Policies and Procedures

• Guideline for Writing Policies and Procedures Colorado Office of Behavioral Health
  What Is A Policy and Procedure Document And What Does It Do:
  Policies and procedures form the backbone for an organization. They help align the missions and goals of the organization, the applicable laws and rules, and the processes by which the work is to be done. It serves as a consistent source for organizational policy, which are the overall regulations that govern the business, and the procedures that define how those policies will be implemented. Therefore, writing them well will help keep the organization on path and ensure that standard procedures are being conducted the same way by all staff.  The policies spell out for all employees what is expected of them and how to accomplish it.
  A well written policy and procedure document will serve the organization in the following ways:
   

  1. Protect the organization: It provides evidence that the standards of practice within an organization meet all applicable legal and ethical standards.
  2. Allow the organization to operate more efficiently and effectively: It provides consistency in, and coordination of, agency operations. It also outlines lines of authority/supervision.
  3. Assist in conflict resolution: It clearly delineates the responsibilities of all members.
  4. Streamline staff orientation and training: Policies and procedures are used to orient and train new staff as well as refresh experienced staff. 
  5. Assurance for referral sources and the general public: Written policies and procedures, based on current Rules that are required by statute, help assure the public and referral sources that OBH-licensed agencies and OBH-designated agencies provide and monitor competent treatment carried out by appropriately credentialed staff in a safe environment.
  6. Identification of and response to problems: Written policies and procedures provide an operational baseline by which agencies can identify and generate solutions for problems that occur in administrating and delivering services.
  7. Assist in new member recruitment: Policy and procedures clearly outline your agency processes for interested individuals.
  8. Set a positive direction for the organization: It will help align goals and missions with day-to-day operations.
  9. Provide a way to review existing programs and services: Clearly defined policies and procedures give a tool by which existing programs and services can be measured.  Used effectively, clearly defined policies and procedures is an additional tool that may be used for quality assurance and hold staff accountable in program and service delivery.
  10. Provide a resource for all staff to use when they have a question on how an agency is implementing the Rule or statute.  It is the “how to guide” resource that clarifies and explains the expectations for agency staff when they have a question about a Rule or statute.
  11. Remain in compliance with all rules, regulations and policies associated with current CDHS Behavioral Health Rules"

   
  Why Separate Policies and Procedures:
            Policies reflect governing Rules and are general in nature. Procedures indicate the specific implementation of a given policy. Policies adapt to changes in governmental statutes. Procedures, in addition to adapting to changes in policies, should also evolve with new tools and methods of treatment. This separation will ultimately serve to distinguish what is based on rules and what are the existing standards of practice. 
   
  Where to Begin:
  You must begin by assembling all applicable OBH Rules for the type of license or designation sought. All applicable Rules become the foundation of your new policy and procedure manual. In the absence of all else, these things must be satisfied.
  The key to writing strong procedures and policies is to make the documents rigid enough to clearly indicate the rules of the organization, but flexible enough to be able to be followed easily and without significant deviation. 
   
  Organizational and Treatment Program Introduction: 
  Providing an introduction to the policy and procedure manual can establish a clear picture of the organization’s history, mission, vision, and overall structure.  This information will allow those who work with your agency to get a sense of your organization and to better comprehend how their activities fit into the overall framework.  This information is useful for training staff and volunteers, as it will allow them to align themselves and their work with the philosophies and ideologies of the organization.  Additionally, providing an introduction to the agency’s treatment program, inclusive of relevant treatment curricula and evidence-based practices utilized, helps establish a context for the agencies processes outlined within the policies and procedures.
   
  5 Steps to Policy and Procedure Development:
  The following is a sample method of putting policy and procedure together for your manual.
  1) Identify policy needs and applicable Rule requirements
  2) Draft policy
  3) Approve policy
  4) Implement
  5) Review and evaluate
  
  1) Identify policy needs and applicable Rule requirements

  1. Review underlying concerns. Ask, "Do we have a policy about...?" Then, "Do we need a policy about...?"
  2. Relate to agency philosophy, values, mission, goals and applicable Rules. If it doesn't help further the mission and goals of your organization then it may not be appropriate content for the policy and procedure document.
  3. Collect information that will help you draft the policy.
  4. Describe desired outcome. What do you want this policy to do when implemented?

