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| Policy and Procedure Manual |
The Policies and Procedures of The Mental Health Center
Mission Statement The mission of the Mental Health Center is to improve the lives of the Eastern Band of Cherokee Indians and their families by providing the utmost quality mental health/substance abuse services via treatment, prevention and education utilizing qualified professionals - all in a culturally sensitive and respectful manner. Reva Ballew, Ph.D. Jody Adams Susan Leading Fox
I. TABLE OF CONTENTS II. INTRODUCTION III. OFFICE BUSINESS IV. PATIENT CARE
The Mental Health Center Policy and Procedure Manual is designed to supplement the Eastern Band of Cherokee Indians Personnel Policy Manual. The objective of this manual is to help facilitate the provision of the utmost quality mental health care. It should also clarify daily office activities and interactions with other departments and professionals.
The MentalHealth Center is currently staffed by seven employees: 1) The Mental Health Center Director is a doctoral level psychologist whose office time is primarily administrative with limited clinical duties; 2) A Psychologist who is a child and adolescent specialist. 3) A Psychologist who works primarily with the adult population; 4) A Master’s level clinician working with a mixed population with additional emphasis on psychological testing; 5) A Dual Diagnosis therapist who primarily works with individuals with co-existing mental health and substance abuse issues; (6) A Petition Caseworker who assists individuals (professionals and community members) who are attempting to have someone involuntarily committed for treatment; and (7) The Office Coordinator who ensures the daily functioning of the Mental Health Center in addition to providing administrative assistance to the Mental Health Center Director. A Mental Health Center organizational chart is on the following page. MENTAL HEALTH CENTER ORGANIZATIONAL CHART
DEPARTMENT: MENTAL HEALTH DEPARTMENT DIVISION: HEALTH AND MEDICAL ADMINISTRATION REPORTS TO: EXECUTIVE DIRECTOR OF HEALTH AND MEDICAL
PRIMARY FUNCTION: JOB DESCRIPTION: Develop goals, objectives and priorities concerning the Mental Health Department and staff and recommends these to the Executive Director of Health and Medical Implements all approved plans. Directs, reviews and evaluates results. Supervises all Mental Health staff by assigning duties, setting performance standards, work appraisals, approves leave, interviews and recommends perspective employees, instigates disciplinary action when needed. Insures staff licensure compliance. Manages and oversees the program budget. Coordinates Mental Health services with other health professional/agencies (including, but not limited to: tribal, CIH-IHS, BIA, county state, and private agencies) to maximize patient care and promote improved health care for the Eastern Band of Cherokee Indians and other eligible persons. In addition to administrative duties, provide clinical services on an as-needed basis in the form of outpatient therapy services, psychological evaluations and Cherokee Indian Hospital inpatient consultations and evaluations. Provide clinical supervision to clinical staff as designated by program needs and licensure requirements. Performs other duties as assigned by supervisor. KNOWLEDGE REQUIRED BY THE POSITION: Demonstrate knowledge of quality assurance and program management. Must have a command of budget preparation and be able to develop effective financial assistance requests and the ability to compile, analyze and present budget data in a meaningful format. Must have a background which demonstrates familiarity with the mental health needs of Indian people and Native American culture. Be knowledgeable with tribal and governmental health programs. Requires the ability to establish and maintain professional relationships with Indian people and federal, state and local agencies. Must know the Indian Health Service-RPMS computer system and have the ability to maintain records both manually and via computer. This is necessary for third-party billing and program management. SUPERVISORY CONTROL: GUIDELINES: CONFIDENTIAL DATA: SCOPE AND EFFECT: PERSONAL CONTACTS: ENVIRONMENT:
JOB TITLE: CLINICAL PSYCHOLOGIST (CHILD/ ADOLESCENT AND FAMILY SPECIALIST) DEPARTMENT: MENTAL HEALTH DEPARTMENT DIVISION: HEALTH AND MEDICAL ADMINISTRATION REPORTS TO: DIRECTOR, MENTAL HEALTH DEPARTMENT
Cooperates with the medical staff and other health professionals/agencies in developing a viable therapeutic team network to facilitate patient intake and discharge. Provides complete and comprehensive communications regarding patient progress, discharge planning, discharge summaries, etc. to appropriate personnel and according to Mental Health policies, procedures, and protocol. Assists the Mental Health Director in an ongoing program of utilization review and quality assurance. Assists the Mental Health Director in attaining and maintaining Mental Health Service accreditation by the Joint Commission of Health Care Organizations. Assists the Mental Health Director with changes in policy or procedure which would improve health delivery services. Develops consultative and backup resources with the school system, local mental health and medical communities and State Hospital network to ensure that appropriate referrals, assistance, and support services are available as needed. Provides on-call crisis services as needed. Implements and follows the provisions contained, all applicable privacy/confidentiality policies, procedures, and practices; for release of patient records and clinical information, including tribal, IHS, American Psychological Association or other licensing bodies. Attends medical rounds at Cherokee Indian Hospital. Provides clinical guidance, consultation, relevant education to medical staff of Cherokee Indian Hospital. Plans and participates in community education activities to heighten
mental health awareness and knowledge of services available. Prepares
articles and other communications in support of mental health education
and activities. Collaborates with other health professionals and agencies; serves on committees to promote Mental health, general well being, and improved life styles of EBCl members/families. Performs other duties as directed by supervisor.
