also be informed through a written letter on the exact items missing and the agency’s action to ensure that any missing personal information is protected.

4. The Case File must be replaced with the client within 7 working days of the discovery of the missing file or missing documentation with original Client Signatures.

5. The funding source of the Case File must be informed of the situation by writing.

6. The Manager in Charge will be responsible for conducting, in collaboration with HR, a thorough investigation as to how the File or the Material became lost and if violation of Agency Policies and Procedures were found to have occurred, provide appropriate disciplinary action to ensure that no Case File or Case Material is lost in the future.

Agency Dissolution Contingency Plan: In the event that the agency is dissolved: 1.

All active service recipients will be referred to other community agencies as per individual case plans. Records will be forwarded to the receiving agency.

2.

To the extent possible, a written notice of agency dissolution will be mailed to service recipients, whose cases are on our inactive list, specifying the agency that will be the repository of records.

3.

The repository of case records should be an accredited family service agency, or an agency whose mission is similar to that of Family Service.

CASE RECORD REVIEWS PROCEDURES & PROCESSES Purpose: To assure that Family Service Association of San Antonio, Inc. assesses the ongoing professional practice and competence of its Mental Health and Social Service Professional Practices Updated January 2012

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programming by conducting professional practice evaluations through the use of Peer to Peer Case Record Reviews, Program Consistency and Standards Review and Quality Assurance Compliance Reviews and utilizing the results of these ongoing assessments to improve agency professional competency, practices and services.

Goals: 1). Identify opportunities for practice and performance improvement of Family Service programs and services.

2). Monitor for significant trends in performance by analyzing aggregate data and case findings.

3). Improve the quality of care provided by Family Service programs and clinical practitioners.

4). Provide suggested areas for system-wide improvement addressable by focused project teams and Agency Wide Quality Assurance efforts.

Principles: Confidentiality: All formats of Case Record Review information is privileged and confidential in accordance with Agency Policies and Professional Practices, State and Federal laws and regulations pertaining to confidentiality and non-disclosure. Case Review Committee Members will sign a statement of confidentiality each year.

Participation: For Case Record Review to become an essential component of the Agency’s ongoing Quality Assurance Plan, it is essential that staff members at all levels of the agency fully participate in the process to result in lasting, impactful improvements in the quality of services provided by the Agency. Attendance will be kept for attendance and participation in the various formats of the Case Review Process and members unable to maintain adequate attendance over a year may be replaced.

Reliability: Case Record Review is to be conducted by each Program Department and Project in a manner that is objective, equitable and consistent. The intent of Peer Case Record Review, Program Consistency and Standards Review and the Quality Assurance Monitoring Review is to improve the quality of service delivery within the Agency and ensure Agency compliance with all relevant client services documentation standards.

Case Record Review Procedures and Processes: Peer to Peer Case Record Review Selection of Records: Professional Practices Updated January 2012

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1. Each Department or Project will select case records at random from each service area or project, choosing files to be reviewed from a case file list. Each Department will keep a running record of all case files reviewed through the Peer to Peer Case Review.

Scheduling & Preparation for the Record Review: 1. Each and every Family Service Department/Project will be responsible for scheduling and ensuring the attendance of all project staff members and a representative from the Data and Evaluation Team in a pre-scheduled monthly peer to peer case review. Each department should have their Peer Reviews scheduled in Microsoft Outlook with their entire department members and Data and Evaluation Team invited to participate. Managers for each service area are responsible for training and ensuring full participation of their programming staff in the peer review process for their Department or Project.

2. Prior to each scheduled record review, designated program staff will be responsible for inserting file numbers on Case Record Review Forms (white copier paper), pulling files and ensuring that they are available for Department or Project peer reviewers at the scheduled date/time. When pulling files, program staff will insert a “File Sign-Out Card� into the file cabinet in order to effectively track the location of the file.

3. Program staff designated to oversee the Peer-to-Peer Review will update the Peerto-Peer Review Form on the U Drive with files reviewed by department and issues of non-compliance within 2 business days after the Peer to Peer review session.

Conducting the Peer to Peer Record Review: 1. Department/Project Peer Reviewers will be responsible for reviewing the designated number of files per service area every month, completing a review form for every file, signing the completed form, and returning all files and completed forms to designated program staff immediately upon completion of each monthly review session.

2. Each Case Peer Review must include discussion of the case histories, case management, the observations and feedback of the participants, review of the sufficiency and quality of the documentation of services and a review of the delivery of project services as well as ensuring that the case record is in compliance with all Agency Professional Practices, Program Standards, guidelines and policies.

