MedMark Treatment Centers by GiGi Williams

Administrative Policies and Procedures Manual

ADMINISTRATIVE POLICIES AND PROCEDURES MANUAL I.

MedMark Administrative Policies and Procedures Administrative Policies and Procedures Manual

II.

Human Resources HR-101 Background Check HR-102 Candidate and Physician Referral Program HR-103 Continuing Medical Education HR-104 Drug and Alcohol Policy HR-105 Employee Grievance and Appeal Procedures HR-106 Employee Hiring Procedures HR-107 Employee Separation Procedures HR-108 Exit Interviews HR-109 Family and Medical Leave of Absence HR-110 Georgia Random Drug Testing HR-111 Hiring of Independent Contractors HR-112 Initial and Ongoing Verification of Credentials HR-113 Interns and Volunteers HR-114 Job Postings and Promotion Guidelines HR-115 Jury Duty HR-116 Orientation and Annual Staff Training HR-117 Employee Feedback HR-118 Paid Time Off HR-118.1 Paid Time Off for Georgia Locations Only HR-119 Performance Reviews HR-120 Recruitment and Selection HR-121 Relocation Expenses Policy HR-122 Requisitions HR-123 Review of Contracted Personnel HR-124 RN On-Call Pay Practice For Vista Taos Only HR-125 Salary Administration HR-126 Supervision of Clinical or Direct Service Personnel HR-127 Unplanned Absences of Personnel HR-128 Annual Awards Program

III.

Finance and Accounting F&A-101 Annual Budget Process F&A-102 Authorization for Allowing Extended Payment Terms at Vista Taos and Casa Feliz F&A-103 Authorization of Company Obligations F&A-104 Capital Expenditure Policy F&A-105 Cash Control and Fraud F&A-106 Credit and Collection Policy F&A-107 Collection and Deposit F&A-108 Petty Cash F&A-109 Service Fees F&A-110 Travel Policy

IV.

Compliance Code of Conduct Corporate Compliance Program

Legal L-101 L-102 L-103 L-104 L-105 L-106 L-107 L-108

Contract Approval Patient Records: Retention and Destruction Business Records: Retention and Destruction Legal Procedures and Confidentiality Guidelines Critical Incident Reporting and Management Critical Incident Review OTP Sentinel Events and Reporting Procedures DEA Registrations and Power of Attorneys

VI.

Information Technology End User Computing Policy

VII.

HIPAA HIPAA-101 HIPAA Policies and Procedures Manual

VIII.

Marketing/Media M-101 Media Relations and Communications

IX.

Clinical Compliance CC-101 Clinical Compliance and Quality Review CC-102 Rights and Responsibilities

Health and Safety H&S-101 External Inspections of Facilities H&S-102 Safety Self-Inspections of Facilities ii

H&S-103 H&S-104 H&S-105 H&S-106 H&S-107 H&S-108 H&S-109 H&S-110 H&S-111

Emergency Disaster Plans and Drills: Fire Emergency Disaster Plans and Drills: Bomb Threats and Evacuations Emergency Disaster Plans and Drills: Natural Disasters/Severe Weather Emergency Disaster Plans and Drills: Medical Emergencies Emergency Disaster Plans and Drills: Workplace Threats and Violence Emergency Disaster Plans and Drills Utility Failures Emergency Information Dissemination Incidents Involving Injury

iii

Administrative Policies and Procedures

Administrative Policies & Procedures TOPIC:

ADMINISTRATIVE MANAGEMENT

SUBJECT:

ADMINISTRATIVE POLICY AND PROCEDURE MANUAL

Effective Date:

January 1, 2013

Revised Date:

NONE

PURPOSE To establish the procedures for the development, review and approval of the MedMark Services, Inc. Administrative Policy and Procedure Manual. POLICY MedMark seeks to establish administrative policies to align operations, set expectations, and communicate responsibilities throughout MedMark through an administrative policy and procedure manual in accordance with the procedures stated herein. PROCEDURES 1. MedMark will develop and maintain an Administrative Policy and Procedure Manual (the “APPM”). The APPM will contain policies governing administrative expectations and responsibilities. The APPM will apply to all MedMark employees, independent contractors, interns, and volunteers. 2. All references in the APPM to “MedMark Services, Inc.,” “MedMark,” “MIS,” and “the Company” shall mean MedMark Services. Inc. 3. The CEO, Department Heads, and General Counsel will review and approve each policy proposed for the APPM. Only policies and procedures approved by the individual Department Head, CEO, and General Counsel will be included in the APPM. 4. Each approved policy and procedure will be labeled to reflect: (a) the effective date, and (b) the date revised, if any. 5. The CEO, Department Heads, and General Counsel will annually conduct a comprehensive review of all policies in the APPM. The comprehensive review will include: a. b. c. d.

Determine whether a policy is still necessary, Determine whether a policy should be combined with another policy, Determine whether the purpose and goal of the policy is still being met, Determine if changes are required to improve the effectiveness or clarity of the policies and procedures, e. Ensure that the appropriate education, monitoring, and ongoing review of the policy is occurring. Administrative Policies & Procedures – Administrative Policy and Procedure Manual

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Administrative Policies & Procedures 6. Department Heads are responsible for ensuring that their policy and procedure information is correct, accurate, and readable. Department Heads are also responsible for monitoring compliance, measuring effectiveness, and evaluating feedback. 7. New policies or proposed changes to existing policies must be presented to the CEO and General Counsel for review. If approved, the new policy or revised policy will be included in the APPM and distributed. 8. The APPM and updates to the APPM will be communicated and distributed to all employees. The APPM will be on ExponentHR. 9. Individual programs/clinics may adopt program-specific policies that are not inconsistent with the APPM policies and procedures. Program-specific policies shall be reviewed and approved by the CEO, General Counsel, and Regional Vice President. Program-specific policies shall be distributed and maintained on-site in a format readily available to all employees.

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II. Human Resources

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

BACKGROUND CHECK POLICY

POLICY NO.:

HR-101

Effective Date:

October 1, 2006

Revised Date:

January 27, 2012, January 1, 2013

POLICY

VA CBOC Clinics are excluded from this procedure. background checks.

They follow the VA procedure for

All employees and patient care independent contractors will undergo a background check. It is the policy of MedMark Services that all background checks must be requested prior to the date the employee is to begin work.

II.

PROCEDURES

All candidates must complete the appropriate information form to initiate a background check before the company representative requests any background information. No background checks should be conducted unless the candidate has been offered employment OR is a final candidate for the position.

Background checks for employees will be processed by the HR Coordinator. Once results are obtained they must be reviewed to ensure a satisfactory background. If there is a conviction of any kind, the background check results must be approved, dated and signed by the Program Director.

If the decision is made not to employ the candidate based on the results of the background check the HR Coordinator must be informed so that the required letter and affidavit is sent to the applicant notifying them of that decision. This is a federal requirement under the Fair Credit Reporting Act (FRCA). (Details below.)

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Administrative Policies & Procedures D.

Background reports for candidates that are NOT hired should be shredded. Background reports for candidates who become employees should be placed into their HR file.

To determine whether or not to continue employment based on results of a background check, the following may be considered:

What is the conviction, is it a misdemeanor or a felony?

How long ago was the conviction? (ex: was it 12 months ago or 12 years ago?)

How did they answer the question, “Have you ever been convicted or plead guilty to a criminal offense?” on the application?

As with all terminations, the hiring staff member must work with the HR Director or HR Generalist on the decision to terminate, rescind an offer, or not hire a candidate based on the results of the background check.

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

CANDIDATE AND PHYSICIAN REFERRAL PROGRAM

POLICY NO.:

HR-102

Effective Date:

August 22, 2012

Revised Date:

January 1, 2013

POLICY

The Candidate Referral Program is designed to reward an employee who refers a qualified candidate hired within the MedMark organization as a regular full-time employee. The Physician Referral Program is designed to reward an employee or contractor who refers a qualified physician candidate hired or contracted within MedMark Services, Inc. as a physician, psychiatrist, or nurse practitioner.

II.

PROCEDURES A.

This program applies to all MedMark Services full-time or part-time employees. Any human resources employee and/or any manager with hiring authority for the open position is not eligible to receive a referral bonus.

To be eligible for an award, a referral must be submitted to Human Resources and must include a Candidate Referral Form and a resume or employment application.

To qualify for payment the referring employee must be actively employed by MedMark Services at the time of the referral bonus payment.

The referral must represent the candidate’s initial contact with MedMark Services. Temporary, summer, contract and former employees of MedMark Services are not eligible for referral awards.

In situations where multiple employees have referred the same candidate, the referral award will be paid to the employee who submitted the referral first.

The referral bonus paid is less applicable taxes.

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Administrative Policies & Procedures G.

The referral candidate must be in good standing and remain employed with MedMark Services for at least 90 days before a referral payment is made.

The referral awards are as follows:

Position Administrative Assistant / Medical Assistant / Lab Tech LPN or LVN Pharmacy Technician Social Worker, Counselor or other Behavioral Health Practitioner Dietician Program Director, Clinic Administrator, or other Management position

Amount $300 $500 $500 $750 $750 $1000

Nurse Practitioner or Physician’s Assistant (whether FT or PT) Physician or Psychiatrist (whether FT or PT)

$1,000 $2,000

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Candidate Referral Form Date: Referral Candidate’s Name: (Please Print)

Position Applied For: (Please Print)

(Location) Referring Employee’s Name: (Please Print)

I have read and understand the Employee and / or Physician Referral Program Guidelines.

Referring Employee’s Signature

Date

Human Resources

Date

Fax this form along with the candidate’s resume or application to Human Resources @214.550.2653 and give the original copy to your Program Director or Clinic Administrator.

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

CONTINUING MEDICAL EDUCATION

POLICY NO.:

HR-103

Effective Date:

June 1, 2008

Revised Date:

January 1, 2013

POLICY

MedMark Services understands that all licensed Physicians and Physician Assistants/Nurse practitioners are required to maintain their credentials by participating in continuing medical education sessions offered by various organizations throughout the year. To support our providers in completing these requirements the company offers a stipend toward meeting the cost of such continuing medical education (CMEs). The following is a summary of our CME benefit effective June 1, 2008. II.

PROCEDURES A.

Who is eligible 1.

All Full time physicians, physician assistants, nurse practitioners.

What they get 1.

Physicians get a $2,000 annual stipend and 5 days of CME time.

Physician assistants and nurse practitioners get a $1,000 stipend and 2 days of CME time. If the employee voluntarily leaves the company within 12 months of the day of their training, they will be responsible to repay the prorated share of the cost of the CME benefit they received.

CME time is monitored on a calendar year basis. Unused CME balances or days will not be carried over into the following year.

Attendance at trainings by all other employees must be agreed to in advance between the immediate supervisor and the employee and be applicable to the needs of both the company and the employee.

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Administrative Policies & Procedures C.

How they get it 1.

Individuals must complete a “CME Reimbursement Application” to obtain approval for time off and cost. A 90-day notice must be given prior to taking the CME.

The requestor must complete the form and forward it to their supervisor for approval/processing prior to the course / seminar start date.

Licenses and certifications required to perform one’s duties belong to the respective individual and as such must be maintained by that person. MedMark Services does not reimburse the cost for such obtaining or maintaining such licenses and certifications for employees hired after January 1, 2008. For those employees hired prior to January 1, 2008 and for whom MedMark Services reimbursed the cost of CEU credits, they will be grandfathered and will be reimbursed in the same manner that they had been previously. This grandfathering will end on March 31, 2013.

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APPLICATION FOR CME REIMBURSEMENT ****Must be submitted and approved before the course / seminar begins**** To be completed by Employee prior to course start date (submit one application per course): Name:

Date:

Location:

Title:

Name of course / seminar: Date(s) of course / seminar: Cost of course: Anticipated cost of travel and other related expenses (please be specific)

**** Attach course description with cost information****

Circle One:

Approved

Denied

Director, VA Operations:

Date:

AND National Medical Director, VA:

Date:

Regional VP, OTP:

Date:

OR President, Executive Director, Glass:

Date:

AND VP OTP Operations:

Date:

Once approved send copy to Employee

**** This section to be completed when requesting reimbursement**** Attach all receipts to the approved application along with proof of successful completion of course / seminar. Scan all documents and attach to the expense report in ExponentHR. Print and sign expense report summary, attach original receipts and mail to Deborah Heitzman at the National Support Center for reimbursement. 01/01/13

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

DRUG AND ALCOHOL POLICY

POLICY NO.:

HR-104

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

The Company has a strong commitment to its employees, patients and the public to provide a safe, healthy and secure workplace and to establish programs promoting high standards of employee productivity, quality, security, safety and health. The Company requires all employees to perform their job duties unimpaired by prohibited substances. Practical experience and research has proven that even small quantities of illegal and controlled substances or alcohol can impair judgment and reflexes. Even when not readily apparent, this impairment can have serious results, particularly for employees operating vehicles or potentially dangerous equipment. Drug-using employees are a threat to co-workers, the public, and themselves, and may make costly errors. For these reasons, MedMark Services has adopted a policy that all employees must report to work completely free from the effects of alcohol and/or the presence of drugs, unless used as prescribed by a physician. This policy will be enforced to provide a safe workplace for all employees. Employees should understand that a positive drug or alcohol test is not a necessary prerequisite to discipline if this policy or any other work rule has been violated. The use of illegal drugs and the misuse of alcohol or legal drugs are inconsistent with the behavior expected of employees, are injurious to the employee’s health and subject the Company to unacceptable risk or workplace accidents or other failures that would undermine ability to operate effectively and efficiently. Accordingly, as a result of these laws, the Company has adopted the following drug and alcohol policy. It is the intent of the Company to, at all times, be in compliance with applicable federal, state and local laws. To the extent any portion of this Policy is in conflict with such applicable law, it shall be deemed modified so as to conform to such law. For the purposes of this policy the term “drug” includes alcoholic beverages, prescription drugs as well as illegal inhalants and illegal drugs. Illegal drugs include controlled substances such as, but not limited to, marijuana, cocaine, opiates, amphetamines and PCP. The term “illegal drug” means any drug which (1) cannot be legally obtained; (2) can be legally obtained but was not legally obtained; or (3) is being used in a manner or for a purpose other than that for which it was prescribed or manufactured. This definition includes any controlled substances; any other drugs, the manufacture, distribution, dispensation, possession, use, or purchase of which is unlawful under state or federal law; and hazardous inhalants. “Improper use of legal drugs” refers to the use of prescription medication and/or over-the-counter medication which are legally obtained but which are not being used solely in a manner and for the purpose for which they were prescribed or manufactured. Administrative Policies & Procedures - HR Drug and Alcohol

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Administrative Policies & Procedures II.

PROCEDURES

1. General 1.1

It is the Company’s policy to maintain a drug free workplace. Employees are prohibited from the use, being under the influence, possession, purchase, dispensation, distribution, or manufacture of any illegal drug or alcohol on the Company’s premises, while performing services for the Company, or during working hours. Company property includes all facilities in which the Company conducts business, offices, buildings, equipment, vehicles driven for Company purposes and parking areas whether owned, leased, used or under the control of the Company.

1.2

The use or being under the influence of a legal drug on the Company’s premises, while performing services for the Company, or during working hours also is prohibited if such use might impair in any manner an employee’s ability to safely, efficiently, and completely perform his/her job, or might otherwise adversely affect the Company in the conduct of its business operations. Employees should notify their supervisor if he/she is or potentially may be using any such legal drug.

1.3

Any employee convicted of a criminal drug statute violation occurring in the workplace must notify his/her supervisor in writing within five (5) days of the conviction. The Company also prohibits reporting to work or performing services for the Company while impaired by prohibited substances.

1.4

Employees who abuse alcohol off the job run the risk of jeopardizing the safety of themselves, their family, the public, and the Company. Whenever such usage interferes with the Company’s ability to carry out its responsibilities, or increases potential liability for the Company, discipline, up to and including termination of employment, may be imposed. Employees who are convicted of or plead guilty to alcohol-related off-the-job activities may be considered in violation of this policy. The Company will consider the nature of the charges and other factors relative to the impact of the employee’s conviction or plea upon the conduct of the Company’s business.

1.5

Employees in violation of this policy and/or convicted of any criminal drug statute violation occurring in the workplace will be subject to discipline up to and including termination, or may, at the Company’s sole discretion, be required to satisfactorily participate in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, state or local health, law enforcement or other appropriate agency as determined by the Company. The Company will take action pursuant to the foregoing within thirty days of notification of a conviction or violation of this policy.

1.6

Violation of this policy will result in disciplinary action up to and including termination of employment.

2. Alcohol Consumption 2.1

Each employee is viewed as a representative of the Company, whether at work or at Companysponsored events. Employees may occasionally find themselves in situations where alcoholic beverages are being consumed at an after-hours event sponsored by the Company or an off-site event where employees’ attendance is being funded by the Company. The Company does not

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Administrative Policies & Procedures have a policy prohibiting consumption of alcohol in these instances, but the Company does have an expectation that such consumption will be in moderation so as not to reflect poorly on the Company’s professional reputation or expose the Company to undue legal liability involving the safety of others. 2.2

After consuming alcohol at such a function, employees should not drive or otherwise engage in any hazardous activity.

2.3

Possession, consumption or being under the influence of alcohol on Company premises, while performing services for the Company, or during working hours is prohibited.

2.4

A Breath Alcohol Concentration (BrAC) of .04 or greater will be accepted as presumptive evidence of violation of this policy. Evidential breath testing devices (EBTs) on the National Traffic Highway Safety Administration Conforming Products List will normally be used to determine BrAC.

3. Substance Screening 3.1

Applicants (Pre-Employment/Initial) 3.1.1

3.2

Substance screening may be required for all final applicants following a conditional job offer. Applicants are required to sign a consent/release form before submitting to screening. Applicants will be disqualified for hire if they test positive for drugs or adulterants, refuse to submit to a test, or refuse to execute the required consent/release form.

All Current Employees 3.2.1

Reasonable Suspicion 

All employees may be required to submit to screening whenever a supervisor observes circumstances which provide reasonable suspicion to believe an employee has used alcohol or a controlled substance or has otherwise violated the Company’s drug and alcohol policy. The determination that reasonable suspicion exists to require the employee to undergo an alcohol and drug test must be based on observations concerning the appearance, behavior, speech or body odors of the employee.



The supervisor/manager requesting testing shall prepare and sign written documents explaining the circumstances and evidence upon which they relied within 24 hours of the testing, or before the results of the tests are released, whichever is earlier. While one supervisor/manager may request a reasonable suspicion test, when feasible, supervisors/managers are encouraged to obtain a second supervisor/manager as a witness. No reasonable suspicion testing shall be administered without the express written and/or verbal authorization from the Human Resources Director, Compliance Officer or CEO.

3.2.2

Random Testing (Fitness-for-Duty) 

The Company may conduct random unannounced drug and alcohol screening of all

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Administrative Policies & Procedures employees. There will be no maximum number of samples that any one individual will be required to provide during the testing schedule. The list of employees in the random pool will be updated on an as needed basis. Employees may be required to report to the Company’s designated collection site for testing immediately following notification. No random testing shall be administered without the express written and/or verbal authorization from the Human Resources Director or the Compliance Officer or CEO. 4. Testing Procedure 4.1

General Guidelines 4.1.1

4.2

Substances Tested For 4.2.1

4.3

The Company and its lab shall rely on the guidance of the federal Department of Transportation, Procedures For Transportation Workplace Drug Testing Programs, 49 C.F.R. Parts 40, as amended, and on the further guidance of the Omnibus Transportation Employee Testing Act provided in 49 C.F.R. Parts 382, 391, 392 and 395, as amended, and any state and locality specific statutes. Relative to the protocols for determining dilute, substituted or adulterated specimens, the Company will rely on the guidance issued by the Substance Abuse and Mental Health Service Administration in its program documents related to this issue.

All Employees may be tested for alcohol, amphetamines, cannabinoids, cocaine, opiates, phencyclidine, barbiturates, benzodiazepines, methadone, methaqualone, and propoxyphene. Testing for alcohol will be conducted subject to the Omnibus Transportation Employee Testing Act of 1991, as amended and 49 CFR Part 40, as amended. The Company reserves the right to test for additional controlled substances without additional notice.

Testing Procedure 4.3.1

The Company reserves the right to utilize, any form of testing, including, but not limited to, blood, hair, breath, saliva or urinalysis testing procedure. All drug testing will be laboratory-based testing at SAMHSA-certified laboratories with certification by Medical Review Officer (MRO).

5. Collection Sites 5.1

The Company will designate collection sites in areas where it maintains facilities or job sites where individuals may provide specimens.

6. Collection Procedure 6.1

The Company, Employers Drug Program Management, and the laboratory, have developed and will maintain a documented procedure for collecting, shipping and accessing specimens.

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Administrative Policies & Procedures 7. Occasions When Collection Personnel Should Directly Observe the Specimen Being Provided 7.1

The Company has adopted the direct observation procedure as set out in Section 40.67 of the Department of Transportation regulations as amended. An employer or medical representative at the collection site may directly observe an employee provide the specimen where there is reason to believe that an individual may alter or substitute the specimen. Section 40.67 sets out the only circumstances where direct observation is appropriate: (1)

An employer must direct an immediate collection under direct observation with no advance notice to the employee if: (a) The laboratory reported to the MRO that a specimen is invalid, and the MRO reported to the employer that there was not an adequate medical explanation for the result. (b) The MRO reported to the employer that the original positive, adulterated or substituted test result had to be cancelled because the test of the split specimen could not be performed.

(2)

An employer MAY direct a collection under direct observation of an employee if the drug test is a return-to-duty test or a follow-up test.

(3)

A collector must immediately conduct a collection under direct supervision if: (a)

The collector observes materials brought to the collection site or the employee’s conduct clearly indicates an attempt to tamper with a specimen;

(b)

The temperature on the original specimen was out of range; or

(c)

The original specimen appeared to have been tampered with.

The collector or the employer must explain to the employee the reason for the direct observation. 8. Evaluations and Return of Results to the Company 8.1

The laboratory will transmit (by fax, mail, or computer, but not orally over the telephone) the results of all tests to the Company's MRO. The MRO will be responsible for reviewing test results of employees and confirm that the individuals testing non-negative have used drugs or adulterated or substituted the specimen in violation of the Company policy. Prior to making a final decision, the MRO shall give the individuals an opportunity to provide a medical explanation for the positive, adulterated, or substituted test result either face to face or over the telephone.

8.2

The MRO shall then promptly report to the Designated Employer Representative which employees or applicants test positive.

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Administrative Policies & Procedures

9. Request for Retest and Statement of Explanation 9.1

Where a split specimen has been collected an employee may request a retest of the split specimen within 72 hours of notification of the final test result. Where a single specimen is submitted for testing the employee may request a retest of the original sample within 72 hours after notification of the final test result. Requests must be submitted to the MRO. A donor is not allowed to have his or her specimen reconfirmed for an adulterant if the original sample has tested positive for one. The employee may be required to pay the associated costs of retest in advance.

9.2

The employee or job applicant who receives a positive verified test result from the MRO may contest or explain the result to the Designated Employer Representative within five (5) working days after receiving notification of the test result.

10. Statement of Confidentiality 10.1

The Company, beyond the MRO and Company’s management, without the individual’s written authorization, shall not release test results. However, all employees will be required to execute a consent/release form permitting the Company to release test results and related information to its workers’ compensation provider, the workers' compensation, unemployment compensation commissions, and/or other relevant government agencies and/or legal proceedings.

10.2

The MRO shall retain the positive test results for five (5) years and negative test results for twelve (12) months.

10.3

All information, interviews, reports, statements, memoranda, and test results, written or otherwise, received through Company’s substance use testing program shall be held as confidential communications by the Company’s MRO, laboratories, drug and alcohol rehabilitation programs, employee assistance programs, and their respective agents. These communications may be used or received in evidence, obtained in discovery, or disclosed in any civil or administrative proceeding. Release of such information under any other circumstance shall be solely pursuant to a written consent form signed voluntarily by the individual that was tested, unless the release is compelled by an agency of the state or a court of competent jurisdiction or unless deemed appropriate by a professional or occupational licensing board in a related disciplinary proceeding.

11. Employer Discipline for Policy Violations 11.1

The Company will discipline, including termination of employment, employees for any violation of the policy, including refusing to submit to screening, to execute a release, or otherwise cooperate with an investigation or search by the Company. Disciplinary measures will be instituted in accordance with state and federal laws.

11.2

An MRO-verified positive test, an adulterated/substituted test, a refusal to test for alcohol/drugs, or any other violation of Company policy will result in disciplinary action, up to and including termination of employment.

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Administrative Policies & Procedures 12. Employee Responsibility 12.1

It is a condition of employment, and continuing employment, that all employees comply with the terms of this policy.

12.2

Any employee who reports to work or performs services for the Company while impaired by the use of alcohol, illegal drugs or improper use of legal drugs will be subject to discipline up to and including termination of employment.

12.3

The decision to seek early diagnosis and accept treatment for a drug or alcohol problem is the primary responsibility of the employee. Employees are urged to use any qualified rehabilitation program to get corrective help.

12.4

An employee who is convicted of a criminal drug statute violation occurring in the workplace must notify his/her supervisor in writing no later than five (5) days after such conviction. Failure to provide such notice will result in discipline up to and including termination.

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

EMPLOYEE GRIEVANCES AND APPEALS PROCEDURE

POLICY NO.:

HR-105

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

II.

POLICY A.

The company is committed to helping its employees solve problems. Part of this commitment is encouraging an open and frank atmosphere in which any problem, complaint, suggestion, or question receives a timely response from the company's supervisors and management.

The company strives to ensure fair treatment of all employees. Supervisors, managers, and employees are expected to treat each other with mutual respect. Employees are encouraged to offer positive and constructive criticism.

If employees disagree with established rules of conduct, policies, or practices, they can express their concern through the problem resolution procedure. No employee will be retaliated against or penalized, formally or informally, for voicing a complaint with the company in a reasonable, business-like manner, or for using the problem resolution procedure.

If a situation occurs when employees believe that a condition of employment or a decision affecting them is unjust or inequitable, they are encouraged to bring those issues to management's attention using the same procedure described in the Employee Handbook.

PROCEDURES A.

Employee presents problem to immediate supervisor preferably immediately after incident occurs. If supervisor is unavailable or employee believes it would be inappropriate to contact that person, employee may present problem to any other member of management or the Human Resource Department.

Supervisor responds to problem during discussion or after consulting with appropriate management, when necessary. Supervisor documents discussion.

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Administrative Policies & Procedures C.

Employee contacts the Human Resources Department if the problem is unresolved.

The Human Resources Department counsels and advises employee.

Human Resources Department reviews and considers problem. Human Resources will communicate with Senior Management when in its judgment further information or discussions are required. The company informs employee of decision and forwards copy of written response to employee's file.

Not every problem can be resolved to everyone's total satisfaction, but only through understanding and discussion of mutual problems can employees and management develop confidence in each other. This confidence is important to the operation of an efficient and harmonious work environment, and helps to ensure everyone's job security.

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

EMPLOYEE HIRING PROCEDURES

POLICY NO.:

HR-106

Effective Date:

October 1, 2006

Revised Date:

August 2, 2012, January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to seek and employ the most qualified personnel and to do so in a manner which will not discriminate against any person because of race, color, ancestry, religious creed, national origin, sex, marital status, disability, medical condition, sexual preference, genetic background information or age. A.

Relatives 1.

The employment of relatives or individuals involved in a dating relationship in the same area of an organization may cause serious conflicts and problems with favoritism and employee morale. In addition to claims of partiality in treatment at work, personal conflicts from outside the work environment can be carried over into day-to-day working relationships.

For purposes of this policy, a relative is any person who is related by blood or marriage, or whose relationship with the employee is similar to that of persons who are related by blood or marriage. A dating relationship is defined as a relationship that may be reasonably expected to lead to the formation of a consensual "romantic" or sexual relationship.

Relatives of current employees may not occupy a position that will be working directly for or supervising their relative. It is the responsibility of relatives to inform their supervisor(s) if they have another relative working in the company as soon as they are aware. Individuals involved in a dating relationship with a current employee may also not occupy a position that will be working directly for or supervising the employee with whom they are involved in a dating relationship. The company also reserves the right to take prompt action if an actual or potential conflict of interest arises involving relatives or individuals involved in a dating relationship who occupy positions at any level (higher or lower) in the same line of authority that may affect the review of employment decisions.

Administrative Policies & Procedures – HR Employee Hiring Procedures

Page 1 of 4

Administrative Policies & Procedures

II.

If a relative relationship or dating relationship is established after employment between employees who are in a reporting situation described above, it is the responsibility and obligation of the supervisor involved in the relationship to disclose the existence of the relationship to management.

In other cases where a conflict or the potential for conflict arises because of the relationship between employees, even if there is no line of authority or reporting involved, the employees may be separated by reassignment or terminated from employment. Employees in a close personal relationship should refrain from public workplace displays of affection or excessive personal conversation.

Applicants for employment will only be considered after they have completed an application for employment. Applications will remain active for a period of six (6) months. After such time, applicants must submit another completed application in order to be considered for any open position.

PROCEDURES A.

A completed application must be submitted by each applicant to either a Supervisor or the Human Resources Representative. If the application is given to the Supervisor, the Supervisor shall fax a copy of completed application to the Human Resources Representative. Whenever possible, applications should be completed at the place of business. A completed application must include: 1.

Applicant information

Applicant experience

Applicant references

Applicant signature and date

Incomplete applications will be returned to the applicant for completion.

Supervisor may conduct the interview; applicants should be interviewed by at least 2 different Supervisors, when possible. Make sure the applicant has an application filled out before interviewing and checking references.

Supervisor shall provide the applicant with a job description.

Applicants shall be informed of company benefits and general working conditions during the interviewing process.

Administrative Policies & Procedures – HR Employee Hiring Procedures

Page 2 of 4

Administrative Policies & Procedures F.

Prior to the Program Director hiring an applicant, he/she must send and obtain approval using a “Request for Additional Staffing” signed by the Regional Director of Operations, Director of Human Resources, Chief Financial Officer and Chief Executive Officer.

The Program Director will: 1.

Review all applications

Selects the person that they would like to hire and makes a condition offer of employment.

Have the person sign a release of information for MTC to facilitate a background check and a letter indicating where the person should report to submit a pre-employment drug screen.

Fax and send the Release of Information for the background check and Application to the Human Resources Representative

Complete reference checks.

Complete verification of credentials.

Obtain results from background check and pre-employment drug screen from the Human Resources Representative

Unless the results from the references, background check, drug screen or credentials turn up problematic, the person is given an offer letter and start date. The entire personnel file is sent to the Human Resources Representative at the National Support Center. A copy of the personnel file is also maintained on-site.

Selection, Compensation and Rate of Pay shall be non-discriminatory.

Personnel Records 1.

At a minimum, personnel records should contain: a.

The employment application or resume

Verification of credentials, including certification, licensure, or registration, when applicable, and / or competencies

Evidence of orientation

Performance Evaluation Reports

Administrative Policies & Procedures – HR Employee Hiring Procedures

Page 3 of 4

Administrative Policies & Procedures e.

A background check and a release of information for a background check

TB test, chest X-ray, or completed questionnaire

Emergency Contact Information

Verification of First staff only)

Verification that the employee received their employee handbook

Signed attestation stating compliance program

Other information required by law

Administrative Policies & Procedures – HR Employee Hiring Procedures

Aid / CPR certification (for medical

acceptance

company

Page 4 of 4

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

EMPLOYEE SEPARATION PROCEDURES

POLICY NO.:

HR-107

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

MedMark Services, Inc. asks that employees give advanced notice when voluntarily resigning from a position. In regard to terminations, termination proceedings will be prompt and in accordance with company policy. II.

PROCEDURES A.

RESIGNATION 1.

Resignation is a voluntary act initiated by the employee to terminate employment with the company. Although advance notice is not required, the company requests at least 2 weeks' written notice of resignation from nonexempt employees, 4 weeks' notice from exempt employees, nurses and counselors, and 90 days from all Medical Providers including Physicians, Physician Assistants, and Nurse Practitioners.

TERMINATION 1.

The Program Director shall pull employee’s personnel file to review all documentation that has led to the termination.

The Program Director shall present all of the documentation that has led to the decision to terminate and discuss the decision with the Regional Director of Operations and the Director of Human Resources.

The Regional Director of Operations or the Director of Human Resources of MedMark Services, Inc. will have an opportunity to advocate for the employee, or discuss any legal issues that may occur based on the documentation or support the termination prior to termination actions with the employee.

Administrative Policies & Procedures – HR Employee Separation Procedures

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

EXIT INTERVIEWS

POLICY NO.:

HR-108

Effective Date:

None

Revised Date:

NONE

POLICY

II.

PROCEDURES

[UNDER DEVELOPMENT BY HR]

Administrative Policies & Procedures – HR Exit Interviews

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

FAMILY AND MEDICAL LEAVE OF ABSENCE (FMLA)

POLICY NO.:

HR-109

Effective Date:

February 15, 2012

Revised Date:

NONE

POLICY

Under the federal Family Medical Leave Act (“FMLA”) and the California Family Rights Act (“CFRA” ), Regular full-time employees are eligible to take up to 12 weeks of unpaid FMLA Leave within any 12 month period and be restored to the same or an equivalent position upon your return from leave provided you: (1) have worked for an otherwise covered worksite employer or for The company for at least 12 months, (2) have worked for at least 1,250 hours in the last 12 months, and (3) are employed at a worksite that has 50 or more The company employees within 75 miles from the location from which you were assigned. A "rolling" 12 month period measured backwards from the date you take leave will be used for computing the period within which the 12 weeks of leave may be taken. If you and your spouse both work for The company, the maximum amount of FMLA Leave available to you and your spouse for reasons (1) and (2) below is a combined total of 12 weeks. If you live in a state, county, or city which provides more generous benefits, you will be given those benefits. Please check with the Human Resources Department for any local variations applicable to this policy. To be covered under the CFRA, you must work in the state of California. II.

PROCEDURES A.

Reasons for Leave 1.

You may take FMLA Leave for any of the following reasons: (1) the birth of a son or daughter and to care for such son or daughter; (2) the placement of a son or daughter with you for adoption or foster care and to care for the newly placed son or daughter; (3) to care for a spouse, son, daughter or parent ("covered relation") with a serious health condition; or (4) because of your own serious health condition which renders you unable to perform an essential function of your position. Leave because of reasons (1) or (2) must be completed within the 12 month period beginning on the date of birth or placement.

Notice of Leave 1.

To request leave, you must notify the company of your need for leave by completing a Request for FMLA Leave Form available from your

Administrative Policies & Procedures – HR FMLA Policy

Page 1 of 4

Administrative Policies & Procedures supervisor or the Human Resources Department. You should give 30 days' prior written notice, or as much advance written notice as possible, to your supervisor and/or your Human Resources professional. However, if it appears that you may be absent due to a FMLA-qualified event or serious health condition, the company may preliminarily designate your time off as FMLA Leave, pending the receipt of documentation from you. Failure to provide requested FMLA Leave documentation and certification within the time limits requested will result in the company making a determination on your leave status without such documentation. The company may delay or deny leave, demand that you return to work, treat absences as unauthorized time off which could subject you to discipline up to and including termination, and/or discontinue your FMLA Leave. C.

Medical Certification 1.

If you are requesting FMLA Leave for a serious health condition (reasons (3) or (4)), you and the relevant health care provider must supply appropriate medical certification. You may obtain the Medical Certification Form from your supervisor or the Human Resources Department. Whenever possible, the Medical Certification should be supplied before the leave begins. Further, the company, at no expense to you, may require an examination by a second health care provider designated by the company. If the second health care provider's opinion conflicts with the original medical certification, the company, at no expense to you, may require a third, mutually agreeable, health care provider to conduct an examination and provide a final and binding opinion. The company may require a subsequent medical recertification. Failure to provide requested certification within 15 days, if such is practicable, may result in delay of further leave until it is provided, and/or may subject you to discipline up to and including termination for taking unauthorized leave or excessive absenteeism.

While On Leave 1.

If you take leave because of your own serious health condition or to care for a covered relation (reasons (3) or (4)), you must contact your supervisor and or the HR Department as soon as possible if there is a change in your leave status. In addition, you must give notice to your supervisor and the Human Resources Department as soon as practicable (within 2 business days, if feasible) if the dates of leave change, are extended or initially were unknown.

Administrative Policies & Procedures – HR FMLA Policy

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Administrative Policies & Procedures E.

Intermittent and Reduced Scheduled Leave 1.

Leave because of a serious health condition (reasons 3 and 4) may be taken intermittently (in separate blocks of time due to a single health condition) or on a reduced leave schedule (reducing the usual number of hours you work each workday) if medically necessary. You will receive your current rate of pay for hours worked and time spent working will not count against your available FMLA Leave. In addition, while you are on an intermittent or reduced schedule leave, The company may temporarily transfer you to an available alternative position which better accommodates your recurring leave and which has equivalent pay and benefits.

Leave is Unpaid 1.

FMLA Leave is unpaid leave. Pay that will end during Leave includes all forms of compensation paid by the company to you, including but not limited to wages, bonuses, commissions and discounts. You are required to use any accrued paid time off for the applicable FMLA Leave, unless you are currently receiving workers' compensation benefits. FMLA Leave does not affect your eligibility, if any, for short or long term disability payments and/or workers' compensation benefits under those insurance plans.