  2) Draft policy

  1. Make it as clear as possible. Use plain language, be brief and to the point.
  2. Be certain it is in agreement with current Rules and statutes.

  3) Approve policy

  1. Director (or designee) approves policy and procedures.
  2. Director (or designee) signs and dates the policies at time of policy approval.
  3. Add to policy handbook.

  4) Implement policy

  1. Communicate policy to all agency staff.
  2. Notify staff of effective or revised dates.

  5) Review and evaluate

  1. Review regularly.
  2. Evaluate effectiveness in service delivery.
  3. Is the policy applicable and relevant?
  4. Adapt to meet changing situations, modifications in licensure or designation or revision of Rule.

  Writing Policies 
  Rules are sometimes too general in scope to be used as agency operating policies. This is illustrated in the following Rule example:
  Service plan reviews shall be developed, by an interdisciplinary team when applicable, as soon as is reasonable after admission and no later than current Rule defines, for given level of care.
  The Rule is not specific enough to directly translate to an operational policy governing service plan reviews. It doesn’t define “regular intervals,” reference any particular treatment modality, indicate a planned length of treatment, or mention other conditions that might prompt a services plan review. The following example demonstrates how an effective policy might be developed from the Rule:
  Service plan reviews shall be completed and documented when there is a change in the individual’s level of functioning or service needs, and no later than current Rule defines for the given level of care.
  The policy is specific enough to be effective in guiding the process of reviewing service plans. It sets the expected review frequency for a specific length of treatment in a particular modality and, in general, describes what types of events might require an interim review. Additional detail to make the policy even more specific would be examples of events that would significantly affect planned treatment outcomes and lengths of stay.
  Note: The more specific the policy, the easier it is to write procedures.
  Writing Procedures 
  Procedures make policies operational. They are comprehensive action statements consisting of three key elements: what is to be done; when it will be done; and who will do it, not necessarily in that order.
  In the following examples, the key elements in each procedure are bracketed and in bold type.Example 1:
  (Policy)
  Service plan reviews shall be completed and documented when there is a change in the individual’s level of functioning, or when individual-related events occur that significantly affect planned treatment outcomes and/or lengths of stay in treatment, and within timeframes identified in current Rule, based on level of care.
   (Procedures)

  1. [who] Clinicians [what] shall schedule clients for service plan reviews and revisions [when] according to the current Rule requirement from the creation of the initial services plan and within the current Rule requirement thereafter.
  2. [who] Clinicians and the clinical director [what] will evaluate individual treatment-related events to determine whether they have a significant impact on treatment outcomes, length of stay or other important aspects of individual treatment. When events are evaluated as having significant impact on individual treatment, [who] clinicians [what] shall schedule service plan reviews with clients [when]within 72 hours following evaluations.

  Example 2: (Policy)
  At least 50% of all counseling staff shall be certified or licensed addiction counselors whose credentials are current and in good standing.
  Note: As previously mentioned, rules are usually too general in scope to be used as operating policies. However, some Rules are written so specifically that they translate
  directly to a policy statement. The above policy is an exact translation of such a Rule.
  (Procedures)

  1. [what] Copies of addiction counselor certificates and licenses shall be kept in clinician personnel files and their current status shall be checked [when] at least once per year by [who] the clinical director or a staff person specifically designated by the clinical director.
  2. [what] The ratio of certified and licensed clinicians to non-certified clinicians shall be checked [when]at least once per year by [who] the clinical director or a staff member, specifically designated by the clinical director or whenever additional clinical staff are hired.
  3. [who] The director [what] shall make sure that the need for certified and licensed addiction clinicians is emphasized [when] in all advertising for new clinicians.