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3. Program staff designated to pull case files will re-file records and ensure that the designated supervisor for their area receives the completed peer to peer review forms for implementing action plans with staff including appropriate signatures.

4. Program staff designated to pull files should maintain a list of cases reviewed and notify the Manager and/or Director of the service area immediately in the event that completed/signed forms are not received in a timely manner for filing in the case.

Peer Case Review Supervisory Review & Signature/ Distribution & Filing of Completed Peer Review Forms: 1. Program and support staff designated to pull files will route completed peer review forms to the appropriate supervisor for implementing action plans and signatures.

2. The Manager of the service area will be responsible for ensuring that the supervisory review is conducted, review forms are signed by the Service Provider and Supervisor, filed in the appropriate case with a copy returned to the designated Quality Assurance, Systems and Contracts staff within two weeks.

3. Periodic reports (at least every other month) will be published and reviewed by the Management Cabinet and Supervisors to discuss trends and address issues through developing and implementing an approved corrective action plan.

Monthly Peer Case Review Targets by Department/Project: Each Peer Case Review is expected to review a minimum of 10% of Department/Project Case Files.

Case Record Review Procedures and Processes: Agency Consistency and Standards Review Selection of Records: 1. Quality Assurance, Systems and Contracts staff will select records from each service area or project from the most recent Client Listing per program.

2. Quality Assurance, Systems and Contracts staff will forward a list of records to be submitted to the QA File Review Committee at the beginning of each month.

Each list will include record numbers (names) for selected cases.

Scheduling & Preparation for the Record Review:

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1. Each member of the Agency Consistency and Standards Review committee will be responsible for attending a pre-scheduled monthly case review. The Agency Consistency and Standards Review committee will be comprised of Managers and Supervisors for each service area of the Agency. Data & Evaluation Team will randomly select the client files to be reviewed two weeks before scheduled case reviews each month and post the requested files within the Case Review Tracking sheet on the U drive.

2. Prior to each scheduled record review, designated program staff will be responsible for inserting file numbers on Case Record Review Forms (white copier paper), pulling files and ensuring that they are available for Department or Project peer reviewers at the scheduled date/time. When pulling files, program staff will insert a “File Sign-Out Card� into the file cabinet in order to effectively track the location of the file.

3. Program staff designated to pull case files will email a list of files selected for review to the Quality Assurance, Systems and Contracts staff or appointed designee prior to the review session.

Conducting the Agency Consistency and Standards Review: 1. Manager and Supervisors who are members of the Agency Consistency and Standards Review Committee will be responsible for reviewing the designated number of files per service area every month, completing consistency and standards review for every file, signing the completed form, and returning all files and completed forms to designated program staff immediately upon completion of each monthly review session.

2. Program staff designated to pull case files will re-file records and ensure that the designated supervisor for their area receives the completed Agency Consistency and Standards review forms for implementing action plans with programming staff including appropriate signatures.

3. Program staff designated to pull files should maintain a list of cases reviewed by the Agency Consistency and Standards Review committee and notify the Manager and/or Director of the service area immediately in the event that completed/signed forms are not received in a timely manner for filing in the case.

4. The Agency Consistency and Standards Review committee will be reviewing randomly chosen files to ensure that all Agency Programs and Projects are meeting Agency Standards for file documentation, quality of service delivery as well as to review existing Departmental and Project Policies and Procedures regarding client services and client records to ensure an agency-wide standard of care and client service delivery expectations.

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Agency Consistency and Standards Review, Supervisory Review & Signature/ Distribution & Filing of Completed Peer Review Forms: 1. Program staff designated to pull files will route completed Agency Consistency and Standards review forms to the appropriate supervisor for implementing action plans and signatures.

2. The Manager of the service area will be responsible for ensuring that the supervisory review is conducted, review forms are signed by the Service Provider and Supervisor, filed in the appropriate case with a copy returned to the designated Quality Assurance, Systems and Contracts staff within two weeks.

3. Periodic reports (at least quarterly) will be published and reviewed by the Management Cabinet and Supervisors to discuss trends and address issues through developing and implementing any required corrective action plan Case Record Review Procedures and Processes: Quality Assurance Compliance Review Selection of Records: 1. Quality Assurance, Systems and Contracts Data & Evaluation Team staff members will review each record from the most recent Agency Consistency and Standards Review that failed review.