Requires a thorough knowledge of psychological diagnosis, treatment and therapy with children, adolescents and their families. Clinical expertise in crisis intervention, as well as families experiencing acute episodes of psychological distress. Good communications skills, both written and verbal Familiar with Indian Health Service-RPMS computer system and have the ability to maintain records and files, both manually and on a computer. Ability to establish and maintain professional relationships with other tribal service providers, school systems, CIH medical staff, state and local professionals/agencies. Possess cultural awareness in working with Native Americans. CONFIDENTIAL DATA: PURPOSE AND CONTACTS: PHYSICAL CONTACTS:
DEPARTMENT: MENTAL HEALTH DEPARTMENT DIVISION: HEALTH AND MEDICAL ADMINISTRATION REPORTS TO: DIRECTOR, MENTAL HEALTH DEPARTMENT
Cooperates with the medical staff and other health professional/agencies in developing a viable therapeutic team network to facilitate patient intake and discharge. Performs psychological evaluations for the Cherokee Police Department. Provides complete and comprehensive communications regarding patient progress, discharge planning, discharge summaries, etc. to appropriate personnel and according to Mental Health policies, procedures, and protocol. Assists the Mental Health Director in an ongoing program of utilization review and quality assurance. Assists the Mental Health Director in attaining and maintaining Mental Health Service accreditation by the Joint Commission of Health Care Organizations. Assists the Mental Health Director with changes in policy or procedure which would improve health delivery services. Develops consultative and backup resources with the local mental health, medical communities, the school system and hospitals to ensure that appropriate referrals, assistance, and support services are available as needed. Provides on-call crisis services as needed. Implements and follows the provisions contained, all applicable privacy/confidentiality policies, procedures, and practices; for release of patient records and clinical Information, including tribal, IHS, American Psychological Association or other licensing bodies. Attends medical rounds at Cherokee Indian Hospital Plans and participates in community education activities to heighten
Mental health awareness and knowledge of services available. Prepares
articles and other communications in support of Mental health education
and activities. Collaborates with other health professionals and agencies; serves on committees to promote Mental health, general well being, and Improved life styles of EBCI members/families. Performs other duties as directed by supervisor. KNOWLEDGE REQUIRED BY THE POSITION: Requires a thorough knowledge of psychological diagnosis, treatment and therapy, individual, group and couples. Clinical expertise in crisis intervention, as well as individuals and families experiencing acute episodes of psychological distress. Good communications skills, both written and verbal Familiar with Indian Health Service-RPMS computer system and have the ability to maintain records and files, both manually and on a computer. Ability to establish and maintain professional relationships with other tribal service providers, school systems, CIH medical staff, state and local professionals/agencies. Possess cultural awareness in working with Native Americans. GUIDELINES: CONFIDENTIAL DATA: PURPOSE AND CONTACTS: PHYSICAL CONTACTS: ENVIRONMENT:
JOB TITLE: MASTER'S LEVEL OUTPATIENT THERAPIST DEPARTMENT: MENTAL HEALTH DEPARTMENT DIVISION: HEALTH AND MEDICAL ADMINISTRATION REPORTS TO: DIRECTOR, MENTAL HEALTH DEPARTMENT
Provides mental status assessments and psychological testing. Cooperates with the medical staff and other health professionals/agencies in developing a viable therapeutic team network to facilitate patient intake and discharge. Provides complete and comprehensive communications regarding patient progress, discharge planning, discharge summaries, etc. to appropriate personnel and according to Mental Health policies, procedures, and protocol. Assists the Mental Health Director in an ongoing program of utilization review and quality assurance, Assists the Mental Health Director in attaining and maintaining Mental Health Service accreditation by the Joint Commission of Health Care Organizations. Assists the Mental Health Director with changes in policy or procedure which would improve health delivery services. Develops consultative and backup resources with the local mental health, medical communities, the school system and hospitals to ensure that appropriate referrals, assistance, and support services are available as needed. Provides on-call services