  Note: In C., above, [when] is implied by the phrase, “in all advertising for new clinicians,” since it is at the time the agency advertises for new counselors that CAC IIs, IIIs and LACs will be emphasized.

  1. [who] Clinician trainees [what] shall complete all required courses and supervised clinical hours required to obtain certification [when] within time frames appropriate to their full or part-time status.[who] The clinical director [what] shall oversee and report their progress to the director [when] on a monthly basis.

   
  Updating Policy and Procedure Documents:
  Policy and Procedure documents should be regularly updated, so as to ensure that they are in accordance with current statutes and Rules, as well as being reflective of current best practices. It is likely that the policy and procedure document was comprehensive and efficacious at its inception, but changes in Rules and practices have since rendered it obsolete. On the other hand, a policy and procedure document may have initially been written too vaguely and, therefore, difficult to follow, which would also necessitate a review and update. The question is always ‘do these policies and their procedures allow us to most efficiently and effectively do our work?’.
  Therefore, it can be most helpful to set aside time at a regular interval, such as annually, to review, revise, and update the policy and procedure document. Also, it can be helpful to assign a particular individual to being in charge of keeping the document current. 
  Further, there is also an obligation to keep in mind the interest of those who will be impacted by any changes. It is, further, an obligation to ensure that all those expected to operate under a revised set of policies and procedures be made fully aware of any and all changes.  Upon revision of OBH Rules, agency policies and procedures shall be updated within 30 calendar days.
   
   
  In Summation:
  Writing a thorough policy and procedure document can feel like an overwhelming task. However, done correctly it will ultimately save your organization both time and money while increasing productivity. Therefore, the more work put into the creation of the document, the more benefit that will be realized. An applicant agency can use its own numbering system for its policies and procedures, but it speeds up the review process if they are in the same order as the OBH Rules on which they are based.
  The key in writing policy and procedure documents is to not make your manual overly restrictive. Write your procedures to meet the mandatory requirements as outlined by applicable and current laws and Rules. Next, write your procedures to ensure consistency in the areas where operational demands obviously require consistent behavior. Steer clear, however, of too many "thou shalt not" type statements, and leave your staff some discretion as to how to accomplish their tasks.
  The Policy and Procedures manual should be viewed as a guide for current, as well as new members to the organization. This then puts the imperative on keeping the document clear, concise, and easy to follow. Also, the manual should not be viewed as a static tool, rather it something that is to evolve with the changing world in which the specified services are to be provided. 
• Analyzing a Rule and Writing a Policy

  Example rule taken from 2 CCR 502-1, Behavioral Health Treatment Rules

  21.210.42 Screening [Eff. 5/1/16]

  A. Agencies shall screen all female individuals of child bearing age seeking or being referred to substance use disorder treatment for pregnancy.
  B. At admission individuals shall be screened for past and present risk factors associated with substance use disorders that are associated with:

  1. Pregnancy complications, including risks to the health of the pregnant woman and fetus;
  2. Acquiring and transmitting Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), Tuberculosis (TB), Hepatitis A, B, or C, and other infectious diseases; and,
  3. If clinically indicated by the presence of continuing risk factors, screening shall be conducted at a minimum on a quarterly basis.

  C. Individuals shall be apprised of risk factors associated with acquiring and transmitting HIV/AIDS, T.B., Hepatitis A, B, C, and other infectious diseases. Appropriate testing and pre and post-test counseling shall be offered on-site or through referral.
  D. Criminal justice system referrals for substance use related offenses, such as DUI, DWAI, BUI, FUI and/or controlled substance violations, may be exempt from further substance use disorder screening if previously assessed, or evaluated. Supporting documentation from the referring agency shall be present in the individual record.
  E. Adults shall be screened for past and present criminal charges in any state. Persons with out-of-state charges must be registered by the licensed agency with the interstate compact office in accordance with Title 17, Article 27-1, Section 101, et seq., C.R.S.
  