2. This review will take place on the last working day of each month.

Scheduling & Preparation for the Record Review: 1. The Director of Contracts & Scalability will be responsible for ensuring the review occurs on a monthly basis, scheduled for the last working day of the month.

4. Prior to each scheduled record review, designated program staff will be responsible for inserting file numbers on Case Record Review Forms (white copier paper), pulling files and ensuring that they are available for Department or Project peer reviewers at the scheduled date/time. When pulling files, program staff will insert a “File Sign-Out Card� into the file cabinet in order to effectively track the location of the file.

5. It the responsibility of each Program Manager to ensure that any files within their supervisory purview that failed the most recent Agency Consistency and Standards Review is re-submitted on the last working day of the month to the Professional Practices Updated January 2012

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Data & Evaluation specialist assigned by the Director of Contracts & Scalability for the Quality Assurance review.

Conducting the Agency Quality Assurance Compliance Review: 1. Members of the Quality Assurance Compliance Review will be responsible for reviewing 10% of program files each month randomly selected from the program’s client listing in agency databases, completing a compliance review to ensure that suggested or required actions were completed from the previous Peer Case Review for every file, signing the completed form, and returning all files and completed compliance review forms to the designated program staff immediately upon completion of each monthly review session.

2. Program staff designated to pull case files will re-file records and ensure that the designated supervisor for their area receives the completed Quality Assurance Compliance review forms for implementing action plans with programming staff including appropriate signatures.

3. Program staff designated to pull files should maintain a list of cases reviewed by the Quality Assurance Compliance Review committee and notify the Manager and/or Director of the service area immediately in the event that completed/signed forms are not received in a timely manner for filing in the case.

Quality Assurance Compliance Review, Supervisory Review & Signature/ Distribution & Filing of Completed Peer Review Forms: 1. Program staff designated to pull files will route completed Quality Assurance Compliance review forms to the appropriate supervisor for implementing action plans and signatures.

2. The Manager of the service area will be responsible for ensuring that the supervisory review is conducted, review forms are signed by the Service Provider and Supervisor, filed in the appropriate case with a copy returned to the designated Quality Assurance, Systems and Contracts staff within two weeks.

3. Periodic reports (at least quarterly) will be published and reviewed by the Management Cabinet and Supervisors to discuss trends and address issues through developing and implementing any required corrective action plan.

Documentation of the files reviewed, compliance or non-compliance by program and caseworker are documented monthly in the Case Review Tracking form on the U drive. Quarterly, the Director of Contracts and Scalability submits a Trend Report documenting Quality Review compliance and non-compliance trends to all agency Supervisors, Managers, Directors and Executives.

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Peer to Peer Case Review by Project/Program Department (Program/Project Staff Members)

Quality Assurance Compliance Review (Quality Assurance Dept)

Agency Consistency and Standards Review of Random Agency Case Records (Managers & Supervisors) Monthly Case Review Findings and Quarterly Trend Report

Case files differ by project and funding requirements, however, the following items are reviewed for quality assurance purposes to ensure that services provided to clients are timely, necessary, helpful and of the highest quality. Below are the basic case review standards from the Council on Accreditation that should be taken into account with the review of each case record throughout the various agency review processes: Demographics Reason for Requesting Services Assessments: Assessment is up to date Assessment is comprehensive Assessment is directed to concerns identified during intake Assessment is limited to information pertinent to meeting service requests and objectives Assessment is culturally responsive Completed within established timeframe Service Plan: Developed with full participation of the service recipients Professional Practices Updated January 2012

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Service Plan is based upon the assessment Includes service goals and desired outcomes- Short Term, Mid-Term and Longer-Term Includes timeframes for achieving services goals and outcomes Identifies services/supports to be provided Identifies who will provide specific services/supports Includes signature of services recipient Service recipient received explanations of options and how the agency can help them Explanation of benefits, alternatives, and risk of consequences Identifies the person’s/family’s unmet services/support needs Demonstrates a regular review of progress by worker and service recipient Service recipient signature on revisions or updates to service goals/plan Signed Copies of all Relevant Consents Routine Documentation of ongoing services Case Record Entries Made by Authorized Personnel Up-to-Date Completed, Signed and dated by worker providing services Supervisor Signature, dated, where appropriate. Files that have been open for more than 60 days should have supervision documentation within the file.