as needed. Implements and follows the provisions contained, all applicable privacy/confidentiality policies, procedures, and practices; for release of patient records and clinical information, Including tribal, IHS, American Psychological Association or other licensing bodies. Attends medical rounds at Cherokee Indian Hospital Provides clinical guidance, consultation, relevant education to medical staff of Cherokee Indian Hospital Plans and participates in community education activities to heighten mental health awareness and knowledge of services available. Prepares articles and other communications in support of mental health education and activities. Participates in professional development, training, seminars, and meetings as required. Collaborates with other health professionals and agencies; serves on committees to promote mental health, general well being, and improved life styles of EBCI members/families. Performs other duties as directed by supervisor. Performs other duties as directed by supervisor. KNOWLEDGE REQUIRED BY THE POSITION: Requires a thorough knowledge of psychological diagnosis and treatment, therapy experience, individual, group and couples. Clinical expertise in crisis intervention, as well as individuals and families experiencing acute episodes of psychological distress. Good communication skills, both written and verbal. Familiar with Indian Health Service-RPMS computer system and have the ability to maintain records and files, both manually and on a computer. Ability to establish and maintain professional relationships with other tribal service providers, school systems, CIH medical staff, state and local professionals/agencies. Possess cultural awareness In working with Native Americans. GUIDELINES: CONFIDENTIAL DATA: PURPOSE AND CONTACTS: PHYSICAL CONTACTS: ENVIRONMENT:
DEPARTMENT : MENTAL HEALTH DEPARTMENT DIVISION : HEALTH / MEDICAL ADMINISTRATION REPORTS TO : DIRECTOR, MENTAL HEALTH CENTER PRIMARY FUNCTION: JOB DESCRIPTION : Provides substance abuse assessments, mental status assessments and psychological testing. Cooperates with the medical staff and other health professionals/agencies in developing a viable therapeutic team network to facilitate dual diagnosis patient intake and discharge. Provides complete and comprehensive communications regarding dual diagnosis patient progress, discharge planning, discharge summaries, etc. to appropriate personnel and according to Mental Health policies, procedures, and protocol. Assists the Mental Health Director in an ongoing program of utilization review and quality assurance. Assists the Mental Health Director in attaining and maintaining Mental Health Service accreditation by the Joint Commission of Health Care Organizations. Assists the Mental Health Director with changes in the policy or procedure; which would improve health delivery services. Develops consultative and backup resources with the local substance abuse, mental health, medical communities, the school system, and hospitals to ensure that appropriate referrals, assistance, and support services are available as needed. Provides on-call crisis services as needed. Implements and follows the provisions contained, all applicable privacy/confidentiality policies, procedures, and practices; for release of patient records and clinical information, including tribal, IHS, American Psychological Association or other licensing bodies. Attends medical rounds at Cherokee Indian Hospital. Provides clinical guidance, consultation, relevant education to medical staff of Cherokee Indian Hospital. Plans and participates in the community education activities to heighten mental health/substance abuse awareness and knowledge of services available. Prepares articles and other communications in support of mental health/substance abuse education and activities. Participates in professional development, training, seminars, and meetings as required. Collaborates with other health professionals and agencies; serves on committees to promote mental health/substance abuse general well being, and improved life styles of EBCI members and families. Performs other duties as directed by supervisor. KNOWLEDGE REQUIRED BY THE POSITION: Requires a thorough knowledge of psychological diagnosis and treatment, therapy experience, individual, group, and couples. Clinical expertise in crisis intervention, as well as individuals and families experiencing acute episodes of psychological/substance abuse distress. Good communication skills, both written and verbal. Familiar with Indian service-RPMS computer system and have the ability to maintain records and files, both manually and on a computer. Ability to establish and maintain professional relationships with other tribal service providers, school systems, CIH medical staff, state and local professionals/agencies. Possess cultural awareness in working with Native Americans. GUIDELINES: CONFIDENTIAL DATA: PURPOSE AND CONTACTS: ENVIROMENT:
JOB TITLE: ORDINANCE 72 – CASEWORKER DEPARTMENT: MENTAL HEALTH CENTER DIVISION: HEALTH AND MEDICAL ADMINISTRATION REPORTS TO: DIRECTOR , MENTAL HEALTH PRIMARY FUNCTION: JOB DESCRIPTION: Specific duties include assisting family members or respondents with petitioning, admission, examinations, court hearings, discharge, communication between family, facility and respondent to explore alternate resource and payment issues and in obtaining ancillary services for restoration or respondents baseline of functioning. Provides complete and comprehensive communications regarding caseworker patient progress, discharge planning, discharge summaries, etc., to appropriate personnel and according to Tribal and IHS policies, procedures and protocol. To be on-call, via beeper services for twenty-four hours per day. Liaison between inpatient facility and designated outpatient aftercare facilities. Effectively coordinates existing mental health, chemical dependency and hospital resources to maximize patient outcomes and avoid unnecessary hospitalizations. Implements and follows the provisions contained, all applicable privacy/confidentiality policies, procedures, and practices; for release of patient records and clinical information, including tribal, IHS, or other licensing bodies. Participates in professional development, training, seminars, and meetings as required. Collaborates with other health professionals and agencies and performs other duties as directed by supervisor, including but not limited to the Cherokee Indian Hospital staff. Performs other duties as directed by the Executive Director of the Health and Medical Division. KNOWLEDGE REQUIRED BY THE POSITION: Good communication skills, both written and verbal. Familiar with Indian Health Service-RPMS computer system and have the ability to maintain records and files, both manually and on a computer. Ability to establish and maintain professional relationships with other tribal service providers, schools systems, CIH medical staff, state and local professionals/agencies. Possess cultural awareness in working with Native Americans. GUIDELINES: CONFIDENTIAL DATA: PURPOSE AND CONTACTS: PHYSICAL CONTACTS: ENVIROMENT: JOB TITLE: OFFICE COORDINATOR DIVISION: HEALTH AND MEDICAL SERVICES REPORTS TO: DIRECTOR, MENTAL HEALTH CENTER DEPARTMENT: CHDS SECTION: MENTAL HEALTH Schedules patients assuring timely, confidential treatment of information received in telephone referrals. Prepares patient charts for providers as required. Maintains all employee files and time sheets. Greets all visitors and refers them to the appropriate program staff. Maintains specified files, logs and chart information as required. Keeps reception/office area neat and clean at all times. Maintains the level of inventory of office supplies and equipment repair; ordering supplies or service as needed, including preparation of purchase orders. Types standard forms, letters, documents, correspondence, etc., on a daily basis or as deemed necessary. Sends and receives all office mail distributing to appropriate staff. Send and receives all office facsimiles distributing to appropriate staff. Prepares and sends staff training/travel requests with corresponding purchase orders. Performs job duties according to established safety guidelines and tribal policies. Performs other duties as assigned. JOB KNOWLEDGE: EXPERIENCE AND TRAINING: SCHOOLING OR EQUIVALENT: CONTACT WITH OTHERS: CONFIDENTIAL DATA: RESPONSIBILITY FOR ACCURACY: MENTAL/VISUAL/PHYSICAL EFFORT: RESOURCEFULNESS AND INITIATIVE: ENVIRONMENT: The Mental Health Center is one of the departments within the Health Division of the Eastern Band of Cherokee Indians. Below is a list of the 22 departments and departmental directors. The services that each department provides may be found in the EBCI Resource Manual. Department Director 1) Mental Health Center Reva Ballew Ph.D. The Health Division Administration is made up of seven employees; Deputy Officer – Susan Leading Fox, Health Operations Director - Jody Adams, Executive Secretary - Janice Jones, Medical Director - Ann Bullock, M.D., Accounting Director – Karen Kennedy, Administrative Assistant – Summer Lossiah, and Receptionist – Loretta Mills. An organizational chart of the Health Division Administration is provided. The Health Division is one of five divisions within
the Eastern Band of Cherokee Indians. There are approximately 700
Tribal employees in the five divisions. An organizational chart
for the Eastern Band of Cherokee Indians is provided.