For more information regarding use of your accrued paid time off, or eligibility for disability and/or workers compensation insurance payments, call the Human Resources Department and refer to the plan documents (which are controlling).

FMLA Leave runs concurrently with any other applicable paid or unpaid leave. Using available paid time off, short-term disability or workers' compensation will not extend your leave time beyond the maximum time allowed of 12 weeks of FMLA Leave per 12 month period.

Medical and Other Benefits 1.

During an approved FMLA Leave, the company will maintain your health and other benefits, as if you continued to be actively employed. However, you must continue to pay your portion, if any, of the group health plan premiums or your benefits may be cancelled. Accrual of benefits such as paid time off will be suspended during the duration of the leave. Accrual of seniority will also be suspended during the leave and your annual review date will be adjusted accordingly. If you return to work owing any employer-made contributions to your insurance premiums to maintain coverage during your leave, you will be required to reimburse the company through payroll deduction immediately upon return. If you elect

Administrative Policies & Procedures – HR FMLA Policy

Page 3 of 4

Administrative Policies & Procedures not to return to work at the end of the leave period, you will be required to reimburse the company for contributions to the health insurance premiums made to maintain coverage during your leave, unless you cannot return to work because of a serious health condition or because of other circumstances beyond your control. H.

Returning From Leave 1.

When you are able to return to work following a leave because of your own serious health condition, you should attempt to give the company at least one week's notice by mailing or faxing to your supervisor or the Human Resources Department a medical certification stating that you are able to resume work. However, you must make sure that the company receives this notice no later than 2 business days before your return to work at the conclusion of your leave. If your FMLA Leave resulted from a workers' compensation injury, your health care provider may send an updated medical work status form to your supervisor as soon as your return to work date is known, even if less than two business days before your return to work. You may obtain Return to Work Medical Certification Forms from your supervisor or the Human Resources Department. This is important so that your return to work is properly scheduled.

Extended Leave for Serious Health Condition 1.

Leave taken because of your own serious health condition may be extended under certain circumstances. If you cannot return to work at the end of your FMLA Leave due to your own serious health condition, please contact your supervisor and the Human Resources Department. Please understand that reinstatement from an extended leave of absence (beyond 12 weeks of FMLA Leave) is not guaranteed and will depend upon the availability of a vacancy for which you are qualified.

Administrative Policies & Procedures – HR FMLA Policy

Page 4 of 4

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

GEORGIA RANDOM DRUG TESTING

POLICY NO.:

HR-110

Effective Date:

October 1, 2012

Revised Date:

NONE

POLICY

As required under Georgia regulations, MedMark Services, Inc. will randomly test its Georgia employees for compliance with its drug-free workplace policy. As used in this Policy, "random testing" means a method of selection of employees for testing, performed by an outside third party. The selection will result in an equal probability that any employee from a group of employees will be tested. The random selection process may result in an employee being selected more than once per year. Furthermore, MedMark has no discretion to waive the selection of an employee selected by this random selection method.

II.

PROCEDURES A.

Scheduled Periodic Testing 1.

MedMark reserves the right to conduct periodic testing on a regularly scheduled basis for employees in designated departments, classifications or work groups.

Substances Covered By Drug/Alcohol Testing 1.

Employees will be tested for their use of commonly-abused controlled substances, which include: Amphetamines, Barbiturates, Benzodiazepines, Opiates, Cannabinoids, Cocaine, Methadone, Methaqualone, Phencyclidine (PCP), Propoxyphene, and chemical derivatives of these substances.

Employees must advise the Medical Review Officer (MRO) of all prescription drugs taken in the past month before the test, and to be prepared to show proof of such prescription to the MRO.

Testing Methods and Procedure

Administrative Policies & Procedures – HR Georgia Random Drug Testing Policy

Page 1 of 2

Administrative Policies & Procedures

All testing will be conducted by a licensed independent medical laboratory, which will follow testing standards established by the State or federal government. Testing will be conducted on a urine sample provided by the employee to the testing laboratory under procedures established by the laboratory to insure privacy of the employee, while protecting against tampering/alteration of the test results.

Employees will be considered to be engaged at work for the time spent in taking any tests, and will be compensated for such time at their regular rate.

MedMark will pay for the cost of the testing, including the confirmation of any positive test result by gas chromatography. The testing lab will retain samples in accordance with State law, so that an employee may request a retest of the sample at his/her own expense if the employee disagrees with the test result.

Refusal to Undergo Testing 1.

Employees who refuse to submit to a test are subject to immediate discharge.

Administrative Policies & Procedures – HR Georgia Random Drug Testing Policy

Page 2 of 2

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

HIRING OF INDEPENDENT CONTRACTORS (FOR MANAGERS ONLY)

POLICY NO.:

HR-111

Effective Date:

February 13, 2012

Revised Date:

January 1, 2013

POLICY

Independent contractors are workers who are considered to be in business for themselves. They may use a number of different terms to describe their employment situation, such as freelancers, consultants, selfemployed workers or entrepreneurs. Regardless of the name they use, independent contractors don't have the same legal status as employees. All contractors who interact with patients will go through the following process. This includes physicians, nurse practitioners, therapists and any other position that may come in contact with patients. II.

PROCEDURES 1. Once you have identified the candidate you want to hire, you need to contact MedMark Services General Counsel to provide him/her with names, compensation, duties, etc. Our counsel will then prepare a draft of an independent contractor agreement for your review. Once the contract is ready for signature, it is to be sent back to our counsel along with a contract approval form. Our counsel will sign off for the legal department and then send the agreement to our CEO to approve (the approval form only at this time). 2. The independent contractor agreement will require that the contractor comply with all MedMark policies and procedures including MedMark’s HIPAA policies and procedures. The contractor must also agree to comply with all federal and state confidentiality regulations including HIPAA and the federal confidentiality regulations governing Alcohol and Drug Abuse Records as contained in 42 CFR Part 2.3. 3. All independent contractor providers’ credentials must be verified prior to hiring. The procedures in policy HR-112 must be followed. 4. Once the agreement is approved by the CEO you may then make a contract offer contingent upon a satisfactory background check and drug screen. Return the background check form and send the applicant for a drug screen. Have the contractor sign the approved agreement first, return to the NSC, and then our CEO will sign the agreement. 5. The applicant will need to provide you with his/her current license and W-9.

Administrative Policies & Procedures – HR Hiring of Independent Contractors

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Administrative Policies & Procedures

6. Send complete package/documentation to our Human Resources Coordinator (Fax 214.550.2653). The contractor will then be entered into Exponent and a file maintained at the NSC. 7. All contractors falling into this category will be paid through the ExponentHR system.

Administrative Policies & Procedures – HR Hiring of Independent Contractors

Page 2 of 2

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

INITIAL AND ONGOING VERIFICATION OF CREDENTIALS

POLICY NO.:

HR-112

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to verify the credentials of personnel hired and employed by the organization with the primary source of the credentials. In addition, references of personnel will also be verified. The verification process will be done in a manner that ensures the organization’s requirements for employment are met, and the integrity of our services and the persons served are not compromised. This policy includes providers such as contractor and employee physicians, nurses, and physician assistants. Independent contractors are subject to these procedures as well. The Directors of Operations, Program Directors and Clinic Administrators are responsible for ensuring that the procedures in this policy are followed and met.

II.

PROCEDURES

All credentials required of potential employees to hold specific positions in the organization will be verified with the primary source prior to employment (with exceptions noted in 4. below). In addition, required credentials must remain current throughout employment. Requirements of credentials will be determined through job descriptions, which identify the educational, training, credentialing, and/or licensure requirements of each position. A.

INITIAL VERIFICATION FROM A PRIMARY SOURCE 1.

Professional Licensure: (1) The potential employee will provide a copy of the required license to the Human Resource Department as part of the pre-employment process. (2) The Program Director will determine the appropriate agency to contact based on the type of license. (3) The licensure agency will be contacted via web site, phone call, or fax to determine if the license is current and in good standing. (4) The Program Director will note the outcome of the action by completing the verification form/checklist and placing it in the employee’s personnel folder. Any additional documentation sent for verification will also be placed in the

Administrative Policies & Procedures – HR Initial and Ongoing Verification of Credentials

Page 1 of 3

Administrative Policies & Procedures personnel folder. (5) If the potential employee is in good standing, final hiring procedures will be completed. If the potential employee does not have a current license or is not in good standing with the licensing board, employment will not occur. 2.

Professional Certification: (1) The potential employee will provide a copy of the required certification to the Human Resource Department as part of the pre-employment process. (2) The Program Director will determine the appropriate agency to contact, based on the type of certification. (3) The certification agency will be contacted via web site, phone call, or fax to determine if the certification is current and in good standing. (4) The Program Director will note the outcome of the action by completing the verification form/checklist and placing it in the employee’s personnel folder. Any additional documentation sent for verification will also be placed in the personnel folder. (5) If the potential employee is in good standing, final hiring procedures will be completed. If the potential employee does not have the required certification or is not in good standing with the certification board, employment will not occur.

Education (higher education degrees): (1) Potential employees will be instructed to have the institution from which the degree was obtained send a notarized or appropriately identified transcript directly to the employer. (2) Program Director will review the transcript to ensure it is a valid document and compare data contained on the document with employment requirements. (3) If the educational materials meet requirements, final hiring procedures will be completed. If they do not, the potential employee will not be hired for the position.

Exception to Education Verification Requirements: Due to the lengthy response time of most educational institutions in providing the required information, verification of education prior to active employment can be waived if ALL of the following conditions are met: (1) A copy of the required degree is provided. (2) The employee’s Supervisor has been notified that verification has not occurred and this is documented in the personnel file. (3) The verification from the primary source occurs within 90 days of the first official date of employment.

References: The Director of Operations will obtain three references from former employers.

Training: If a position requires the completion of a specific training to be eligible for employment, the training will be verified prior to the start of employment in the following manner: (1) The potential employee will provide the human resources department with the original training certificate (2) If the original training certificate is not available, the employee will contact the training organization or educational institution and request that verification of training be sent to the employer (3) The

Administrative Policies & Procedures – HR Initial and Ongoing Verification of Credentials

Page 2 of 3

Administrative Policies & Procedures employer will copy the original training certification and place copy in the employee’s personnel file, or place verification materials received from outside source in personnel file.

DEA: For OTP clinics, the Director of OTP Operations will verify that the potential employee is in good standing with the DEA.

California OTP Clinics: Potential providers will complete a “Live Scan” which is an electronic fingerprinting machine that does a background check. The results of the background check are forwarded to the California Department of Alcohol and Drug Programs. If the results have “red flags,” MedMark is notified by the Department that the provider is not acceptable to provide services for MedMark.

VERIFYING THAT EMPLOYMENT

CREDENTIALS

ARE

CURRENT

THROUGHOUT

If employment is offered and accepted by a licensed or certified employee, the employee will provide their Program Director or Human Resources Department with a copy of their professional license or certificate within 30 days of their yearly or bi-yearly renewal. Program Director and the National Support Center will keep track of the expiration dates of licenses and certification of certain employees. If the employee does not have the required license, certification or registration or is not in good standing with the certification board or state regulatory agency, he or she may be terminated. C.

VERIFICATION OF NON-EXCLUSION Prior to employment all providers must be screened on the U.S. Department of Health and Human Services, Office of Inspector General’s List of Excluded Individuals/Entities for exclusion from participation in Medicare, Medicaid and all other Federal health care programs. All providers must be screened annually as well. If any provider or potential provider is found to be on the List of Excluded Individuals, he or she may be terminated or denied employment.

Administrative Policies & Procedures – HR Initial and Ongoing Verification of Credentials

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

INTERNS AND VOLUNTEERS

POLICY NO.:

HR-113

Effective Date:

October 1, 2006

Revised Date:

NONE

POLICY

Interns and Volunteers are welcomed to work with MedMark Services, Inc. All interns and volunteers shall be required to go through a background check, pre-employment drug screen, company orientation and training process as is any new employee. Interns/volunteers shall have a written agreement between themselves and the Company, which will outline their duties, scope of responsibility, and supervision. II.

PROCEDURES A.

Interns and volunteers shall receive the same new employee packet as employees, which will include all of the Company’s policies and procedures, including confidentiality policies.

Interns and volunteers shall be assessed on their job performance and given feedback to enhance their skills, by their direct supervisor on an as needed basis, not less than annually. If the Company finds it necessary to relieve an Intern/Volunteer from their duties, the following procedures shall be followed: 1.

Supervisor shall notify the Program Director of the decision to separate.

Program Director shall prepare a separation letter and forward it to the Supervisor.

Supervisor shall have a meeting with the intern/volunteer and proceed with the separation.

Supervisor shall be responsible for retrieving all Company property from the intern/volunteer.

Administrative Policies & Procedures – HR Interns and Volunteers

Page 1 of 1

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

JOB POSTINGS AND PROMOTION GUIDELINES

POLICY NO.:

HR-114

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

MedMark Services, Inc. would like to offer its employees the opportunity for development and career advancement through transfer/promotion within the entire organization.

II.

PROCEDURES A.

Employees are encouraged to apply for any position for which they feel that they are qualified. It is the policy of MedMark Services, Inc. to hire the best candidate possible. MedMark will always try to hire an internal candidate over an external candidate all things being equal. Promotions shall be non-discriminatory.

All open positions will be known at our National Support Center and posted in the “Job Opportunities” area on ExponentHR. Employees may contact the Human Resources Department to learn of open positions.

Internal applicants must meet skill, licensure/certification and education requirements as outlined in the job posting, or have equivalent experience. Performance, results, and effort shown in current position will be taken into consideration.

Internal application must have had a performance review of “satisfactory” or better to be considered for another internal position. Applicants on a performance improvement plan are not eligible.

Positions will remain posted until an offer is extended and accepted. Qualified internal applicants should complete and fax an Internal Position Application (IPA) signed by their manager to Human Resources at 469-327-0851. IPA’s can be obtained from the Program Director at each clinic or from the National Support Center’s Human Resources office.

MedMark Services may elect not to post certain positions on an exception basis and may elect to slot internal incumbents into the open position.

Administrative Policies & Procedures – HR Job Postings and Promotion Guidelines

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Administrative Policies & Procedures G.

The Human Resources Department will have the responsibility of administering this program.

External candidates will be considered after the internal candidates have been interviewed.

The Hiring Manager and the Director of Human Resources will determine the most qualified candidate.

Administrative Policies & Procedures – HR Job Postings and Promotion Guidelines

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

JURY DUTY

POLICY NO.:

HR-115

Effective Date:

September 13, 2011

Revised Date:

NONE

POLICY

Any active regular full-time and part-time employee who is required by law to serve as a juror on normal scheduled work day will be granted paid time off based on their normally scheduled hours for the period of his/her jury service up to a maximum of two (2) weeks per year. If the jury duty extends for a period beyond that which is normally or customarily required, or if the employee is called for extended jury service, e.g., grand jury investigation; the amount of time he/she remains on leave status will be reviewed by his/her supervisor or manager in consultation with the Human Resources Department. II.

PROCEDURES A.

If an employee is excused from serving on a jury for part of a day or the entire day during his/her period of jury duty, it is expected that he/she will come to work whenever it is reasonably possible to do so in order that he/she may discharge his/her responsibilities to the Company.

In order to be entitled for jury duty leave, an employee must, within a reasonable time after he/she receives a summons or other notice for jury duty, and in any event before the commencement of such duty, notify the employee’s supervisor of his/her pending jury duty. Upon completion of jury duty service, the employee must promptly present satisfactory evidence of attendance to the employee’s supervisor and the Payroll Department.

The Company does not take adverse action against an employee for serving on a jury.

Jury duty leave laws vary per state. Provisions which are most favorable to our employees will be applied.

Abuse of the Company’s policy on jury duty is grounds for disciplinary action, up to and including termination of employment.

Administrative Policies & Procedures – HR Jury Duty Policy

Page 1 of 1

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

ORIENTATION AND ANNUAL STAFF TRAINING

POLICY NO.:

HR-116

Effective Date:

October 1, 2006

Revised Date:

NONE

POLICY

It is the policy of the MedMark Services, Inc. to encourage and/or provide orientation and training to all staff to ensure that individuals new to this setting receive full and complete training prior to the delivery of services and throughout their employment. II.

PROCEDURES A.

Provide a timely orientation to personnel and new staff members.

Provide periodic assessment of training needs of all personnel.

Provide In-Services based on the needs identified in periodic assessments.

Provide Initial and Annual Training for all staff members on: 1.

Prevention of violence and management of unsafe behaviors

Confidentiality requirements

Cultural sensitivity

Rights of the Persons Served

Person and family centered services

Expectations regarding professional conduct

Identification and reporting of critical incidents

Medication Management, if applicable

Health and Safety Practices

10.

Identification of unsafe environmental factors

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Page 1 of 2

Administrative Policies & Procedures

11.

Sexual Harassment

12.

Corporate Compliance

13.

Customer Service

14.

Diversity

15.

Expectations regarding professional conduct

16.

Health issues and advocacy

17.

Mobility

18.

Person Centered Practice

19.

Personal privacy

20.

Professional boundaries

21.

Reporting of suspected abuse and neglect

22.

Rights of personnel

23.

Safety of persons served

24.

Unique needs of persons served

Provide continuous training related to: 1.

Clinical and Pharmacotherapy issues

First aid, CPR, Overdose, and Emergency and Evacuation Procedures

Resources for problem solving and troubleshooting

Infectious Disease

Universal Precautions

Maintain documentation of in-services and/or training to include: 1.

Content outline

Description of methods

Record of attendee

Administrative Policies & Procedures – HR Orientation and Annual Staff Training

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

EMPLOYEE FEEDBACK

POLICY NO.:

HR-117

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

The Company will survey all employees to assess satisfaction and to obtain employee feedback which may be utilized for program development and improvement.

II.

PROCEDURES

The Company will elicit feedback from employees by: A.

Employee Feedback Survey Questionnaire 1.

Timetable of Administration a.

Annual administration to at least 60% of employees who we employ.

Information Measured a.

The degree to which the employees are satisfied.

The degree to which the Company made decisions that improved or worsened the workplace.

Areas leadership needs to focus on.

Administrative Policies & Procedures – HR Employee Feedback

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

PAID TIME OFF

POLICY NO:

HR-118

Effective Date:

April 24, 2009

Revised Date:

July 1, 2012

POLICY

PTO is a benefit meant to be used as needed by employees. It is the company’s philosophy that time away from the job is a good thing. Time off spent with family, friends or just doing nothing can recharge a person. Therefore, we encourage all employees to take advantage of our generous PTO benefit and use up your hours during the calendar year and enjoy yourself. Paid Time Off (PTO) is an all purpose time-off policy for eligible employees to use for vacation, illness or injury and personal business. It combines traditional vacation and sick leave plans into one flexible, paid time-off policy. All full-time employees are eligible to earn and use PTO as described in this policy. Once employees enter an eligible employment classification, they begin to earn PTO according to the schedule below. Employees are eligible to use the accrued PTO once they have completed 90 days of employment. MedMark recognizes certain national holidays. Employees may discuss with their supervisor the holidays recognized at their work site. This policy is not applicable to employees serving in Georgia locations. All employees for Georgia locations must follow HR Policy No. HR-119.1. II.

PROCEDURES A.

Eligibility for PTO Accrual 1.

Employees will begin to accrue PTO in the pay period they were hired or entered an eligible classification. The employee status must be active on the last day of the pay period for accruals to occur. No PTO accrues during leave status.

The following formula is used in determining the maximum length of an employee’s potential PTO accrual:

Administrative Policies & Procedures – HR PTO

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Administrative Policies & Procedures All Salaried and Hourly Employees Length of Continuous Service Potential Length of Annual Paid Time Off Accrual Up to five (5) years 4.62 hours for each pay period of continuous active service (up to 120 hours) After five (5) years 6.16 hours for each pay period of continuous active service (up to 160 hours) Director Level and Above Employees Up to five (5) years 6.16 hours for each pay period of continuous active service (up to 160 hours) After five (5) years 7.70 hours for each pay period of continuous active service (up to 200 hours) 3.

In order to ensure that PTO is used, there is a cap placed on the amount of PTO an employee can accrue equal to the total hours the employee is entitle to in one year. When an employee reaches the maximum amount they are entitled to accrue within a year, no further accrual will occur until the PTO is used, at which time the accrual will begin again until the cap is reached. a.

The higher rate of accrual will become effective with the first pay period following your 5th year anniversary date.

Limits on PTO Accrual 1.

For example: if an employee is entitled to 120 hours of PTO and doesn’t use any hours during the year, that employee will have reached their cap and cannot accrue any additional PTO until PTO hours are used. If they used 24 hours of PTO, they will begin to accrue more hours until the cap is reached again.

Each time the employee reaches the maximum accrual level applicable to the employee, he/she will not accrue further PTO. Accruing beyond the maximum accrual level is not allowed

Scheduling of PTO 1.

Your manager must approve your requested dates for PTO, subject to operating requirements. You must complete the Paid Leave Reporting process in ExponentHR at least two (2) weeks prior to the requested

Administrative Policies & Procedures – HR PTO

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Administrative Policies & Procedures dates off. Failure to give advance notice may result in the PTO request being denied. a.

All Providers are required to provide 90 days notice when requesting PTO time. All Nurse Practitioners, Physician Assistants and Physicians should submit their PTO requests to their local Medical Director. All Medical Directors should submit their PTO request to the National Medical Director. Make sure to notify your Clinic Administrator / Program Director as well.

Providing the 90 day notice period is essential when trying to provide adequate coverage. Exceptions may be made in cases of emergency or someone being ill. However, these occurrences should be minimal.

Requests will be reviewed based on a number of factors, including business needs and staffing requirements.

Non-exempt employees must take PTO in one-hour increments. PTO must be taken in ½ day (4 hour) increments by exempt employees and should be used only when the absence is a half day.

If an employee has a special reason for requesting a particular time for his/her PTO, the employee should make that reason known and an attempt will be made to accommodate the request. Once PTO has been scheduled it may not be changed without the joint approval of the employee and manager.

Due to business necessities at some facilities, PTO may be scheduled by management. Your manager may require that you use PTO before approving time off without pay.

In the event of an unforeseen illness or injury of the employee, or an immediate family member when the employee’s presence is necessary, the employee must notify his/her manager, by speaking directly with the manager, prior to the beginning of each workday the employee will be absent. If the employee is on an approved leave of absence, notification requirements in accordance with the leave of absence policy will apply.

In the event of absence due to illness or injury of the employee, certification from a recognized healthcare provider stating the fact that you are ill and may not work may be required.

Administrative Policies & Procedures – HR PTO

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Administrative Policies & Procedures necessary. An employee must contact Human Resources regarding any such absence as soon as he/she becomes aware of the need for time off greater than five (5) consecutive work days. D.

Miscellaneous 1.

PTO will be paid at straight time base rate. Hours charged to PTO will not be counted toward credited hours worked for overtime pay eligibility.

Employees will not be given additional pay in lieu of unused PTO, nor will the Company purchase unused PTO from employees.

Status Change a.

Employees who are rehired after a separation from the Company will accrue PTO based on length of service from adjusted date of hire.

Part-time, Full-time Temporary and PRN employees transferring to full-time regular or full-time on-call status will start accruing PTO at the rate of accrual relevant to the original date of hire or adjusted date of hire and will be able to use any PTO as of the effective date of the transfer.

If an employee leaves the Company for any reason or changes from fulltime status to a non-eligible status, all PTO that has been accrued, but not used, will be paid out to the employee.

It is the intent of the Company to, at all times, be in compliance with applicable federal, state and local laws. To the extent any portion of this Policy is in conflict with such applicable law, it shall be deemed modified so as to conform to such law.

Administrative Policies & Procedures – HR PTO

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

PAID TIME OFF FOR GEORGIA LOCATIONS ONLY

POLICY NO.:

HR-118.1

Effective Date:

April 24, 2009

Revised Date:

April 12, 2012

POLICY This policy applies only to MedMark’s Georgia locations. All Georgia employees are to follow this policy. Policy No. HR-119 is not applicable to Georgia employees. PTO is a benefit meant to be used as needed by employees. It is the company’s philosophy that time away from the job is a good thing. Time off spent with family, friends or just doing nothing can recharge a person. Therefore, we encourage all employees to take advantage of our generous PTO benefit and use up your hours during the calendar year and enjoy yourself. Paid Time Off (PTO) is an all purpose time-off policy for eligible employees to use for vacation, illness or injury and personal business. It combines traditional vacation and sick leave plans into one flexible, paid time-off policy. All full-time employees are eligible to earn and use PTO as described in this policy. Once employees enter an eligible employment classification, they begin to earn PTO according to the schedule below. Employees are eligible to use the accrued PTO once they have completed 90 days of employment.

II.

PROCEDURES A.

Eligibility for PTO Accrual 1.

The following formula is used in determining the maximum length of an employee’s potential PTO accrual:

Administrative Policies & Procedures – HR PTO for Georgia Locations Only

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Administrative Policies & Procedures All Salaried and Hourly Employees Length of Continuous Service Up to two (2) years After two (2) years

Potential Length of Annual Paid Time Off Accrual 2.01 hours for each pay period of continuous active service (up to 56 hours) 3.69 hours for each pay period of continuous active service (up to 96 hours)

Director Level and Above Employees Up to five (5) years

6.16 hours for each pay period of continuous active service (up to 160 hours)

After five (5) years

7.70 hours for each pay period of continuous active service (up to 200 hours)

The higher rate of accrual will become effective with the first pay period following your 5th year anniversary date.

Limits on PTO Accrual 1.

Each time the employee reaches the maximum accrual level applicable to the employee, he/she will not accrue further PTO. Accruing beyond the maximum accrual level is not allowed

Scheduling of PTO 1.

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Administrative Policies & Procedures a.

Requests will be reviewed based on a number of factors, including business needs and staffing requirements.

Non-exempt employees must take PTO in one-hour increments. PTO must be taken in ½ day (4 hour) increments by exempt employees and should be used only when the absence is a half day.

Due to business necessities at some facilities, PTO may be scheduled by management. Your manager may require that you use PTO before approving time off without pay.

In the event of absence due to illness or injury of the employee, certification from a recognized healthcare provider stating the fact that you are ill and may not work may be required.

A leave of absence must be requested for any absence of more than five (5) consecutive workdays due to the illness or injury of the employee, or an immediate family member when the employee’s presence is necessary. An employee must contact Human Resources regarding any such absence as soon as he/she becomes aware of the need for time off greater than five (5) consecutive work days.

Administrative Policies & Procedures – HR PTO for Georgia Locations Only

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Administrative Policies & Procedures D.

Miscellaneous 1.

PTO will be paid at straight time base rate. Hours charged to PTO will not be counted toward credited hours worked for overtime pay eligibility.

Employees will not be given additional pay in lieu of unused PTO, nor will the Company purchase unused PTO from employees.

As PTO is not accrued until 90 days of continuous service, employees are not eligible to receive any payment for PTO until they complete 90 days of continuous service.

Status Change a.

Employees who are rehired after a separation from the Company will accrue PTO based on length of service from adjusted date of hire.

If an employee leaves the Company for any reason or changes from fulltime status to a non-eligible status, all PTO that has been accrued, but not used, will be paid out to the employee.

Administrative Policies & Procedures – HR PTO for Georgia Locations Only

Page 4 of 4

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

PERFORMANCE REVIEWS

POLICY NO.:

HR-119

Effective Date:

June 1, 2011

Revised Date:

January 1, 2013

POLICY A.

Instructions for Performance Reviews Annual performance reviews are to be conducted for all employees once a year. These procedures may be used for the new employee appraisal. The process should occur as follows: 1.

Supervisors may ask for feedback on employees’ performance from coworkers. This step may be done verbally. This part of the process is under the discretion of the reviewing supervisor. Forms: The OTP clinics must use the CARF approved performance evaluation forms which may be obtained from your Regional VP. All other managers may use the attached Management / Exempt or Non-Exempt performance evaluation forms.

The employee being reviewed should complete an employee selfappraisal form prior to the supervisor’s final review.

Upon receipt of the completed self-appraisal and verbal input, the supervisor completes Part 1 of the evaluation. Supervisors will share the completed evaluation with their supervisor if the evaluation is extremely negative or controversial. Together, they will review the evaluation to ensure fairness and to avoid potential liability. Supervisors are always encouraged to discuss employee evaluations with their clinic lead associate (e.g., the medical director and the clinic administrator).

Once Part 1 has been completed, the supervisor and employee meet to discuss the review. This meeting should encompass: a.

appropriate feedback and

construction of goals for the upcoming year

Administrative Policies & Procedures – HR Performance Reviews

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Administrative Policies & Procedures 5.

At the conclusion of the meeting, the employee may add his or her own comments to the end of the review. He or she must sign the review indicating that s/he has seen it. Signatures do NOT necessarily indicate agreement by the employee, only that the supervisor has reviewed the document with the employee.

The original performance appraisal is then sent to the Human Resources Department at the National Support Center. A copy may be issued to the employee, as well.

Administrative Policies & Procedures – HR Performance Reviews

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MANAGERIAL / EXEMPT APPRAISAL & DEVELOPMENT FORM Name: _________________ Department: __________________ Date Hired: ____________ Position Title:

______________________ Years in Position: __________________________

Period Covered by Review:

From (Mo./Yr.): _____ to (Mo./Yr.): ______

_____________________________________________________________________________ This performance appraisal form is intended to build a better understanding between the employee and the supervisor, clarify mutual objectives, and provide a basis for ongoing dialogue, regarding the employee’s professional development.

Description of Performance Ratings: (to be used in rating employees on following pages) Outstanding - 4 Points Expert in their position. No improvement needed in areas marked Outstanding.

Exceeds Expectations - 3 Points The employee’s performance is consistently above expectations for this position.

Meets Expectations - 2 Points The employee’s performance consistently meets expectations for this position.

Opportunity for Improvement - 1 Point The employee’s performance is meeting some requirements, but not consistently meeting expectations for this position. Improvement is needed.

Unsatisfactory Performance - 0 Points The employee’s performance is unsatisfactory and does not meet the expectations for this position.

POSITION DUTIES AND RESPONSIBILITIES: Review the significant duties and responsibilities for the employee’s position. If necessary, update the position description to reflect the current functions of the job. The performance appraisal is not complete unless a position description has been reviewed/discussed with the employee and is attached to this performance appraisal. Please indicate your selection with an “X”. [ ] Newly developed position description effective _____________ is being submitted. [ ] Attached position description dated ___________ has been reviewed and there is no change. [ ] Attached position description dated _____________ has been updated and discussed with the employee.

PREVIOUS YEAR OBJECTIVES List the employee’s specific goals for the previous year and specify how well the objectives were met:

OBJECTIVE

RESULTS ACHIEVED (Indicate measurement)

ADDITIONAL ACCOMPLISHMENTS AND CONTRIBUTIONS Describe the accomplishments and contributions that the employee made in areas other than those covered by specific objectives:

ACCOMPLISHMENTS/CONTRIBUTIONS

RESULTS ACHIEVED

EVALUATION OF SKILLS Review the essential functions of the employee’s position description and evaluate how well they fulfilled those duties and responsibilities using the following skill sets: Verbal/Written Communication: Effectiveness of expression in individual and group situations (including listening, non-verbal communication and appropriate language. Ability to express ideas clearly and concisely in good grammatical form.

Rating: {4} {3} {2} {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Rating: {4} {3} {2} {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Comments:

Customer Focus: Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to internal customers.

Comments:

Decision Making/Judgment: Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others.

Rating: {4 } {3} {2} {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Rating: {4} {3} {2} {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Rating: {4 } {3 } {2 } {1 } {0 }

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Comments:

Interpersonal Skills: Has good listening skills, builds strong relationships, is flexible/open-minded, negotiates effectively, solicits performance feedback and handles constructive criticism. Deals with others in a straight-forward manner. Comments:

Technical Products/Process Knowledge: Stays abreast of current trends, changes and new developments and processes as related to the job/professional field. Includes knowledge of MedMark Services, Inc’s. Systems.

Comments:

Planning: Develops realistic plans, sets goals, aligns plans with company goals, plans for and manages resources, creates contingency plans, coordinates/cooperates with others and holds appropriate number of meetings with subordinates.

Rating: {4} {3} {2} {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Rating: {4} {3} {2 } {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Rating: {4 } {3 } {2 } {1 } {0 }

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Comments:

Teamwork: Meets all team deadlines and responsibilities, listens to others and values opinions, helps team leader to meet goals, welcomes newcomers and promotes a team atmosphere. Comments:

Budget/Cost Control: Plans for and uses resources efficiently, always looks for ways to reduce costs, and/or increase revenue, creates accurate realistic budgets, tracks and adjusts budgets, contributes to budget planning. Comments:

Leadership: Leads through change and adversity, makes the tough call when needed, builds consensus when appropriate, motivates and encourages others.

Rating: {4} {3} {2} {1} {1}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Rating: {4} {3} {2} {1} {0}

Outstanding Exceeds Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

Comments:

People Management: Defines roles and responsibilities, motivates and challenges employees, delegates effectively, rewards contributions, manages collaboratively. Diffuses volatile situations (patients or employees). Comments:

Overall Rating (Add individual scores above and divide by 10)

DEVELOPMENTAL NEEDS AND ACTIONS Areas for improvement are: 1.

Specific actions that will be taken to increase job-effectiveness (address above “Areas for improvement”). 1.

CARREER ASPIRATIONS What other positions is the employee interested in at MedMark Services, Inc. and able to effectively perform? Now? Within One Year? Within Two to Five Years? Long Range?

Comments

PARTICIPATION IN TRAINING ACTIVITIES Did the employee participate in any training activities during the appraisal period? Is additional training either needed in the employee’s current position or desired by the employee to further his/her advancement within MedMark Services Inc.? 1

EMPLOYEE COMMENTS (or attach additional sheet)

Rating: { } { } { } { }

OVERALL PERFORMANCE RATING:

Above Expectations Meets Expectations Opportunity for Improvement Unsatisfactory Performance

ADDITIONAL COMMENTS

Rating Supervisor

Date:

Approved By:

Date:

Performance Appraisal discussed on ___________________ with_________________________________

(Date)

(Employee’s Signature)

EMPLOYEE STATEMENT OF OBJECTIVES FOR PERIOD FROM ___________ TO _____________ Outline below a reasonable number of goals for the year ahead. They should be concise, specific and measurable. The goals should not be ones that are easily attained, but ones that will create a personal challenge and require significant effort to achieve. Goals will be jointly developed by the employee and the supervisor and may be modified throughout the year by mutual agreement of the employee and his/her supervisor.

GOAL

GOAL MEASUREMENT

PLANNED COMPLETION DATE

10.

Employee:

Date:

Supervisor:

Date:

NON-EXEMPT EMPLOYEE PERFORMANCE APPRAISAL FORM Name

Appraisal Period Beginning Date

Ending Date

Date of Employment

Annual Review

Six Month Review

Division

Salary Review

Performance Only

The value of this review depends solely on the person making the rating, his/her impartiality, and sound judgment. The rating should be made with great care and fairness in the interests of the employee and the company. Think carefully of the employee's work and make an honest judgment of the qualities of the employee. Base your judgment on the entire period covered and not upon isolated incidents alone. Base your ratings on accepted standards for that type of work.

QUANTITY OF WORK. Consider the quantity of work turned out and the promptness with which it is completed. 0 Unsatisfactory

8 Slightly Below Average

12 Average

18 Above Average

25 Outstanding

Seldom completes an acceptable amount of work. Generally slow. Wastes time. Productivity inadequate.

Production below average. Does just enough to get by. Needs to work more rapidly.

Usually produces an average volume of work. Works steadily.

Produces a high quantity of work. A thorough and careful worker. Seldom slacks off.

Consistently high production. Works with speed and accuracy. Does more than expected.

Points Assigned: Explanation:

QUALITY OF WORK. standards, neatness.

Consider the ability and accuracy to produce accepted work which meets Company

0 Unsatisfactory

8 Slightly Below Average

12 Average

Makes excessive and repetitive mistakes. Cannot be given work requiring accuracy.

Work often needs excessive inspection. Makes more effort than should.

Quality is above minimum standards.

18 Above Average

Seldom makes errors. Does good work, is accurate.

25 Outstanding

Errors are very few. Does excellent work.

Points Assigned: Explanation:

KNOWLEDGE OF JOB. Consider basic knowledge of present job, of other work closely related to it, and of the equipment necessary to do it. 0 Unsatisfactory

7 Slightly Below Average

10 Average

14 Above Average

20 Outstanding

After sufficient instructions has inadequate knowledge of job & procedures. Fails to grasp anything but most elementary concepts of job.

Work not accurate at times. Sometimes slow to grasp details required. Has acquired limited knowledge of job.

Good knowledge of job and procedures. Needs normal amount of instructions. Has working knowledge of job.

Thorough knowledge of job and Procedures. Has good understanding of both job and details required. Well informed.

Thoroughly knows and follows correct procedures. Has comprehensive understanding of all phases of job. Excellent grasp of detail.

Points Assigned: Explanation:

4. DEPENDABILITY. Consider amount of supervision required, punctuality and attendance. 0 Unsatisfactory

5 Slightly Below Average

7 Average

10 Above Average

15 Outstanding

Requires constant supervision. Lacks follow through. Cannot be depended upon. Absent often or frequently tardy

Requires more than normal supervision. Lacks initiative, is easily distracted. Absent or tardy rather frequently.