Progress Notes Entered Weekly/Monthly depending upon service delivery standards Documentation of regular (at least Quarterly) Supervisor review Includes Review of Service Plan implementation Client Progress towards achieving service goals/desired outcomes Continuing appropriateness of services goals Case Closure Summary Completed within 30 days of case closure After Care provision/contact procedures provided to client Notification of any collaborating service providers Referrals made for persons asked to leave the program Termination of service assessment and summary, if applicable contracts with public authorities-client consent/permission Discharge of Aftercare Plan Development of aftercare plan based on wishes of client, or mandate Professional Practices Updated January 2012

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Identify needed/desired services and specific steps to obtain them/Exit Interview Conducted Assignment of aftercare and follow-up responsibility Documentation of contact with suitable providers with client permission/consent Documentation of Client Reviews of Health Case Records Client Rights Documentation that client received a written summary of rights and responsibilities Consent to communicate confidential information (if applicable) Documentation that client received a copy of the fee schedule (if applicable) Documentation if need for accommodation Client informed of circumstances the agency may be required to release information Miscellaneous Consent to participate in research Documentation of incident/accident review

PARTICIPANT PROTECTIONS IN RESEARCH Confidentiality and Participant Protection/Human Subjects: Protection from Potential RisksThere are few innate risks within the counseling/educational process, following the Hippocratic Oath of "above all, do no harm." However, it is widely recognized that initially counseling/educational services can cause increased distress or discomfort.

Generally this is a short-lived experience and one which not every counseling participant experiences. In cases which create obvious distress to a participant, individual intensive counseling and case management services are offered immediately to help bring quick resolution to the situation. There are no medical risks whatsoever associated with the counseling process.

Family Service respects and protects the health and safety of the persons and families it serves. All facilities are in compliance with the Americans with Disabilities Act (ADA).

Family Service is licensed by the Texas Department of Aging and Disabilities and requires strict compliance with rules and regulations that protect the health and safety of the persons and families it serves. The State provides periodic and unannounced monitoring visits. All staff members receive on-going training on delivery services that respect and protect the health and safety of the persons and families it serves in the office, in the community, and in the recipient’s home.

Family Service is committed to furthering an understanding of the etiology and service of dysfunctional individuals and families. Toward this end, we encourage both basic Professional Practices Updated January 2012

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research to enhance our knowledge of human behavior, and evaluation studies to determine if our interventions indeed accomplish their purpose. The agency will take appropriate measures to insure that whatever research is proposed and conducted is in keeping with the mission and humanistic values of the agency.

Procedures: 1.

All research proposals, whether originating from within the agency by staff, or from outside researchers, must be submitted to the President/Chief Executive Officer for approval.

2.

The President/Chief Executive Officer has the authority to reject research proposals.

3.

If approved by the President/Chief Executive Officer, the Program Planning and Evaluation Committee of the Board must then review the proposal. Once approved, the research may be implemented. The President/Chief Executive Officer or his or her designee may monitor the research to ensure the research continues to abide by the terms of the original proposal. The agency retains the right to end any research project not in compliance with the original proposal.

The President/Chief Executive Officer will refer such concerns to the Program Planning and Evaluation Committee of the Board whose decision will be final.

4.

All research must provide the following assurances: a.

Service recipient’s right to privacy and anonymity is not violated;

b.

The agency complies with applicable laws governing research with human subjects;

c.

The service recipient’s understanding that participation in research is entirely voluntary, and is indicated by signed informed consent that is made part of the service record;

d.

The service recipient’s eligibility for service and the quality of service provided is not adversely affected by refusal to participate in proposed research;

e.

If the research subject is a minor, the parent or legal guardian must sign the informed consent; and

f.

The research proposal must specify the procedures for minimizing potential risks of the research and make a reasonable risk statement.

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5.

The research proposal must also specify the proposed involvement of human subjects, the sources of research material, the recruitment of subjects and the consent procedures. Family Service participates in the University of Texas Health Science Centers’ Internal Review Board evaluation process and if the agency is participating in Federally funded research projects, submits the project for IRB review and oversight.

Equitable Selection of ParticipantsAll Family Service programs have written material describing the service population and eligibility criteria. Written material includes policies and procedures disseminated to staff, the agency evaluation report disseminated to stakeholders, and brochures and outreach material disseminated to potential service recipients. If there are certain legal and/or governmental mandates that dictate service delivery, those conditions are published. Each year the staff and our Evaluation Committee of the Board review services and intended populations to ensure all are aligned with the agency mission.