  To turn this rule into a policy, highlight the parts of the rule that tell the reader what needs to be done to follow the rule. Here it is again, with the action parts highlighted:
  
  21.210.42 Screening [Eff. 5/1/16]
  
  A. Agencies shall screen all female individuals of child bearing age seeking or being referred to substance use disorder treatment for pregnancy.
  B. At admission individuals shall be screened for past and present risk factors associated with substance use disorders that are associated with:

  1. Pregnancy complications, including risks to the health of the pregnant woman and fetus;
  2. Acquiring and transmitting Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), Tuberculosis (TB), Hepatitis A, B, or C, and other infectious diseases; and,
  3. If clinically indicated by the presence of continuing risk factors, screening shall be conducted at a minimum on a quarterly basis.

  C. Individuals shall be apprised of risk factors associated with acquiring and transmitting HIV/AIDS, T.B., Hepatitis A, B, C, and other infectious diseases. Appropriate testing and pre and post-test counseling shall be offered on-site or through referral.
  D. Criminal justice system referrals for substance use related offenses, such as DUI, DWAI, BUI, FUI and/or controlled substance violations, may be exempt from further substance use disorder screening if previously assessed, or evaluated. Supporting documentation from the referring agency shall be present in the individual record.
  E. Adults shall be screened for past and present criminal charges in any state. Persons with out-of-state charges must be registered by the licensed agency with the interstate compact office in accordance with Title 17, Article 27-1, Section 101, et seq., C.R.S.
  
  Here is an example of what this policy might look like:
  
  OBH Princeton counseling staff are responsible for the following screening of individuals requesting services. This screening takes place at the first intake appointment with a counselor. The purpose of this screening is to identify immediate needs relating to health risk factors or to community risk factors based upon criminal justice involvement. The following screenings take place at intake:

  1. Women of childbearing age are screened for pregnancy with the question: “Is it possible you could be pregnant?”
  2. Counseling staff ask all individuals seeking treatment to complete the OBH Infectious Disease screening tool. There is an option with this tool for an individual to refuse this screening.
  3. Individuals seeking services complete the Out of State Offender Questionnaire at intake to determine whether they are completing treatment in order to fulfill the requirements of another state’s criminal justice system.

  Individuals referred by the criminal justice system are not required to be re-screened if they have already been screened or evaluated and the clinical record contains this information.

  Counseling staff provide to all service participants at intake information in writing form on the risks associated with continued substance use, which include pregnancy complications and the possibility of acquiring and transmitting HIV/AIDS, TB, Hepatitis A, B,or C, and other infectious diseases. Counseling staff review this information at the second counseling session in order to determine these risk factors should be included in further assessment and treatment planning.

• Tips for Uploading Policies and Procedures
  • Have your Policies in a Word Document.
  • Have a user ID issued to you by emailing CDHS_LADDERS@state.co.us .
  • Use Chrome as your Browser.
  • Enter the Provider Portal from the For Providers tab.
  • Create an application so you can select the services you offer. This will generate the Rules that require a policy be submitted to appear in the Policy and Procedure section on the LADDERS Provider Home Page.
  • Have a copy of 2 CCR 502-1 Behavioral Health Rules.
  • Make sure polices are streamlined, to the point, and under 30,000 characters each.
  • Have your Insurance, Org Chart, and Zoning and Fire documents ready to upload from your computer.
• Why can't I load my policy?

  If you are experiencing difficulty, getting an error message, or getting logged out of LADDERS, here are a few tips that may correct the issue.

  • Always cut and paste your policy into the text box.
  • Cutting and pasting from a PDF is the most common mistake, causing error messages. Always cut and paste from a Word document, as plain text.
    https://www.thewindowsclub.com/paste-plain-text-without-formatting-word
    https://wmtang.org/2008/01/11/how-to-convert-word-document-files-into-plain-text-files/
  • Borders are special formatting will cause an error if pasted.
  • Make sure not to paste logos.
  • Do not paste tables without converting them to plain text first.
  • Text must not exceed the 30,000 character limit. If your policy is too large it will cause an error message.