Works steadily and requires only normal supervision. Follows instructions well. Usually on time; not often absent, only when necessary.

Works well and steadily with minimum amount of supervision. Follows instructions and shows initiative. Has very good attendance record, rarely absent or tardy.

Is a self-starter who is resourceful and self-reliant. Requires little or no supervision. Follows instructions with great accuracy. Excellent attendance and punctuality.

Points Assigned: Explanation:

5. WORKING RELATIONS. Consider willingness to work with and help others, ability to accept constructive criticism, attitude, and cooperativeness with fellow employees and supervisors. 0 Unsatisfactory

5 Slightly Below Average

7 Average

Does not cooperate. Resents supervision. Gets along poorly with other workers.

Lacks interest in assignments. Shows reluctance to cooperate.

Assumes share of work. Usually good team worker. Cooperates with other workers.

10 Above Average

Is responsive to assignments and cooperates well. Always ready to do his/her share willingly.

15 Outstanding

Tactful and courteous. Very effective in dealing with co-workers. Does full share in department. Loyal worker.

Points Assigned: Explanation:

6. PERFORMANCE RELATED STRENGTHS:

7. DEVELOPMENTAL PLANS

OVERALL PERFORMANCE RATING. TOTAL THE POINTS IN CATEGORIES 1-6. Place a check mark in the point range that encompasses the employee's total points. 0 - 32 Unsatisfactory

33 - 48 Slightly Below Average

48 - 70 Average

70 - 89 Above Average

90 - 100 Outstanding

Represents an unsatisfactory level of performance.

Represents the minimum level of performance which is unacceptable.

Represents the level of performance expected from most of our experienced employees.

Represents upper 25% of performance and generally indicates a high level of achievement.

Represents the top in overall performance. Top 10% of all employees.

SUPERVISORS COMMENTS ON OVERALL PERFORMANCE EVALUATION:

AFTER RATING, DO NOT DISCUSS YOUR EVALUATION WITH THE EMPLOYEE UNTIL THIS REVIEW IS RETURNED TO YOU WITH PROPER APPROVAL.

SIGNATURES Supervisor’s Signature

President's Approval (if required)

Date

Employee's Comments

Employee Signature

Date Reviewed with Employee

Return to Human Resource Department

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

RECRUITMENT AND SELECTION

POLICY NO.:

HR-120

Effective Date:

September 5, 2012

Revised Date:

NONE

POLICY

MedMark Services, Inc. is committed to employ, in its best judgment, the most qualified candidates for approved Company positions while engaging in recruitment and selection practices that are in compliance with all applicable employment laws. It is the policy of the Company to provide equal employment opportunity for employment to all applicants and employees. The appropriate authorization is required to initiate any action for an open position including any recruitment efforts, advertising, interviewing and offers of employment, and is required to extend any offers of employment to any candidate. It is the responsibility of the Program Director or Clinic Administrator to maintain the appropriate level of staffing in his or her clinic. II.

PROCEDURES A.

DEFINITIONS 1.

Requisition Form - The “Requisition" is an approved form authorizing the recruitment of regular full-time, part-time, and temporary employees. All requisitions require appropriate approvals. All open or newly created positions will require a requisition to fill the vacancy. This includes internal promotions or transfers within an organization. If an internal candidate is identified, a “Status Change” form should be completed to move the employee into the open position.

Replacement Requisition - Indicates a position that has been vacated by the transfer or termination of a current, regular employee and requires management approval. These requisitions are opened for the same or comparable position as the employee who vacated the position to include salary structure.

Add to Headcount Requisitions - Indicate a new position is being created and that there is not a current, regular employee in the position; or that

Administrative Policies & Procedures – HR Recruitment and Selection

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Administrative Policies & Procedures you want to change a part-time position to full-time or increase the hours for a position. This requisition requires management approval. Required for the addition of temporary (agency) workers for either long term or short term assignments. Requisition Approval Matrix Program Director or Clinic Administrator Next Level Manager VP OTP or Director, Human Resources CFO CEO

RECRUITMENT PROCEDURE 1.

Once approved, the CEO returns the completed Requisition to Human Resources.

Human Resources assigns a requisition number to assist in tracking and reporting and returns the approved Requisition to the Program Director or Clinic Administrator.

Human Resources will place appropriate advertising based on the information contained on the Requisition. a.

Potential sources of candidates: • Newspaper advertising • Internet advertising • Internet search • Temporary agency • Employee referral

Human Resources will screen resumes and submit qualified candidates to the Program Director or Clinic Administrator. He or she will identify the most appropriate candidates for interviewing and set up phone screens and interview as appropriate.

SELECTION PROCEDURE

Administrative Policies & Procedures – HR Recruitment and Selection

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Administrative Policies & Procedures

Program Directors or Clinic Managers are responsible for conducting timely, effective interviews of qualified candidates for the position. Human Resources is available to advise on interview techniques when requested. All candidates selected for an interview must complete an Employment Application.

Employment reference checks will be completed by the Program Director or Clinic Administrator.

A verbal offer may be extended at that point. Human Resources will process a written offer of employment to the candidate when requested.

After the offer is extended, the candidate will be provided with the background check form and Chain of Custody for a pre-employment drug screen. The background check will be conducted by Human Resources for the selected candidate.

RESPONSIBILITY 1.

Human Resources is responsible for placing all ads, screening the resumes and forwarding qualified candidates to the Program Director or Clinic Administrator. The overall responsibility to fill the position and maintain the appropriate level of staffing is that of the Program Director or Clinic Administrator. Recruiting methods other than those listed above should be discussed with your direct supervisor.

Suggestions other than ads for recruiting: 1.

Employee referrals

Professional conferences (NAATP, ASAM, AATOD and local OTP organizations)

Local Job Fairs

College recruiting – both recent graduates and alumni – most colleges have a job posting broad

Use Google as a search tool

Linked In

Professional contacts

Sales reps who visit your office

Administrative Policies & Procedures – HR Recruitment and Selection

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

RELOCATION EXPENSES POLICY

POLICY NO.:

HR-121

Effective Date:

NONE

Revised Date:

NONE

POLICY

II.

PROCEDURES

[UNDER DEVELOPMENT BY HR]

Administrative Policies & Procedures – HR Relocation Expenses Policy

Page 1 of 1

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

REQUISITIONS

POLICY NO.:

HR-122

Effective Date:

January 27, 2012

Revised Date:

NONE

POLICY

Personnel requisitions must be completed in order to fill any open position or to change an existing employee’s status (FT or PT). II.

PROCEDURES A.

Requisitions must be initiated and completed by the department supervisor/manager. Requisition approval by the Regional Director or VP Operations of MedMark Services, Inc. is also required and then the requisition must be forwarded to Human Resources.

Personnel requisitions should indicate the positions’ hours/shifts, status, reason for the opening, and a job description if the position is new.

The requisition will be reviewed by the CFO and CEO and will then be returned to the originating manager. Advertising for positions will not be initiated until an approved requisition is received in Human Resources.

Administrative Policies & Procedures – HR Requisitions

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

REVIEW OF CONTRACTED PERSONNEL

POLICY NO.:

HR-123

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to facilitate annual reviews of all contract personnel utilized by the organization. II.

PROCEDURES A.

Annual Reviews will be conducted by supervisory personnel. Annual reviews are to include the following: 1.

Assess performance of their contracts.

Ensure that they follow all applicable policies and procedures of the organization.

Ensure that they conform to CARF standards applicable to the services they provide.

Provision of feedback to enhance skills.

Supervision will be provided by that contracted employee’s direct report.

Supervisory personnel shall send all Annual Reviews to the Department of Human Resources.

Administrative Policies & Procedures – HR Review of Contracted Personnel

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

RN ON-CALL PAY PRACTICE FOR VISTA TAOS ONLY

POLICY NO.:

HR-124

Effective Date:

February 14, 2012

Revised Date:

NONE

PROCEDURES Reporting Time Worked RNs are scheduled for on-call shifts for 24-hour shifts. For being available during this time, the RN is paid a piece rate which is equal to 2.5 hours, paid at their standard rate. This is reported in ExponentHR as “Report Pieces; On Call Pay.” If the RN is called to report to work during this 24 hour period, instead of the piece rate, they are guaranteed 4 hours paid at the standard hourly rate. This is reported in ExponentHR as “Report Pieces; Call-Back Guaranteed Pay.” The RN will not be paid the On Call Pay AND the Call-Back Guaranteed Pay in the same 24 hour period. It must be reported as one or the other. Should the RN be called to work during the 24 hour shift and be required to work longer than 4 hours, the RN must complete the Time Sheet Adjustment Form and present to the Executive Director before leaving for the day. The Executive Director will enter the time in excess of the 4 hour guaranteed Call-Back Pay into the ExponentHR system.

Administrative Policies & Procedures – HR RN On-Call Pay Practice for Vista Taos Only

Page 1 of 1

Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

SALARY ADMINISTRATION

POLICY NO.:

HR-125

Effective Date:

March 12, 2012

Revised Date:

NONE

POLICY

This Salary Administration Policy is developed to guide management in maintaining fair and equitable pay, job change, promotions and/or transfer opportunities for employees while maintaining fiscal responsibility. Guidelines have been established for hiring, promoting, transferring, job changes and merit considerations. Exceptions to these guidelines will require secondary approval(s). II.

PROCEDURES A.

PERSONNEL REQUISITION FORM (Required prior to extending an offer to any candidate.) 1.

The hiring manager creates a personnel requisition form and obtains required signatures.

All areas of the requisition form must be completed. Specifically, please note the area to record the hiring range, the salary of the person being replaced and, in case of internal movement, will the existing position be backfilled.

The requisition is forwarded to Human Resources after the Program Director, Executive Director, Director of Operations, CEO Glass Health Programs (if applicable) and VP of OTP Operations (if applicable) have approved it.

Human Resources will review the requisition for completeness and forward to the CFO and CEO for approval. If the requisition is incomplete, it will be returned to the hiring manager for correction.

Once approved, a copy of the requisition will be emailed to the hiring manager.

Human Resources cannot place recruiting ads without an approved requisition on file.

Administrative Policies & Procedures – HR Salary Administration

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Administrative Policies & Procedures B.

NEW HIRE 1.

After the Personnel Requisition Form has been signed and approved by all required individuals, the hiring manager interviews, selects, offers position, and determines the hire date of the most appropriate candidate.

Pay rate should be within position hiring range defined on the Personnel Requisition Form.

Secondary approval(s) are required for a pay rate exceeding hiring range. Before making an offer above the hiring rate, written approval must be obtained from the Executive Director, Director of Operations, CEO Glass Health Programs (if applicable), VP of OTP Operations (if applicable) and the CEO.

Internal candidate pay increase may not exceed the approved hiring range or the job change/ promotion increase guidelines without appropriate approvals.

JOB CHANGE A job change occurs when an employee changes from their current position to an equivalent (lateral) or lower level (demoted) position.

Hiring manager discusses potential job change with candidate’s manager. Hiring manager interviews, selects and offers position to the most appropriate candidate. Hiring manager determines effective date of job change, which is also the effective date of the rate change.

Pay increases are not given with a job change. A salary change to reduce pay rate may be required. The reduced pay rate should be within the position salary range.

The pay rate decrease, if any, will take effect on the effective date specified by the hiring manager.

Employee Status Change Form for pay decrease, if any, with appropriate approvals must be completed and approved before the effective date. Rate changes that are not submitted on the Status Change Form before the effective date may require retroactive handling.

TRANSFER A transfer is when an employee moves from one location to another. 1.

Hiring manager discusses potential transfer with candidate’s manager. Hiring manager interviews, selects and offers position to the most

Administrative Policies & Procedures – HR Salary Administration

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Administrative Policies & Procedures appropriate candidate. Hiring manager determines effective date of transfer, which is also the effective date of the change.

A salary change to decrease/increase the pay rate may be required with appropriate approvals if the current pay rate for the employee is above/below the salary range for the new position at the new location.

The pay rate change will take effect on the effective date specified by the hiring manager.

Employee Status Change Form for pay increase or decrease, if any, with appropriate approvals must be completed and approved before the effective date. Rate changes that are not submitted on the Status Change Form before the effective date may require retroactive handling.

PROMOTION A promotion is occurs when an employee advances to a position situated in a higher pay range.

Hiring manager discusses potential promotion with candidate’s manager. Hiring manager interviews, selects and offers position to the most appropriate candidate. Hiring manager determines effective date of promotion, which is also the effective date of the change.

The hiring manager will recommend a promotion increase within guidelines.

All promotional increases require written approval from the Director of Operations, Executive Director, CEO Glass Health Programs (if applicable), VP of OTP Operations (if applicable) and the CEO.

The pay rate change will take effect on the effective date specified by the hiring manager.

The Status Change Form must be submitted and approved before the effective date of the promotion.

INTERIM PROMOTION An Interim promotion occurs when an employee is temporarily promoted to fill an opening – usually a supervisory opening. 1.

An employee who is temporarily promoted will receive up to a 10 percent increase in salary during the temporary promotion period until a replacement is put in place. At that time the employee will return to their

Administrative Policies & Procedures – HR Salary Administration

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Administrative Policies & Procedures previous position and salary. Any variance from this practice requires written approval of the CEO.

There must be an approved requisition on file for the open position. The form should clearly state that this is an Interim change only and will terminate upon the open position being filled.

A Status Change Form must be submitted to Human Resources documenting the interim increase.

A Status Change Form must be submitted at the time the employee’s salary returns to the previous level.

MISCELLANEOUS 1.

Any increase greater than 5% must have the written approval of the CEO prior to making the offer to the employee.

Administrative Policies & Procedures – HR Salary Administration

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

SUPERVISION OF CLINICAL OR DIRECT SERVICE PERSONNEL

POLICY NO.:

HR-126

Effective Date:

October 1, 2006

Revised Date:

NONE

POLICY

It is the policy of MedMark Services, Inc. that personnel that provide direct service to persons served shall be provided with appropriate supervision and direction. Direct service personnel include staff members, volunteers, trainees, interns, and contract employees. II.

PROCEDURES A.

Supervision may occur through the supervisor’s participation in treatment/service planning meetings, staff meetings, side-by-side sessions with the person served, or one-to-one meetings and/or telephone conversations between the supervisor and personnel.

The frequency of supervision sessions shall occur according to any applicable state regulation.

Documented ongoing supervision of clinical or direct service personnel addresses, when applicable: 1.

Accuracy of assessment and referral skills.

The appropriateness of the treatment of service intervention selected relative to the specific needs of each person served.

Treatment/service effectiveness as reflected by the person served meeting his or her individual goals.

The provision of feedback that enhances the skills of direct service personnel.

Issues of ethics, legal aspects of clinical practice, and professional standards, including boundaries.

Clinical documentation issues identified through ongoing compliance review.

Administrative Policies & Procedures – HR Supervision of Clinical or Direct Service Personnel

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

UNPLANNED ABSENCES OF PERSONNEL

POLICY NO.:

HR-127

Effective Date:

October 1, 2006

Revised Date:

NONE

POLICY

It is the policy of the Company that each employee is responsible for being prompt in attendance on assigned workdays. Dependability is essential to a smooth-running operation and is a factor considered during both the employee introductory period and Performance Evaluation. The Company expects employees to work as scheduled and to arrange personal schedules to accommodate the Company’s established working hours.

II.

PROCEDURES A.

Employees who are unable to report to work due to illness or injury should notify their direct supervisor before the scheduled start of their workday if possible. The direct supervisor must also be contacted on each additional day of absence. If an employee is absent for three or more consecutive days due to illness or injury, a physician's statement must be provided verifying the disability and its beginning and expected ending dates. Such verification may be requested for other sick leave absences as well. Before returning to work from a sick leave absence of 3 calendar days or more, an employee must provide a physician's verification that he or she may safely return to work.

If a Dispensing Staff Member (CRN, LVN, or Psychiatric Technician) must be absent, he/she is to contact backup employees (other qualified and licensed staff member) on the evening prior to the scheduled shift for the following day, if possible. If backup employees cannot be reached or are unable to cover the shift, the Dispensing Supervisor or Physician Assistant or Nurse Practitioner must cover the shift.

If a Counselor must be absent, the Program Director shall divide the staff member’s caseload between the remainder of the counseling staff members to cover for the absent members in the event that a patient or patients may need immediate assistance. All other counseling appoints of the absent member will be rescheduled.

Administrative Policies & Procedures – HR Unplanned Absences

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Administrative Policies & Procedures D.

If a Program Director must be absent the Regional Director will be notified by either the Program Director or Senior Counseling Staff member on site. The Regional Director will provide coverage for the absent Program Director.

If a Medical Staff member must be absent the Regional Director will be notified by the Program Director or Senior Staff member on site. The Regional Director will assess available resources at sister clinics and make adjustments in staff assignments as needed and as able.

Administrative Policies & Procedures – HR Unplanned Absences

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Administrative Policies & Procedures DEPARTMENT:

HUMAN RESOURCES

SUBJECT:

ANNUAL AWARDS PROGRAM

POLICY NO.:

HR-128

Effective Date:

NONE

Revised Date:

NONE

POLICY

II.

PROCEDURES

[UNDER DEVELOPMENT BY HR]

Administrative Policies & Procedures – HR Annual Awards Program

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III. Finance & Accounting

Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

ANNUAL BUDGET PROCESS

POLICY NO.:

F&A-101

Effective Date:

October 1, 2006

Revised Date:

NONE

POLICY

It is the policy of MedMark Services, Inc. to develop an annual budget that ensures resources are being appropriately allocated for the mission, goals, and objectives of the organization to be met. In addition, the budget process will assist with monitoring the performance of the organization against the financial targets. II.

PROCEDURES A.

Budget Preparation

The budget preparation, approval, and monitoring process require the full involvement of program and administrative personnel as well as members of the governing authority, with each area providing specialized assistance to the process.

The budget process will be influenced by the requirements of Federal, State, and local revenue sources; however, internal procedures will govern the process.

The CFO will provide all Program Directors with revenue and expense worksheets three months prior to the new fiscal year.

The Program Directors will provide monthly estimates of revenue by payer source and any anticipated increases or decreases in operating expenses within their program areas to the CFO.

The Program Directors will work in cooperation with the appropriate administrative personnel in providing an estimate of revenue by payer source.

The administrative department Regional Director of Operations will provide any anticipated increases or decreases in expenses within their areas of operation The Human Resource Manager will be responsible for salaries and fringe benefits of personnel in all programs and departments.

All reports will contain a brief justification for any budget increases of over 10% from the previous fiscal year in any operating category.

Administrative Policies & Procedures – Finance & Accounting Annual Budget Process

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Administrative Policies & Procedures 8.

The revenue and expense estimates are due two weeks after the worksheets are distributed by the CFO.

The CFO will submit to the Executive Management Team proposals for spending increases and decreases based on the MTC strategic plan and estimates submitted by the Program Directors.

10.

The CFO will compile the results of all submissions and develop a draft of the budget for the next fiscal year.

11.

The draft budget will be presented to the Executive Management Team no later than two months prior to the beginning or the next fiscal year for review, feedback, and revision.

12.

The CFO will make the final adjustments following the review, feedback, and revisions and will present the final budget proposal for approval to the Executive Management Team.

13.

Following final approval, the final budget for the fiscal year will be distributed to all program, unit, and administrative Supervisors to ensure an organization-wide awareness of the financial plan for the next fiscal year.

Budget Monitoring

All Program Directors will be responsible for operating within the approved allocated budget amounts.

Revenues connected to federal, state, and local sources that have historically been interrupted or lacked consistency will be monitored closely.

All purchasing and hiring will be monitored closely, along with personnel costs related to fringe benefits and merit raises.

The financial results and budget variances of the organization will be updated monthly and distributed to all Program Directors and the Executive Management Team no later than 20 days after the first of each month for the purpose of identifying trends and corrective actions.

Administrative Policies & Procedures – Finance & Accounting Annual Budget Process

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

AUTHORIZATION FOR ALLOWING EXTENDED PAYMENT TERMS AT VISTA TAOS AND CASA FELIZ

POLICY NO.:

F&A-102

Effective Date:

April 19, 2010

Revised Date:

NONE

POLICY

This policy cannot be revised without the consent of Healthcare Finance Group, LLC. The Executive Director (ED) of Vista Taos is granted the following delegation of authority by the CEO of MedMark Services, Inc.

II.

The ED shall have authority to approve granting of extended payment terms for patients at both Vista Taos and Casa Feliz only under the following conditions. This authority may not be delegated to anyone else at Vista Taos and Casa Feliz.

In general, extended payment terms are to be avoided whenever possible. In the event that the ED determines a patient’s account can only be paid by use of extended terms, the following guidelines shall be followed. 1.

No more than 25 extended payments agreements having more than four (4) payment installments (disregarding the initial payment upon admission) may be made in any one calendar year at either Vista Taos or Casa Feliz. To ensure that no more than 25 payment agreements are made each year at each facility, the agreements should be numbered with the sequential agreement number followed by the year (e.g., 01-2010).

In no case may terms extend beyond six (6) months from admission- shorter is always preferable. Extended payment terms under this policy must be documented by an agreement with the patient in the form of the attached Exhibit A or Exhibit B as applicable. In the event that payments are not made as required by the terms of the Exhibit A or Exhibit B as applicable, the ED shall notify the Controller who will give the collection responsibility to a collection agency.

PROCEDURES A.

Vista Taos 1.

In the event that Vista Taos’ census before admitting the new private-pay patient is 10 or less, the patient must pay at least 75% of the Vista Taos treatment program total charge

Administrative Policies & Procedures – Finance & Accounting Authorization for Extended Payment at Vista Taos & Casa Feliz

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Administrative Policies & Procedures upon admission. The balance can be payable in monthly installments over a period not to exceed 6 months.

In the event that Vista Taos’ census before admitting the new private-pay patient is 11 or more, the patient must pay at least 87.5% of the total charge upon admission. The balance can be payable in monthly installments over a period not to exceed 6 months.

In the event that Vita Taos’ census before admitting the new third-party-payor patient is 10 or less, the patient must pay upon admission the difference between the third-partypayors’ approved payment amount and the total charge such that the total of the patient payment and the third party committed reimbursement is at least 65% of the total charge. The balance can be payable in monthly installments over a period not to exceed 6 months.

In the event that Vista Taos’ census before admitting the new third-party-payor patient is 11 or more, the total of the patient payment upon admission and third-party-payor committed reimbursement must be at least 92% of the total charge. The balance can be payable in monthly installments over a period not to exceed 6 months.

Casa Feliz 1.

In the event that the Casa Feliz census before admitting the new private-pay patient is 8 or less, the patient must pay at least 87.5% of the total charge for the anticipated entire stay upon admission or, in the case of a patient paying on a monthly basis, of this total charge for each month of accommodation in advance of each month. Patients may pay for each month separately, as long as they fulfill this requirement. The balance can be payable in monthly installments over a period not to exceed 6 months.

In the event that Vista Taos’ census before admitting the new private-pay patient is 9 or more, no extended terms may be granted, and full payment is expected upon admission.

For a new third-party-payor patient, the third-party-payor commitment plus the patient’s contribution upon admission must total at least 80% of the full 1-month rate plus $145/day for the balance of the time expected to be spent. This shall be received upon admission. Subsequent months must be paid in advance. The balance can be payable in monthly installments over a period not to exceed 6 months.

Whenever possible, it is always preferable to have payment terms that conclude while the patient is still in treatment.

If the ED wishes to admit a patient outside of the delegation, approval of either the CEO or CFO of MedMark Services, Inc. must be received in advance.

Administrative Policies & Procedures – Finance & Accounting Authorization for Extended Payment at Vista Taos & Casa Feliz

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Administrative Policies & Procedures Exhibit A

Payment Plan Agreement This Payment Plan Agreement is made and entered into as of the date indicated below by and between _________________________________ (Payor) and MedMark Vista Taos, Inc. d/b/a Vista Taos Renewal Center (Vista Taos). ____________________________, a patient, will receive services under the Vista Taos residential treatment program. Payor agrees to pay for these services, and acknowledges and agrees that the total charge for such treatment services is $____________. Payor agrees and promises to pay Vista Taos such amount in the following manner: $___________________ shall be paid to Vista Taos on or before first day of admission to the treatment program. $___________________ shall be paid to Vista Taos in ___ monthly installments of $___________________ each on or before the ___ day of each consecutive month commencing _________________ until the outstanding balance is paid in full.

The unpaid balance may be paid in full at any time. I have read the Payment Plan Agreement. I understand and accept all its terms in full.

Signature: Payor Name (printed): Date: ______________

MedMark Vista Taos, Inc., d/b/a Vista Taos Renewal Center

By: Executive Director Date: ______________

Agreement Number: _________

Administrative Policies & Procedures – Finance & Accounting Authorization for Extended Payment at Vista Taos & Casa Feliz

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Administrative Policies & Procedures

Exhibit B Casa Feliz Payment Plan Agreement This Payment Plan Agreement is made and entered into as of the date indicated below by and between ________________________ (Payor) and MedMark Casa Feliz, Inc., d/b/a Casa Feliz (Casa Feliz). _________________________, a patient, will receive services under the Casa Feliz residential program. Payor acknowledges and agrees that the total charge for such services in $________________. Payor agrees and promises to pay Casa Feliz such amount in the following manner: $____________ shall be paid to Casa Feliz [on or before first day of admission] or [on or before ___________, __________.] $____________ shall be paid to Casa Feliz in _____ monthly installments of $_______ each on or before the _____ day of each consecutive month commencing ________________, _________ until the outstanding balance is paid in full. The unpaid balance may be paid in full at any time. I have read the Payment Plan Agreement. I understand and accept all its terms in full.

___________________________________________________________

Payor Name (printed) __________________________________________ Date ___________________________________ MedMark Casa Feliz, Inc. d/b/a Casa Feliz

by___________________________________________________________ Executive Director

Date ___________________________________

Agreement Number ________________________

Administrative Policies & Procedures – Finance & Accounting Authorization for Extended Payment at Vista Taos & Casa Feliz

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

AUTHORIZATION OF COMPANY OBLIGATIONS

POLICY NO.:

F&A-103

Effective Date:

March 31, 2009

Revised Date:

October 29, 2010, January 1, 2013

POLICY

To clearly define the appropriate levels of approval authority prior to obligating MedMark Services, Inc. in certain financial, contractual, or employment matters. This policy is not intended to be all inclusive. The omission of a specific event from this policy does not convey approval to authorize the omitted event. All employees should continue to use good judgment and seek the advice of Management when in doubt about the right to approve certain expenditures or other contractual obligations of the Company. Simultaneously, the policy is not intended to restrict Managers from making daily decisions in the normal course of their business operations. A.

Delegation of authority always flows from the Board of Directors, to the CEO, and then sequentially to the remaining levels of the organization. Certain authority remains exclusively with the Board, and their approval in advance is always required. Included in this category are: the appointment of any employee as an Officer of the company, the approval of any acquisition of a company or business, and spending authority in excess of that delegated to the CEO. Further, any Officer or Director may delegate higher approval limits than given below, to their direct reports, up to a maximum of their own spending authority, if such delegation is approved in advance and is given in writing with a copy to the CEO, CFO, and Controller.

Financial and contractual obligations would include any scenario where the Company is contractually bound to purchase goods and/or services and remit payment at a directed point in time for such goods and/or services. Financial and/or contractual obligations could include entering into an agreement to purchase equipment or property, goods over an extended period of time, charitable contributions, an agreement to settle a pending legal suit, setting up a direct bill account with a vendor, or any other action that may require a signature of authorization in order to obtain the intended goods or services.

Employment obligations would be any action guaranteeing or offering employment or other compensation to a person. Other compensation can include actions such as pay increases, bonuses, promotions, or an agreement to pay someone as a contractor.

Administrative Policies & Procedures – Finance & Accounting Authorization of Company Obligations Policy

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Administrative Policies & Procedures

II.

PROCEDURES A.

Operational Goods and Services 1.

Operational goods and services would be items such as medical supplies, office supplies, lab services, cleaning services, etc. Operational goods and services are often recurring expenditures that are necessary for the daily efficient operation of the business. Managers are expected to purchase these items as needed according to their respective budget constraints and business flow. Managers should continue to follow the current approval process for such orders and related invoices. Managers must approve all vendor invoices prior to the company issuing checks in payment for these goods and services.

Operational goods and services other than the items cited in the paragraph above (i.e. repairs and maintenance of office equipment, refurbishing furniture, painting, and similar items) may be purchased and approved if within budgeted expenses, according to the following spending limits:

Director - $1,000

Regional or NSC Director - $2,500

Vice Presidents - $5,000

Chief Financial Officer - $25,000

Chief Executive Officer – All in excess of $25,000

Board of Directors approval is required for expenditures above the CEO’s limit.

Managers may engage Finance any time they are investigating new vendors. Finance can assist with evaluating the vendor regarding the proposed pricing and any other contractual constraints such as length of the contract. Upon review of the proposed vendor relationship by Finance and any follow up discussions with the Operations team, a collective conclusion will be reached about the next steps involving the vendor.

Capital Expenditures 1.

Capital expenditures are any expenditure approved by the Company to acquire or upgrade physical assets such as property, buildings or equipment. They include purchasing or leasing of any asset with a useful life in excess of one year, and a purchase price equal to or greater than $500. Also included are improvements that extend the useful life of an existing asset by a year or more. These expenditures can include everything from repairing a roof or repainting a facility to buying new computer

Administrative Policies & Procedures – Finance & Accounting Authorization of Company Obligations Policy

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Administrative Policies & Procedures equipment or office furniture. In general, the CFO must approve any single capital expenditure totaling more than $500 or an aggregate capital expenditure of more than $1,500. The CEO must approve any capital expenditure above $5,000. 2.

Charitable Contributions 1.

Only Officers of the Company are authorized to enter into capital or operating lease agreements. Additionally, at least one signature on the lease agreement must be that of the CEO or CFO.

Any single or combined charitable contribution in excess of $250 must be approved by the CEO. Documentation must be provided by the charity that indicates their charitable status and related tax information. No political contribution may be made without the approval in advance of the CEO.

Other Obligations 1.

All legal settlements must be approved by the CEO with advice from General Counsel.

The Board of Directors must approve any definitive agreement to acquire a business or company.

Matters involving the intent of the Company to enter into a merger or acquisition agreement must be approved in advance by the CEO. This includes but is not limited to letters of intent and definitive agreements.

Any payment of $10,000 or more that is not related to existing approved contractual obligations must be approved by the CEO or CFO prior to submission to Accounts Payable.

All use of attorneys must be approved by the CEO.

Employee Obligations 1.

All employment obligations as listed below must be approved by the CEO and CFO. Note that intended obligations to employees should not be communicated until after proper approvals are obtained. a.

All new hires.

All promotions.

Any increase in employee compensation equal to or greater than 7% of their current compensation.

Administrative Policies & Procedures – Finance & Accounting Authorization of Company Obligations Policy

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Administrative Policies & Procedures

Any increase outside of the standard annual review process unless specifically related to a promotion.

All employee bonuses and bonus plans.

Any obligation that is outside of the Company’s standard benefits plans.

Consultant Arrangements 1.

A consultant is an individual or organization that provides advice or expertise to an organization for a fee. Consultants can be used for a variety of activities such as IT, medical staffing, compliance, due diligence related to a contemplated acquisition, or other professional services. Prior approval by the CEO or CFO is required for all single or collective consulting engagements in excess of $2,500. Prior approval by the CEO is required for any single or collective consulting engagement in excess of $20,000. The consulting individual or organization must provide a completed W9 prior to payment being remitted for services.

Approval Procedures MedMark Services requires that all check requests, and invoices, have at least two employees indicating their approval for payment. One of those approvers must have sufficient delegation of authority for the amount of the invoice or check request. The first approver should be knowledgeable about the item or service being purchased, as approval indicates that the item was received, and the price is correct. The second approval should be from the person to whom the first approver reports. If the second approver does not have sufficient authority for the amount to be paid, then it should be forwarded to the second approver’s supervisor, and continue up the hierarchy until the final approver has sufficient authority for the amount to be paid. The following are exceptions to the requirement that two employees approve an invoice or check request: 1.

UTILITIES a.

Accounting should review the invoice, and if consistent with past billing, should enter the invoice for payment without further approval signatures required. Accounts Payable should check to ensure amounts are consistent with prior periods. Of course, the checks themselves will still require 1 or 2 signatures from the CFO and the CEO depending on size.

Utilities include: electricity, gas, water, sewer, local telephone service, the long distance service, alarm companies and T-1 lines. Occasionally, Accounting should verify that there are no changes in service from utilities such as alarm companies.

Administrative Policies & Procedures – Finance & Accounting Authorization of Company Obligations Policy

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Administrative Policies & Procedures 2.

LEASES a.

Leases for real estate at all clinics plus the NSC were approved by management by signing a lease. Therefore, the routine monthly payments for the lease and the CAM associated with it can be processed by accounting without additional approvals. Of course, the checks themselves will still require 1 or 2 signatures from the CFO and the CEO depending on size.

Leases for office equipment (copiers, postage machines, computers, etc) are also approved by management when the initial contracts are signed. Accounting should know what machine each lease is for, when it terminates, and all payments defined in the contract for the entire life of the contract. These can be entered into our system and checks prepared without further approvals. Of course, the checks themselves will still require 1 or 2 signatures from the CFO and the CEO depending on size.

INTEREST AND PRINCIPAL PAYMENTS a.

PACKING SLIPS a.

When a packing slip reaches accounting, the signature connotes that all materials on the slip were received. This does not constitute approval for payment, as there is usually not a dollar amount on a packing slip. So, when an invoice for that shipment comes in, it needs to be approved with at least two signatures where one of the approvers has sufficient approval limit for the invoice.

EMPLOYEE BENEFITS a.

Interest and principal payments to Sellers, and to lenders, are agreed to when the initial contract is signed. Again, no separate signature is required for accounting to enter the payment into our system and to have a check prepared. Accounting should verify that the amounts invoiced are correct. The CEO and/or the CFO should sign the checks.

The HR Director or designee shall review and approve all invoices for benefit plans (insurance, 401-k, flex spending, etc.) and initial the invoice prior to payment.

LEGAL INVOICES a.

MedMark’s legal department shall review and approve all legal invoices. The CEO shall be the second approver.

Administrative Policies & Procedures – Finance & Accounting Authorization of Company Obligations Policy

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

CAPITAL EXPENDITURES

POLICY NO.:

F&A-104

Effective Date:

None

Revised Date:

NONE

POLICY

II.

PROCEDURES

[TO BE DEVELOPED BY FINANCE DEPARTMENT]

Administrative Policies & Procedures – Finance & Accounting Capital Expenditures

Page 1 of 1

Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

CASH CONTROL AND FRAUD

POLICY NO.:

F&A-105

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to maintain active controls on the receipt of revenues and to ensure that revenues are deposited to appropriate depository accounts. II.

PROCEDURES A.

The CFO is responsible for maintaining procedures for the security of revenues generated by the organization.

MedMark Services, Inc. will maintain the security of revenues through the following methods: 1.

All incoming revenue by mail from payer sources is delivered to the organization’s corporate office and logged into the financial accounting system by authorized financial personnel.

All payments received onsite by designated and authorized program personnel are logged into the appropriate patient record system and receipted, with one receipt copy given to the paying patient, and the other receipt copy filed onsite for recordkeeping purposes.

All payments received daily on-site are secured in the on-site safe, with limited access given to authorized personnel only.

Before the close of business each day, all forms of payment are counted and compared to the day’s receipt log to ensure proper accounting for all funds received. A deposit slip is prepared daily for all cash and check funds received. The Program Director and other designated person must both initial a copy of the deposit slip verifying that the total indicated on the deposit slip agrees to the funds recorded in the system for the day and to the daily receipt log.

A copy of the deposit slip and all payments should be made and faxed to the Senior Accountant at the National Support Center daily.

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Administrative Policies & Procedures 6.

For all credit card payments, a copy of the daily settlement report retrieved from the credit card machine is to be sent to the National Support Center with a copy of the daily deposit log indicating all credit card payments received.

The Program Director or other designee is to make a deposit when the funds secured on site total more than $500.00 but no less than every other business day. The deposit slip received from the bank must be faxed to the National Support Center confirming receipt of funds at the bank.

Accounting is responsible for reconciling the organization’s depository accounts weekly to ensure all funds were deposited to the designated institutional depository account.

The Corporate Compliance Policy, specifically the procedures on monitoring and auditing, will serve as the organization’s oversight in the area of fraud. Procedures will ensure that monitoring and auditing practices are being conducted on an ongoing basis in critical areas of the organization’s operation to maintain compliance with all laws and guidelines governing the organization. Internal self-audits will include, but not be limited to, fiscal services (billing and coding), marketing, contractual services, health and safety practices, use of agency resources, confidentiality, dual relationships, and medical necessity.

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Administrative Policies & Procedures DEPARTMENT:

FINANCE

SUBJECT:

CREDIT AND COLLECTION POLICY

POLICY NO.:

F&A-106

Effective Date:

May 23, 2007

Revised Date:

December 1, 2011

POLICY

It is MedMark Services, Inc.’s (including all of its wholly owned subsidiaries) policy to only extend credit to governmental agencies and not to individuals, except for small nominal advances to individuals of under $50.00. Employee advances are permitted if authorized by the CEO, CFO or the VP of Human Resources. This policy cannot be revised without the consent of Healthcare Finance Group, LLC. II.