Services are focused on identifying the expressed needs and problems facing individuals and families served and engaging them in mutual efforts to achieve desired outcomes. In group and community intervention modalities, the focus is on identifying the needs and problems of groups of community members to engage them in mutual efforts to achieve the desired outcomes of the group. Family Service retains the right to determine, from among applicants for its services, those it can serve appropriately within the limits of its mission, resources, and capacities. Each program determines the eligibility requirements for that service or service array. Family Service only accepts applicants whose expressed needs can be met through our services. For those we cannot serve we make appropriate referrals to other community service providers.

Family Service does not discriminate against any applicant or service recipient based on race, color, religion, national origin, sex, sexual orientation, age, disability, or inability to pay for services.

During the intake process, Family Service staff conducts a screening with the potential service recipient to determine eligibility and the need for services. Within two weeks, the agency will inform the applicant as to whether services are available, will be delayed, or if other services are more appropriate. In emergency situations, services may begin immediately following the intake or an appropriate community referral will be made.

The Program Manager assigns intake duties for specific service areas. Intake workers must be knowledgeable about agency services and eligibility criteria. The intake worker makes the determination as to whether a client’s needs are congruent with the services the agency provides. If there is a lack of match between applicant needs and agency resources, the intake worker will offer to make a referral(s) to appropriate resource(s). If, in the intake worker’s opinion, the applicant’s needs would best be met through referral to a private practitioner or a for-profit resource, at least three must be suggested. The intake worker must make clear to the applicant that in providing a resource list, he or she is only imparting information and is not making a recommendation or endorsement.

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The applicant will be given a target timeframe in which the requested services will begin.

In those cases where the time delay is unacceptable, where another provider would be more appropriate, or additional services are needed through an active community network, Family Service will promptly provide the applicant with community referral information and/or link the individual directly with needed services. If an immediate opening is not available and the applicant wishes to wait for the service, he or she will be placed on a waiting list and given an estimate of the expected time before services will begin and how the initial service contact will be made. The applicant’s ability to pay is not a determining factor in placement on a waiting list for services. It is prohibited for the intake worker or any other person associated with the agency to accept any payment or reward in order to improve an applicant’s position on the waiting list or to provide immediate entry into a program. It is prohibited for an intake worker to give preferential treatment to board members, other service providers or consultants in the application process.

Absence of CoercionFamily Service provides voluntary counseling/educational services. The topics of discussion and activities are interesting, enjoyable, and applicable to participant’s daily struggles and thus it is rare that they choose not to participate in the program. Group facilitators make special efforts to ensure that all participants feel comfortable in the group learning environment and that each member experiences a sense of inclusion.

Family Service informs all persons served of their rights and responsibilities and provides sufficient information for them to make an informed choice about using the organization’s services. Rights and Responsibilities are posted in the reception area at each office location, provided to each client in writing during their initial contact, provided in English and Spanish, and are effectively and appropriately communicated to service recipients with special needs. Written rights and responsibilities include basic expectations, rights of participants, and information on how to lodge a complaint. A service provider is to be knowledgeable of, uphold and give full assistance to service recipients in exercising their rights. Prior to the initiation of services, each service recipient signs the “Service Recipient Bill of Rights and Responsibilities” Appropriate Data CollectionIn order to investigate program/project outcomes, data must be collected from a variety of sources. Written pre and post tests are used to demonstrate an increase in knowledge. In addition, surveys are administered to determine which skills learned they consider most useful and those which they have already begun to implement in their lives. In person or phone interviews are conducted at the conclusion of services to gain perspective regarding qualitative impressions of group services and in order to make referrals for any additional services required.

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All client records and data are held in strict confidence according to agency Professional Practices. The identity and privacy of all participants is safeguarded in all phases of research. Evaluation findings, reports and scientific papers include only aggregate data.

Adequate Consent ProceduresEvery participant receiving services must have a voluntary, informed consent for participation in Agency Service. Consent forms are written in English and Spanish. No individual may attend group counseling/educational research services without consent for participation.

Participants may cancel or revoke their authorization for the evaluators to collect, use and disclose their Personal Health Information (PHI) at any time. Requests to revoke PHI data collection authorization must be sent in writing to: Richard Davidson Director of Contracts and Scalability Family Service Association of San Antonio 702 San Pedro Avenue San Antonio, Texas 78212 (Or the assigned designee) If a participant revokes authorization, their participation in the evaluation will end and the research project staff members will stop collecting information regarding the participant.

However, the staff will continue to use the PHI collected about participants (in the aggregate) prior to the cancellation of their authorization.

Risk / Benefit DiscussionThere are few or no risks involved to the participant in well-designed counseling/ educational programs. By the nature of our mission and programs, Family Service provides services disproportionately to individuals and families who may be considered at-risk of exploitation in research owing to age, economic status, and other factors.