This manual should provide the Mental Health Center Staff information
that will allow them to most effectively perform their jobs. Additionally,
included in this introduction section is a list of abbreviations
for each department. Also, the current Health Division employee
list, current tribal phone directory, Cherokee Indian Hospital phone
directory and BIA phone directory may be found in the Appendix section.
A comprehensive list of local and regional resources is located
in the Mental Health Center resource reference area of the office. APA American Psychological Association
PURPOSE: Define New Employee Orientation STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: January 01, 2000 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: To ensure that new employees complete necessary paperwork, activities and develop a familiarity with policies and procedures within thirty days. 1. On the first day of employment, the new Mental Health Center employee will be given a copy of the Eastern Band of Cherokee Indians Policies and Procedures and the Mental Health Center Policies and Procedures. 2. In section three of the Mental Health Center policy and procedure, there is a Mental Health Center New Employee Orientation Checklist that should be completed within thirty days. 3. The new Mental Health Center employee will check off activities, contacts, as they are completed. 4. At the mandatory new employee thirty-day evaluation meeting the new Mental Health Center employee will review this with the Mental Health Center Director.
SUBJECT: MHC Staff Credentialing PURPOSE: Define process for completing BHC Credentialing personnel file. STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: August 31st, 2001 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: 1. Clinicians will be responsible for getting the following to
the Office Coordinator: 2. It is the clinician’s responsibility to keep
his/her credentialing folder up-to-date and
PURPOSE: Define Standard Office Hours STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center POLICY:The Mental Health Center Staff observes working hours consistent with the tribal Personnel and Policy Manual, 7:45 A.M. through 4:30 P.M. The designated 15-minute breaks are at 10:00A.M and 2:00P.M. Depending on patient demand, the clinical staff works till 5:00 P.M. 1. Report to work at 7:45 A.M. and also at 12:45 P.M. unless other leave arrangements have been made. 2. If longer patient hours are needed, present proposed new schedule
to Director. 4. BHC Director will send new employee work schedule to Director of Operations.
PURPOSE: Define Procedure for Closing or Vacating the Office During Normal Hours STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center
POLICY/PROCEDURE: Infrequently the Mental Health Center is closed or vacant during normal tribal working hours, due to training or outside commitments. If that should occur: 1. Turn on the Mental Health Center answering machine. 2. Leave a sign on the entrance door stating that the office is closed, why the closing is necessary, and that emergencies should report the Cherokee Indian Hospital emergency room. 3. Notify Health Director of Operations or the Health Executive Secretary that the office is closed/vacant and where a staff member can be located. Health Division PURPOSE: Define Procedure for Securing Office STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center
POLICY/PROCEDURE: Due to the sensitive nature of the confidential material that is in the possession of the Mental Health Center Office, confidentiality/security standards meet or exceed all Tribal, IHS, or other licensing bodies requirements. 1. The Mental Health Office appointment book, phone log, computer screen or other confidential material will not be left unattended in an open office area. 2. If the confidential material is to be left unattended for a few minutes it should be placed in a secure unobservable location; (i.e. the office coordinator’s desk drawer). 3. If the confidential material is to be left unattended for more than a few minutes it should be placed in the top drawer of the patient file cabinet and locked.