PROCEDURES A.

Notification 1.

Original Invoice: An invoice should be prepared as soon as possible after the end of the month and sent to the appropriate governmental agency.

The invoices should be posted to the G/L and in the subsidiary ledger that is maintained in excel for cash forecasting purposes. An estimated payment date should be shown on the excel statement based upon our experience with the governmental entity and the contract that governs our relationship.

Reminders 1.

Cash receipts are to be posted on a daily basis to the G/L and the subsidiary ledger. Provide that information to the CFO and Finance Manager at least weekly on Friday.

Past due is when payment is late based upon our experience with the governmental entity and the contract that governs our relationship.

15 Days Past Due: Contact the appropriate governmental representative by email to remind them that payment is due. Notify the CFO if there are any problems or potential penalties.

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Administrative Policies & Procedures

30 Days Past Due: A telephone call should be made to the delinquent governmental agency finding out why the payment has not been made. Notify the CFO if there are any problems or potential penalties.

45 Days Past Due: Contact the appropriate governmental representative by email to remind them that payment is due. You should copy the CEO CFO and your governmental contact’s superior on this email. Follow up within 48 hours if you are not contacted with a resolution.

50 Days Past Due: Turn over collection to the CFO.

Conclusion 1.

Following these simple, clear and basic credit and collection policies and procedures will help to keep our accounts receivable healthy. The Controller is responsible for implementing and following this policy.

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

COLLECTION AND DEPOSIT POLICY

POLICY NO.:

F&A-107

Effective Date:

October 6, 2006

Revised Date:

January 1, 2013

POLICY

MedMark Services, Inc. understands the importance of being flexible when collecting fees for long term methadone detoxification or methadone maintenance services. As a result, MedMark Services, Inc. will allow program patients to pay fees for treatment on a weekly, semi-monthly or monthly basis. II.

PROCEDURES A.

MedMark’s clinics accept cash, money orders, debit and credit cards and business checks. The clinics do not accept personal checks at any time.

All cash collected and remaining on the premises is to be locked up in a safe until deposited in the bank account. The clinics may not keep more than $500 in cash overnight. Once $500 in cash has been accumulated, all cash, checks and money orders must be deposited in the bank by the end of the business day. A copy of the prepared deposit slip and the bank’s confirmation of deposit must be faxed to the Accounting Manager at the National Support Center by the next business day.

Self-Pay Patients 1.

All opioid treatment patients who are not covered in full by insurance and/or Medicaid are considered “Self-Pay” patients and are responsible for all charges for treatment at monthly rates determined by each clinic. These charges are due and payable in advance of treatment. In general, clinics may not carry accounts receivable balances for Self-Pay patients (see exceptions 1 and 2 which are defined below).

Program directors are authorized to approve payment plans for patients on a monthly, semi-monthly, bi-weekly, weekly or daily basis. However, at no time can a payment plan be approved that allows a Self-pay patient to receive treatment “on credit” (again, see exceptions 1 and 2 defined below).

All patient balances on file when this policy becomes effective must be collected and made current as soon as possible. If necessary, and in limited cases, a payment plan that provides for total payment within 180 days can be offered to select patients only

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Administrative Policies & Procedures upon the prior written approval of the Chief Financial Officer (CFO) or the Chief Executive Officer (CEO). a.

Exception 1: In California only, program directors are authorized to allow Self-pay patients no more than 3 days of treatment without payment in advance, if the number of such credit patients is no more than 5% of SelfPay patients on census at one time. For example, a clinic with 100 selfpay patients on census can allow up to 5 credit patients at a time. Selfpay patients who are unable to pay for treatment are to be immediately initiated on an administrative discharge process under the supervision of a physician. If necessary, and in limited cases, Self-Pay patients will be allowed to transition to pay in advance through 2010. However all SelfPay patients are to pay in advance beginning January 1, 2011 with no more than 3 days of treatment without payment in advance (again, the sole exception is defined below).

Spend Down Patients 1.

Patients who are covered by insurance and/or Medicaid but are required to meet a monthly, quarterly, or annual deductible are considered “Spend Down” patients. Because it is impractical to burden our clinic staff with verifying the met deductible and collecting the difference from each patient at the end of every month, and because the typical Spend Down amount is greater than our monthly fee, each “Spend Down” patient is to be considered a Self-Pay patient with the same pay in advance requirements, effective immediately. In the event Medicaid pays any portion of the Spend Down patient’s charges, that amount will be refunded to the patient or applied to future charges at the patient’s option. a.

Exception 2: Clinic directors may provide service in advance of payment to patients if all of the following three requirements are met: i.

The patient receives regular income at a certain time of the month (e.g. a social security check), and

ii.

The patient pays immediately after receipt of that income, and

iii.

The patient has a history of reliably making his/her payments for at least 3 months (this requirement only applies when this policy first becomes effective).

In the event such patient does not make the required payment timely, then they are to be immediately initiated on an administrative discharge process under the supervision of a physician. As with all medication changes, a doctor’s order shall be obtained prior to starting medication taper that will not be less than 14 days and will be individualized taking into consideration the patient’s medical history Administrative Policies & Procedures – Finance & Accounting Collection & Deposit Policy

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Administrative Policies & Procedures including, but not limited to, medication dose. If the patient is a female a pregnancy test will be administered prior to starting medication taper and the medical director or program physician and the patient will be made aware of the results prior to the start of a medication taper.

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

PETTY CASH

POLICY NO.:

F&A-108

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to assign to the Program Director the responsibility of distributing and the reconciliation of petty cash. II.

PROCEDURES

Each program is allotted up to $500.00 per month in petty cash. The amount will be approved by the Regional Vice President and CFO. The Program Director is responsible for overseeing the petty cash fund. An original receipt must be collected to verify purchased made with petty cash. Petty cash is reconciled and submitted to corporate at the end of each month. Petty cash is not replenished if: 1) no receipt is provided 2) the petty cash log isn’t completed properly. The amount replenished shall be the same as the amount spent during the previous month. The Program Director is responsible for replenishing the petty cash fund as necessary to insure there is a timely way to pay for petty cash needs as required.

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

SERVICE FEES

POLICY NO.:

F&A-109

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to provide each patient with a fee schedule prior to the beginning of any services received for which MedMark intends to seek reimbursement from the patient. II.

PROCEDURES 1.

Each patient of MedMark will be provided with a fee schedule associated with the program in which the patient is seeking enrollment prior to the beginning of any services received for which MedMark intends to seek reimbursement from the patient. Each fee schedule specifies the fees charged for all services associated with each program, as well as miscellaneous charges that the patient may incur. Said fee schedule indicates the amount each patient will be responsible to pay. Each Patient will also receive information on available payment options and schedules for each service. Each patient will be required to sign and date said fee schedule, which will be retained in the patient’s permanent record.

Each patient will receive the patient handbook, which discusses the types of services and treatment offered and typical duration times associated with the program. This allows patients to carefully evaluate the program, treatment expectations, and the fees associated with program participation.

MedMark also accepts Drug Medi-Cal (DMC) or Medicaid payments, and private insurance if they cover treatments provided by MedMark Services, Inc.

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Administrative Policies & Procedures DEPARTMENT:

FINANCE AND ACCOUNTING

SUBJECT:

TRAVEL POLICY

POLICY NO.:

F&A-110

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

MedMark Services, Inc. will reimburse colleagues for actual expenses incurred in the performance of Company business. Reasonableness of expenses will be determined according to the specified business purpose and the location visited. Any unique provisions which are applicable only to a specific business unit will be set forth in an addendum to this document. II.

PROCEDURES A.

Travel Arrangements Colleagues shall make all travel arrangements through the Company’s approved travel agency including airline, hotel, and all commercial ground transportation. Meeting arrangements for groups of 10 or more, when travel is required, must be made via the Company’s designated travel agency unless otherwise authorized by Management. Company’s authorized travel agency has been instructed to offer reservations that provide the lowest possible cost to the Company, within the desired travel parameters, and to provide the Company with detailed summary spending reports including offered reservations and booked reservations. The Company reserves the right to withhold reimbursement if travel arrangements are not made through the Company’s designated travel agency. 1.

Colleagues are not authorized to set up direct billing to MedMark Services, Inc. for any reason, or negotiate contractual agreements with any travel related vendors, without the approval of Company’s CFO. At no time should any colleague direct a vendor to invoice MedMark Services, Inc. directly for travel related costs without prior approval from the Company’s CFO.

Attendance at industry/professional association meetings, seminars and conventions requires pre-approval by the colleague’s immediate supervisor. All payments received daily on-site are secured in the on-site safe, with limited access given to authorized personnel only.

Off-site group or departmental functional meetings require prior written approval from the appropriate Company leadership.

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Administrative Policies & Procedures

Colleagues should always validate the price charged by the travel vendor (e.g. auto rental, hotel, etc.) against the travel itinerary. Any unfavorable discrepancies should immediately be brought to the vendor’s attention by the colleague.

Reimbursement for Spousal/Family Travel expense is not authorized. The Operations Manager must approve in writing any emergency or unique situations in advance. Such approval must accompany the submission of such expenses for reimbursement.

Air Travel 1.

Colleagues should be flexible in making travel arrangements, and schedule trips in consideration of the lowest airfare, including the use of connecting flights.

Travelers should initiate arrangements well in advance of the travel date, in order to take advantage of advance booking fares. Significant discounts may be obtained when tickets are booked in advance.

Non-refundable tickets provide significant cost savings and should normally be purchased when available and appropriate for the situation.

Colleagues are expected to travel in coach accommodations.

Travel by specific airline, route or class of service based on personal preference, or that increases the cost of travel in order to participate in a “travel program or upgrade,” is strictly prohibited. Downgrading or exchanging tickets for the financial benefit of the colleague is not permitted.

Airlines offer discounted fares for a guaranteed minimum number of travelers flying to a meeting or convention. Travel arrangements should be initiated well in advance of the meeting in order to take advantage of this opportunity. Contact the Company designated travel agency for selection of venue and specific requirements.

MedMark Services, Inc. does not reimburse the following types of expenditures without the approval of the CEO: a.

Airline club memberships.

Upgrade charges.

Other airline awards of any type.

“Air-phone” or on board phone charges.

Accommodations incurred for non-business related purposes.

Accommodations for spouse or family members.

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Administrative Policies & Procedures

In-room movies, electronic games, etc.

Honor bar charges.

All unused tickets must be immediately reported to the Company’s authorized travel agency or the airline, if a ticket or a portion of a ticket is not used. All cancellations must be made prior to the original departure date, to ensure a proper refund.

Refundable tickets must be sent in to the travel agency for a credit. The average time period to receive a credit is six to eight weeks.

10.

All unused tickets will be held within the travel reservation system for future use. Each traveler is responsible for notifying the travel agency of a pending credit when making a reservation.

Lodging Company’s travel agency will advise the traveler if MedMark Services, Inc. has negotiated a discounted rate with a hotel at the traveler’s destination. Colleagues should refrain from negotiating contractual lodging rates with hotels. All such negotiations should be directed to the Company CFO. 1.

Hotel selection guidelines Travelers are required to use: a.

Properties where there are Company-negotiated rates.

Properties where there are travel agency negotiated rates.

If a Company-negotiated or special agency hotel rate is not available, travelers must use: a.

Hotel chains in a similar price category. Examples include: Hampton Inn Fairfield Inn

The least expensive property in a similar hotel category.

Best available or lowest corporate/promotional rate.

Upon arrival, it is recommended that each traveler verify the lowest rate available. On occasion, hotels will run promotional offers not available at the time of booking. Administrative Policies & Procedures – Finance & Accounting Travel Policy

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Administrative Policies & Procedures 2.

The traveler is responsible for knowing the cancellation policy of the hotel as stated on the invoice/itinerary. Cancellation policies are different at each hotel. All cancellations must be made by the colleague calling within the appropriate time in order to avoid incurring fees. Cancellations can be made by any of the following: a.

Calling directly to the hotel or 800 # of the hotel chain

Calling the Company designated travel agency.

It’s required to request and record a cancellation number for future reference. Travelers will be held responsible and will not be reimbursed for failure to cancel unless there is evidence of error.

The cost of the room plus all related taxes should be entered in the “Lodging” column on the expense report. All other items on the bill (meals, phone calls, etc.) should be entered in the appropriate columns.

All lodging expenses require a detailed hotel bill in addition to the original receipt.

MedMark Services, Inc. requires colleagues to use a corporate approved personal longdistance calling card to avoid excessive hotel charges. While traveling on Company business, one personal call per day is authorized for reimbursement, not to exceed 20 minutes per call. Making long distance calls through the hotel switchboard should be limited to emergency situations only.

Auto Rental 1.

The Company’s travel agency will make all travel arrangements, including reservations for rental cars.

Colleagues are required to use the Company’s preferred vendors for all rentals. If unavailable, the travel agency will book a secondary vendor.

Car rentals will be reimbursed for intermediate sized cars. Exceptions may be granted when transporting supplies or equipment, or when more than three people will be in the car. Whenever possible, the most economically sized car should be used.

Private limousines or car services are strictly prohibited unless one of the following circumstances exists: a.

Where Limousine or car service is more economical than taxi service; or

Executives or Board Members; or

Client Entertainment with Management approval

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Administrative Policies & Procedures 5.

Colleagues should rent an automobile if and when the required travel makes a rental car more cost effective than traveling by air, taxi or other available transportation. When a colleague is traveling to and from a hotel at their destination, colleagues should make use of more economical services such as taxicabs or shuttle services, where available.

Colleagues are expected to combine ground transportation with co-workers to the same destination.

Decline fuel replacement options. The colleague must refuel the vehicle and provide a receipt of fueling prior to returning it to the rental agency to avoid excessive charges.

Decline the insurance coverage that is offered by the rental agency (third party collision, third party liability and collision damage to the rental car). The Company insures these risks separately.

If some portion of a car rental is for personal use, verify that you have adequate insurance coverage from the car rental company. Additional insurance is not a reimbursable expense.

10.

The rental agreement and original gas receipts should be included with the expense report for payment.

11.

Should a rental car accident occur, travelers should submit a written accident report as soon as possible to:

12.

The rental car company;

Local authorities, as required;

Your manager

Parking and Moving Violations. Colleagues who incur parking fines or are cited for any moving violations are responsible for the prompt payment of all fines and tickets. MedMark Services, Inc. will not reimburse a colleague for these expenses. a.

Vehicles should be parked so as not to present a hazard or obstruction to other traffic or in a manner that places the vehicle in a potentially hazardous situation.

The ignition key and any portable navigation device must be removed from all unattended or parked vehicles. The vehicle must be locked when unattended.

Unattended vehicles with automatic transmissions should be parked with the ignition turned off, the emergency brake set and the transmission placed in the "park" position.

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Administrative Policies & Procedures 13.

Use of Cellular Telephones– MedMark Services, Inc. strictly forbids the use of handheld wireless communication devices while driving. Such usage may be in violation of state and/or local laws. The use of these devices while operating a vehicle is distracting and can lead to an accident. Drivers must pull off of the highway or roadway at a safe distance from traffic to place or receive calls when using a handheld device. If the assigned driver receives a citation and/or fine for using a cellular telephone while driving, the driver will be responsible for the payment of the fine.

Use of Personal Vehicle 1.

Use of a personal automobile in the performance of Company business is entirely voluntary.

The Company does not provide insurance for any colleague who uses his or her personal auto for business purposes. The mileage allowance policy is provided to cover the cost of gas, maintenance, repair and insurance while on Company business. Mileage from a colleague’s home to his/her regular office location is not reimbursable.

Since the Company assumes no responsibility beyond making available a mileage reimbursement allowance, it is the colleague’s responsibility to protect against damage to his/her auto and legal liability in such form and amount, as the colleague deems adequate. Colleagues also assume full liability for any damage or injuries that may arise while driving their personal automobile.

Colleagues using their personal vehicles will be reimbursed a per mile rate established by the Company for miles traveled on Company business. All tolls and parking charges will also be reimbursed. Colleagues must include the business need/purpose, and the travel origin and destination (city and state).

Colleague Meals and Entertainment 1.

Colleagues should use appropriate discretion when choosing a restaurant for meals, based on reasonableness of cost.

The Company will reimburse colleagues for meals while traveling overnight; up to $35 per day. Tips for meals are to be included in the total meal price (15% allowable). Tips in excess of 15% will be the responsibility of the colleague. The actual cost of the meal must be recorded (no rounding). A credit card receipt or a hotel/motel bill must support meals. A restaurant tab is not considered a valid receipt. Whenever possible, each colleague should report his or her own meal cost. When this is not practical, the senior person in attendance should report the meal cost. Meals charged to a hotel/motel bill must be itemized separately on the expense report (to identify meals/entertainment).

The following meals are not reimbursable: Meals on single day trips, breakfast on the day of departure (unless departure is before 7:00 a.m. or arrival after 8:00 p.m.), dinner on day of return (unless late arrival); and extraordinary or extravagant expenditures (as

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Administrative Policies & Procedures defined by the IRS), or any meals for other than a bona fide business reason. It is imperative that the cost of meals be properly documented to avoid disallowances by the IRS.

A maximum of $35 per diem daily is allowable per colleague. Any deviation must be preapproved by the immediate supervisor.

Expenditures for meals must be detailed by dates with tips included in the cost of the meal.

A receipt is required for each single meal. If cash is paid, a cash register receipt is acceptable.

Restaurant tear tabs are not acceptable receipts.

Meals are reimbursable only when trips include an overnight stay, except as noted elsewhere in this document.

Business Meals and Entertainment Business meals and entertainment often facilitate business transactions on the Company’s behalf. As such, reasonable expenditures for customers, potential customers, vendors or consultants that relate directly to the act of conducting business are reimbursable. Expenditures directly preceding or following a substantial and bona fide discussion related to Company business are also reimbursable. 1.

Business meals and entertainment events should be planned, with specific goals and objectives established, and with a view of the strategic or tactical cost/benefit relationship when incurring entertainment expense.

During an audit, the Internal Revenue Service will do a thorough review of Company’s expenses. The colleague must provide the following information if requesting reimbursement for business meals or entertainment: a.

Date of the entertainment

Location: Name, if any, address or location, and designation of type of entertainment, such as dinner or theater, if such information is not apparent from the designation of the place

Amount: Amount of each separate expenditure for entertainment

Business Purpose: Business reason for the entertainment or nature of business benefit derived or expected to be derived as a result of the entertainment and the nature of any business discussion or activity

Attendees: Include a list of all attendees

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Administrative Policies & Procedures f.

A maximum expenditure of $75 per day, per person, per instance, is allowed for external client/customer entertainment, unless approved by an officer of the Company in advance.

Meals for fellow colleagues will be reimbursed only in the following circumstances:

5. H.

This required information should be entered on the expense report or on the original receipt provided with the expense report - taking a few extra minutes in providing this information will save a tremendous amount of time during an audit.

When the meal is a necessary incident to the entertainment of, or business meeting with, outside business associates.

When the meal is directly preceded or followed by a business meeting/ conference of more than 1/2 day’s duration, or a colleague performance evaluation.

If travel is involved.

When business meals or entertainment including two or more colleagues are to be included on the Expense Report, the most senior Company colleague present should pay and request reimbursement for the expense. A maximum of $45 per person is allowed.

A list of attendees must be included in the expense report.

Management must approve group meetings in advance.

Other Business Expense 1.

Expenses not classified elsewhere on the Expense Report should be entered in the “Other” column, with a specific description of the expense noted in the explanation column. By way of example, non-business related expenses such as traffic fines, babysitting and kennel fees are not reimbursable, unless specifically approved by appropriate business unit leadership.

Club or Professional Association Memberships Dues and CME: a.

In order to encourage the enhancement of the professional skills of its colleagues, the Company may reimburse for initiation fees, dues and meeting expenses for authorized and approved membership in professional organizations.

Reimbursement for these fees and dues must be approved in advance by the Regional Director or an Officer of the Company.

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Administrative Policies & Procedures 3.

The following are examples of other reimbursable expenses: a.

Tolls and parking.

Taxicab fares.

Telephone charges–For business use of personal phone.

Tips–Not included elsewhere.

Office Supplies.

Flowers, cakes and gifts are generally not reimbursable, except in unusual circumstances, with Senior Management approval.

Expense Report and Reimbursement Procedure 1.

It is the sole responsibility of the colleague to obtain the required approval for all expense reports.

Colleagues will record the cost of airfare on the face of the Expense Report whether it is a reimbursable expense or not. Airfare charged to the Company will then be deducted to show no net reimbursement to the colleague. This record is necessary for accounting purposes. Whereas the charge is to the colleague’s corporate credit card, the expense shall be reported on the colleague’s expense report.

Colleagues are responsible for indicating the correct location to be charged in the top section of the Expense Report.

An expense report will be filed regardless of the method of payment used. However, Company credit card expenses shall be submitted on a form separate from colleague reimbursable expenses. The colleague shall submit expenses to their supervisor/manager for approval within seven (7) days of incurring the expense. Under no circumstances may a colleague approve his/her own expense report. a.

The colleague must send the original expense report with all original receipts neatly attached to the Corporate office for reimbursement.

The colleague may fax the expense report to their respective manager for approval and the manager may fax a copy of their signature approval to Corporate to be matched with the original expense report.

At no time, shall expenses be reimbursed without either an original signature on the face of the expense report or an attached facsimile copy of the manager approval.

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Administrative Policies & Procedures 5.

Any expenses which are not submitted for reimbursement within 90 days from the actual date the expense was incurred may not be approved for payment. Each manager is responsible for promptly reviewing the expense reports of his/her colleagues within 4 business days after receipt. The manager is responsible for ensuring that all required receipts are available for review before approving.

Expense Report approval authority cannot be delegated in the supervisor’s/manager’s absence. However, in the supervisor’s absence, the approval authority may move up the colleague’s organizational hierarchy until an approver is available to review the expense report.

The responsible Accounts Payable department will perform the final expense report audit following the supervisor’s approval. Unique audit rules may be formalized for each respective business unit.

Business expenses that will be reimbursed are those incurred by the colleague and resulting directly from a qualifying business activity. All related expenses must be reported on the expense report.

Colleagues are required to submit original receipts for all reimbursements. Photocopies and statements are not acceptable for the purpose of submitting an expense report.

10.

A specific statement of the business purpose must be included on the face of the expense report.

11.

Colleagues must attach a copy of the passenger itinerary or PDF File for airfare to the expense report.

12.

Expense reports will be audited for compliance to policy. Any expenses incurred by the colleague, which are not reimbursable under the policy, are the responsibility of the colleague.

13.

MedMark Services, Inc. reserves the right to deny or modify reimbursement of any expense if it is deemed to be excessive or unnecessary for business purposes.

14.

Gifts and awards granted by MedMark Services, Inc. to a colleague for items such as achievement, length of service, and for special occasions such as holidays and birthdays may be considered taxable income to the recipients. IRS Code Section 274 defines different awards along with the stipulations governing how the awards should be treated. The IRS emphatically states that cash or gift certificates cannot be given to colleagues tax-free. No personal gifts to colleagues will be reimbursed unless approved in advance by Management.

15.

If international travel is involved, the exchange rate for converting foreign currency and its source must be clearly indicated.

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Administrative Policies & Procedures 16.

Inclusion of fraudulent receipts, mischaracterization of expenses or other unethical conduct undertaken by a colleague in connection with company travel or the submission of expenses for reimbursement constitutes grounds for immediate termination.

17.

The Company will reimburse colleagues up to $75 per year for the annual fee incurred on a personal credit card.

18.

The Company policy is to not offer company credit cards. There are currently 7 grandfathered credit cards that are in use. For those, the Company issued credit card should only be used by the intended colleague for travel and other business related expenses filed on an expense report. Colleagues are responsible for submitting a Company Credit Card Detail Report for all expenses incurred on the credit card. The Company shall issue payment directly to the Credit Card vendor; provided the expenses submitted by the colleague on the Credit Card Detail Report are in accordance with this policy. The Company may not pay the Credit Card vendor until an approved Credit Card Detail Report is reviewed by Accounts Payable. Colleagues should not use a Company issued credit card for any non-business or personal purchases. In the event a Company issued credit card is lost or stolen, it is the colleague’s responsibility to contact the credit card issuer directly. If there is a disputed charge, the colleague should first contact the credit card issuer. If the matter is not satisfactorily resolved, the colleague should then contact Accounts Payable. Colleagues who terminate employment with MedMark Services, Inc. shall submit their cards to their supervisor or a designee.

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IV. Compliance

Administrative Policies & Procedures DEPARTMENT:

COMPLIANCE

SUBJECT:

CODE OF CONDUCT

Effective Date:

August 1, 2008

Revised Date:

December 28, 2010, December 16, 2011, August 1, 2012

POLICY

It is the policy of MedMark Services, Inc. to provide services that fully comply with all federal, state, and local regulations and applicable laws, and that adhere to high ethical standards. MedMark will institutionalize these ethical standards through an organized and ongoing comprehensive corporate compliance program. MedMark’s Corporate Compliance Program seeks to meet the following overall goals: • • • •

Maintain and enhance the quality of services Compliance with all applicable laws and regulations Empower all involved parties to prevent, detect, respond to, report, and resolve conduct that does not conform to applicable laws and regulations, and MedMark’s ethical standards/code of conduct Establish mechanisms for staff members to communicate questions and concerns about compliance issues and to appropriately address such questions and concerns

I. PURPOSE OF THE CODE OF CONDUCT All directors, officers, employees, contractors, students, and volunteers (collectively referred to as “staff”), are expected to perform their designated functions in a manner that reflects the highest standards of ethical behavior. The ethical standards contained in this Code of Conduct shape the culture and norms of MedMark’s administrative, operations, and clinical practices. Both staff and members of the governing body will be held fully accountable to these standards. In addition to the specific guidelines contained in this Code of Conduct, employees who are licensed professionals are expected to follow the ethical standards required by their specific licensing and certification boards. The purpose of the Code of Conduct is to have as our corporate objective that all employees’ actions reflect a competent, respectful, and professional approach when serving our patients, their families and/or representatives, our customers, other providers of services, and members of the communities we serve. It is expected that staff and members of the governing body will perform their duties in compliance with all federal, state, and local regulations in accordance with standards set forth in this Code of Conduct. Violation of the Code of Conduct will lead to disciplinary actions, which may include termination of employment and/or separation from MedMark. Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures

II. STANDARDS

Professional Conduct 1. Staff will respect the rights of our patients by demonstrating full integration of the guidelines contained in our Rights and Responsibilities Policy. This includes the right of the patient to make decisions in their own behalf and fully participate in every aspect of the service delivery process. 2. Staff will provide services in a manner that fully respects the confidentiality of patients, by demonstrating a functional knowledge of confidentiality laws, policies and guidelines. 3. Employees will be fair and honest in their work. They will not exploit or mislead, and will be faithful to their contractual obligations and their word. 4. Employees will consult with, refer to, and cooperate with other professionals to prevent and avoid unethical conduct. Employees will be accountable for upholding professional standards of practice.

Personal Conduct 1. All prior personal relationships between staff and persons entering MedMark’s programs shall be disclosed by the staff member and subject to review by the appropriate Supervisor. 2. Staff will limit relationships with persons served to their defined professional roles. 3. Staff will not establish ongoing personal or business relationships with patients, family members of patients, or significant others of patients receiving services. 4. Staff will conduct themselves in a professional, ethical, and moral manner and follow MedMark’s practices on conduct at all times. 5. Sexual relationships between staff and patients, family members of patients, or significant others of patients receiving services are never appropriate. Sexual relationships include, but are not limited to the following: engaging in any type of sexual activity, flirting, advances and/or propositions of a sexual nature, sharing sexually suggestive writings or pictures, comments of a sexual nature about an individual’s body or clothing, or lewd sexually suggestive actions or comments. 6. Staff will not accept money or gratuities or gifts of value from a patient, family member, or stakeholder, and cannot accept personal favors or benefits that may reasonably be construed as influencing their conduct. 7. Staff shall accurately represent their competence, education, training and experience. A copy of all diplomas, licenses, certifications shall be provided by all staff for inclusion in his/her file. 8. Staff will refrain from using, possessing, or trafficking in illicit drugs. Staff shall not be under the influence of drugs and/or alcohol while working. 9. Staff will refrain from witnessing the signing of outside documents, including but not limited to, power of attorney, guardianship, advance directives or any other legal forms for patients without the permission of an officer of MedMark. Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures Business Practices 1. All financial, purchasing, personnel, facility development and information technology practices shall comply with local, state, and federal law and guidelines. 2. Staff shall not establish a business relationship with patients, family members of patients, or significant others of patients or their own family members. 3. Staff shall not accept gifts that could in any way be construed to influence their clinical or business decisions. 4. MedMark does not tolerate waste, fraud, abuse, and other wrong doing.

Marketing Practices 1. MedMark will conduct marketing practices in an honest and factual manner. Marketing materials and practices will in no way mislead the public or misrepresent MedMark abilities to provide services. MedMark will not claim any service outcomes unless represented by valid and reliable outcome data and/or research studies. 2. MedMark will utilize clear and consistent methods of communicating information to consumers, family members, third-party entities, referral sources, funding sources, and community members, and will exhibit sensitivity to the educational and reading levels of all persons when distributing information. 3. MedMark will not utilize monetary rewards or gifts to any potential consumer of services or referral source in an attempt to entice them to enter programs or refer patients to our programs.

Clinical Practices 1. Staff will adhere to all professional codes of conduct and ethical standards for his/her specified professional discipline. 2. Staff will not present their credentials or experience to be anything other than factual and will take no actions that could be viewed as misleading.

Conflicts of Interest 1. No patient will be hired or placed in an employee/employer relationship with MedMark while an active participant in programming. 2. Any programming that involves a work task, and remuneration for the task, will be therapeutic in nature and will be documented as such by programming guidelines based on theoretical constructs. 3. MedMark employees will not engage in outside professional mental health services that are incompatible or in conflict with job duties within MedMark. 4. Private practice must be done on the staff’s own time and outside MedMark. Such activities must not be adverse to the interests and goals of MedMark and shall be approved in advance by the organization and will meet MedMark’s guidelines on conducting a private practice. 5. Staff will not recruit patients for their private practice while acting in a professional role as MedMark staff members. Staff will not treat MedMark patients in their private practice. Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures 6. If an employee leaves MedMark and enters private practice, the patient may choose to continue their therapy with the former employee. However, the employee must offer therapy/care at the same cost with equal accessibility. 7. No staff shall engage in any other employment or activity on MedMark’s premises or to an extent that affects, or is likely to affect, his or her usefulness as an employee of MedMark. Any such activity must be approved in writing by the CEO.

Quality of Care 1. MedMark will provide quality health care in a manner that is appropriate, determined to be necessary, efficient, and effective. 2. Health care professionals will follow current ethical standards regarding communication with patients and their representatives regarding services provided. 3. MedMark will inform patients about alternatives and risks associated with the care they are seeking and obtain informed consent prior to any clinical interventions. 4. MedMark recognizes the right of patients to make choices about their own care, including the right to do without recommended care or to refuse care.

Necessity of Care 1. MedMark shall only submit claims for payment to governmental, private, or individual payers for those services or items that are clinically reasonable and appropriate. 2. When providing services, MedMark employees shall only provide those services that are consistent with generally accepted standards for treatment and are determined by the professional to be clinically reasonable and appropriate. 3. Service providers may determine that services are clinically necessary or appropriate; however, the patients funding source may not cover or approve those services. In such a case, the patient may request the submission of a claim for the services to protect his/her rights with respect to those services or to determine the extent of coverage provided by the payer. 4. Coding and documentation will be consistent with the standards and practices defined by MedMark in its policy, procedures, and guidelines, as well as applicable state and federal regulations.

Coding, Billing, and Accounting 1. MedMark employees involved in coding, billing, documentation and accounting for patient care services for the purpose of governmental, private or individual payers will comply with all applicable state and federal regulations and MedMark policies and procedures. 2. MedMark will only bill for services rendered and shall seek the amount to which it is entitled. 3. Supporting clinical documentation will be prepared appropriately for all services rendered. 4. All services must be accurately and completely coded and submitted to the appropriate payer in accordance with applicable regulations, laws, contracts, and Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures MedMark policies and procedures. Federal and state regulations take precedence, and MedMark policies and procedures must reflect those regulations. 5. Patients shall be charged in a consistent manner as it applies to the MedMark business segment and to MedMark’s designated charges when applicable. 6. Billing and collections will be recorded in the appropriate accounts. 7. An accurate and timely billing structure and medical records system will ensure that MedMark effectively implements and complies with required policies and procedures.

Cost Reports 1. MedMark will ensure that all preparation and cost reports submitted to governmental and private organizations are properly prepared and documented according to all applicable federal and state laws. 2. All cost reports will be submitted and prepared with all costs properly classified, allocated to the correct cost centers, and supported by verifiable and auditable cost data. 3. All cost report preparation or submission errors and mistakes will be corrected in a timely manner and, if necessary, clarify procedures and educate employees to prevent or minimize recurrence of those errors.

Personal and Confidential Information 1. MedMark will protect personal and confidential information concerning the organization’s system, employees, and patients. 2. MedMark personnel shall not disclose confidential patient information unless at the patient’s written authorization and/or when authorized by law. Appropriate use of patient information for research purposes must be obtained with the full informed consent of participants in the research. 3. Confidential information will only be discussed with or disclosed to persons and entities outside MedMark through the written authorization of the patient. Persons outside MedMark may include family, business, or social acquaintances of the patient. 4. MedMark personnel will be familiar with all organizational policy and procedures regarding confidentiality.

Creation and Retention of Patient and Institutional Records 1. Records are the property of the MedMark. Personnel responsible for the preparation and retention of records shall ensure that those records are accurately prepared and maintained in a manner and location as prescribed by law and MedMark policy. 2. Employees will not knowingly create any patient, financial or other records that contain any false, fraudulent, fictitious, deceptive, or misleading information. 3. Employees will not delete any entry from a record. Records can be amended and material added to ensure the accuracy of a record in accordance with policy and procedures. If a record is amended, it must indicate that the notation is an addition or correction and record the actual date that the additional entry was made. 4. Employees will not sign someone else’s signature or initials on a record. 5. Records shall be maintained according to specific MedMark policy and procedure. Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures 6. Employees shall not destroy or remove any record from MedMark’s premises. 7. MedMark will maintain record retention and record destruction policies and procedures consistent with federal and state requirements regarding the appropriate time periods for maintenance and location of records. Premature destruction of records could be misinterpreted as an effort to destroy evidence or hide information.

Government Investigation 1. MedMark employees shall cooperate fully with appropriately authorized governmental investigations and audits. 2. MedMark will respond in an orderly fashion to the government’s request for information through employee interviews and documentation review. 3. MedMark will respond to the government’s request for information in a manner that enables MedMark to protect both MedMark and consumer’s interests, while cooperating fully with the investigation. 4. When a representative from a federal or state agency contacts a MedMark employee at home or at their office for information regarding MedMark, a patient, or any entity with which MedMark does business, the individual will contact the CEO immediately. If the CEO is not available, the individual will contact the CFO. If that person is not available they will contact the Corporate Compliance Officer. 5. MedMark employees will ask to see the government representative’s identification and business card, if the government representative presents in person. Otherwise, the employee should ask for the person’s name, office, address, phone number, and identification number and then contact the person’s office to confirm his/her identity.

Prevention of Improper Referrals or Payments 1. MedMark employees will not accept, for themselves or for MedMark, anything of value in exchange for referrals of business or the referral of patients. 2. Employees must not offer or receive any item or service of value as an inducement for the referral of business or patients. 3. Federal law prohibits anyone from offering anything of value to a Medicare, Medi-Cal or Medicaid patient that is likely to influence that person’s decision to select or receive care from a particular behavioral health care provider. 4. MedMark shall establish procedures for the review of all pricing and discounting decisions to ensure that appropriate factors have been considered and that the basis for such arrangements is documented. 5. Development or initiation of joint ventures, partnerships, and corporations within MedMark must be reviewed and approved by the CEO of MedMark to ensure compliance with MedMark policy and federal regulations.

Antitrust Regulations 1. MedMark will comply with all applicable federal and state antitrust laws. 2. Employees should not agree or attempt to agree with a competitor to artificially set prices or salaries, divide markets, restrict output, or block new competitors from the market, share pricing information that is not normally available to the public, deny staff Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures privileges to qualified practitioners, or agree to or participate with competitors in a boycott of government programs, insurance companies, or particular drugs or products.

Avoiding Conflicts of Interest 1. All MedMark employees shall conduct clinical and personal business in a manner that avoids potential or actual conflicts of interests. 2. Employees shall not use their official positions to influence a MedMark decision in which they know, or have reason to know, that they have a financial interest. 3. Employees must be knowledgeable about activities that may be an actual or potential conflict of interest. Examples of such activities may include, but are not limited to the following: a. Giving or receiving gifts, gratuities, loans, or other special treatment of value from third parties doing business with or wishing to do business with MedMark. Third parties may include, but are not limited to, consumers, vendors, suppliers, competitors, payers, carriers, and fiscal intermediaries. b. Using MedMark facilities or resources for anything other than MedMark sanctioned activities. c. Using MedMark name to promote or sell products, personal services, or personal causes. d. Contracting for goods or services with family members of those employees who are directly involved in the purchasing decision.