However, these individuals and families are protected to the greatest possible extent from risk of harm in all programming, services, and research, and efforts are made to maximize the benefits that accrue to them. Benefits of Family Service programs and services are many and all aim to fulfill our mission of “empowering individuals and families to transform their lives and strengthen their community�. At all times, service providers strive to offer the highest possible quality of services to benefit clients to the greatest possible extent. All proposed research undergoes an evaluation of possible risks and benefits to participants to ensure that benefits are likely to outweigh risks.

COMPLAINT and GRIEVANCE PROCEDURES

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Definitions : A "complaint" is a claim based upon an event or condition causing dissatisfaction and disagreement between or among the parties involved.

The "complainant" is the person(s) who make the claim.

Purpose: The purpose of this policy is to secure, at the lowest possible administrative level, equitable solutions to complaints which may arise.

Goals: 1) Identify opportunities for practice and performance improvement of Family Service programs and services.

2). Monitor for significant trends in performance by analyzing aggregate data and complaint resolutions.

Principle: Family Service recognizes the right of those we serve to file complaints or grievances when they believe services have been unsatisfactory or their rights have been violated.

Complaint Procedure Informal complaints are to be resolved at the lowest possible administrative level. The complainant and other person(s) involved shall resolve issues of concern via a personal meeting or other appropriate communication. Once the complaint has been received, it is handled confidentially and expeditiously. The agency acknowledges receipt of complaints within 24 hours. If the immediate parties have attempted and failed to resolve the issues, the principal, or immediate supervisor, shall coordinate and mediate the processes necessary for satisfactory resolution of the complaint. Upon receipt of an informal complaint, the principal or immediate supervisor shall initiate action to resolve the issue within five (5) working days.

Complaints received via phone or in personal conversation, shall be documented by the staff member to whom the complaint is presented by using the Family Service Complaint or Grievance Form, (Exhibits 15 & 15a). All complaints once documented on the Family Service Complaint or Grievance Form, (Exhibit 15b), shall then be submitted to the Manager of the staff member receiving the complaint. Managers shall then log the complaint in the Agency Complaint Tracking Form including the resolution or if the complaint is an outstanding concern. Each month, all complaints shall be documented on the Agency Complaint Tracking Form by the Agency Department and submitted to the Management Cabinet by the 15th of the following month. Members of the Management Cabinet discuss interpretation or application of the Agency’s Professional Practices policy with regard to complaints brought by a service recipient and report to Senior Leadership as appropriate. The Management Cabinet strategizes on how these issues and trends need to be addressed and incorporated into service delivery. Supervisors, with

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oversight from Managers and Directors, are responsible for incorporating the needed changes.

Grievance Procedure Formal Grievances are to be made in writing when the complainant is not satisfied with the disposition of the issue through the informal complaint process. The complainant may, within ten (10) working days after the informal complaint decision has been rendered, file the complaint in writing, with any member of the agency’s staff members.

When a service recipient wants to file a complaint or grievance, they are given the appropriate procedural material (Exhibits 15 & 15a) and assisted, as needed, to complete this process. Specific service recipient grievances are responded to by the agency’s Vice President of Agency Services. Unresolved grievances can be appealed to and are responded by the agency’s President/Chief Executive Officer. The decision is to be provided to the service recipients in writing and/or communication in a manner of the complainant’s choice. In the event the complaint is not resolved, the complainant may request a hearing before the Board of Directors. The Board shall review the complaint at the next scheduled Board meeting after receipt of the request. The Board's decision shall be final and shall be made within ten (10) working days of the hearing.

Notification Complaint and grievance procedures are posted on walls near the reception area and can be obtained from the front lobby desk or from any staff (Exhibits 14, 14a). Additionally, service recipients are given contact information upon entering services for filing a complaint and/or grievance.

Documentation All complaints and grievances should be documented both in writing on a Complaint and Grievance Form as well as briefly documented within the Complaint and Grievance Tracking log located on the U drive. The Complaint and Grievance Tracking log is utilized to compile the quarterly trend analysis that is distributed on a quarterly basis to all Supervisors, Managers, Directors and Executive Leaders.