PURPOSE: Define What Patients are Eligible for Mental Health Center
Services EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center provides mental health services to all persons who are eligible for services at the Cherokee Indian Hospital Indian Health Service Facility and their families. This includes enrolled members of Eastern Band of Cherokee Indians, first descendents of enrolled members of the Eastern Band of Cherokee Indians, enrolled members of other federally recognized tribes and anyone else designated by the Cherokee Indian Hospital Indian Health Service facility. 1. When a new patient is scheduled for an appointment the Office Coordinator will look up the patient’s chart number utilizing the Cherokee Indian Hospital Indian Health Service RPMS computer system. 2. In the event they do not have an open chart at the Cherokee Indian Hospital Indian Health Service facility they will be required to do so prior to their initial appointment. 3. Non-eligible persons may receive services if they are receiving services concurrent with eligible persons, i.e. couple, family therapy or consultations. 4. Non-eligible persons may receive services if they are married
to eligible persons, are Health Division PURPOSE: Define Flextime and Documentation/Utilization Procedure STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center
POLICY/PROCEDURE: In an effort to be receptive to the demands placed on the Mental
Health Center at times it is 1. When work activities are necessary outside the normal office hours, complete the Earned/Utilized Flextime Leave Form. This applies for utilizing earned flextime also. 2. Upon approval of the Earned or Utilized Flextime, give the signed sheet to Office Coordinator. 3. Place a notation of the extra activity or use of earned flextime in the Mental Health Center office appointment book. 4. Enter time earned or used in the Mental Health Center Flextime notebook under the employees designated section. The Flextime notebook is located in the bottom drawer of the patient file cabinet. Flex time sheet Health Division
PURPOSE: Define Process for Accessing Office Materials STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: Materials needed for use in the office. Supplies and professional
materials will be made available to 1. Fill out Office Material Request form and give to the Mental Health Center Director. 2. After evaluating request for financial resources and utilization in the office the materials request will be forwarded to appropriate purchasing agent or the person requesting will receive written explanation for denial.
Health Division SUBJECT: Mental Health Center Staff Meeting PURPOSE: Define Mental Health Center Staff Meeting Schedule STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center will have a weekly staff meeting to keep the staff up-to-date on office and Health and Medical Division information. 1. The Mental Health Center staff meeting will be scheduled for Tuesday at 10:00 A.M. for one hour. 2. The Staff meeting will be recorded weekly in the Mental Health Center appointment book by the Office Coordinator. 3. This meeting will be canceled only in the event that the Mental Health Center Director is unavailable.
PURPOSE: Define Mental Health Center Clinical Case Meeting Schedule STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center will have a weekly clinical case meeting to discuss clinical cases to ensure quality patient care and provide clinical support. 1. The Mental Health Center clinical case meeting will be scheduled for Tuesday at 11:00 A.M. for one hour. 2. The Clinical Case meeting will be recorded weekly in the Mental Health Center appointment book by the Mental Health Center Office Coordinator. 3. If a clinician wishes to staff a particular case they should tell the Mental Health Center Director, preferably prior to the clinical case meeting. PURPOSE: Define Ethical Standards STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: August 31st, 2001 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The BHC will maintain the most stringent of ethical standards regarding patient care including, but not limited to, Tribal, Indian Health Service, JCAHO, American Psychological Association, and/or other licensing bodies. 1. All BHC staff will be familiar with the ethical standards of APA, NC Psychology Practice Act, NASW, EBCI, IHS, JCAHO, and/or other licensing bodies. 2. Violations of ethical standards will be dealt with according to APA, NC Psychology Practice Act, NASW, EBCI, IHS, JCAHO, or other licensing bodies’ recommendations. 3. The BHC Director should be consulted if there is a question of ethical violations.
PURPOSE: Define Confidentiality Standards STAFF GOVERNED BY THIS POLICY: Mental Health Center (BHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center will maintain the most stringent of confidentiality standards regarding patient information including, but not limited to: tribal, Indian Health Service, JCAHO, APA and/or other licensing bodies. The Mental Health Center staff will take the utmost care in regard to patient information: 1) All patient documentation will be kept in the patient’s Mental Health Center patient chart. 2) Patient charts may be removed from the Mental Health Center only if the patient is being seen at another tribal facility and the chart is being taken directly to the other facility. 3) Patient records should be returned to the locked patient file cabinet at the end of the day. 4) Patient information should not be left on the top of a desk at the end of the day, but stored in a locked desk drawer or file cabinet. 5) Mental Health Center staff should safeguard that patient information should not be viewed by another patient, i.e., patient charts, appointment book, phone messages, etc.