External Relations 1. MedMark employees shall adhere to fair business practices and accurately and honestly represent themselves and MedMark’s services. 2. MedMark employees will be honest and truthful in all marketing and advertising practices pertaining to the business practices of the MedMark’s service delivery system. 3. Vendors who contract to provide goods and services to MedMark will be selected on the basis of quality, cost-effectiveness and appropriateness for the identified task or need, in accordance with MedMark policy.

Treatment of Employees 1. MedMark prohibits discrimination in any work-related decision on the basis of race, color, national origin, religion, sex, physical or mental disability, ancestry, marital status, age, sexual orientation, citizenship, or status as a covered veteran. MedMark is committed to providing equal employment opportunity in a work environment where each employee is treated with fairness, dignity, and respect. 2. MedMark does not tolerate harassment or discrimination by anyone based on the diverse characteristics or cultural backgrounds of those who work for MedMark pursuant to MedMark’s affirmative action policy. 3. Any form of sexual harassment is prohibited. 4. Any form of workplace violence is prohibited. Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures III. PROCEDURES

Code of Conduct Orientation and Training 1. All employees, students, volunteers and governing body members, as part of MedMark’s initial orientation, will review the Code of Conduct and Corporate Compliance Program. 2. All staff will receive a copy of the Code of Conduct, sign a form acknowledging their review and full understanding of the Code of Conduct, and return the form to be filed in the employee’s personnel file. 3. To assure an awareness of ethical practices, reviews of the Code of Conduct and continued training will be conducted on an annual basis.

Procedures for Communicating and Acting on Violations of The Code of Conduct 1. When any consumer, family member, authorized representative, advocate or other person believes that an ethical violation has occurred within the operations of MedMark, they may report such suspicion directly to any employee, or management staff, or by calling the Ethics Compliance Hotline 888-786-8584. 2. When employees believe a violation of the Code of Conduct has occurred they are obligated to report the violation in one of the following ways: a. Immediate notification of the incident or violation through MedMark’s Ethics Compliance Hotline 888-786-8584; or b. Immediate reporting to their supervisor or directly to the Corporate Compliance Officer 3. Supervisors who have been informed of a suspected violation are required to immediately inform the Corporate Compliance Officer of the suspected violation. 4. If the violation involves a direct and immediate threat to the safety of a patient, staff member, or clinic visitor, employees are obligated to report the alleged violation immediately to their Supervisor. 5. Staff is required to report any suspected violation of the Code of Conduct. 6. When any suspected violation of the Code of Conduct is reported to a Supervisor, Program Sponsor or the Corporate Compliance Officer, the Corporate Compliance Officer will begin an investigation of the matter immediately. 7. Code of Conduct investigations will follow the guidelines outlined in the MedMark Corporate Compliance Program.

No Retaliation MedMark believes in the importance of ethical practices within MedMark. Any employee who submits a good faith report regarding waste, fraud, abuse or any other questionable practices will not be subject to reprisal by management of MedMark. The Corporate Compliance Officer will provide assurance and oversight that there are no adverse actions toward the employee. Investigations of fraud, waste, abuse or other wrong doing Administrative Policies & Procedures – Compliance – Code of Conduct

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Administrative Policies & Procedures will follow the guidelines outlined in the MedMark Corporate Compliance Program for investigating each report.

Ethics Compliance Hotline 888.786.8584 MedMark Financial Hotline 877.861.2990

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Administrative Policies & Procedures DEPARTMENT:

COMPLIANCE

SUBJECT:

CORPORATE COMPLIANCE PROGRAM

Effective Date:

August 1, 2008

Revised Date:

December 28, 2010, December 28, 2011, January 1, 2013

POLICY It is the policy of MedMark Services, Inc. (MSI) to provide services that fully comply with all federal, state, and local regulations and applicable laws, and to adhere to explicit ethical standards throughout all facets of the organization’s operations. MSI will ensure these conditions of operation are met through an organized and ongoing comprehensive corporate compliance program. MedMark’s Corporate Compliance Program seeks to meet the following overall goals: 

Maintain and enhance the quality of services



Demonstrate a sincere effort to comply with all applicable laws



Revise and develop new policies and procedures to enhance compliance



Enhance communications with governmental entities to ensure compliance



Empower all involved parties to prevent, detect, respond to, report, and resolve conduct that does not conform to applicable laws and regulations, and the organization’s ethical standards/code of conduct



Establish mechanisms for staff members to ensure that questions and concerns about compliance issues are appropriately addressed

MSI has adopted a Code of Conduct applicable to all employees of MSI. The Code of Conduct governs and controls over all aspects of the MedMark Corporate Compliance Program. The following policies and procedures are subject to and should be followed in conjunction with the Code of Conduct. As used herein the Corporate Compliance Program and these policies and procedures include the Code of Conduct. II.

PROCEDURES A.

Organizational Responsibilities 1. Compliance Management Team: The Compliance Management Team shall consist of the CEO, CFO, and Corporate Compliance Officer. The Compliance Management Team shall also serve as the Compliance Committee for MSI.

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Administrative Policies & Procedures 2. Corporate Compliance Officer: The Corporate Compliance Officer (the “CCO”) shall be appointed by the CEO and approved by the MSI Board of Directors. The CCO shall provide leadership and oversight of the Corporate Compliance Program. The CCO’s duties shall include, but not be limited to: a.

Serve as the organization’s internal and external point of contact for overall corporate compliance issues.

Develop, implement, and monitor the organization’s Corporate Compliance Program, including internal and external monitoring, auditing, investigative and reporting processes, procedures, and systems.

Provide communication to the Compliance Management concerning all areas of the Corporate Compliance Program.

Provide specific guidance and ongoing education to staff members who are expected to know and comply with specific laws and guidelines in their regular job duties.

Ensure that mechanisms for preventing, detecting, reporting, and resolving compliance issues are operating in a functional manner.

Ensure that the organization’s reporting mechanisms enhance and encourage active participation of all staff members, and provide confidentiality in the reporting process.

Ensure that all suspected violators and/or violations are handled according to documented policy and resolved in a manner that ensures the integrity of the organization’s compliance with applicable guidelines and laws.

Submit an annual report to the Management Team that includes a summary of all allegations, investigations, and/or complaints processed in the preceding 12 months, a complete description of all corrective actions taken, and any recommendations for changes to the organization’s policies and/or procedures.

In performance of his/her duties, the CCO shall have direct and unimpeded access to the MSI Board of Directors, and the organization’s legal counsel and/or accounting firm, for matters pertaining to corporate compliance.

Insure that at least once each year, all MedMark employees submit an attestation that they are following the Code of Conduct, that they are unaware of any violations of the Code of Conduct, or that they are aware and that they are providing specific evidence of such issues.

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Administrative Policies & Procedures k.

Maintain a corporate compliance hotline (toll free number) by which employees can report anonymously if desired any compliance concerns.

3. Corporate Compliance Officer’s Job Duties: The duties of the CCO, or designee, will include, but not be limited to:

Ongoing identification and assessment of compliance systems and issues.

Plan and provide guidelines for development of service specific compliance procedures through the development, revision, and ongoing monitoring of the Corporate Compliance Program.

Plan and provide support for educational training and programming.

Disseminate compliance information.

Provide controls to prevent and reduce errors, and to identify wrongdoing.

Receive, evaluate, and respond to reports of potential violations.

Work with administrative and clinical leadership to implement remedial actions, and take appropriate corrective and disciplinary actions.

Employee Training 1.

The Corporate Compliance Program will be fully integrated into the organization’s education and training systems through the following processes: a.

All new employees will receive and review the Code of Conduct and the Corporate Compliance Program as part of the new employee orientation process.

All staff members will review the Code of Conduct as part of their annual performance review evaluations.

Supervisors will inform staff members of specific ongoing compliance issues that pertain to their job duties at regularly scheduled staff meetings.

All staff members will participate in ongoing compliance in-service presentations and competency-based trainings.

Regular publication of reporting mechanisms will occur throughout the organizations communication systems. These will include, but not be

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Administrative Policies & Procedures limited to, email notification, internal memos, a toll free call in number and postings on bulletin boards in staff and public areas. C.

Monitoring and Auditing 1.

MSI will utilize the CCO to ensure that it conducts business in an ethical manner and ensure that any questionable business practices are thoroughly investigated through the organization’s written investigation procedures.

All programs shall implement internal controls, including monitoring activities to ensure compliance with the organization’s program.

Internal self-audits will include, but not be limited to, fiscal services, marketing, contractual services, health and safety practices, use of agency resources, confidentiality, dual relationships, and medical necessity.

Reporting System 1.

MSI will provide mechanisms to assist staff members and/or agents in reporting suspected violations of possible criminal conduct or violation of the organizational code of ethics by persons within the organization, without fear of retribution.

Specific processes of reporting suspected violations include the following: a.

Compliance Forms: Employees may complete a Corporate Compliance Program Employee Attestation form (the “Attestation Form”) and submit it to the CCO concerning possible violations. The Attestation Form can be obtained from an employee’s supervisor or the Human Resources Department.

Toll Free Telephone Number: Employees may call and leave an anonymous message regarding suspected violations. The number is: 888-786-8584. The voice message will be picked up by the CCO.

Financial Hotline: For concerns of a financial or fraudulent nature there will be an internal hotline. The calls will go to the chairman of the audit committee of the board of directors. This information is also provided in the MedMark Services Inc. Employee Handbook.

Investigation Procedures 1.

The CCO shall initiate and conduct investigations of all reported alleged incidents.

Upon receiving information of an alleged incident or violation, the CCO will inform the Management Team of the allegation and begin an investigation immediately.

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Administrative Policies & Procedures 3.

If a member of the Management Team is directly connected to the alleged incident that is being investigated, he/she will be excused from the team/investigation until the final outcome and corrective action plan has been completed.

All information concerning the alleged incident with be held in strict confidentiality by all parties involved in the process, and will not be shared with any other staff member.

The CCO will conduct an initial investigation through an interview process with staff members who are assigned to duties and areas related to the alleged violation.

The CCO will determine from the initial investigation whether the situation would benefit from the involvement of the organization’s legal counsel in the investigation process, and recommend such action to the Management Team, should it be appropriate.

The employee is notified that there is a complaint and, if warranted by the initial information and involves a direct service situation, may be instructed to not continue direct services with a client until the issue is resolved. The supervisor assisting with the investigation will take primary responsibility for helping the client with access to a clinician that can provide services during the investigation should a change in clinicians be warranted.

If the suspected violation of the Code of Conduct involves the Executive Management of the organization, the organization will enlist assistance from their legal counsel to serve as the final review of outcome and recommendations.

The investigation may involve interviews with witnesses and clients, as well as reviewing other relevant information. At all times the client’s rights will be respected.

10.

If at any time during the investigation it is determined that the client’s rights have been violated, the appropriate advocacy representative or entity will be immediately contacted to begin their own investigation process according to applicable laws and guidelines.

11.

If involved, the organization’s legal counsel will help ensure the confidentiality and attorney-client privilege of any information which may be complied, help management focus on critical issues which should be investigated, and help design a strategy for effectively using the findings of the investigation.

12.

Following an investigation, the CCO will file a report to the Management Team that will include a summary of all allegations, results of the investigation, and recommendations for corrective actions.

13.

The CCO, the Management Team, and the Supervisor of the staff member(s) involved in the incident will review the recommendations and develop a corrective plan of action.

14.

Should the investigation indicate a serious violation of policy, the organization’s legal counsel will advise the appropriate entity with regard to the need to self-report the

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Administrative Policies & Procedures violation to the appropriate government regulatory agency, and will assist in the process should it be necessary. 15.

16.

A written report will be compiled and submitted within fourteen (14) days from the notification of the complaint. The report will detail the following: a.

The nature of the complaint, including time, date, persons involved, services involved.

The person whom the complaint is lodged against.

Results of persons interviewed and investigation of circumstances surrounding the incident.

A recommendation based on the gathered information.

The CCO will make one of three possible findings in the recommendation to the Management Team: a.

Founded: The suspected violation of the Code of Conduct was found to have occurred.

Unfounded: The suspected violation of the Code of Conduct was found not to have occurred.

Undetermined: It cannot be determined whether or not a violation of the Code of Conduct has occurred.

Once approved by the Management Team, the Supervisor will inform the employee, who is the subject of the investigation, of the outcome of the investigation.

17.

If the finding was undetermined, the Supervisor will adjust the supervision of the employee to a level necessary to ensure that the suspected behavior is not occurring. The employee will be informed of the details and will be actively involved with the supervisor in this process.

18.

If it is determined that the suspected violation is a consumer rights violation, then the investigation, notification, and appeal procedure will follow the consumers right’s policy and procedures.

19.

When the results of an investigation of ethical complaints are founded, the incident will be reported to the executive management as a Critical Incident, and will be reviewed within the appropriate format to assist in quality improvement, risk management, and corrective measures.

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Administrative Policies & Procedures

20.

The CCO will monitor and evaluate the corrective plan interventions through consistent communication and contact with the Supervisor in charge, and will re-evaluate the actions/corrections on a monthly basis.

21.

The CCO will provide updates of the situation to the Management Team until the situation has been resolved.

22.

The Incident, investigation, and outcome will be included in the annual Corporate Compliance Report to the Management Team.

23.

The Management Team will utilize all information consistent with an Incident, investigation, and outcome to recommend revision and development of policy, procedures, and guidelines in the area of corporate compliance.

Enforcement and Discipline 1.

Remedial Actions a.

Remedial actions are not disciplinary and are done to correct mistakes, and enhance compliance with the Corporate Compliance Program and State and Federal regulations. In most cases, remedial actions are designed to improve performance of individual staff members. Upon investigating what appears to be behavior requiring remedial actions, the CCO will clarify policies, and will review, and revise if necessary, administrative procedures to prevent future errors.

If remedial action is deemed necessary, the affected staff member will be notified, prior to the initiation of the action, and informed of the concerns regarding his/her performance.

Examples of behaviors that could require remedial action may include, but are not limited to, failure of an individual to understand and carry out organizational-wide required procedures and policies, inappropriate or improper implementation of the organization’s specific corporate compliance policies and procedures, ambiguous communications regarding job performance expectations, or negligent behavior.

Examples of remedial actions may include, but are not limited to, staff members required to take part in an education program focused on the problem area, future money management handled in a specifically designated manner, a staff member reassigned, or a change in duty until remediation has successfully corrected the error.

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Administrative Policies & Procedures 2.

Corrective or Disciplinary Actions a.

In cases of repeated violations of intentional misconduct, or after documented remedial actions have failed to correct the problem, the organization will initiate corrective or disciplinary actions where necessary to address wrongdoing or malfeasance. The initiation of corrective or disciplinary action by the organization does not preclude or replace any criminal proceedings that may be taken by legal authorities.

Should the organization initiate corrective or disciplinary action, it will do so in accordance with existing and applicable personnel policies.

Prevention a.

Education and training will serve as the core of MSI prevention efforts to ensure minimal violations of law, ethics, and the Code of Conduct. Prevention efforts will include, but not be limited to: i.

New employee orientation training

ii.

Training related to the staff member’s specific position

iii.

Documentation of competency in required areas through performance appraisals and/or competency based exams

iv.

Routine, targeted, and random audits of systems and medical charts

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V. Legal

Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

CONTRACT APPROVALS

POLICY NO.:

L-101

Effective Date:

December 14, 2010

Revised Date:

January 13, 2012, January 1, 2013

POLICY To establish procedures for the review, approval, and execution of contracts. Any contract for goods, services, or agreements must follow the procedures stated in this policy in order to be executed.

II.

PROCEDURES 1. Only officers of MedMark can execute contracts on behalf of MedMark and any subsidiary. contract executed by anyone other than a MedMark officer will be considered null and void.

Any

2. All contracts must first be submitted to the General Counsel with a signed Contract Approval Form. (See attachment) 3. The contract approval form must be completed in its entirety, including stating who is to receive a copy of the executed contract. 4. Only after all necessary signatures are obtained on the Contract Approval Form will it be signed by an officer of MedMark. 5. Once the contract is signed by an officer of MedMark the executed contract will be submitted to the individuals named on the Contract Approval Form distribution list. 6. Fully executed copies of the contracts shall be returned to MedMark and saved to the contracts file. Original copies shall be maintained by the General Counsel.

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Contract Approval Form Contracting Company or Individual

MedMark Location

Purpose of contract ; explanation of why this provider was selected

This approval form must be signed by the appropriate individuals in order for a contract to be executed.

Person initiating contract

Date

Title

2nd level of approval if necessary

Date

Finance approval

Date

HR approval (if necessary)

Date

Legal approval  Straight Template  If not template—redline attached

Date

David K. White, Ph.D. President and CEO

Date Clerical use:

Distribution List: Please list individuals who are to receive a fully executed copy

Contract Drive file path

1. 2. 3. 4.

401 E. Corporate Drive #220

Lewisville, TX 75057

214.979.3300

Administrative Policies & Procedures

DEPARTMENT:

LEGAL

SUBJECT:

PATIENT RECORDS: RETENTION AND DESTRUCTION

POLICY NO.:

L-102

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to develop and maintain a complete and accurate record to ensure that all appropriate individuals have access to relevant clinical and other information regarding each person served. MedMark has adopted HIPAA policies and procedures applicable to all employees. The following procedures are subject to and should be followed in conjunction with MedMark’s HIPAA policies and procedures. This policy shall apply to all OTP programs and Vista Taos. The VA clinics shall follow the VA policies regarding the maintenance of patient records. The retention and destruction of non-patient business records are addressed in Policy L-103 Business Records: Retention and Destruction. “Records” as used in this policy are defined as any documentary material, regardless of physical form, that is generated or received by MedMark related to patients, including written, printed, and recorded materials, as well as electronic records (i.e., emails and documents saved electronically).

II.

PROCEDURES A. To maintain uniform individual records that protect the integrity of demographic, financial, and clinical information, the individual records will be assembled according to the following guidelines: a. The individual record is defined as all information collected and used regarding an individual seeking services from MedMark. b. The individual record will contain three distinct types of information: demographic, financial, and clinical. c. The assembly of the record is initiated upon admission to services and/or programs.

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Administrative Policies & Procedures

B. All individual records will contain, at a minimum, the following information: 1. The date of admission 2. The name, address, and telephone number of the person’s representative, conservator, guardian, or representative payee, if appointed 3. Emergency contact information including a name, address, and telephone number 4. The name of the person coordinating services 5. The location of any other records 6. The name, address, and telephone number of the person’s primary care physician 7. Health care reimbursement information 8. The person’s health history, current prescription medications, admission screening, documentation of orientation, assessments, and individual plan and reviews 9. Authorization for release of information 10. Documentation of internal or external referrals C. Documentation in records will be consistent, directly related to services provided, and in compliance with legal, risk management, and clinical care standards. The following guidelines apply to documentation in the record: 1. Written documentation will be completed in ink only. 2. All written documentation will be clear, concise, accurate, and legible. 3. All entries will be made in a timely fashion to increase accuracy of documentation. 4. Most entries will occur immediately after the service is performed. 5. Any late entries will be documented using the actual date the note is written with a reference to the exact date the service occurred. 6. If a mistake is made in the record, a single line will be drawn through the incorrect information, “error” will be written above the entry, and the provider’s initials and date will be noted. “Liquid Paper”, or any kind of marking over an error so it cannot be read, is not appropriate in any circumstance as it may invalidate the entire record in a legal proceeding. Administrative Policies & Procedures – Legal: Patient Records: Retention and Destruction

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D. Maintenance: All records will be maintained in accordance with federal and state law and MedMark’s HIPAA policies and procedures. All patient records are maintained in a uniform manner, are secure, and are available to support continuity of care. The following guidelines apply to the maintenance of records. 1. Each record will be issued an identifying number upon the first admission to any MedMark services or programs. This number will be uniform throughout all services and dates of services provided. 2. Individual records will be maintained at the program site. 3. All records will be maintained in a systematic fashion that follows a standard format for record organization established by MedMark. 4. Documentation in the individual record will be clear and legible. 5. All information in the record will be current and complete, and documents that require signatures will contain original or electronic signatures. Electronic signatures may include Authenticode, VeriSign, or equivalent signatures. Electronic systems that restrict or automatically identify the person entering the data and the date the information is entered is also acceptable. Typing a name or using a typed scripted font on a record is not considered an electronic signature. 6. All records will be filed, secured, and retrieved by the designated program staff. Programs will follow site-specific procedures that limit access to the records and that require the records are maintained in a secure fashion. 7. MedMark is responsible for controlling the records and implementing policies and procedures pertaining to the records. 8. All records will be kept in a secured area such as locked file cabinets or other locked storage areas, with access limited to only designated staff. The records area will be secured by lock at any time staff are unable to remain within the area. Only designated staff and designated supervisory personnel will have access to keys to the area. A designated staff member will be available and known to all staff in order to access the records after hours and in case of an emergency. 9. If the record is in a staff office, that office will be locked when not occupied. 10. Patient protected health information shall not be left in plain view where unauthorized persons may use or access it. 11. Outside regular MedMark hours, workforce members must clean their workstations so that all records are properly secured in a locked drawer or cabinet. Administrative Policies & Procedures – Legal: Patient Records: Retention and Destruction

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Administrative Policies & Procedures

12. All records will be kept in areas that provide reasonable protections from fire, water damage, and other hazards. 13. Records will be made available in a timely manner to authorized personnel by the staff for scheduled appointments, for documentation purposes, and for reviews upon request. 14. Staff must return and file all records before the end of the business day. 15. The filing of all loose materials in the record is a function of the clinical and/or front office staff. The filing is to be kept current and will be placed in individual records within three working days. All loose filing will be kept in a container designated as “to be filed” within a secured records area/room or in a locked cabinet in a staff office if at a service location. 16. Any loose filing that cannot be identified will be turned over to a Supervisor. The material in question will be identified through exploration with service providers of content contained in the materials. 17. Records shall not be placed in general garbage receptacles for disposal. Each location shall establish marked receptacles to hold documents until those items are destroyed. These marked receptacles will be emptied routinely, and, where necessary, the contents will be stored in a locked area, awaiting destruction. Destruction of documents will be performed by either designated MedMark staff or a contracted document destruction company approved by the Privacy Officer, in accordance with MedMark’s HIPAA policies and procedures. 18. All data files maintained in electronic systems will be backed up on a daily basis and will be securely preserved at a separate location from the regular files. 19. All electronic record files maintained in any manner on MedMark’s electronic data system are subject to the policy and procedures regarding electronic records. 20. Remote access, use, or maintenance of records shall only be accomplished via a MedMark-owned or MedMark-approved device. To the maximum extent possible, records viewed or accessed via a remote location shall be encrypted. 21. In the event records need to be transported to a different location, such as court proceedings, the Program Director will contact MedMark’s Privacy Officer and Regional Director. No records shall leave a MedMark facility without the approval of MedMark’s Privacy Officer. When records containing confidential protected health information are transported the records will be placed in a sealed manila envelope or boxes marked “confidential” and placed in the locked trunk of a car for transportation to the destination. The Program Director is responsible for safeguarding the records while they are in transport. At no time will the records be left unattended. A notation will be made in the patient’s file noting when the files were transported and confirming their receipt by the intended recipient. Administrative Policies & Procedures – Legal: Patient Records: Retention and Destruction

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Administrative Policies & Procedures

E. Storage: All records will be stored in accordance with federal and state law and MedMark’s HIPAA policies and procedures. The following guidelines apply to the storage of records. 1. Upon discharge from MedMark the individual record is filed in a locked storage room or lockable file cabinet designated for discharged files on site at the program. The discharge files will remain at the program location for a minimum period of one (1) year. After one (1) year the discharge files will be archived and filed in a locked storage room or lockable file cabinet designated for discharged files on site at the program. 2. A complete listing of closed records that have been disassembled according to procedures will be maintained on site at the program. 3. Individual records will be retained for seven (7) years after the most recent discharge date or such longer period as required by applicable federal or state law. 4. All preadmission screening forms of persons not admitted to MedMark will be retained for two (2) years at the program. If the form has no identifiable information regarding the person served, it will be destroyed within one (1) year or such longer period as required by applicable federal or state law. 5. External referral forms for referrals to MedMark will be included in the record for persons admitted and will be retained for at least seven (7) years or such longer period as required by applicable federal or state law. 6. All records will be stored on site at the program in a locked storage room. Such storage room shall be secured by at least two locks and under the security alarm system of the program. 7. In the event the program is unable to store all records at the program location, the Program Director shall contact the Regional Director and MedMark Privacy Officer. In the event records are approved by the Privacy Officer to be transferred to an offsite storage location the records should be packaged to ensure that they cannot be viewed by persons without proper identification and MedMark’s approval, and such secure containers shall be marked “Confidential.” The Privacy Officer must give the offsite storage company instructions on who may have access to the records. An accurate inventory of records in offsite storage will be kept at all times by MedMark.

F. Destruction: All records will be destroyed in accordance with federal and state law and MedMark’s HIPAA policies and procedures. The following guidelines apply to the retention and destruction of records. 1. MedMark’s HIPAA Policy “Destruction/Disposal of Protected Health Information” shall be followed at all times regarding the destruction and disposal of records. Administrative Policies & Procedures – Legal: Patient Records: Retention and Destruction

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2. All records involved in any investigation, litigation, or audit will not be destroyed until legal counsel has confirmed that no further legal reason exists for retention of the record. 3. In the event a legal proceeding is initiated against MedMark, the staff will be notified immediately by Program Director to stop the destruction of patient records. 4. Prior to the destruction of records by staff, the following information will be gathered from the record and permanently maintained for all persons served: a. Person’s name b. Social Security number c. Date of birth d. Dates of admission and discharge e. Name and address of legal guardian, if any 5. All records will be destroyed in a manner that eliminates the possibility of reconstruction of the information. 6. Paper records shall not be discarded in trash bins, unsecured recycle bags, or other publicly-accessible locations. Records must be shredded. Shredding of documents shall be performed on no less than a weekly basis. 7. Secure methods will be used to dispose of electronic data and output. MedMark’s Information Technology department shall be responsible for the destruction of electronic records and for permanently removing deleted emails and files from the computer system. 8. In the event hardcopy records (paper, microfilm, microfiche, etc.) cannot be shredded, it must be incinerated. 9. Any CD-RW disks that contain document imaging that cannot be overwritten will be destroyed through pulverization. 10. All activities related to the destruction of records by staff will be documented and maintained by the staff. The following information will be included in the documentation of the destruction: a. The date of the record destruction b. The method of destruction c. A description of the records that were destroyed Administrative Policies & Procedures – Legal: Patient Records: Retention and Destruction

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d. The start and end date of the records e. The signatures of the individual conducting the destruction and of the witness of the action 11. In the event of bulk disposal, records shall be shredded by a firm specializing in the disposal of confidential records and approved by the Privacy Officer or be shredded by a member of MedMark’s workforce authorized to handle and shred records. 12. In the event a bonded shredding company undertakes the destruction, the bonded shredding company must provide MedMark with documentation of the destruction that contains the date of destruction, the method of destruction, a description of the disposed records, the inclusive dates covered by such records, a statement that the records have been destroyed in the normal course of business, and the signatures of the individuals supervising and witnessing the destruction. 13. To the extent records are destroyed or deleted from an electronic device no longer used or owned by MedMark, such documentation shall be maintained by MedMark’s information technology department. Such documentation shall further include the date of destruction, the documents being destroyed, and the names of the persons handling the destruction of the documents. 14. The Program Director or Executive Director of Vista Taos, as applicable, shall maintain documentation of destruction permanently.

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Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

BUSINESS RECORDS: RETENTION AND DESTRUCTION

POLICY NO.:

L-103

Effective Date:

January 1, 2013

Revised Date:

NONE

POLICY To establish MedMark's policy for identifying, retaining, storing, protecting, and disposing of MedMark records and to ensure that records management practices adhere to customer, legal, and business requirements and are conducted in a cost-efficient manner. This policy applies to non-patient business records. For storage and retention of patient records employees must follow Policy No. L-102 Patient Records: Retention and Destruction. It is MedMark's policy to maintain complete and high-quality business records. Records are to be maintained only while they may substantially affect MedMark's operations, unless a longer period is required by law or some other reason. “Records” as used in this policy are defined as any documentary material, regardless of physical form, that is generated or received by MedMark in connection with its business operations or is related to MedMark's legal obligations including written, printed, and recorded materials, as well as electronic records (i.e., emails and documents saved electronically). This definition specifically includes documents containing personal information, such as appointment calendars and logs. Records that are no longer of use, or which have been retained for the legally required period of time, will be destroyed. Destruction of documents shall take place only according to this policy. All employees are responsible for retaining active business records and for identifying documents for destruction within their work area. PROCEDURES SECTION 1: TYPES OF RECORDS Appendix “A”, attached at the end of this policy, lists several categories of records, as well as specific records that contain specific retention periods. This is referred to as a Document Retention Schedule (“DRS”). All records not provided for in the DRS or described herein, shall be classified into three types, (1) Temporary Records, (2) Final Records, and (3) Permanent Records.

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Administrative Policies & Procedures 1.1

Temporary Records Temporary records include all business documents that have not been completed. Such include, but are not limited to, written memoranda and dictation to be typed in the future, reminders, to-do lists, report, case study, and calculation drafts, interoffice correspondence regarding a client or business transaction, and running logs. Temporary records can be destroyed, or permanently deleted if in electronic form (see procedures below for proper destruction of data in electronic form) when a project/case/file closes. Upon the closing of a project/case/file, employees shall gather and review all such temporary records. Before destruction or permanent deletion of these documents, employees shall make sure they have duplicates of all the final records pertaining to the project/case/file. Upon destruction or deletion, the final records (and duplicates) shall be organized in a file marked “FINAL” and stored according to this policy.

1.2

Final Records Final records include all business documents that are not superseded by modification or addition. Such include, but are not limited to: documents given (or sent via electronic form) to any third party not employed by MedMark, or government agency; final memoranda and reports; correspondence; handwritten telephone memoranda not further transcribed; minutes; design/plan specifications; journal entries; cost estimates; etc. All accounting records shall be deemed final. Except as provided for in the DRS, all final documents are to be discarded ten (10) years after the close of a project/case/file.

1.3

Permanent Records Permanent records include all business documents that define MedMark’s scope of work, expressions of professional opinions, research and reference materials. Such include, but are not limited to contracts, proposals, materials referencing expert opinions, annual financial statements, federal tax returns, payroll registers, copyright registrations, patents, etc. Except as provided for in the DRS, all permanent documents are to be retained indefinitely.

SECTION 2: RECORDS SCREENING PROCEDURES 2.1

All departments should screen their records annually to determine if they should be retained in the department's files or stored. Factors to be considered are: •

Business need for retention;

•

Frequency of reference;

•

Reason for reference;

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2.2

•

Assigned retention period;

•

Filing requirements; and

•

File volume

Duplicates of records are to be eliminated.

SECTION 3: RECORDS STORAGE PROCEDURES 3.1

Tangible Records Tangible records are those in which employees must physically move to store, such as paper records (including records printed versions of electronically saved documents), photographs, audio recordings, advertisements and promotional items. Active records and records that need to be easily accessible may be stored in MedMark’s office space or equipment. Inactive records can be sent to MedMark’s off-site storage facility.

3.2

Records designated for storage should be grouped by category and placed in storage file boxes obtained from MedMark’s Records Retention Coordinator.

3.3

The storage containers should be dated and labeled and include enough detail to enable prompt and accurate identification of their contents.

3.4

Each storage container should also include a planned destruction date, using the retention periods found in the Appendix. EXAMPLE:

A&A (Company) ____ (Dept)

BAR CODE

____ 2006 (Destruct Date) Cleared Checks 2000 January through March

3.5

Authorization for retrieval of stored records should be made by the relevant Department Heads and transmitted to the Records Retention Coordinator.

3.6

Upon receiving properly labeled storage containers, the Records Retention Coordinator will review labeling and proper identification and then assign a unique bar code number to the box. The box will be indexed and added to the master off-site storage index and then sent to the offsite storage unit.

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Administrative Policies & Procedures 3.7

Electronic Records Electronic mail (“E-mail”) should be either printed and stored as tangible evidence, or downloaded to a computer file and kept electronically. MedMark has computer software that duplicates files, which are then backed-up on central servers.

SECTION 4: RECORDS REVIEW AND DESTRUCTION PROCEDURES 4.1

Records are to be retained in storage for the retention periods found in the DRS, as marked on each storage container.

4.2

Tangible records should be destroyed by shredding or some other means that will render them unreadable.

4.3

MedMark’s information technology (“IT”) department is responsible for permanently removing deleted emails and files from the computer system. Deleting files and emptying the recycling bin is usually sufficient in most circumstances to get rid of a record. However, because electronic records can be stored in many locations, the IT department is responsible for permanently removing deleted files from the computer system.

4.4

Where duplicate records are involved, both copies must be destroyed/deleted where proper.

4.5

Beginning in December of each calendar year, the Records Retention Coordinator will provide each Department Head with a summary of all stored records scheduled for destruction. The Department Head will then provide the Records Retention Coordinator with written acknowledgement of the summary of records scheduled for destruction and disposal.

4.6

Destruction of stored records will take place on or about December 31st of the year in which the retention period for the specific type of record has expired. For example, records that are stored at any time in 2003 and assigned a retention period of three (3) years, shall be scheduled for destruction and disposal on December 31, 2006.

SECTION 5: RETENTION OF RECORDS RELEVANT TO LEGAL ACTION 5.1

MedMark is required by law to retain all records and other documents which are or may be relevant to ongoing legal actions, including pending civil, administrative, or criminal proceedings, of which MedMark has knowledge, whether the legal action involves MedMark, or not. It is MedMark's policy to comply with this requirement at all times. The following procedures shall be used to ensure compliance. •

The Legal Department shall, as soon as possible after receiving notice of legal action in which MedMark is involved, identify, and notify the Department Head of all records which MedMark must retain for legal action purposes, regardless of their scheduled destruction date. Any such documents must be forwarded to the Legal Department and must not be destroyed until released for destruction by the Legal Department.

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Administrative Policies & Procedures •

The Legal Department and the Department Head must work closely together and with any legal counsel retained by MedMark in determining if pending legal action requires MedMark to maintain records beyond their scheduled destruction date.

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Administrative Policies & Procedures CORPORATE DOCUMENTS RETENTION AND DESTRUCTION POLICY APPENDIX Document Retention Schedule GENERAL FINANCIAL / ACCOUNTING RECORDS (ACC) Includes: Accounts Payable (AP), Accounts Receivable (AR) and Finance TITLE / DESCRIPTION RETENTION EXPLANATORY NOTES OF RECORDS PERIOD Check and voucher records, registers, cancelled checks, etc.

7 years

Assuming no pending audits

Accounts payable, invoices, freight invoices or bills, voids and adjustments, trial balances, etc.

7 years

Assuming no pending audits

1099's Expense report information, checks, etc.

Permanent 7 years

Assuming no pending audits

Physical inventory

Permanent

Audit reports, certified

Permanent

Audit reports, internal

7 years

Assuming no pending audits

Bank reconciliations, including statements; deposit slips, cancelled checks, etc.

7 years

Assuming no pending audits

Bank debt deduction documents

7 years

Assuming no pending audits

Royalty and commission statements

6 years

Maybe necessary to defend a civil litigation concerning royalty payments

P & L statements

Permanent

General ledger

Permanent

Final Documents Only

Accounts receivable and supporting information, cash receipts, shortages, special claims, account adjustments, defectives, incentives, trial balances, summaries, etc.

7 years

Assuming no pending audits

Collection information

4 years

Unless resolved sooner. Four years is the time to prosecute a breach of contract action.

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Administrative Policies & Procedures

Credit Reports

12 months after notification to business credit applicant (25 months for personal credit applicants)

12 C.F.R. § 202.12(b)

Bonds and related information

Permanent

Budgets and related worksheets

3 years

Entertainment and gift records

3 years

Assuming no pending audits

Cost accounting records

3 years

Assuming no pending audits

Fixed capital records

Permanent

Financial Records including, board of directors communications, monthly financial statements packages

Permanent

Monthly Budget Reports

Permanent

SEC Forms

Permanent

Draft Support for 10-K and I0-Q

Permanent

Exhibits to Loan agreements

Permanent

Capital Expenditures (Capex)

3 years after useful life

Financial Statements, certified

Permanent

Financial Statements, periodic

7 years

Cleared checks

7 years

TITLE / DESCRIPTION OF RECORDS

Generally keep 15 years since length of expenditure is unknown when at first filed. Assuming no pending audits.

CORPORATE RECORDS RETENTION PERIOD

EXPLANATORY NOTES

Agreements -General, Consulting, Research Licensee, Rental, etc.

Term of Agreement + 4 years

Annual Reports; annual financial statements

Permanent

Articles of Incorporation/organization, including Minutes of Meetings, Election records, etc.

Permanent

No specific authority; but recommended that corporate policy require their retention as “vital records,” necessary to authorize corporate action

Bylaws, Corporate Certificates, Charters, constitutions, etc.