ETHICAL CONDUCT Code of Ethics: Family Service requires all service providers, consultants and volunteers to be knowledgeable of and adhere to the Family Service “Code of Ethics”. In addition, all licensed professionals are required to be knowledgeable of and adhere to any code of ethics specific to their licensure. This requirement is reinforced through supervision and in-service training. Family Service requires all Board Members to be knowledgeable of and adhere to the Family Service “Board Members’ Code of Conduct” (Exhibit 16). The word “service provider” in this Code of Ethics refers to service providers, volunteers and paid consultants.

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1.

A service provider shall not refuse to do or refuse to perform any act or service for which the person is licensed or employed by this agency, solely on the basis of a service recipient’s age, gender, race, color, religion, national origin, disability, sexual orientation or political affiliation.

2. A service provider shall truthfully report or present his or her services, professional credentials, qualifications and experience to applicants and clients/participants.

3. A service provider shall only offer those services that are within his or her professional competency and shall strive to maintain and improve his or her professional knowledge, skills and abilities.

4. A service provider shall base all services on an assessment, evaluation or diagnosis of the service recipient’s specific circumstances.

5. A service provider is to be knowledgeable of and adhere to the agency’s procedures on Service Recipient Information and Confidentiality specified in these procedures so as to safeguard confidentiality within the limits of the law.

6. A service provider is to be knowledgeable of and abide by “The Request for Services and Informed Consent”. This is completed prior to the initiation of services and a copy given. Informed consent is given, the cost of service and responsibilities of the service recipient specified.

7. A service provider is knowledgeable of and abides by Family Service policy not to terminate any service recipient because they cannot pay for services. A service provider is aware that only the Director or his/her designee has the authority to lower or waive the usual fee for services.

8. A service provider shall be responsible for setting and maintaining professional boundaries. A service provider shall not enter into a business or personal relationship with a client, including but not limited to, exchanging gifts and communicating on social media networks, until at least two years after services to the client cease.

9. A service provider shall not have sexual contact with a service recipient or a person that has been a service recipient.

10. A service provider shall refrain from providing service while impaired due to the service provider’s physical or mental health or use of medication, drugs or alcohol.

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11. A service provider shall evaluate a client’s progress on a continuing basis to guide service delivery and will make use of supervision and consultation as indicated by the service recipient’s needs.

12. A service provider shall refer a service recipient for needed services that the service provider is unable to provide and terminate service to a service recipient when continued service is no longer in the service recipient’s best interest.

13. A service provider shall not exploit his or her position of trust with a service recipient or former service recipient. A service provider may not accept gifts, services or other consideration from a service recipient.

14. A service provider shall have no direct or indirect financial interest in the assets, leases, business transactions or professional services of the agency.

15. A service provider is prohibited from receiving or giving preferential treatment to board members, other service providers or consultants in application for and receipt of services.

15. A service provider is prohibited from making or accepting payment or other consideration from another provider of services for referrals made or received.

16. Direct or indirect referral of applicants/service recipients to a private practice in which agency professional personnel, consultants, or the immediate families of personnel or consultants are engaged is expressly prohibited.

17. Transfer of service recipients to professional personnel or consultants who are leaving the agency for private practice will take place only with the written permission of the President/Chief Executive Officer.

18. Use of agency premises for private practice or personal gain is prohibited.

19. A service provider provides service in a manner that involves integrity in decision- making, emphasizes freedom of choice by the service recipient in determining the services to be delivered and gives preference to professional responsibilities over personal interests. When there is a conflict, it is the responsibility of the service provider to bring the case to the attention of his or her immediate supervisor for resolution of the conflict. Priority is always given to the needs and rights of the service recipient.

PROTECTION OF HEALTH AND SAFETY Family Service respects and protects the health and safety of the persons and families it serves. All facilities are in compliance with Americans with Disabilities Act (ADA).

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Family Service is licensed by the Texas Department of Aging and Disabilities and requires strict compliance with rules and regulations that protect the health and safety of the persons and families it serves. The State provides periodic and unannounced monitoring visits. All staff receives on-going training on delivery services that respect and protect the health and safety of the persons and families it serves in the office, in the community, and in the recipient’s home.

EMERGENCY PREPAREDNESS Basis of Policy: This policy is based upon the requirements contained within the Texas Administrative Code, including, but not limited to Title 40, Part 1, Chapter 97 and RULE: 97.256: Emergency Preparedness Planning and Implementation I.

II.

POLICY: This agency has developed, will maintain and implement the following Emergency Preparedness and Response Plan.

PROCEDURE 1. In the event of an emergency or disaster, Family Service must take the following actions:  The Agency Administrator and/ or Alternate Administrator will carry out the Emergency Preparedness and Response Plan.  Additional agency leaders may be involved as designated by the Administrator as necessary and may include direct service providers.