Permanent

No specific authority, but recommended that corporate policy require their retention as “vital records,” necessary to authorize corporate action

Administrative Policies & Procedures – Legal: Business Records: Retention and Destruction

Texas statute of limitations for contract actions.

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Confidential Files Corporate transfer, merger, acquisition, consolidation records, etc. Earnings Reports, Stock data, Reports, etc.

Useful life (1 year minimum)

No specific authority; business judgment.

Permanent

Useful life (1 year minimum)

No specific authority; business judgment.

Deeds to property, easements, etc.

Permanent

May be necessary to prove title.

Licenses and permits

Permanent

Minute books

Permanent

No authority, but recommended that corporate policy require their retention as “vital records,” necessary to authorize corporate action

Patents, (foreign & domestic)

Permanent

It is advisable to retain certificates and applications permanently in the event of a contest or other dispute.

Copyrights and certificates

Permanent

See Patents, above.

Patent Applications

Permanent

Necessary to show continuous use in the event of a lawsuit

Trademarks

Permanent

Necessary to show continuous use in the event of a lawsuit

Government contracts and agreements

Permanent

Stocks – Certificates (incl. cancelled), ledgers, transfer records, dividend registers, applications, authorities to issue, SEC reporting, etc.

Permanent

Corporate policy or banking regulations controlling stock transfer agents generally dictate permanent retention

CORRESPONDENCE (FILE BY DEPT. CODE) TITLE / DESCRIPTION RETENTION EXPLANATORY NOTES OF RECORDS PERIOD Routine office correspondence

Useful life (1 year minimum)

Matter of business judgment. Always should consider knowledge of pending legal actions.

Correspondence regarding sales, contracts, etc.

Term of relevant contract or agreement + 4 years

Statutes of limitations governing contracts, 15 U.S.C. § 15b

To a large extent, copies of correspondence should be retained as long as other records concerning the subject matter of the correspondence are retained. For example, correspondence concerning the hiring of an employee should be retained as long as that employee's personnel information is retained. Correspondence regarding tax issues should be retained for the same period as the relevant tax records. Note that backup copies of electronic mail messages (e-mail) should be treated -- and disposed of when no longer relevant - like any other piece of correspondence. Administrative Policies & Procedures – Legal: Business Records: Retention and Destruction

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Other correspondence

TITLE / DESCRIPTION OF RECORDS

Retain for period required for underlying subject matter EMPLOYEE SAFETY RECORDS RETENTION PERIOD

OSHA 300 Log, OSHA privacy case list (if one exists), OSHA annual summary, OSHA 301 Incident Report forms; and OSHA Forms 200 and 101 (In Texas, an employer’s First Report of Injury form may be use in lieu of OSHA Form 101). Employee medical records

Recommended that these records be kept 6 years)

Occupational Safety and Health Act (OSHA), 29 C.F.R. § 1904.33; Regulations require that records be kept 5 years following the end of the relevant reporting year. A total of 6 years is recommended for these records.

30 years after termination of employment

29 C.F.R. § 1910.2. Note – these records should be kept separate from employee personnel files.

Employee exposure records (and related analysis using exposure or medical records)

30 years

Accident reports and injury claims

11 years

TITLE / DESCRIPTION OF RECORDS

EXPLANATORY NOTES

29 C.F.R. § 1910.2

ENVIRONMENTAL RECORDS RETENTION PERIOD

EXPLANATORY NOTES

Emissions testing (source and compliance testing and reports for criteria pollutants and hazardous pollutants)

2 years

Clean Air Act, 40 C.F.R. § 51.19(a)

Continuous monitoring data, including calibration and maintenance of monitoring equipment

2 years

40 C.F.R. § 60.7

Reoccurrence/duration of start-up, shut-down, or malfunction in any facility, air pollution control equipment or monitoring device

2 years

Spill Prevention, Control, and Countermeasure Plans

Life of facility

Written inspection procedures and inspection records regarding SPCC plans

3 years

Discharge monitoring records and reports

3 years

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Clean Water Act; 40 C.F.R. §§ 112.3(e) and 112.7 40 C.F.R. § 112.7

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Pretreatment standards - reports by industrial discharger on discharge rate and composition, compliance standards, etc.

3 years

40 C.F.R. § 403.12

Monitoring data and reports concerning pretreatment standards

3 years

40 C.F.R. § 403.12

Records of transportation, storage, and disposal of hazardous waste

3 years

RCRA

Records concerning ownership or operation of storage, treatment or disposal sites for hazardous substances not permitted or operating with interim status under subtitle C of RCRA

50 years

CERCLA

Consumer allegations of injury to health

5 years

Toxic Substances Control Act; 15 U.S.C. § 2607

Records of adverse reactions to health of employees

30 years

Toxic Substances Control Act; 15 U.S.C. § 2607; OSHA record-keeping requirements

Records of adverse environmental effects

5 years

Toxic Substances Control Act; 15 U.S.C. § 2607

Written agreements for labeling hazardous substances

2-years

Federal-Hazardous-Substances Act

Pre-manufacture notification forms and supporting information

Check with environmental counsel before destroying

Public water system chemical and bacteriological analysis

Chem: 10 years Bact: 5 years

Safe Drinking Water Act; 40 C.F.R. § 141.33

Reports or communications relating to sanitary surveys of public water systems

10 years

Safe Drinking Water Act; 40 C.F.R. § 141.33

Records of corrective action regarding violations of primary drinking water standards

3 years

Safe Drinking Water Act; 40 C.F.R. § 141.33

Records concerning variances or exemptions

5 years after expiration

Safe Drinking Water Act; 40 C.F.R. § 141.33

PENSION AND PROFIT SHARING PLANS TITLE / DESCRIPTION RETENTION EXPLANATORY NOTES OF RECORDS PERIOD Tax Returns, correspondence, investments, stock transfers, etc.

Permanent

Plans and trust agreements

Permanent

Associated financial statements

Permanent

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Administrative Policies & Procedures

Associated ledgers, journals, actuarial reports

Permanent

Reports under Title I of ERISA, including annual return for an employee benefit plan (IRS Form 5500)

6 years after the filing of such reports

INSURANCE RECORDS RETENTION PERIOD

TITLE / DESCRIPTION OF RECORDS Insurance Policies

7 years

Claims information

7 years

Workers’ Compensation Insurance policies and claim records

EXPLANATORY NOTES

Permanent

LEGAL RECORDS TITLE / DESCRIPTION OF RECORDS

RETENTION PERIOD

Tort and contract litigation

Permanent

Trademarks/copyrights

Permanent

Patents and related materials

Permanent

TITLE / DESCRIPTION OF RECORDS Drafting records, drawings, blueprints

EXPLANATORY NOTES

MANUFACTURING RECORDS RETENTION PERIOD Permanent

Inspection records

2 years

Production reports

3 years

Quality control reports

4 years

Reliability records

Permanent

Tool control

3 years after employee termination

Word orders

3 years

Time & motion studies

Permanent

Customer specifications

Permanent

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EXPLANATORY NOTES

Business judgment

Statutes of limitations should control Business judgment

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Administrative Policies & Procedures TAXATION – TAX and SALES TAX TITLE / DESCRIPTION RETENTION OF RECORDS PERIOD Annuity/deferred payment records

Permanent

Tax Returns, supporting schedules, files and work papers, tax bills and statements.

Permanent

IRS approval letters

Permanent

Depreciation schedules, long-life assets

Permanent

Depreciation schedules, short-term assets

7 years after end of depreciation schedule

Divided registers

Permanent

Payroll tax returns

4 years

Excise reports and exemption certificates

3 years

Inventory reports

4 years

Tax returns, bills, and statements

Permanent

Sales and use tax returns

Permanent

Sales and use tax back-up to return Social security taxes

EXPLANATORY NOTES

All taxation records not retained permanently should be evaluated against the “materiality” rule. That is, they should be retained if material to an existing or potential IRS action.

7 years Permanent

PERSONNEL AND PAYROLL INFORMATION TITLE / DESCRIPTION OF RECORDS

RETENTION PERIOD

Form EEO-1

1 year

Applications for employment (nonhire)

1 year

Payroll or other records containing employee identifying information: Name, address, DOB sex, job title, etc.

3 years

Administrative Policies & Procedures – Legal: Business Records: Retention and Destruction

EXPLANATORY NOTES

Age Discrimination in Employment Act (ADEA) and FLSA, 29 C.F.R. § 516.5

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Employment contracts

Term of contact + 4 years

Family & Medical Leave records: Requests for leave, confirmation of leave eligibility, medical certification forms, dates & hours on leave, etc.

3 years

Employment Verification Form I-9

3 years after employment begins or 1 year beyond termination, whichever is later

Note: Certain collective bargaining agreements, plans, trusts, and employment contracts which provide extra compensation at a premium rate for an employee are required to be kept for at least 3 years. See FLSA, 29 C.F.R. § 516.5. Family and Medical Leave Act (“FMLA”)

Physical exams of employees

1 year

ADEA, American With Disabilities Act (“ADA”)

Payroll data: payroll ledgers, regular rate of pay, hours worked per day/week, total daily/weekly earnings, deductions from pay, authorizations for deductions, wage garnishments

3 years

FLSA, 29 C.F.R. § 516.5

Timecards & piece work tickets

2 years

FLSA, 29 C.F.R. § 516.5

Individual earnings records

5 years

Tax department should be consulted before disposing of these records. Also, FLSA requires retention for 3 years.

Employee tax withholding statements

4 years

Employee exposure records (and related analysis using exposure or medical records)

30 years

Personnel files, performance reviews, etc.

3 years

Job descriptions

1 year

Collective bargaining agreements (CBAs)

3 years

FLSA, 29 C.F.R. § 516.5

Employee insurance records, disability & sick benefits

6 years

Unless otherwise required by insurance policies.

Wage rate tables

2 years

FLSA, 29 C.F.R § 516.6

Cancelled payroll checks

2 years

FLSA, 29 C.F.R. § 516.6

1099’s, W-2’s, etc.

Permanent

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Administrative Policies & Procedures

Supplementary wage records

2 years

Including such records as: (1) time cards and earnings records; (2) work-time schedules; (3) records of additions to or deductions from wages. FLSA, 29 C.F.R. § 516.6 and Equal Pay Act (EPA)

Records required under HIPAA privacy rules

6 years

Including such documents as: (1) policies and procedures with respect to the use and disclosure of protected health information; (2) notice of privacy practices; (3) employee HIPAA training materials; (4) signed authorizations; (5) individual complaints; (6) plan documents and certifications;

TITLE / DESCRIPTION OF RECORDS

PROPERTY RECORDS RETENTION PERIOD

Detail site ledgers

Permanent

Appraisals and surveys

Permanent

Maps, specifications, blueprints

Permanent

Construction contracts

Permanent

Maintenance records and damage reports

Permanent

Deeds, titles

Permanent

Purchase and lease records

Permanent

Water rights

Permanent

TITLE / DESCRIPTION OF RECORDS Purchase orders and contracts

Price lists, catalogs, quotations, etc.

PURCHASING RETENTION PERIOD 1 year on site, 3 years after purchase

EXPLANATORY NOTES No specific authority for these time periods. However, all of these records may be significant for litigation (civil and tax) concerning the disposition of these items.

Documents affecting title need not be retained once they have been recorded, although it is recommended that they are kept. Unrecorded documents affecting title should be retained for as long as the property is owned.

EXPLANATORY NOTES Generally, these periods are calculated based upon the applicable statute of limitations for a contract action.

Useful life

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Administrative Policies & Procedures SALES TRAINING & MARKETING (Includes Support Services and Sales Training) TITLE / DESCRIPTION RETENTION EXPLANATORY NOTES OF RECORDS PERIOD Bills of material, specifications, and drawings

Useful life

Orders, contracts, acknowledgements, revisions, etc.

3 years after useful life

Market research, surveys, analyses

Permanent

Sales rep contracts, commission reports, etc.

3 years after useful life

Manager Qualification Requirements

3 years after useful life

Incentives

3 years after useful life

Generally, these periods are calculated based upon the applicable statute of limitations for a contract action.

SHIPPING, RECEIVING, AND TRANSPORTATION TITLE / DESCRIPTION RETENTION EXPLANATORY NOTES OF RECORDS PERIOD Original bills of lading; order, shipping and billing records; manifests and express receipts

2 years

Receiving department copies of receiving reports, numeric file

2 years

Vendors packing slips

Useful life

Shipping department copy of shipping advice

2 years

Truck delivery receipts

2 years

Freight claims

3 years

FLSA 29 C.F.R. § 516.6 Recommended: hard copies on site; database can be used to track UPS/Fedex

Special claims are handled by A/R Direct shipments are retained 9 mo. – 1 year or until paid Losses are retained 9 mo. – 1 year

Paid Freight Expense Invoice

1 ½ years

Employee travel

1 year after useful life

Return Freight Adj.

18 mo.

Tracing Paperwork

18 mo.

Special Shipment Paperwork

18 mo.

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Recommended: hard copies retained on site and also on database

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Administrative Policies & Procedures

Account Adj. Fiche

7 years

Carrier Check Stubs

1 year

Direct Credit Adj.

6 mo. – Claims under $15.00

Carrier Claims/Carrier Declines

1 year

Carrier General Correspondence

1 year

Branch General Claims Correspondence/faxes or letters

18 mo.

Sealed Trailer Loss Claims

1 year

Charges to Accounts

1 year

Reports/Carrier Decline Reports

5 years

Old Freight Claims

2 years

Check copies/EDI Carriers

5 years

Remittance Recap/EDI Carriers

6 years

Commercial Invoices

5 years

Customs Documentation

5 years

Tariffs

Permanent

Foreign Subsidiary Setup Docs.

Permanent

Shipping Research

Permanent

Leases or contractor operating agreements for trucks

Original kept by carrier for the lease period

49 C.F.R. § 376.12

Driver Qualification File (including motor vehicle record, road test record, and medical examiner’s certificate of physical qualifications)

Duration of employment of driver + 3 years

49 C.F.R. § 391.51(c)

Records of on-duty status (driver’s logbooks)

6 months

49 C.F.R. § 395.8(k)

Drug and alcohol testing results and related records

5 years

49 C.F.R. § 382.401

Records related to the alcohol and controlled substance collection process

2 years

49 C.F.R. § 382.401

Negative or cancelled drug test results

1 year

49 C.F.R. § 382.401

Records related to the education and training of alcohol testing technicians

During of employment + 2 years

49 C.F.R. § 382.401

Motor carrier vehicle maintenance records

Period of control over vehicle + 6 months

49 C.F.R. § 396.3

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Daily motor carrier vehicle inspection reports and certification of repairs

3 months from date reports are prepared

49 C.F.R. § 396.11

Periodic motor carrier inspection reports

14 months from date reports are prepared

49 C.F.R. § 396.21

TITLE / DESCRIPTION OF RECORDS

WAREHOUSING RECORDS RETENTION PERIOD

Inventory records

Permanent

Warehouse copy of delivery tickets

Permanent

Billing records

EXPLANATORY NOTES

2 years after useful life

FLSA, 29 C.F.R. § 516.6

Customer order file

2 years

FLSA, 29 C.F.R. § 516.6

Sales and purchase records

3 years

Includes: (1) a records of the total dollar volume of sales or business; and (2) a record of the total volume of good purchased or received during such periods, in such form as the employer maintains records in the ordinary course of business. FLSA, 29 C.F.R. § 516.5

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Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

LEGAL PROCEDURES AND CONFIDENTIALITY GUIDELINES

POLICY NO.:

L-104

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. that the confidentiality of current and former persons served is protected throughout all legal proceedings which may involve verbal and/or written communication between employees of the organization and outside individuals and legal entities. Patient records may not be disclosed or used in any civil, criminal, administrative, or legislative proceedings conducted by any Federal, State, or local authority. Records may only be disclosed or used as permitted by HIPAA, 42 CFR Part 2 Confidentiality of Alcohol and Drug Abuse Patient Records, and state law. MedMark has adopted HIPAA policies and procedures applicable to all employees. The following procedures are subject to and should be followed in conjunction with MedMark’s HIPAA policies and procedures.

II.

PROCEDURES A.

Duty to Warn 1.

Duty to Warn is defined as a person served revealing by any means a specific and immediate threat to cause serious bodily injury or death to an identified person(s), including self, and the person receiving the information reasonably believes that the person has the intent and the ability to carry out the threat immediately or imminently. The duty to warn supersedes all confidentiality laws.

In situations which involve a substance abuse diagnosis, 42 CFR Part 2 requires that the duty to warn does not include disclosure or any inference concerning information that a third party could use to identify the individual as having a substance abuse diagnosis or problem.

Response to Imminent Threat or Danger In the event of a serious and imminent threat to the health or safety of a person or the public, the following actions should be taken.

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Administrative Policies & Procedures

Notify a Supervisor for assistance, support, and consultation.

Warn the intended victim or the victim’s parent, if a minor.

Contact law enforcement having jurisdiction in the area where the person served or intended victim lives or works.

Attempt to prevent, through verbal means the individual from using violence until law enforcement can take custody.

Continue the interaction with the person making the threat if by doing so, the person’s intention to cause injury or death to self or another may be diminished to the extent the “duty to warn” is no longer valid.

If the person is no longer a threat requiring a “duty to warn”, immediately seek consultation with a Supervisor following the interaction to assess the level of continued contact or care that may be necessary to assure the situation has been stabilized.

Record the event in the individual’s record and complete a Critical Incident form.

Medical Emergencies Patient identifying information may be disclosed to medical personnel who have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual and which requires immediate medical intervention.

Crimes on Program Premises or Against Program Personnel Program personnel may communicate with law enforcement personnel regarding a patient’s commission of a crime on the premises of the program or against program personnel or to a threat to commit such a crime. Such communications are limited to the circumstances of the incident, including the patient status of the individual committing or threatening to commit the crime, that individual’s name and address, and that individual’s last known whereabouts.

Reports of Suspected Child Abuse and Neglect Confidentiality restrictions do not apply to the reporting under state law of incidents of suspected child abuse and neglect to the appropriate state or local authorities. However, confidentiality restrictions still apply to the patient records. Incidents of suspected child abuse and neglect must be reported first to a Supervisor prior to the reporting to authorities. Notices compelling disclosure of medical records pursuant to an investigation of reported child abuse must be reviewed by MedMark’s Privacy Officer.

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Administrative Policies & Procedures F.

Communicable Disease If a public service employee is requested to arrest, detain or transfer an individual known to have a communicable disease that may threaten the health of the public service employee, the following guidelines apply:

Public safety employees should be made aware of the potential risk or exposure to a communicable disease without revealing the specific type of disease the individual is known to carry.

Communicable disease is defined as any airborne infection or disease as well as those transmitted by contact with blood or human body fluids.

Public safety employees are defined as any person with law-enforcement authority under the control of state and/or local governing bodies.

Employees involved in the situation should make every reasonable attempt to determine if the person served is known to be infected with a communicable disease by referring to the record, asking the individual directly, or consultation with other employees who have direct service contact with the individual.

Public safety employees must be informed of the “potential risk of exposure to a communicable disease” by communicating the necessary information to alert the public safety personnel of the risk, without disclosing the suspected or known condition.

State Laws No state law may either authorize or compel any disclosure prohibited by 42 CFR Part 2 Confidentiality of Alcohol and Drug Abuse Patient Records.

Subpoenas 1.

A subpoena is a mechanism for obtaining records from someone who is not a party to a legal case. A subpoena is a legal document or order requiring an individual to appear, and usually testify, in court on a certain date and/or to produce documents. Not all subpoenas are court-ordered. In some state subpoenas can be issued by attorneys. A subpoena generated by a court order is considered a court order and is generally only issued after a hearing before a judge. 1.

A document subpoena or a “subpoena duces tecum” requires the person named in the subpoena to appear and produce documents.

A subpoena to testify or a “witness subpoena” requires the person named in the subpoena to appear and give testimony.

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Administrative Policies & Procedures 2.

The recipient of a subpoena will immediately route it to the Program Director who will forward the subpoena to the Privacy Officer. The Privacy Officer shall review the document and ensure that it includes the following: 1.

It is the original copy and is signed by the clerk of the court in which the action is pending.

It states the full name and address of the recipients of the subpoena as well as the action number and names of both the plaintiff and the defendant.

A “document subpoena” lists the documents to be produced as well as the time and place they are to be produced.

The subpoena was properly served.

If there are concerns with the subpoena, the Privacy Officer shall contact the party who issued the document.

If a decision is made to contest the subpoena legal counsel will pursue action to quash or modify the subpoena.

If a notice is received indicating that a motion has been filed to quash the subpoena, the motion shall immediately be sent to the Privacy Officer.

If the subpoena is issued by a patient’s attorney, the attorney should be contacted to request that his/her client complete and sign MedMark’s Authorization to Release/Request Protected Health Information form.

Any answer to a request for records must be made in a way that will not affirmatively reveal that an identified individual has been, or is being diagnosed or treated for alcohol or drug abuse.

It is permissible to disclose that an identified individual is not and never has been a patient.

Reviewing and Responding to a Subpoena 1.

All responses to subpoenas will be made in consultation with the Privacy Officer.

If the records sought are covered by HIPAA and/or 42 CFR Part 2 Confidentiality of Alcohol and Drug Abuse Patient Records, the records may only be released if the subpoena is accompanied by a court order that complies with the HIPAA requirements found in 45 CFR 164.512(e) and/or the requirements in 42 CFR Part 2.61 through 2.64.

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Administrative Policies & Procedures 3.

If the person is an active participant in services, he/she and/or their legal guardian shall be notified of the request to ensure that the patient has an adequate opportunity to assert his or her rights.

If the patient’s whose records are named in the subpoena has consented to releasing the requested records, the Privacy Officer shall establish that all legal requirements have been met that permit the release of the records, and that specific details are available that communicate the exact documents or information that is to be released.

Records sent in response to a subpoena should be sent only to the clerk of the court issuing the subpoena using the following procedure: 1.

Place the records in a securely sealed envelope.

Attach a cover letter to the sealed envelope, which states that confidential health care records are enclosed and are to be held under seal pending the court’s ruling any motions to quash the subpoena.

Place the sealed envelope and the cover letter in an outer envelope or package for transmittal to the court.

If documents are not confidential or if a release from the person served is obtained, the Privacy Officer shall seek to excuse the employee from appearing by offering the records in advance of the proceeding. Records shall never be disclosed in advance in when there are any questions concerning confidentiality.

During any legal proceeding employees shall refrain from disclosing patient protected health information until it is conferred with the judge at the proceeding on whether the information should be released. The judge shall be advised that the information sought is confidential and that the law prohibits disclosure without a court order. The judge shall be asked to rule on whether records should be disclosed. Only if the judge orders disclosure may an employee lawfully do so.

For depositions in which a judge is not present, MedMark’s legal counsel will submit written objections to the release of confidential information in advance of the deposition if the person served has not consented to the information’s release.

Since the court may retain the originals while the case is pending, copies are to be made of all records sought by the court. These are to be maintained in the record until the original records are returned. The party who issued the subpoena is responsible for having copies made and does not have the right to obtain the originals.

10.

If any records are disclosed a notation shall be made in the patient’s file stating the date of disclosure, to whom it was disclosed, the purpose of the disclosure, and a description of the information that was disclosed.

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Administrative Policies & Procedures J.

Subpoenas, Testimony, and Privileged Communication 1.

Privileged communication is conversation that takes place within the context of a protected relationship in which the disclosure of the content of that conversation may be deemed to do harm to the provider of the information. The concept of privileged is distinct from confidentiality in that it applies only to testimony in a judicial or quasi-judicial proceeding.

If an employee is subpoenaed to testify in a judicial proceeding, and information is requested that the employee believes is confidential or privileged, the subpoena does not authorize the employee to disclose the information. The information may only be disclosed if a judge issues an order requiring the employee to answer the questions.

If an employee is subpoenaed for testimony in a deposition and questioned about what is known or believed to be confidential or privileged information, the employee shall decline to answer the question. The party seeking the information bears the responsibility of seeking a court order (judge’s authorization) requiring the disclosure.

Confessions of past crimes within a confidential relationship will only be reported if the crime is of such a nature that the public welfare is jeopardized.

In civil matters, the parameters of privilege exist as defined by legal precedent and licensure requirements for licensed physicians and licensed clinical psychologist. Legal clarity is less defined for other mental health professionals and legal counsel will assist employees with preparation for testimony.

In all cases of testimony, employees should assert privilege by respectfully stating that he/she believes the information is privileged within the mental health provider/client relationship and allow the court to rule if he/she must respond to questions.

Under no circumstances should an employee testify regarding substance abuse treatment unless the court has conducted a hearing and issued an order pursuant to 42 CFR Part 2.61.

If, during the course of testimony, a judge orders the employee to reveal substance abuse related information, the employee should inform the judge that special federal law applies to such information and request the opportunity to confer with legal counsel.

Search Warrants 1.

A search warrant is a written court order that authorizes law enforcement officials to search a specific place for specific persons or materials. The search is conducted under the belief that there is probable cause to suspect that criminal activity or evidence of a crime may exist. Persons or items may be “seized” if they fit the description within the written order.

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Administrative Policies & Procedures 2.

If a law officer presents a search warrant and demands to access records of persons served by the organization, the following guidelines should be followed: 1.

Immediately contact the Program Director and inform him/her of the search warrant. The Program Director shall contact the Regional Director and MedMark’s general counsel.

Ask to see and read the warrant and determine if it contains the following: i.

The time and location of the search

ii.

The date of issuance of the search warrant

iii.

The scope of the search and the object(s) to be seized, if found

iv.

The reason for the search

Ask the officers for time to contact the prosecuting attorney or supervisory law officer so that clarification of the warrant and the situation can be further discussed.

If the officers insist on entry or confiscation of records, do not resist. Refusing to obey the orders may constitute a crime.

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Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

CRITICAL INCIDENT REPORTING AND MANAGEMENT

POLICY NO.:

L-105

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide prompt and complete responses to persons served, staff members, and visitors needs in situations containing risk of injury; to call attention to physical situations that need to be investigated or resolved to ensure a safe environment for persons served; staff members, and visitors, to determine issues that can be addressed for enhancement or improvement through management and planning; and to manage risk of situations with potential liability for the organization. Incidents, of a serious nature, that compromise the health and safety of persons served by MedMark Services, Inc., its staff members and visitors, will be documented and reviewed for the purpose of decreasing the likelihood of similar future incidents. Critical incidents shall be defined to include any situation, action, or result of an action that is not consistent with the routine care of a person served, the routine services provided by the organization, the routine operation of the organization, or the safety and security of environments in which services are provided. It is the policy of MedMark Services, Inc. that all situations, behaviors, actions meeting the criteria for a reportable incident and timely debriefing of critical incidents are documented and forwarded to the appropriate staff for further investigation and management, as per the procedures contained in this policy.

II.

PROCEDURES A.

Responsibility for Reporting and Management of Critical Incidents are as follows: 1.

The Program Director/Administrator is charged with the responsibility of health and safety management for the program and within this role ensures that critical incident issues that affect the overall stability and continuing operation of the program are reported.

The Program Director/Administrator is responsible for overall organizational oversight in the area of critical incident reporting and

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Administrative Policies & Procedures management, and provides monthly reports to the applicable Regional Director of Operations regarding trends, legal liability, and insurance issues, recommended policy and procedure changes, and management of critical incidents. In addition, the Program Director/Administrator is charged with the responsibility of providing and managing information regarding outside entities should an incident require such action. 3.

The Program Director/Administrator is responsible for the day-to-day oversight of the critical incident reporting and management system. The Regional Director of Operations is the point of contact for all supervisory personnel when a critical incident occurs within the organization. In addition, the Regional Director of Operations advises the CEO and general counsel of incidents of a severe nature that acutely threaten the therapeutic milieu of MedMark and result in a death, serious injury, alleged abuse, neglect, or exploitation of a person served, staff member, or visitor. The Regional Director of Operations provides monthly reports to Senior Management that assist in evaluation and management of the organization’s practices and environment.

The Director of Human Resources is responsible for serving as the organization’s point of contact, in addition to the Program Director/Administrator, for all critical incidents that involve staff members. The Director of Human Resources will serve as the liaison with the staff member and outside entities in areas such as health insurance, worker’s compensation, and return-to-work issues. The Director of Human Resources will ensure that all legal and regulatory requirements are being addressed in the area of employment practices and staff involvement in a critical incident.

The Program Director/Administrator in his/her role as the overall coordination of the health and safety program is responsible for any immediate response to any critical incident by ensuring that all health and safety policy and procedures are followed immediately after a critical incident has occurred.

The Program Director/Administrator reviews critical incidents and reports, and provides recommendations and information to minimize future incidents to the Regional Director of Operations.

Program Directors/Administrators are responsible for ensuring that all staff members report critical incidents in a prompt manner and serve as the direct point of contact for all staff under their supervision for the reporting of critical incidents. Program Directors/Administrators will be the point of contact between staff members and the organization’s Regional Director of Operations and will ensure that he/she is provided prompt and clear information concerning any critical incident. Program Directors/Administrators will be fully aware of all procedures regarding

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Administrative Policies & Procedures critical incident reporting and management of any acute situation that may occur within their areas of responsibility. 8.

All MedMark staff members are responsible for promptly reporting, to their immediate supervisors, any incident that fits within the reporting guidelines for a critical incident. To support this process, staff members are expected to be knowledgeable with all organizational policy, procedures, and practices in the area of critical incident reporting.

Criteria for reporting a Critical Incident is as follows: 1.

Injury or potential injury to a person served by MedMark Services, Inc. on its property or off-site involving community and/or home-based services, a sponsored event, or a planned outing

Injury or potential injury to a staff member of MedMark while conducting business for MedMark

Injury of potential injury to any individual on MedMark property

Any event that may have potential liability for MedMark

Deaths

Medical emergencies

Medication errors

Alleged physical, psychological, or sexual abuse

Alleged neglect

10.

Self-abuse by a person served

11.

Alleged exploitation and/or harassment

12.

Assaultive behavior

13.

Alleged criminal activity

14.

Restraints

15.

Vehicular accident in the performance of duties

16.

Physician’s order errors

17.

Fires, natural disasters, and power failures

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Administrative Policies & Procedures

18.

Property damage/theft including MedMark property and personal property

19.

Incidents that have the potential for public access to information that may discredit MedMark or compromise confidentiality

20.

Any evidence or suspicion of medication diversion or mishandling

Critical Incidents will be responded to and reported in the following manner: 1.

Employees shall promptly report all incidents that fit the reporting criteria to his/her immediate supervisor. If an employee is unsure if an incident fits the reporting criteria, an employee shall contact his/her supervisor for guidance.

The following events require local authorities to be notified within 15 minutes of the discovery of the event: a.

The death of a person served by any means

Physical or sexual assault between persons served determined to be a reportable law violation

A suicide attempt that results in a serious medical emergency/injury to a person served

Physical assaults of staff by persons served determined to be a reportable law violation

If an incident involves a person served, staff members will make every effort to protect the rights of the person served, especially confidentiality. No information will be released without the written consent of the person served, with the exception of emergency medical information that is permissible through prior consent at orientation to services.

In response to a physical injury or medical emergency incident, MedMark policy and procedure will be followed.

If it appears that medical assistance is needed, the staff member will ask the person served or individual for their permission to seek help. If the person served or individual refuses, or otherwise does not consent, but requires medical attention based on the staff member’s observation, the staff member should seek medical personnel to offer assistance.

For OTP programs, the Program Director will complete a Critical Incident Report as soon as the situation is within control. If staff is off-site and a Critical Incident Report is not available, it will be completed immediately upon arrival at a MedMark facility.

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Administrative Policies & Procedures a. The Program Director, Supervisor or designee will record the incident into the Accreditation Now web based program by the end of that work day, which will automatically be emailed to a designated management staff. b. The computer generated Critical Incident Report will be filed in the Critical Incident binder. c. The Program Director shall respond to each Critical Incident Report within 72 hours of receipt, excluding holidays and weekends.

VA clinics shall report all Critical Incidents as required by VA policies.

The Program Director/Administrator will immediately report to the Regional Director of Operations all incidents that involve matters of a serious nature (deaths, suicides, serious injury or medical emergency, alleged abuse, serious property damage, and public incident involving outside organizations or media).

If an incident occurs outside of MedMark’s operating hours, notification of the Program Director/Administrator can occur at the beginning of the next business day; however, in cases where the incident is of a serious nature, notification should occur immediately through contacting the Program Director/Administrator or Regional Director of Operations via their cell phone.

10.

All critical incidents are considered confidential information. All Critical Incident Reports and distributed copies are to be maintained in a safe and secure location by the Program Director/Administrator and are never to be reviewed by unauthorized personnel. All specific information related to the actual event will be contained within the appropriate forum of discussion and is not to be disclosed outside of formats authorized by organizational policy and procedures. Critical Incident Reports are not to be filed in the medical record of the person served.

11.

Critical Incident Reports have serious legal implications. They are not to be circulated beyond senior management personnel.

12.

In any situation in which a person refused medical care, it should be clearly documented on the Critical Incident Reporting.

Procedures for completing a Critical Incident Report on Accreditation Now (OTP locations only): 1.

The staff member involved or a staff member witnessing the critical incident should complete a Critical Incident Report on Accreditation Now, including, at minimum, the following information:

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Administrative Policies & Procedures

The date, time of the event, and the location are completed, with specific information such as AM or PM, and the specific location within facilities

Information about the Person Served: The identity (by first name only), and chart number should be completed for each person served involved in the incident. If additional persons served are involved, it should be noted on the bottom of the form

Staff Information: The identity and position of the staff members involved.

Visitor Information: The identity of any visitors involved in a critical incident, which should be requested for identifying information

The “Incident Description” section requires specific behavioral description of the event, in addition to listing all witnesses. If additional space is needed, affix an additional sheet to the form, titled “Critical Incident Report, Continued,” and indicate the attachment on the original form.

The “Immediate Action Taken” section requires noting of action taken to alleviate the situation and the rational for the actions.

The Critical Incident Report must be signed and dated by the Program Director. The report will then be placed in the designated binder.

MedMark will manage critical incident information in the following manner to ensure improved health and safety for all persons served, staff members, and visitors: 1.

The Program Director/Administrator will review all critical incidents. The Regional Director of Operations is charged to review incidents that require further investigation and information to assess outcome and formulate recommendations.

The Regional Director of Operations will provide regular reports to the Senior Management, summarizing past critical incidents, presenting any trends which may be occurring, and recommending changes in policy, procedures, and/or operational guidelines.

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Administrative Policies & Procedures 3.

The Regional Director of Operations will submit requests for changes in policy, procedures, and/or operational guidelines to the Director of Quality and Clinical Services when needed based on the recommendations of the Program Director/Administrator. This information will additionally be used to assist in the revision of the organization’s risk management planning, insurance coverage, compliance planning, and code of conduct.

Critical Incident Debriefings shall be offered in a timely manner following traumatic emergencies to provide support to personnel and/or persons served. These debriefings will be held when deemed necessary by the Program Director/Administrator. The timeframe for debriefings shall be at the discretion of the Program Director/Administrator and shall be documented. Documentation will be placed in the Critical Incident Binder.

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Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

CRITICAL INCIDENTS REVIEW

POLICY NO.:

L-106

Effective Date:

AUGUST 2, 2012

Revised Date:

NONE

PURPOSE To establish the procedures for reporting and reviewing of any incident that resulted in injury, harm, or loss to any patient, visitor, or employee of MedMark, or that may result in litigation against MedMark and/or its employees. POLICY Any occurrence that resulted in injury, harm, or loss to any patient, visitor, or employee of MedMark, or may result in litigation against MedMark and/or its employees shall be reported for review and assessment regarding improving the quality of care provided to patients and improving safety to patients and employees. PROCEDURES 1. As used in this policy, an “incident” is defined as an occurrence that is not consistent with routine medical care or clinic operations or an occurrence that resulted in injury, harm, or loss to any patient, visitor, or employee of MedMark, or an occurrence that may result in litigation against MedMark and/or its employees. 2. All incidents as defined above shall be reported by the Regional Director to the CEO and MedMark Counsel using the Incident Reporting Form. 3. A confidential review and assessment of the incident shall be conducted as directed by MedMark counsel. The personnel shall provide a draft of his/her incident review to MedMark counsel. MedMark counsel shall review the incident review. The incident review shall be reviewed by the appropriate senior personnel if necessary. The incident review shall be labeled “Confidential Incident Review Conducted at the Direction of MedMark Counsel.” 4. A final incident review shall be placed on a confidential network file labeled “Confidential Quality Improvement Reviews.” Once a final incident review is prepared only the final incident review will be retained and all previous drafts shall be discarded. 5. Final incident reviews will be distributed only to appropriate senior personnel, which may include the CEO, medical director, vice president of operations, and the director of operations. No Incident Reporting Forms or incident reviews shall be placed in patient or employee files. No reference to an Administrative Policies & Procedures – Legal: Critical Incidents Review

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Administrative Policies & Procedures Incident Reporting Form or incident review shall be made in the patient medical record or employee file. No other copies of Incident Reporting Forms or incident reviews shall be made or distributed. 6. Remedial actions or quality improvement actions shall be implemented as directed by the CEO and confirmed when completed to MedMark counsel who shall periodically report on all outstanding incomplete incident reviews or incomplete responsive measures to the CEO. 7. Incident reviews shall be considered confidential communications protected by the attorney-client privilege and attorney-work product privilege. They are not subject to release to a patient or other person, even in response to a subpoena.

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INCIDENT REPORTING FORM This is a confidential report and should not be made part of a patient file or an employee’s employment record. This form should be completed and returned to the MedMark CEO and MedMark counsel within 24 hours of the incident. Information about individuals involved in the incident Client(s) Involved: Visitor Involved: Staff Involved: Information about the incident Incident Date: Incident Time: Location: Incident Description:

Did the incident result in an injury? Treatment for Injury: List all individuals notified:

Immediate Action Taken:

Report Prepared by: Date:

MedMark Services, Inc. – Incident Reporting Form July 2, 2012

Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

OTP SENTINEL EVENTS AND REPORTING PROCEDURES

POLICY NO.:

L-107

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY All opioid treatment programs will follow State, Federal and accrediting entities suggestions and mandates for the occurrence of sentinel events. Sentinel events will be identified and investigated with root cause analysis. Staff will identify and respond appropriately to all sentinel events. PROCEDURES As used in this policy sentinel events are defined as lawsuits, investigations, and unexpected occurrence to a patient such as death, loss of limbs, or permanent loss of function. Permanent loss of function is defined as motor, sensory, physiological, or intellectual impairment not present upon admission. These incidents will require continued, ongoing treatment of lifestyle changes. Sentinel events include, but are not limited to: 1. Patient death, coma, paralysis or any major permanent loss of function associated with a medication error 2. Death of a patient, or major permanent loss of function 3. Suicide of a patient on facility grounds 4. Overdose while utilizing take home medications 5. Injuries occurring on site resulting in a permanent loss of function or death 6. Child abduction from facility 7. Crimes committed on the facility premises or against facility personnel Prevention: Sentinel events are prevented in a number of ways: 1. 2. 3. 4.

Staying in compliance with State and Federal regulations to avoid investigations Educating patients about the symptoms of an overdose Educating patients about medications that interact negatively with methadone Conducting internal and external inspections to ensure that our environment is safe from hazards 5. Conducting assessments for suicide 6. Educating patients about the dangers of misusing take home medications

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Administrative Policies & Procedures Remedial Actions: Should a sentinel event occur MedMark will notify the state methadone authority within ninety (90) days of the event. CARF and/or the Joint Commission will be notified within thirty (30) days of the event. Patient Death: The Medical Director, Program Director, Regional Director of Operations and the Director of Quality and Clinical Services will be notified as soon as possible and a Critical Incident Report will be completed and processed as per the Critical Incident Reporting and Management Policy. If a patient dies while in treatment, a death report will be completed, signed by the Medical Director or Program Physician and faxed to the state methadone authority within ninety (90) calendar days from the date of death. An OTP Mortality Report Form will be completed via paper form or online and submitted to SAMHSA/CSAT. The Commission on Accreditation of Rehabilitation Facilities (CARF) will be notified of a patient death electronically by submitting the information electronically on the “Accreditation Now” website. If a patient death occurs on-site, or if ingestion of medication provided by the program may have been the cause of death, a patient death report will be submitted via fax to the state within one working day of the death. All death reports shall be signed by the Medical Director or Program Physician. If possible, a coroner’s report should be submitted with the death report.

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Administrative Policies & Procedures DEPARTMENT:

LEGAL

SUBJECT:

DEA Registrations and Power of Attorney

POLICY NO.:

L-108

Effective Date:

December 10, 2012

Revised Date:

NONE

POLICY All opioid treatment programs will maintain current DEA registrations and maintain valid Power of Attorneys for all necessary program personnel. PROCEDURES 1. Every opioid treatment program (OTP) shall be registered with the DEA. Every OTP program shall maintain a valid Certificate of Registration from the DEA at the registered location in a readily retrievable manner. 2. Renewal registration forms shall be completed and signed for by the Regional Vice President. It is the responsibility of the Regional Vice President to ensure that DEA renewal registrations are timely completed and submitted to ensure continuation of services to patients. 3. Power of Attorney forms shall be completed and signed by the same person who signed the most recent application for registration or reregistration to authorize other personnel to obtain and execute order forms. The attached Power of Attorney form shall be used. 4. When a person to whom a Power of Attorney is granted is no longer able to or is no longer to have such power then the Regional Vice President shall ensure that the Power of Attorney is revoked with a signed Notice of Revocation. 5. If the person who signed the most recent application for registration or reregistration is no longer authorized to grant POA’s then the new person who is in such position shall revoke all POA’s for program personnel and sign new POA’s for all necessary personnel. 6. It is the responsibility of the Regional Vice President to ensure that POA forms are completed for all necessary personnel, and revocations are completed when necessary. 7. The Power of Attorney shall be filed with executed DEA order forms and retained for the same period as any order form bearing the signature of the person designated in the POA. The POA must be available for inspections with other order forms.

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Power of Attorney for DEA Forms 222 and Electronic Orders DEA Registrant: _______________________________________________________________ Address: _____________________________________________________________________ DEA Registration No.: __________________________________________________________

I, , the undersigned, who am authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint , my true and lawful attorney for me in my name, place, and stead, to execute applications for Forms 222 and to sign orders for Schedule I and II controlled substances, whether these orders be on Form 222 or electronic, in accordance with 21 U.S.C. 828 and Part 1305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney must lawfully do or cause to be done by virtue hereof. This Power of Attorney hereby supersedes any prior Power of Attorney granted to _____________ to execute applications for Forms 222 and to sign orders for Schedule I and II controlled substances on behalf of the above name-named registrant.

Signature of Person Granting Power I, hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

Signature of Attorney-in-Fact Witnesses: 1. 2. Signed and dated on the __________ day of ___________, 201_, at __________.

Notice of Revocation The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or the Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact this same day.

Signature of Person Revoking Power Witnesses: 1. 2. Signed and dated on the __________ day of ___________, 201_, at __________.

VI. Information Technology

Administrative Policies & Procedures

DEPARTMENT:

INFORMATION TECHNOLOGY

SUBJECT:

END USER COMPUTING POLICY

EFFECTIVE DATE:

10/1/2012

REVISED DATE:

NONE

POLICY It is the policy of MedMark Services, Inc. to provide IT services that comply with all federal, state, and local regulations and applicable laws, and that adhere to high ethical standards. Therefore, protective measures shall be followed to ensure against the unauthorized use or disclosure of protected health information and confidential proprietary information through the use of MedMark’s Digital Environment. Any employee who accesses MedMark’s Digital Environment must adhere to the following End User Computing Policy. Table of Contents 1.0 1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.2.6 1.3 1.3.1 1.3.2 1.3.3 1.4 1.5 1.5.1 1.5.2 1.6 1.6.1 1.6.2 1.6.3 1.6.4 1.7 1.7.1 1.7.2 1.7.3

End User Computing Policy Usage Responsible Use Priority Use Ethical Use Legal Use General Use Examples of Misuse Privacy Information Storage Portable Electronic Media Devices Monitoring & Disclosure Purchasing Software Usage Software Removal Usage Review and Compliance Internet Access Usage Instant Messaging (IM) Software Peer-to-Peer (P2P) File Sharing Software Electronic Email Usage Access to the Digital Environment Access Examples Access via MedMark Services Inc. Equipment Access via Client Equipment

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1.7.4 Access to the Digital Environment via Personal Equipment 1.8 Removal of Company Laptop Computers from Company Facilities 1.9 Copyright 1.9.1 The Internet 1.9.2 Email 1.9.3 Software Copyright Infringement 1.9.4 Fair Use Doctrine 1.10 Enforcement 1.10.1 Applicability of Other Policies 1.10.2 Investigation 1.10.3 Reporting Violations 1.10.4 Violations and Penalties 1.11 Liability & Warranty 1.12 Policy Revisions & Questions Section 1.0

End User Computing Policy

Introduction MedMark Services Inc. provides its employees with access to a wide range of information resources. This digital environment includes the use of computers, networks, phone, and fax communication. These services are essential for supporting and administering patient care throughout MedMark Services Inc. Such systems are to be used for business purposes in serving the interests of the company, our patients and customers in the course of normal operations. While MedMark Services Inc. values freedom of expression and an open exchange of ideas and information, the company acknowledges that there is a delicate balance between freedom of expression and respect for the rights of co-workers of the MedMark community. Essentially, the MedMark Services Inc. End User Computing Policy (EUCP) requires all users to maintain reasonable standards of professional and personal respect and courtesy. All MedMark Services policies that apply elsewhere in MedMark Services Inc. also apply to the use of the digital environment. For example, all MedMark Services Inc. harassment and discrimination policies apply to the use of MedMark’s digital environment. Purpose The purpose of the MedMark Services Inc. EUCP is to define the boundaries of acceptable use of the company’s electronic resources. All employees must acknowledge and comply with this policy. Scope This policy applies to employees, interns, contractors, consultants, temporaries, and all other workers at MedMark Services Inc., including all personnel affiliated with third parties. This policy applies to all equipment that is owned or leased by MedMark Services Inc.

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Definition of the Digital Environment The MedMark digital environment encompasses all use of MedMark material. "Material" includes items such as computer hardware, software, data, networks, user and computer accounts, communication devices and lines, telephone system, voice mail system and fax machines. "Use" of MedMark material includes all forms of electronic communication and computation, information storage, retrieval, publishing and printing. The digital environment extends to all materials and uses, whether accessed by employees on site or off site.

1.2 Usage 1.2.1 Responsible Use Users are responsible for their use of the digital environment, including computer accounts and user IDs. Users must take all reasonable precautions, including password maintenance and file protection measures, to prevent use of accounts by unauthorized persons or use of accounts in an unauthorized manner. Do not share your passwords. Whoever has access to your user ID and password can access the system in your name. Therefore, the system is auditing you. Always protect your password so it will not be inadvertently disclosed or easily retrieved. You may be held accountable for unauthorized use of network resources due to disclosures on your part. The primary purpose of the MedMark digital environment is to provide authorized users with resources to perform their job functions. Personal use of the MedMark digital environment is permitted, provided it is incidental and does not interfere with the legitimate use of the digital environment by other users. The digital environment may not be used for private monetary gain. 1.2.2 Priority Use MedMark and its authorized personnel reserve the right to set priorities on the use of the MedMark digital environment. Patient care, medication dispensing, support and administration always take precedence over other uses. 1.2.3 Ethical Use All users are responsible for conducting themselves in the digital environment in an ethical manner. Users must respect all copyrighted, personal, or proprietary information belonging to others. Additionally, users shall refrain from unethical activities, such as: 

Improper Access: Gaining or attempting to gain improper access to the MedMark digital environment or the files/accounts of another.

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Administrative Policies & Procedures 

Destructive Behavior: Any action that might be harmful to the MedMark digital environment.



Offensive Behaviors/Harassment: Any behavior that is harmful to users of the MedMark digital environment or to MedMark patients, partners or vendors.



Improper Attribution: When creating and sending messages through the MedMark digital environment, users shall not give the impression that they are representing, giving opinions, or otherwise making statements on behalf of MedMark or its employees unless appropriately authorized to do so.

1.2.4 Legal Use Some Internet sites may contain material that is illegal under state or federal law (for example, laws and sexual harassment statutes governing hostile environments). Users must take care to act within the confines of the law, as well as within all MedMark Services Inc. policies. Users should be aware that MedMark prohibits the use of its facilities to commit criminal activities. MedMark will cooperate with appropriate authorities to enforce the law. Moreover, although an activity may arguably be legal, the MedMark EUCP may be more rigorous than the legal standard. 1.2.5 General Use The primary purpose of MedMark’s network accounts is to facilitate each user's specific job function. The MedMark digital environment must be used in accordance with the Responsible Use provision contained in this policy. 1.2.6 Examples of Misuse Examples of misuse include, but are not limited to, the following activities: 

Using a computer or user account that you are not authorized to use



Using the MedMark network to gain unauthorized access to any computer system



Attempting to circumvent data protection schemes or uncover security loopholes



Attempting to gain unauthorized access to data of any kind



Masking the identity of an account or machine



Tampering with, hacking, abusing, or otherwise damaging computer hardware, software or data. This includes tampering such as attempting to crack or guess passwords, attempting to gain control of systems or services, sending anonymous mail, or "bombing" a mailbox with multiple copies of a message

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Administrative Policies & Procedures 

Irresponsible use of or deliberate wasting of computing resources such as storage space, processing power, network capacity or printer paper or toner. This also includes overloading computers with non-work related items



Knowingly running or installing on any computer system or network, or giving to another user, a program intended to damage or to place excessive load on a computer system or network. This includes but is not limited to programs known as computer viruses, Trojan horses, and worms



Installing any software onto a MedMark computer without authorization from the MedMark Information Technology Department



Violating terms of applicable software licensing agreements or copyright laws



Attempting to monitor or tamper with another user's electronic communications



Using email to harass others



Initiating or propagating electronic chain letters



Unauthorized mass mailing including multiple mailings to newsgroups, mailing lists, or individuals, or using email or personal web page advertising to solicit or proselytize others for commercial ventures, religious or political causes, or for personal gain



Sending harassing or pornographic messages either locally or over the Internet



Using MedMark computing resources such as servers to store harassing, illegal or pornographic materials



Posting materials on electronic bulletin boards that violate existing laws or MedMark Services Inc. policies

1.3 Privacy A user's programs and data are to be treated by other users as private property. 1.3.1 Information Storage MedMark Services Inc. employs reasonable means to maintain the privacy of information that is stored in the MedMark digital environment. MedMark reserves the right to access user data for appropriate management purposes, such as making backup copies and to ensure system integrity. When information is copied to backup media, every file will be backed up irrespective of any file protection mechanisms that have been set. When MedMark Services Inc. users delete information, they cannot be assured that every copy of it will be deleted. A number of copies may be retained on backup media.

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Both the nature of email and the character of the MedMark digital environment make email less private than users may anticipate. The privacy of email messages may be compromised by the fact they must routinely pass through numerous computers and are sometimes seen by system administrators in the course of maintaining these systems, redirecting lost mail, or by antivirus screening. MedMark Services Inc. ability to maintain the privacy of information on workstations is limited. Be wary of using your personal computer system for the storage of highly sensitive information or information that you do not want anyone else to access. Users of these facilities are cautioned that absolute privacy cannot be assured. 1.3.2 Portable Electronic Media Devices Protective measures shall be followed to ensure against the unauthorized use or disclosure of protected health information and confidential proprietary information through the use of Portable Electronic Media Devices. “Portable Electronic Media Device” means any electronic device that may include protected health information and confidential proprietary information and that may be removed, transported, or otherwise moved within or without Company facilities, including, but not limited to, laptop computers, flash drives, memory sticks, and removable hard drives. Only Company-approved Portable Electronic Media Devices are permitted to save Company information. Company information may not be downloaded onto any non-Company approved device. The IT Department shall maintain all approved Portable Electronic Media Devices. All approved Portable Electronic Media Devices shall be encrypted. The IT Department shall maintain an inventory of all approved Portable Electronic Media Devices, including the employee who is authorized to use such device, and where the device is maintained. When an employee wishes to use a Portable Electronic Media Device he/she shall first request an approved Portable Electronic Media Devices from his/her supervisor. The supervisor shall contact the IT Department. The IT Department shall approve or deny the request. The IT Department shall provide the employee with a Company-approved Portable Electronic Media Device. Only the approved employee shall use the Portable Electronic Media Device for the approved action. Company approved Portable Electronic Media Devices are to remain within Company facilities. All Portable Electronic Media Devices shall be stored in a secure manner such as in locked file cabinets or other locked storage areas, and accessed only by Company employees. Portable Administrative Policies & Procedures – Information Technology Policies

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Electronic Media Devices shall not be left in plain view where unauthorized persons may use or access it. If an employee wishes to remove a Company-approved Portable Electronic Media Device from a Company facility then he/she shall follow the same procedures identified in the Removal of Company Computers from Company Facilities Policy. If a Portable Electronic Media Device is lost or stolen the employee shall immediately notify his/her supervisor and the IT Department. All protected health information and confidential proprietary information shall be deleted from the Portable Electronic Media Device as soon as possible. The Portable Electronic Media Device shall only be used with Company-approved devices. 1.3.3 Monitoring & Disclosure MedMark Services Inc. does not routinely monitor the content of email, voice mail or other stored information. Nonetheless, all information is subject to a number of laws, policies, and practices that apply to the disclosure and protection of MedMark records. MedMark Services Inc. may audit email, voicemail and other information storage to satisfy a legal obligation or to insure proper operation of these systems. MedMark reserves the right to take appropriate investigatory and/or disciplinary action. For more information see the Enforcement section of this policy.

1.4 Purchasing All purchasing of company hardware, software and third-party technology services shall be centralized with the Information Technology Department. This will ensure that all purchases conform to company standards and are purchased at the best possible price. All employees must submit their technology purchasing requests to their supervisor or Department manager for approval. The request must then be sent to the Information Technology Department which will determine the best technology solution to accommodate the desired request.

1.5 Software Usage All software acquired for or on behalf of MedMark Services Inc. or developed by company employees or contract personnel on behalf of the company is and shall be deemed company property. All software must be legally licensed and the systems must be kept virus free. Users are forbidden from installing software onto computers owned by MedMark Services Inc. without Administrative Policies & Procedures – Information Technology Policies

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prior permission from the Information Technology Department. Any person installing software on MedMark equipment that was not purchased and registered as stated above may be subject to disciplinary action and shall assume sole liability for all consequences arising from the installation and operation of that software. This may include the cost of network remediation (example: virus removal) or computer repair caused by that software. Any person wishing to install personal software on MedMark equipment must show proof of ownership of the software to the Information Technology Department, in advance, in the form of original media, license certificate or invoice. Generally, MedMark owned software cannot be taken home and loaded on a user's home computer if it also resides on a MedMark computer. If an employee is to use such software at home, MedMark will purchase an additional license, at its expense, and record it as a company asset in the software registry. However, some software publishers provide in their license agreements that a secondary use is permitted under certain circumstances. If a user requires the use of MedMark owned software at home, s/he should consult with the Information Technology Department, to determine the permissible use of a particular software title. In the event the employee for whom software has been purchased leaves MedMark, it will be the responsibility of employee’s manager and the Information Technology Department to recover the software from the user. This shall include a signed form from the Information Technology Department and software user verifying the removal of the software from the user’s home computer. Upon completing the above, all manuals, documentation, and installation media are to be returned to the software library and the software registry updated to reflect the change and availability of that software title. Shareware is copyrighted software that is typically distributed via the Internet. It is the policy of MedMark Services Inc. to pay shareware authors the fee they specify for use of their products (see the „README‟ file that typically accompanies the software). Under this policy, the acquisition and registration of shareware products will be handled in the same way as commercial software products are handled. The Information Technology Department must maintain a complete record of all software that has been purchased by MedMark Services Inc. and must support and upgrade such software accordingly. Registration of software with a publisher must be performed by the Information Technology Department not by individual users. The Information Technology Department shall ensure that only properly licensed and documented software is installed on MedMark computing devices (desktops, laptops, servers, handheld computers, and any other devices that use licensed software) at all times. 1.5.1 Software Removal The following steps shall be taken when licensed software is no longer needed by a MedMark Services Inc. employee. 1. Non-current software no longer being used will be removed from the computer and the change reflected in the software registry. All documentation for the removed software shall be retained in the software library. Administrative Policies & Procedures – Information Technology Policies

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2. When a computer is transferred from one Department to another for the use of the receiving Department, the registry shall reflect the transfer of all licensed software. The Information Technology Department will enter the computing device, and all licensed software in the software registry. 3. When a computer is transferred to Property Surplus for disposal, the operating system, all data and software shall be removed from the computing device by the Information Technology Department beforehand. 1.5.2 Usage Review and Compliance MedMark Services Inc. shall establish a regular schedule for auditing software licensing. This audit is intended to reconcile the installed software with information kept in the software registry, thus assuring compliance with all software license agreements, applicable law, and MedMark Services Inc. policy. During an audit, any software for which proper license and purchase documentation cannot be found must be removed immediately. MedMark Services Inc. reserves the right to perform software audits on MedMark computing devices with prior notice being given where applicable. Unannounced audits may be initiated or conducted by management and/or the Information Technology Department using any technological resources and support as deemed necessary.

1.6 Internet Access 1.6.1 Usage It is MedMark Services Inc. policy to offer unlimited access to the Internet. However, as with any user-oriented service, MedMark Services Inc. has certain rules which will be enforced. Therefore, MedMark Services Inc. requires its users to adhere to the following guidelines: 

The MedMark Services Inc. Internet connections must be used lawfully and in accordance with all applicable MedMark Services Inc. policies at all times. Unlawful or personal activities that inhibit MedMark’s ability to provide or receive services will result in disciplinary measures



MedMark’s users are prohibited from viewing, storing or distributing any unlawful or inappropriate material through MedMark Internet connections. Examples include but are not limited to direct threats of physical harm, pornography, and copyrighted, trademarked and other proprietary material used without proper authorization



Streaming Media and or streaming audio is not permitted



Users are cautioned that the Internet is not always secure and the privacy of credit card purchases and other communications is not assured by MedMark Services Inc.



While MedMark Services Inc. makes every effort to provide stable and effective Internet access for its employees, the Internet is an electronic medium with interdependent links and is subject to disruptions beyond MedMark’s control

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MedMark Services Inc. assumes no responsibility for the content found on Internet sites other than those created by MedMark. 1.6.2 Instant Messaging (IM) Software Instant messaging is a type of electronic communication. IM software is available from such companies as AOL, Cerulean Studios (Trillian), Groove, ICQ, Microsoft and Yahoo. It is relatively easy to use over a company network or over the Internet. It differs from e-mail in that typed messages are sent and received in real-time between two or more participants in a conversation. Use of IM software for personal use follows the same guidelines as personal use of telephone equipment and email, i.e. these are assets provided by MedMark Services Inc. to facilitate the performance of your job responsibilities. 1.6.3 Peer-to-Peer (P2P) File Sharing Software There has been significant media coverage, and controversy, surrounding the use of Napster, KaZaA, LimeWire and other peer-to-peer file sharing programs and services available on the Internet. These programs are designed to let people easily exchange music, movies, videos, and other files over the Internet. The use of P2P software does not contribute to MedMark Services Inc. business. Performance of computers and the network can be adversely affected by P2P software use, thereby reducing overall company productivity. There is also a high risk that a user may violate copyright law through the use of P2P software, with or without the user’s intent, which may implicate MedMark Services Inc. in the violation. Therefore MedMark Services Inc. prohibits the installation or use of P2P software within the company’s digital environment. 1.6.4 Electronic Email Usage E-Mail is considered official communication for MedMark Services Inc. and users bear sole responsibility for all material they access and/or send through E-Mail channels. Protective measures shall be followed to ensure against the unauthorized use or disclosure of protected health information and confidential proprietary information through the use of Company email on a Personal Communication Device. Any employee who accesses the Company email system through a Personal Communication Device must follow this policy. 

Do not use email to exchange or store protected health information (PHI)



Activities such as chain letters, pyramids or similar electronic mail schemes can quickly overload a system. Do not respond to any E-Mail that instructs you to forward the message to others. These could easily become an effective, intentional offense against the network



Delete unnecessary e-mail from your Inbox folder. This is where most e-mail messages accumulate

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

Save attachments to the appropriate folder on the server and delete the e-mail or remove the attachment



Multiple message threads – when the conversation is over, delete the previous e-mails since the last thread has all conversations (Inbox and Sent folders)

1.7 Access to the Digital Environment Access to the MedMark Services Inc. digital environment is available to employees at company offices and from remote locations. Employees may only use equipment owned by MedMark Services Inc. Remote access by employees from any equipment, regardless of ownership, is subject to the terms of the MedMark Services Inc. EUCP. 1.7.1 Access Examples Access to the digital environment may include, but is not limited to: 

Plugging devices into MedMark Services Inc. computers or network



Direct Internet connection, virtual private network connection (VPN) or Remote access via modem dial-up



Communication with company systems via cell phone, Internet or wireless connection

1.7.2 Access via MedMark Services Inc. Equipment This includes equipment located at MedMark Services Inc. company sites as well as mobile equipment assigned to remote or traveling employees. The Information Technology Department implements hardware and software configuration standards for productivity, performance and security. Employees shall not modify, or allow others, including client technical staff or contractors to modify company equipment without prior authorization from the Information Technology Department. 1.7.3 Access via Client Equipment MedMark Services Inc. employees may have occasion to use equipment owned by MedMark Services Inc. clients in order to access the MedMark digital environment. When using client equipment MedMark Services Inc. employees shall adhere to usage policies of the client organization so long as doing so does not violate MedMark Services Inc. policies.

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1.7.4 Access to the Digital Environment via Personal Equipment This includes all personal communication devices used at or outside the MedMark Services Inc. company sites and home computer systems to access the MedMark Services Inc. digital environment. “Personal Communication Device” means any electronic communication device including, but not limited to, Smart Phones, tablet computers, and personal digital assistants (PDAs). Only MedMark Services Inc. issued devices as defined by the Information Technology Department are authorized to access MedMark Services Inc. digital environment. When an employee wishes to access Company email on his/her Personal Communication Device the employee must first request approval to do so from his/her supervisor. The supervisor shall notify the IT Department of the request. The IT Department shall review and approve the request. No employee is permitted to access Company email on his/her Personal Communication Device without approval Once approved the IT Department will contact the employee and install access to Company email on the employee’s Personal Communication Device. Access shall not be installed by any person other than the IT Department or its designee. Any employee with access to Company email will maintain password protection on his/her Personal Communication Device at all times. The IT Department shall maintain a list of all employees with access to Company email on Personal Communication Devices. The inventory shall also include the employee’s type of Personal Communication Device. The IT Department will review the Personal Communication Device inventory each month. If an employee’s Personal Communication Device is lost or stolen the employee shall immediately notify his/her supervisor and the IT Department. Once the IT Department is notified that a Personal Communication Device is lost or stolen the IT Department will immediately re-set the employee’s password. In the event an employee’s employment is terminated the employee will provide his/her Personal Communication Device to his/her supervisor for the removal of email from the Personal Communication Device. The supervisor shall inform the IT Department when an employee’s employment is terminated. The IT Department will remove the employee’s access to the Company’s email system. If an employee replaces his/her Personal Communication Device he/she shall follow the same procedures identified in this policy for each Personal Communication Device.

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1.8 Removal of Company Laptop Computers from Company Facilities Protective measures shall be followed to ensure against the loss of Company laptop computers (“laptops”). This policy shall apply whenever an employee wishes to remove a Company laptop from a Company facility or approved location. When an employee wishes to remove a laptop from a Company facility or approved location, the employee must first request approval from his/her supervisor. The laptop must have digital protection in the form of Full Disk Encryption. Prior to removing the laptop the employee must fully shut down the laptop. The laptop must then be placed in a case sufficient to protect the laptop from damage. Once the laptop has been removed from the facility the employee must immediately place the laptop in the trunk of his/her vehicle. If the vehicle does not have a trunk then the employee shall place the laptop where it is not visible from outside the vehicle. Every effort must be taken to prevent the laptop from being removed from the vehicle without authorization. The employee shall ensure that the vehicle remains locked at all times the laptop is in the vehicle. The employee shall not leave a laptop in the vehicle for an extended period of time. Upon reaching the employee’s final destination the employee shall remove the laptop from the vehicle and place it inside the employee’s residence. The employee shall not permit anyone to access the laptop. The employee shall ensure that the laptop’s screen locks within three minutes of the laptop being idle. While traveling a laptop shall never be checked as luggage, but shall remain on the employee. While traveling the employee shall take measures to keep the laptop from being readily visible in hotel rooms. In the event a laptop is lost or stolen the employee shall immediately notify his/her supervisor and the IT Department.

1.9 Copyright "Copyright” is the ownership and control of intellectual property in original works of authorship. A copyright owner has five specific rights: to reproduce (copy) the work, to prepare derivative works based on the copyrighted work, distributing copies of the work to the public, publicly performing the work, and publicly displaying the work." ("Licensing of Instructional/Informational Technology," Adrian Arima, Gary Cary Ware & Freidenrich, March 1, 1996). Works published

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Administrative Policies & Procedures

after March 1, 1989 may maintain a valid copyright even if they are not specifically labeled with a copyright symbol or other notification. Any action that violates the rights of a copyright owner may constitute copyright infringement. The digital environment includes media subject to copyright laws, including the Internet, email, computer software, music and video files. 1.9.1 The Internet Copyright infringement via the Internet may occur in a variety of ways, including making unauthorized copies of any copyrighted material and publishing another's copyrighted materials over computer networks. 1.9.2 Email Like the Internet, email may be used to publish, manipulate, or otherwise attribute original works of authorship. Such action may constitute copyright infringement. 1.9.3 Software Copyright Infringement Software Copyright Infringement includes receiving and/or using unauthorized copies of software, making unauthorized copies of software for oneself or others, or attempting to modify the computer systems in any unauthorized manner. 1. Software License Agreements: MedMark Services Inc. has purchased licenses that permit employees of the company to access and use many software packages and files that are protected and regulated by copyright law. Software license agreements are contracts in which the seller agrees to provide the program, provided that the buyer agrees to abide by the rules of the license. Most of the software used at MedMark Services Inc. is licensed to MedMark Services Inc. through independent software companies. 2. Ethical and Legal Use of Software: Copyrighted software must only be used in accordance with the license and purchase agreement between MedMark Services Inc. and independent vendors. Users do not have the right to make copies of licensed software, modify, and/or distribute such copies to anyone. Only authorized copying of files or programs or program utilization is ethical and legal. 1.9.4 Fair Use Doctrine To determine whether particular uses of a copyrighted work are permissible, the courts often refer to the fair use doctrine, described in U.S.C. Title 17, section 107. The fair use doctrine considers: 1. The purpose and character of the use, including whether such use is of a commercial nature or is for non-profit purposes Administrative Policies & Procedures – Information Technology Policies

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Administrative Policies & Procedures

2. The nature of the copyrighted work 3. The amount and substantiality of the portion used in relation to the copyrighted work as a whole 4. The effect of the use upon the potential market for or value of the copyrighted work MedMark Services Inc. policy is to adhere strictly to the letter and spirit of copyright laws and regulations. Copyright infringement may be subject to disciplinary and/or legal action. 1.10 Enforcement MedMark Services Inc. reserves the right to inspect all information stored in the MedMark Services Inc. digital environment and to record any communications that pass through it. All information contained on MedMark Services Inc. equipment is considered MedMark Services Inc. property, though not necessarily the intellectual property of the company. MedMark Services Inc. may report evidence of misconduct to the appropriate authorities. 1.10.1 Applicability of Other Policies MedMark Services Inc. policies regarding appropriate conduct are applicable to all uses of the digital environment. This includes communications sent on site or off site via MedMark Services Inc. email and the Internet. 1.10.2 Investigation Alleged violations of the MedMark Services Inc. EUCP are subject to investigation. In the event of an investigation, MedMark Services Inc. reserves the right to access all information in the MedMark Services Inc. digital environment while making every effort to keep such investigations confidential. Any person who believes such actions are necessary must first obtain the approval of a MedMark Services Inc. executive manager. 1.10.3 Reporting Violations The Human Resources Department will manage all investigations into potential violations of the MedMark Services Inc. EUCP. 1.10.4 Violations and Penalties Penalties for violating the MedMark Services Inc. EUCP will vary depending on the nature and severity of the specific violation. Any employee who violates the MedMark Services Inc. EUCP will be subject to: 1. Disciplinary action as described in the MedMark Services Inc. employee handbook,

including but not limited to reprimand, suspension, and/or termination of employment. 2. Civil or criminal prosecution under federal and/or state law. Administrative Policies & Procedures – Information Technology Policies

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Administrative Policies & Procedures

1.11 Liability & Warranty MedMark Services Inc. is unable to warrant that its digital environment is free of malicious software or content at all times. Use of and/or access to the MedMark Services Inc. digital environment does not entitle the user to seek indirect, consequential, special, punitive, peremptory, or like damages from MedMark Services Inc. in connection with such use and access. 1.12 Policy Revisions & Questions MedMark Services Inc. reserves the right to modify the EUCP as needed. Changes shall be communicated to all employees promptly. Employees are responsible for keeping their understanding of this policy current. If you wish to use the MedMark Services Inc. digital environment and are uncertain as to whether your intended action violates the MedMark Services Inc. EUCP, you should consult the Information Technology Department.

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ACKNOWLEDGEMENT OF MEDMARK’S END USER COMPUTING POLICY I am, or in the future may become, a user of one or more MedMark information technology devices or systems that may include electronic Protected Health Information (ePHI) or confidential information. I hereby certify that: 1.

I have reviewed the MedMark End User Computing Policies & Procedures.

I recognize the importance of maintaining the confidentiality and integrity of MedMark’s Digital Environment, including electronic Protected Health Information that I work with for my job duties.

I agree to abide by the MedMark End User Computing Policies & Procedures as explained in the IT End User Computing Policy document.

By not following the MedMark End User Computing Policies & Procedures, I understand that I could be subject to disciplinary actions, up to and including termination, or civil or criminal penalties as determined by the applicable governmental agencies charged with enforcement of such requirements.

Employee’s Signature

Date

Employee’s Printed Name

FAX this completed Acknowledgement Form to the MedMark’s IT Department at 214.379.3322

MedMark Notice of End User Computing Policy and Procedures

VII. HIPAA

Administrative Policies & Procedures DEPARTMENT:

HIPAA

SUBJECT:

HIPAA POLICY AND PROCEDURES

POLICY NO.:

HIPPA-101

Effective Date:

January 1, 2011

Revised Date:

January 1, 2012

POLICY MedMark is dedicated to the proposition that individually identifiable health information should be private and secure and maintained in compliance with all federal and state laws and regulations MedMark wishes to communicate to its employees who have access to individually identifiable health information that compliance with federal and state laws relating to privacy and security is of utmost importance to MedMark. MedMark wishes to ensure that its workforce is given appropriate information, education, and tools necessary to allow them to conduct their jobs ethically and within legal and regulatory constraints. MedMark adopted HIPAA privacy policies and procedures to reflect MedMark’s commitment to the privacy of protected health information and to reflect revised HIPAA requirements with respect to the security of protected health information as mandated by the HITECH Act. MedMark’s HIPPA policies and procedures are contained in a manual found at each MedMark location and on ExponentHR. The following procedures are subject to and should be followed in conjunction with MedMark’s HIPAA policies and procedures.

II.

PROCEDURES A. The President and CEO of MedMark, or his or her designee, is shall appoint a Privacy/Security Officer to maintain and revise when necessary policies and procedures related to the privacy and security of protected health information, to communicate to the workforce of MedMark of their obligations under such policies and procedures, and to employ such consultants and use such resources as are reasonably necessary to ensure the privacy and security of MedMark patient records subject to the applicable federal and state laws and regulations. B. The HIPAA policies and procedures will be reviewed annually by the Privacy Officer to determine if any revisions are necessary. C. All employees shall undergo training on HIPAA upon employment and annually thereafter. D. Members of MedMark’s workforce who violate MedMark’s HIPAA policies and procedures are subject to disciplinary action, up to and including termination.

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VIII. Marketing/Media

Administrative Policies & Procedures DEPARTMENT:

MARKETING/MEDIA

SUBJECT:

MEDIA RELATIONS & COMMUNICATIONS

POLICY NO.:

M-101

Effective Date:

June 10, 2011

Revised Date:

NONE

POLICY

The purpose of this policy is to ensure that all communication with the public, via media or external agencies, about MedMark Services or any of its facilities is reviewed by marketing and the office of the President & CEO, prior to release or response to the inquiry. II.

PROCEDURES

On occasion, a media representative from television, radio and/or print may contact one of MedMark’s facilities or staff members with inquiries about a current or former patient, an employee, an inquiry for a story of any kind – positive or negative, or an alleged incident. All media inquiries need to be directed to the Marketing Department or the CEO’s office after gathering the information below. A.

No employee is to converse with the media for any reason whatsoever without first obtaining approval from the CEO of the Company. Let the caller know that you can take their information and a representative will get back to them with a response. The caller’s name, phone number, organizational affiliation, topic or information that they are seeking and deadline should be gathered and submitted to: Robin Johnson, Vice President, Marketing Office: 727.772.9551 Mobile: 727.480.0034 or Office of the President & CEO Office: 214.379.3303

Based on the inquiry, an appropriate authorized spokesperson will be designated to respond and coordinated with the appropriate individuals.

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Administrative Policies & Procedures C.

Press Releases: Regional Directors and Clinic Director/Manager will coordinate with marketing any press releases or public announcements to the public prior to distribution.

Proprietary information is not to be released outside of the company.

Information disseminated must follow patient confidentiality laws and regulations. Should a patient agree to participate in a story a Release Form must be completed and kept on file.

When working with the media all information must be communicated in a clear and accurate manner.

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IX. Clinical Compliance

Administrative Policies & Procedures DEPARTMENT:

CLINICAL COMPLIANCE

SUBJECT:

CLINICAL COMPLIANCE AND QUALITY REVIEW

POLICY NO.:

CC-101

Effective Date:

January 1, 2013

Revised Date:

NONE

POLICY

MedMark Services, Inc. will ensure that there is a proper focus on Clinical Compliance and Clinical Quality Improvement. It will do so through its Department of Quality and Clinical Services at the National Support Center. The Department will ensure that there is a focus on quality services and that there are sufficient resources allotted to achieve this goal. The following areas of focus will come under the supervision of the Director of the Department of Quality and Clinical Services. This department will report directly to the CEO of the company II.