2. The following employees are designated to act as Disaster Coordinator:  Administrator  The Administrator may designate any employee to act as the Disaster Coordinator.

3. In the event of an emergency or disaster, this agency will take actions to provide all clients with the following:  Essential functions for client services  Critical personnel  Emergency financial needs 4. In the event of an emergency or disaster, the agency will release client information as allowed by law.

5. At initiation of services, all clients are given a copy of the document entitled, DISASTER PREPAREDNESS as well as SURVIVAL TIPS AND SHELTERING IN PLACE (see attached documents)

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Following a disaster, the agency will return to normal operations as quickly as possible.

6. The agency will develop and implement the Emergency Preparedness Response Plan in a drill prior to the annual review scheduled March of every year, if it has not been tested by an actual incident. The agency will conduct drills and procedures for communicating with staff and will report the results at the next regularly scheduled Performance Quality Improvement Plan (PQIP) and Management Cabinet meetings.

This will include:  The Administrator and /or Alternate Administrator will notify Program Manager to engage the drill.  Program Manager will notify Operations Supervisor/Coordinator who will then notify direct services staff.  Staff will contact each of their designated clients to notify them and to insure that they are prepared and safe.  The Program Manager will ensure that the drills and/or actual emergencies are placed on the agenda for the next scheduled PQIP committee meeting and Management Cabinet meeting.

Staff will then report any necessary information to Program Manager and/or Supervisor for further direction.

7.

Agency will have annual internal review of their written emergency response plan (to occur in the month of March every year) and after each actual emergency response, to evaluate effectiveness and to update the plan as needed. This includes follow up at the following scheduled PQIP meeting and Management Cabinet meeting along with documentation that direct care staff is current with any findings. In addition to the scheduled annual review of the policy, emergency preparedness planning and implementation will be reviewed following each actual emergency response, in order to evaluate effectiveness and to update the plan as indicated.

8. Program managers will be responsible for ensuring the above plan takes place as indicated. This includes:   

Scheduling of annual review of the Emergency Preparedness Plan.

Verifying that the review occurs during the scheduled program meeting in that same month Presenting the results of the review to the PQIP committee and Management Cabinet along with recommendations at the next scheduled PQIP and Management Cabinet meetings.

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FAMILY SERVICE ASSOCIATION OF SAN ANTONIO, INC. Professional Practices Acknowledgement Form

I have received, read and understand the procedures on Professional Practices and I will uphold and abide by all standards set forth in this document including the following:

Purpose Rights and Responsibilities De-escalation Practices Services to Minors Access and Eligibility Culturally Competent Practice Confidentiality and Privacy Protections Access to Case Records Case Record Reviews Procedures & Policies Participant Protections in Research Complaint and Grievance Procedures Ethical Conduct Protection of Health & Safety Emergency Preparedness Professional Practices Acknowledgement Form Case Review Confidentiality Form

________________________________________________ Signature of service provider ________________________ Date of signature

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FAMILY SERVICE ASSOCIATION OF SAN ANTONIO, INC. Case Review Confidentiality Acknowledgement Form

Peer to Peer Case Record Review and Agency Consistency and Standards Review

are subject to Agency and Council on Accreditation Confidentiality Standards.

Client Case Records and their confidentiality are addressed within the Family Service Professional Practices and the Family Service Employee Handbook. Below is an excerpt from the Family Service Employee Handbook. These documents should be referenced regularly to ensure individual and programmatic compliance with Confidentiality Standards.

It is the guideline of the Agency that the general internal business affairs of the organizations should not be discussed with anyone outside the Agency except as may be required in the normal course of business. Information designated as confidential is to be discussed with no one outside the organization and only discussed within the Agency on a “need-to-know� basis.

All employees have a responsibility to avoid unnecessary disclosure of non-confidential internal information about the company, its customers and its suppliers. The responsibility is not intended to impede normal business communications and relationships, but is intended to alert employees to their obligation to use discretion to safeguard internal Agency affairs. Employees who have authorized access to confidential information are responsible for its security. (excerpt from the Family Service Employee Handbook, pg 41).

As a member of the Family Service Quality Assurance Process, I agree to abide by Agency Policies and Procedures; Standards and Guidelines regarding Client and Agency Confidentiality. I understand that the files reviewed by me are considered Confidential Material and I will abide by Agency Confidentiality Standards.

________________________________________________ Signature of Staff Member/Volunteer _______________________ Date of signature

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