PROCEDURES A. Program Surveys The Director of Quality and Clinical Services or his/her designee will ensure that each program is surveyed at least twice annually during the first year and then no more than every 18 months thereafter. Programs can be surveyed more frequently should there be any concern of quality what so ever. The surveyor will give at least 72 hours’ notice of the survey in order to insure that the proper staff members are present and that the necessary documents for review are available. The surveyor has the latitude to inspect all aspects of the program as they see fit. Should the surveyor find any concern that may be considered significant or egregious, it is expected that he/she will report that concern directly and immediately to the CEO. Following the completion of a survey, a written report will be submitted to the National Support Center and the CEO. Copies of the report will be circulated to the Facility Director, Medical Director of the facility, the National Medical Director and the Vice President of Operations and if applicable, any other Senior Operations Staff overseeing the program. The Facility Director is responsible for preparing a Quality Improvement Plan and submitting it to their Vice President of Operations and their immediate supervisor within 14 days of receipt. It is the Vice President of Operations responsibility for managing the Quality Improvement Process. The Director of Quality and Clinical Services may follow up on the report at any time to consider whether appropriate follow up and action has occurred subsequent to the completion of the Quality Improvement Plan.

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Administrative Policies & Procedures B. Staff Education Each facility will develop a Staff Education Committee lead by the clinic director that will plan and hold a minimum of 6 in-service trainings per year. Plans for staff education will be submitted annually, by the beginning of each calendar year, to the Director of Quality and Clinical Services. Compliance with this quality performance measure will be evaluated by the Director of Quality and Clinical Services during site visits. C. Outcome Measurement Collection and Analysis The goal of outcome and performance measurement is to provide the highest quality care in an environment of dignity and respect. The objectives are to assess performance through outcome measures and to integrate outcome monitoring into the ongoing operations of all patient care services provided. The process will include the collection and analysis of data as it relates to goals set. Through the analysis of data, opportunities for improvement can be identified and prioritized. Once identified, interventions to achieve improvement can be designed and implemented The company under the direction of the Director of Quality and Clinical Services will establish what outcome measurements are consistent with the needs of each service. The type of data collected will be under the direction of the Director of Quality and Clinical Services. The Director will monitor outcomes and report on the success of outcome measures by program and for the entire company each year. D. Clinical Compliance and Quality Review Committee The Director of Quality and Clinical Services will chair the Clinical Compliance and Quality Review committee. In addition to the Director of Quality and Clinical Services, the committee will consist of the National Medical Director, the Medical Directors over multiple clinics, the Regional Directors of Compliance and Clinical Services or Compliance Managers, the Vice President of Operations, other operations staff with direct clinic responsibility and the C.E.O. The Committee will meet at least quarterly and more often when indicated. E. Reporting Requirements of Regional Directors of Compliance and Clinical Services Each operating division will have a Regional Director of Compliance and Clinical Services or Compliance Manager reporting directly to Operations and indirectly to the MedMark Services, Inc. Director of Quality and Clinical Services. The Regional Directors will provide the Director of Quality and Clinical Services with the following: 1. Notification of any upcoming accreditation, state, DEA and any other compliance survey within 24 hours of notification. 2. Notification of any “high” level incidents in a program 3. A timely copy of all corrective action plans 4. A copy of any and all correspondence with any individual or agency related to compliance activities or concerns or clinical concerns. 5. Quarterly reports on their region’s compliance and clinical services. 6. Recommendations for improvement of clinical services. Administrative Policies & Procedures – Clinical Compliance: Clinical Compliance and Quality Review

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Administrative Policies & Procedures

F. Policy and Procedure Manual The Policy and Procedure Manual will be reviewed by the Policy and Procedure Manual Review Committee on a yearly basis. Changes in current policies or additions of new policies that are deemed necessary between reviews will be processed on an as needed basis. Requests for policy changes or additions will be made to the Director of Quality and Clinical Services. All policy and procedure changes and additions will be approved by the Policy and Procedure Committee and the National Support Center. The Policy and Procedure Manual Review Committee will include the Director of Quality and Clinical Services, the Vice President of Operations and his/her designee, the National Medical Director and the Regional Directors of Compliance and Clinical Services or Compliance Managers. All changes will be reviewed and approved by the CEO. II.

Reporting and Oversight

The Director of Quality and Clinical Services and the Vice President of Operations will provide the National Support Center with monthly updates during monthly Operations Meetings. Clinical Compliance and Quality Review Reports will be submitted to the National Support Center quarterly. Reports will contain the data from all appropriate, facility specific sources and will include Quality Improvement Plans (when applicable) developed by facility directors. The Director of Quality and Clinical Services will make site visits as needed to provide support, consultation, oversight and perform formal quality and performance evaluations.. Site visits will be performed a minimum of every 6-18 months. The frequency of site visits will be dependent upon the needs of the specific site and at the discretion of the Director of Quality and Clinical Services and the CEO. Visits will be announced to the facility director and Vice President of Operations at least 72 hours prior to site visit. Unannounced visits will occur as needed and at the discretion of the Director of Quality and Clinical Services and the CEO III.

Conflict Resolution

Unresolved conflicts that arise during any phase of the Clinical Compliance and Quality Review Program will be reported to the Director of Quality and Clinical Services who will report unresolved conflicts to the CEO for resolution. IV.

Program Review

The Clinical Compliance and Quality Review Program will be reviewed annually by the Director of Quality and Clinical Services, the Vice President of Operations and the CEO. All change requests will be submitted to the Director of Quality and Clinical Services who will supply the committee with copies of change requests at the time of program review. All changes to the Clinical Compliance and Quality Review Program will be approved by the CEO.

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Administrative Policies & Procedures DEPARTMENT:

CLINICAL COMPLIANCE

SUBJECT:

RIGHTS OF PERSONS SERVED

POLICY NO.:

CC-102

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide quality services in an environment in which the needs of persons served are met through the protection of individual interests. Such an environment is based on respect of the dignity of the person served as an individual who is provided care in a courteous and compassionate manner. The dedication of each employee to the components outlined in this policy is essential in achieving our goal of protection of individual rights and interests.

II.

PROCEDURES A.

All persons receiving services from MedMark shall retain all rights, benefits and privileges guaranteed by Federal, State, and local law, except those specifically lost through the due process of law.

Persons served have the right to live in the community of their choice without restraints on their independence, except those restraints to which all citizens are subject.

Persons served have the right to be treated with courtesy and dignity, and are at all times entitled to respect for their individuality, and the recognition that their strengths, abilities, needs, and preferences are not determinable on the basis of a psychiatric diagnosis.

Persons served have the right to be notified of all rights accorded them as recipients of services at time of admission or intake, and in terms that he or she understands.

Persons served have the right to be treated in the least restrictive setting to meet their needs.

Persons served have the right to receive services conducted in a manner reflecting quality professional and ethical standards of practice, and shall be apprised of the organization’s Code of Conduct.

Persons served have the right to receive services without discrimination based on race, color, gender, sexual orientation, age, religion, national origin, domestic/marital status, political

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Administrative Policies & Procedures affiliation or opinion, veteran’s status, HIV status, physical/mental handicap or ability to pay for services. H.

Persons served have the right to be treated in an environment free from harm, verbal and physical abuse, sexual abuse, physical punishment, financial or other exploitation as well as psychological abuse by threatening, intimidating, neglecting, harassing, or humiliating actions on the part of staff.

Persons served have the right to give informed consent to treatment / services. They also have the right to refuse or express choice regarding treatment / services / involvement in research projects and the service delivery team. Persons served will be told of the consequences of such refusal. This could result in MedMark being unable to provide treatment / services for the person served.

Persons served have the right to privacy during facility visits. Individuals and/or group visits are permitted only when the purpose of the visitation is education or professional in nature. Planning for outside visitors shall provide for limited interruption of consumer routine, therapeutic or rehabilitative programs, and related activities. Persons served will be given notice of such visitation.

Persons served have the right to confidentiality. Information may not be released without the consumer’s written permission, except as the law permits or requires.

Persons served, or the consumer’s legal guardians, have the right to review the consumer’s record at any reasonable time upon request, including prior to an authorized release, and shall be afforded the assistance of an appropriate clinical employee in cases where a reasonable concern exists of a possible harmful effect to the consumer through the misinterpretation of information in the record.

Persons served, along with family or significant other(s), when appropriate, have the right to participate in their treatment and treatment planning. Persons served have a right to a full and complete explanation of the nature of treatment and any known or potential risks involved therein.

Persons served have the right to an individualized, written treatment plan to be developed promptly following admission, treatment based on the plan, periodic review and reassessment of needs, and appropriate revisions of the plan including a description of services that may be needed following discharge from services.

Persons served have the right to request and receive outside (other than MedMark employees) professional consultation regarding their treatment at their own expense.

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Administrative Policies & Procedures P.

Legally competent persons served have the right to refuse treatment, except in emergency situations or other circumstances required by law. Persons served shall not be denied treatment, services, or referral as a form of reprisal, excepting that no individual provider shall be obligated to administer treatment or use methods contrary to his or her clinical judgment.

Persons served shall have access to written information about fees for services and their rights regarding fees for services.

Persons served have the right to an explanation if services are refused to them for any reason including admission ineligibility or continued care ineligibility, and have the right to appeal such decisions.

Persons served have the right to informal complaint and/or formal grievance of practices or decisions that impact their treatment or status without fear or concern for reprisal by the organization or its staff, and have the right to have this process clearly communicated to them upon entry to services and throughout participation in services.

Persons served have the right to an investigation and resolution of alleged infringement of rights.

Persons served have the right to access information important to decision making in sufficient time.

Persons served have the right to refuse to participate in research without loss of services, and participate in research on a voluntary basis only with full written informed consent.

Persons served have the right receive adequate and humane care in a clean and safe place.

Persons served have the right to receive evidence-based information about alternative treatments, medications, and modalities.

Persons served have the right to access guardians, self-help groups, advocacy services and legal services at any time. Access will be facilitated through the person responsible for the consumer’s service coordination.

Persons served have the right to be treated in the least restrictive environment, be provided evidence-based information about alternative treatments, have access their to their records, have equal access to treatment regardless of race ethnicity, gender, age, sexual orientation and sources of payment.

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Administrative Policies & Procedures AA.

Persons served have the right to be informed of appeal procedures, initiate appeals, have access to grievance procedures, receive a grievance appeal decision in writing, and appeal a grievance decision to an unbiased source.

BB.

Persons served have the right to be protected from the behavioral disruptions of other persons served.

CC.

Persons served have the right to file a complaint with the State and the right to freedom from retaliation, barriers to services, retribution or other adverse consequences as the product of filing a complaint. For OTP patients, complaints may be addressed to: For California Opioid Treatment Program Patients: Department of Alcohol & Drug Programs Licensing and Certification Branch 1700 K Street Sacramento, CA 95814-4037 Attn: Complaint Coordinator FAX: 916-322-2911 TDD: 916-445-1942 For Georgia Opioid Treatment Program Patients: Georgia Department of Community Health Kathy Wilcox: #404-657-5421 OR State Opioid Treatment Authority Von Wrighten: #404-657-2386 Website for complaints: www.dch.georgia.gov For Texas Opioid Treatment Program Patients: Substance Abuse Facility Investigations (MC 1979) Texas Department of State Health Services PO Box 149347 Austin, TX 78714-9347 (800) 832-9623 FAX: (512) 834-6638

OR State Opioid Treatment Authority NTP Team Lead - #512-834-6700 Ext. 2146

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Administrative Policies & Procedures

For Maryland Opioid Treatment Program Patients: Office of Health Care Quality Spring Grove Hospital Center Bland Bryant Building 55 Wade Avenue Catonsville, MD 21228 (410) 402-8095, (410) 402-8052, Toll-free 877-402-8218

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X. Health and Safety

Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EXTERNAL INSPECTIONS OF FACILITIES

POLICY No.:

H&S-101

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. to seek outside expertise to assist in assessing the overall safety of our facilities to assure that our services are conducted in an environment that is safe for consumers, employees, and visitors. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan. II.

PROCEDURES A.

The Health and Safety Officer is responsible for the oversight that will ensure external safety inspections at all locations are completed a minimum of twice every three years and will facilitate the following processes: 1.

The Health and Safety Officer will schedule all external safety inspections in cooperation with the Site Safety Coordinator and will serve as the contact and liaison with inspection personnel and organizations.

The Site Safety Coordinator will be responsible for facilitating the external inspections, obtaining a copy of the inspection report, and forwarding a copy of the report to the Health and Safety Officer, upon receipt.

The Site Safety Coordinator will work in coordination with the Program Director and Health and Safety Officer to assure that all recommendations resulting from the safety inspection reports are followed-up and corrections of deficiencies are completed

All Inspection Reports and correction activities will be reviewed by the Health and Safety Officer and documented. The Health and Safety Officer will report the results of the inspections, follow-up activities, and recommendations to the Senior Management to ensure the organization is utilizing the information to increase the level of safety throughout its operations.

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Administrative Policies & Procedures 5.

The Site Safety Coordinator will maintain a record of the inspection report, including recommendations and corrections made. This record will be maintained in the safety binder at each location and copies will be submitted to the Health and Safety Officer for inclusion in the organization’s overall safety record binder.

Two inspections every three years at each facility will be conducted.

Local regulatory guidelines may require specific safety inspections on a yearly basis by the fire department.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

SAFETY SELF-INSPECTIONS OF FACILITIES

POLICY No.:

H&S-102

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY

It is the policy of MedMark Services, Inc. that regular safety self-inspections of the overall safety of our facilities are conducted on a semi-annual basis, and that recommendations resulting from safety self-inspections are corrected to ensure the safety of the persons served, staff members, and visitors. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Environment of Care manual. II.

PROCEDURES A.

The Health and Safety Officer is responsible for oversight that will ensure safety self-inspections at all locations are completed, at minimum, semi-annually, and will facilitate the following processes: 1.

The Site Safety Coordinator, or his/her designee, is responsible for completing safety self-inspections at their designated facility.

The Site Safety Coordinator is responsible for completing semi-annual safety self-Inspection reports and submitting those reports to the Health and Safety Officer upon completion.

All safety self-inspection reports and correction activities will be reviewed by the Health and Safety Officer and noted in meeting documentation. The Health and Safety Officer will report the results of the safety selfinspections, follow-up activities, and recommendations to the Senior Management to ensure the organization is utilizing the information to increase the level of safety throughout its operations.

The Site Safety Coordinator will maintain a record of the safety selfinspection reports, including recommendations and corrections made. This record will be maintained in the “safety binder” at each location and copies will be submitted to the Health and Safety Officer for inclusion in the organization’s overall safety record binder.

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Administrative Policies & Procedures B.

The “Safety Self-Inspection Checklist/Report” form will contain a review of the following areas related to environmental safety: 1.

Entrances/Exits

Evacuation Maps

Fire Extinguishers

Fire and Smoke Alarms

First Aid Kits

Blood Borne Pathogens

Telephones

Emergency Lighting

Evacuation Diagrams

10.

Room Temperature

11.

Plumbing

12.

Chemicals and Potentially Hazardous Materials

13.

Restrooms

14.

Hot Water Heaters

15.

Kitchen

16.

Dining, and Break Areas

17.

Equipment

18.

Appliances & Machinery

19.

Extension Cords

20.

Electrical Closet

21.

Storage Areas and Closets

22.

Windows and Mirrors

23.

Trash Receptacles

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Administrative Policies & Procedures 24.

Walls and Ceilings

25.

Floors and Floor Covering

26.

Furnishings

27.

Air Quality and Odors

28.

Stairways and Docks

29.

Pictures and Signs

30.

Worksites

31.

Exterior

32.

Building

33.

Fences and Outbuildings

34.

Grounds

35.

Parking

Administrative Policies & Procedures – Health & Safety: Safety Self-Inspections of Facilities

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY DISASTER PLANS AND DRILLS: FIRE

POLICY NO.:

H&S-103

Effective Date:

October 1, 2013

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to protect persons served, staff members, visitors, and property in the event of a fire emergency or disaster. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Environment of Care manual.

II.

PROCEDURES A.

The Health and Safety Officer is responsible for oversight of Emergency Disaster Plans and Drills and ensuring that all of the organization’s facilities are well prepared to respond effectively to any emergency.

Specific procedures will be maintained for fires. In addition, emergency fire drills will be conducted at each site on an annual basis. The Site Safety Coordinator will be responsible for coordination of the drills and completing the “Emergency Safety Drill” form following any drill. The form will be forwarded to the Health and Safety Officer for use in addressing safety issues and trends, and developing recommendations for changes. A copy of the form will be maintained in a “safety binder” at the site location.

The following are the overall components of the organization’s Fire Emergency Plans. These serve as basic approaches to responding to fire emergencies; however, each site may have additional components due to the nature of the physical layout of the facility, types of programs and services, special populations, and local regulatory requirements. It is the responsibility of the Health and Safety Officer to ensure that the special needs and characteristics of each facility are addressed in additional policy and procedure, and that these special needs and characteristics are communicated to all affected persons and the Site Safety Coordinator:

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Administrative Policies & Procedures

In the event of the discovery of a fire, evacuate all individuals from the immediate area.

Close all doors to contain the fire.

Pull the nearest fire alarm.

If the fire is small, attempt to contain it by using a fire extinguisher.

Call the fire department and report the fire, providing the name and address of the site. (All emergency phone numbers are listed in the addendum.)

Assist in the evacuation process and account for all persons served and visitors.

To expedite the evacuation process, all ambulatory persons served and visitors are evacuated first, followed by staff members who will assist all others in evacuation.

All persons will be evacuated and assembled at a location that is predetermined by each facility as the evacuation assembly area.

The Supervisor will provide any special information to arriving emergency personnel such as size and location of fire and location of any flammable or explosive items, and will relinquish control of the situation to the local authorities.

10.

The fire department will be the final authority in determining building reentry.

11.

After the immediate danger is past, the Supervisor will determine the necessity for relocation of persons served and/or staff members.

The Regional Director of Operations or Executive Director of Vista Taos, as applicable, will be notified as soon as possible after a fire and a Critical Incident Report will be completed and processed as per the Critical Incident Reporting and Management Policy.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY DISASTER PLANS AND DRILLS: BOMB THREATS AND EVACUATIONS

POLICY NO.:

H&S-104

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide prompt attention and appropriate assistance to persons served, staff members, and visitors in the event of a bomb threat, and the need for evacuation. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan.

II.

PROCEDURES A.

Specific procedures will be maintained for bomb threats, and the need for evacuations. In addition, evacuation drills will be conducted at each site on an annual basis as part of the fire emergency drills. The Site Safety Coordinator will be responsible for coordination of the drills and completing the “Emergency Safety Drill” form following any drill. This form will be forwarded to the Health and Safety Officer for use in addressing safety issues and trends, and developing recommendations for changes. A copy of the form will be maintained in a safety binder at the site location.

The following are the overall components of the organization’s bomb threat and evacuation drills and plans. These serve as basic approaches to responding to bomb threats, evacuations, and building emergencies; however, each site may have additional components due to the nature of the physical layout of the facility, types of programs and services, special populations, and local regulatory requirements. It is the responsibility of the Health and Safety Officer to ensure that the special needs and characteristics of each facility are addressed in additional

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Administrative Policies & Procedures policy and procedure, and that these special needs and characteristics are communicated to all affected persons and the Site Safety Coordinator.

Bomb Threat by Telephone: In the event of a bomb threat received by telephone (a call in which an individual indicates a bomb has been placed within or near the facility), obtain as much information as possible from the caller, noting details of voice, speech patterns, and any background noise, ask where the bomb is and when it will go off, and document the information.

Bomb Threat by Letter or Note: Do not handle the letter or note any more than is necessary so evidence is not destroyed. Upon the discovery of a suspicious object, do not touch or move the device or article. In all cases, remain calm and do not alarm persons served, visitors, or other staff members. Immediately seek your Supervisor to discuss the situation. That person should contact the police (the phone number can be found in the addendum), and activate an alarm and evacuation procedures. Evacuation will be handled as per the facility Evacuation Procedures. Agents of the police or other authorities will assess the situation and if the present danger is terminated, and will then inform the Supervisor. Only the police authority may activate the all clear and only then may anyone enter the building.

Emergency Evacuation: Facility evacuation routes will be clearly marked and posted throughout all sites and evacuation drills will be conducted in conjunction with regular fire drills. If necessary, evacuation of all persons served for a site will be made to the nearest designated shelter. The decision to evacuate a site will be made by the Supervisor upon the recommendation of appropriate municipal emergency services personnel. In such a case, evacuations will be made to an official evacuation center, as directed by authorities.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY DISASTER PLANS AND DRILLS: NATURAL DISASTERS; SEVERE WEATHER

POLICY NO.:

H&S-105

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide prompt attention and appropriate assistance to persons served, staff members, and visitors in the event of a severe weather emergency or disaster. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan.

II.

PROCEDURES A.

Specific procedures will be maintained for severe weather and natural disasters. In addition, emergency severe weather drills will be conducted at each site on an annual basis. The Site Safety Coordinator will be responsible for coordination of the drills and completing the “Emergency Safety Drill” form following any drill. The form will be forwarded to the Health and Safety Officer for use in addressing safety issues and trends, and developing recommendations for changes. A copy of the form will be maintained in a “safety binder” at the site location.

The following are the overall components of the organization’s Severe Weather Emergency Plans. These serve as basic approaches to responding to severe weather emergencies; however, each site may have additional components due to the nature of the physical layout of the facility, types of programs and services, special populations, and local regulatory requirements. It is the responsibility of the Health and Safety Officer to ensure that the special needs and characteristics of each facility are addressed in additional policy and procedure, and that these

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Administrative Policies & Procedures special needs and characteristics are communicated to all affected persons and the Site Safety Coordinator. 1.

Natural Disaster/Severe Weather is defined as any weather condition or natural event that has the potential to cause physical harm and/or property destruction. These events include severe thunderstorms, tornados, flash floods, earthquakes, and hurricanes. Procedures for severe weather are as follows: a.

If a severe weather, tornado, or hurricane watch is issued, each site shall access radio or television reporting that provides information from the National Weather Service.

In the event of a “watch,” employees on duty will be informed of procedures to be taken in the event a “warning” is declared.

All patients and employees will be encouraged to remain inside, if possible, limiting trips and transportation to and from the site.

In the event of a severe weather or tornado warning, all persons within the facility will immediately move to the designated areas in the interior of the building.

Employees will assist consumers in arriving at the designated safety locations, and if time permits, will close all windows and blinds and all doors.

Designated employees will secure the first aid kit, flashlights, and a radio and maintain them in the area being used for shelter.

The Site Safety Coordinator shall oversee the process and conduct a head count when this activity is completed.

The Site Safety Coordinator shall announce the end of the need to remain in the designated location when the warning is no longer in effect, according to the national weather service.

The Site Safety Coordinator will be responsible for contacting any emergency entity that may be needed due to injuries or events such as broken utility lines.

Events such as flash flood warnings and earthquakes will most likely require the evacuation of the facility.

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Administrative Policies & Procedures k.

In certain emergencies, such as those related to infectious disease, disease specific service continuity plans will be developed and implemented as needed.

Emergency Evacuation: Facility evacuation routes will be clearly marked and posted throughout all sites and practice drills will be conducted in conjunction with regular fire drills. If necessary, evacuation of all clients from a site will be made to the nearest designated shelter. In the case of natural disasters such as floods, snowstorms, hurricanes, or earthquakes, the decision to evacuate a site will be made by the Supervisor upon the recommendation of appropriate municipal emergency services personnel. In such a case, evacuations will be made to an official evacuation center, as directed by authorities.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY DISASTER PLANS AND DRILLS: MEDICAL EMERGENCIES

POLICY NO.:

H&S-106

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide prompt attention and appropriate assistance to persons served, staff members, and visitors in the event of a medical emergency. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan.

II.

PROCEDURES A.

Specific procedures will be maintained for medical emergencies. In addition, medical emergency drills will be conducted at each opioid treatment program on an annual basis. The Site Safety Coordinator will be responsible for coordination of the drills and completing the “Emergency Safety Drill” form following any drill. The form will be forwarded to the Health and Safety Officer for use in addressing safety issues and trends, and developing recommendations for changes. A copy of the form will be maintained in a “safety binder” at the site location.

The following are the overall components of the organization’s Medical Emergency Plans. These serve as basic approaches to responding to medical emergencies; however, each site may have additional components due to the nature of the physical layout of the facility, types of programs and services, special populations, and local regulatory requirements. It is the responsibility of the Health and Safety Officer to ensure that the special needs and characteristics of each facility are addressed in additional policy and procedure, and that these special needs and characteristics are communicated to all affected persons and the Site Safety Coordinator.

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Administrative Policies & Procedures 1.

A Medical Emergency is defined as an incident that requires interventions beyond simple first aid available at the facility to stabilize a condition that may result in a serious medical outcome. Conditions include, but are not limited to, excessive bleeding which is unable to be controlled, accidents involving serious injury, failure or obstruction of the respiratory system, failure of the circulatory system, chest pain or severe abdominal pain, loss of consciousness unrelated to predictable seizure activity, or any type of distress that is determined to seriously limit an individual’s normal level of daily functioning. a.

When an event occurs that is determined to be an emergency health care incident, 911 will be immediately called to access emergency personnel to assist and transport the individual to medical services.

The MedMark Critical Incident Reporting and Management Policy will be followed for all medical emergency events.

Staff members who are trained and hold current certification in CPR and First Aid will implement CPR and/or First Aid procedures, when appropriate, to stabilize a condition prior to the arrival of external emergency personnel.

If the individual is a patient, the “Patient Emergency Information” form will be accessed, contact made with the emergency contact names, and given to the transporting emergency technician. All “Patient Emergency Information” forms will include: i. Name, address, and telephone number of the physician to be called, if available ii. Name, address, and telephone number of a relative or other person to be notified, if available iii. Medical insurance company name and policy number, or Medicaid/Medicare number, if available iv. Information concerning the use of medication, medication allergies, and significant medical problems, if available

MedMark Services, Inc.’s staff members will not transport individuals in emergency health care situations unless otherwise dictated by circumstances, e.g., emergency is off

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Administrative Policies & Procedures site with no immediate access to contacting emergency personnel. f.

Following containment of the emergency, a progress note will be completed in the record of the person served and a Critical Incident Report will be completed.

If the emergency involves a staff member, a Supervisor will access the “Emergency Contact” form and will make contact with the person named at the request of the staff member. A contact will always be made if the staff member is incapacitated and unable to request or deny the contact.

The telephone number of the local Poison Control Center will be posted throughout the organization. All staff members and persons served will be orientated to the location of this information.

In the event of poisoning or drug ingestion, staff members will call the Poison Control Hotline at 800-222-1222 and provide the following information: age and weight of the person, names of the substance(s) ingested, strength, and amount ingested if known, and the general condition of the person. Vomiting or the use of Ipecac syrup will not be used unless directed by the poison control center.

Medical clearance must be obtained in writing from the treating physician prior to patients returning to services or staff members returning to employment duties.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY DISASTER PLANS AND DRILLS: WORKPLACE THREATS AND VIOLENCE

POLICY NO.:

H&S-107

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to protect persons served, staff members, visitors, and property in the event of workplace threats and violence. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan.

II.

PROCEDURES A.

Specific procedures will be maintained for workplace threats and violence. In addition, workplace threats and violence drills will be conducted at each opioid treatment program on an annual basis. The Site Safety Coordinator will be responsible for coordination of drills and for completing the “Emergency Safety Drill” form following any drill. This form will be forwarded to the Health and Safety Officer for use in addressing safety issues and trends, and developing recommendations for changes. A copy of the form will be maintained in a “safety binder” at the site location.

The following are the overall components of the organization’s Workplace Threats and Violence Plans. These serve as basic approaches to responding to workplace threats and violence; however, each site may have additional components due to the nature of the physical layout of the facility, types of programs and services, special populations, and local regulatory requirements. It is the responsibility of the Health and Safety Officer to ensure that the special needs and characteristics of each facility are addressed in additional policy and procedure, and that these

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Administrative Policies & Procedures special needs and characteristics are communicated to all affected persons and the Site Safety Coordinator. 1.

Workplace Threats and Violence is defined as any situation in which there is a perceived threat of violence, or a situation where violence has occurred. Procedures to provide the optimal response for safety apply to persons served, staff members, and visitors who may exhibit threats of violence or actual violent acts. a.

Staff members should exercise common sense in a situation with any aggressive person. If a situation involves a weapon such as a knife or gun, do not attempt to remove the weapon from the individual.

If you or anyone else is assaulted or physically threatened by another individual while conducting business, if possible remove yourself from the situation, call for help (vocally or by phone), and/or notify another staff member to summon the police by calling (the phone number is listed in the addendum).

Do not attempt to engage in any type of physical restraint with the person who is threatening, unless your life is in immediate danger.

If you cannot remove yourself from the situation, follow the guidelines provided through the organizational workplace violence training regarding de-escalation of the situation.

At no time should any staff members put themselves at harm in an attempt to diffuse a situation. Always attempt to remove yourself and seek local law enforcement assistance.

The following procedure is to be used to notify staff members of threatening behavior without alarming the aggressor if the situation warrants such an approach, based on the staff member’s assessment: i.

Call a co-worker from your phone and request that they bring you a “coke.” This will serve as notification that their presence is needed in your office to assist you with a situation.

ii.

If you believe that the situation warrants law enforcement intervention, call a co-worker and request that they bring you a “coke with ice.” This

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Administrative Policies & Procedures will serve as notification that an emergent situation is occurring and they are to contact local authorities for assistance prior to assisting you with the situation. g.

Documented Emergency Drills will be unannounced, simulated or following an actual emergency

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY DISASTER PLANS AND DRILLS

POLICY NO.:

H&S-108

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to protect persons served, staff members, employees, visitors, and property in the event of an emergency or disaster. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for adaptability to multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan.

II.

PROCEDURES A.

MedMark Services, Inc. will maintain policies and procedures that outline specific guidelines for addressing emergency situations that may affect the health and safety of persons served, staff members, and visitors. Emergency drills will be conducted, at a minimum, on an annual basis for each of the designated areas of potential emergency: 1.

Severe Weather/Natural Disaster

Fire

Workplace Threats and Violence (OTP Locations and Vista Taos Only)

Power Failure (OTP Locations and Vista Taos Only)

Medical Emergency (OTP Locations and Vista Taos Only)

Other Emergency Situations (OTP Locations and Vista Taos Only)

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Administrative Policies & Procedures C.

The Site Safety Coordinator will be responsible for the following emergency preparedness activities: 1.

Conducting all required emergency drills at their respective site locations

Conducting drills in a manner and with the necessary precautions to not unduly disturb persons served or the ongoing provision of services

Completing the “Emergency Safety Drill” report form

Educating and informing staff members following drills as to response patterns and improvements in responses

Reporting the results of emergency drills to the Health and Safety Officer upon completion of the drill

Maintaining a record of all drills at each site in the “safety binder”

Actual emergencies at any site will be reported as per the Critical Incident Reporting and Management Policy and will follow procedures included in that policy in addressing safety and quality improvement activities following an actual event.

The Regional Director of Operations or Executive Director of Vista Taos, as applicable, will be responsible for the development and revision of emergency preparedness plans based on results of ongoing drills and actual events.

All staff members are responsible for maintaining a working knowledge of emergency procedures through education, training, and simulated emergencies/drills. Training regarding all safety policies and procedures will include an overview of emergency procedures.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

UTILITY FAILURES

POLICY NO.:

H&S-109

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide prompt attention and appropriate assistance to persons served, staff members, and visitors in the event of a utility failure. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for the adaptability of multiple situations. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Operations Environment of Care Plan.

II.

PROCEDURES A.

Specific procedures will be maintained for utility failures. In addition, emergency utility failure drills will be conducted at each opioid treatment program on an annual basis. The Site Safety Coordinator will be responsible for coordination of the drills and completing the “Emergency Safety Drill” form following any drill. The form will be forwarded to the Health and Safety Officer for use in addressing safety issues and trends, and developing recommendations for changes. A copy of the form will be maintained in a “safety binder” at the site location.

The following are the overall components of the organization’s utility failure plans. These serve as basic approaches to responding to utility emergencies; however, each site may have additional components due to the nature of the physical layout of the facility, types of programs and services, special populations, and local regulatory requirements. It is the responsibility of the Health and Safety Officer to ensure that the special needs and characteristics of each facility are addressed in additional policy and procedure, and that these special needs and characteristics are communicated to all affected persons and the Site Safety Coordinator.

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Administrative Policies & Procedures

In the event of the discovery of a utility failure, start using emergency lighting throughout the clinic.

Check the fuse box immediately to restore power.

If the power is unable to be restored in a timely matter, move to hand dosing procedures.

Supervisor should call IT personnel to inform them of the power failure.

Supervisor will coordinate patient flow such that only one patient is allowed into the facility at a time. Only dosing will be provided in this situation.

The Regional Director of Operations or Executive Director of Vista Taos, as applicable, will be notified as soon as possible of the incident and an incident report will be completed and processed as per the Critical Incident Reporting and Management Policy.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

EMERGENCY INFORMATION DISSEMINATION

POLICY No.:

H&S-110

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to ensure that persons served, staff members, and visitors are aware of information to assist them in emergency preparedness and in responding to situations that may occur on the premises of the organization’s administrative and service delivery facilities. This policy shall not apply to VA facilities. All VA facilities shall follow the health and safety policies of the VA and the VA Environment of Care manual.

II.

PROCEDURES A.

The Health and Safety Officer is responsible for the oversight of emergency information dissemination, planning, and evaluation of the effectiveness of the information.

The Site Safety Coordinator will receive ongoing emergency disaster training to ensure each facility has representation that is fully informed and up to date on all Company health and safety policy and procedures.

Emergency information plans, and practices will be clearly communicated to all employees. Employees will review all related health and safety policy and procedures and will understand their roles and responsibilities in the emergency procedures.

Consumer Emergency Plan Education 1.

All persons served will be orientated and informed of the facility’s Emergency Plans upon employment as part of their orientation.

Persons served will participate in emergency drills at the facility locations and will be oriented to facility safety at each location in which they are involved in services.

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Administrative Policies & Procedures E.

Posting of Emergency Plans 1.

The location of exits, first aid kits, and fire extinguishers shall be clearly posted at all locations.

Emergency Exit Plans will be adequate in number and specific to the location of the posting.

Emergency Exit Plans will be in the form of diagrams.

Emergency Exit Plans will indicate the safest and quickest way out of the facility.

Emergency Exit Plans will indicate the location of fire extinguishers and first aid kits.

All of the above requirements will be checked for compliance during the semi-annual safety self-inspection of the site.

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Administrative Policies & Procedures DEPARTMENT:

HEALTH AND SAFETY

SUBJECT:

INCIDENTS INVOLVING INJURY

POLICY NO.:

H&S-111

Effective Date:

October 1, 2006

Revised Date:

January 1, 2013

POLICY It is the policy of MedMark Services, Inc. to provide prompt attention and appropriate assistance to persons served, staff members, and visitors in the event of an injury. All potential emergencies cannot be anticipated; therefore, emergency plans shall provide for the adaptability of multiple situations.

II.

PROCEDURES Prevention: MedMark Services, Inc. orients new hires and patients on infection control, universal precautions, unsafe environmental factors and health and safety procedures. Personnel: a.

The Health and Safety Officer is responsible for oversight of OSHA and OSHA state plans compliance and ensuring that all of the organization’s facilities are well prepared to respond effectively to any injury.

The Program Director/Administrator is responsible for oversight to ensure that the work related injuries are properly reported and documented.

All incidents of injury should be reported within one (1) day of the injury or as soon as possible to the Program Director/Administrator.

Within seven (7) calendar days after the Program Director/Administrator has received the information about the case, he or she decides if the case is recordable under the OSHA record keeping requirements. Work injuries or illnesses that result in the following should be recorded: 1. Death 2. Loss of consciousness 3. Days away from work

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Administrative Policies & Procedures 4. Restricted work activity or job transfer 5. Medical treatment beyond first aid 6. Any significant work-related injury or illness that is diagnosed by a physician or other licensed health care professional. You must record any work-related case involving cancer, chronic irreversible disease, a fracture or cracked bone, or a punctured eardrum. 7. Any needle stick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material 8. Any case requiring an employee to be medically removed under the requirements of an OSHA health standard 9. Tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician or other licensed healthcare professional after exposure to a known case of active tuberculosis

The Program Director/Administrator determines where the incident is a new case or recurrence of an existing one.

Establish whether the case was work-related.

If the case if reportable, the Program Director/Administrator fills out the OSHA 301: Injury and Illness Incident Report.

All employees have the right to request, examine and receive copies of our OSHA record. Requests should be made through the Program Director/Administrator.

Patients: The Program Director/Administrator will be notified as soon as possible of an incident involving injury to a patient. OTP Program Directors and the Vista Taos Executive Director shall complete a Critical Incident Report as per the Critical Incident Reporting and Management Policy. VA locations shall follow VA policies regarding the reporting of incidents involving injuries to patients.

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