Health Division
PURPOSE: Define procedure when the non-disclosure agreement would be used STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: 02/03/00 DATE REVIEWED OR REVISED: April 1, 2004
POLICY/PROCEDURE: In the event that an individual who is not a Mental Health Center Staff member would need to have access to confidential patient information, (i.e. Auditors, compliance officers or like professionals), they will be asked to sign the non-disclosure agreement within the Eastern Band of Cherokee Indians Confidentiality Policy. 1. The individual requesting access to Mental Health Center confidential information will be given a copy of the Eastern Band of Cherokee Indians Confidentiality Policy to review. 2. They will be asked to sign the Eastern Band of Cherokee Indians non-disclosure agreement. 3. The signed and dated Eastern Band of Cherokee Indians non-disclosure agreement will be kept on file at the Mental Health Center.
PURPOSE: Define when confidentiality may be breached STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: 02/03/00 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center
POLICY/PROCEDURE: Communications between a therapist and a patient are privileged except when a patient is an imminent danger to self or other and in the case of mandatory reporting of abuse, neglect, and dependency of children and disabled adults. 1. If a therapist becomes aware that the patient is of imminent danger to self or other they are required to pursue avenues to ensure the patients safety, i.e. voluntary hospitalization, involuntary commitment, incarceration. 2. The therapist has a legal duty to warn the potential victim if the therapist has reason to believe the patient may harm them. 3. In the event that confidentiality must be breached the therapist involved should inform the Mental Health Center Director as soon as possible.
PURPOSE: Define Process of Having External Agencies Attend Meetings
at the Mental STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: Meetings involving other departments or agencies are allowable within space and time constraints. 1. If a Mental Health Center Staff member desires to have a meeting at the Mental Health Center office with other agencies or staff they will inform the Mental Health Center Director. 2. These meetings will be approved based on space availability and patient scheduling. 3. If approved, this meeting with total number attending and names, if possible, will be recorded in the appointment book. 4. In the event it is deemed that the Mental Health Center could not accommodate the meeting, a request may be made to utilize a conference room at the Health Administration Building. 5. The Mental Health Center Office Coordinator may contact the Health Executive Secretary to schedule a conference room. PURPOSE: Define Process when a Mental Health Center Staff Member
Has Been Requested to STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center
POLICY/PROCEDURE: In the event that a Mental Health Center staff member has been requested to attend a meeting outside the department with another agency member, the Mental Health Center Director should be notified and grant approval before attendance thereof. 1. A Mental Health Center staff member receives a request to attend a meeting outside of the office; i.e. multi-disciplinary meetings, placement team meetings, etc. 2. The Mental Health Center employee will inform the Mental Health
Center 3. If there is no time conflict or other conflict the meeting will
be recorded in the Mental 4. If the meeting pertains to a mutual patient, the patient must
have signed a Release of
PURPOSE: Explain Why A Trip Report and Reconciliation Are Necessary EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: When a Mental Health Center staff member has traveled for training purposes they are required to reconcile travel and write a Trip Report (sample Trip Report)within five days. You will not be able to get approval for training if prior training/travel has not been reconciled. 1. Turn in all original receipts to the Office Coordinator. 2. Turn in a trip report to the Office Coordinator. 3. After travel reconciliation, if it is determined that a reimbursement is due to the tribe, the Office Coordinator will ask the staff to write a check to the Eastern Band of Cherokee Indians for the amount due. 4. If your expenses exceeded the amount advanced for the travel a refund check will be issued after the reconciliation is complete.
Health Division PURPOSE: Define procedure in the event of a bomb threat at the Mental Health center STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: 02/03/00 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: In the event that there is a bomb threat at the Mental Health Center all individuals will immediately evacuate the building. 1. If a bomb threat is received at the Mental Health Center, the individual receiving the call should note any detectable sounds or identifying characteristics of the call. 2. The Mental Health Center staff and patients should be notified and evacuate the building immediately. 3. The Cherokee 911 office should be contacted immediately. 4. The Mental Health Center staff will evacuate to the Cherokee Health and Medical Administration building.
PURPOSE: Define Procedure in the event of a fire at the Mental Health center STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: 02/03/00 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: In the event that there is a fire at the Mental Health Center all individuals will immediately evacuate the building. 1. If a fire occurs at the Mental Health Center, the staff member noticing the fire will notify all occupants of the Mental Health Center building to exit utilizing either the front or side exit. 2. If the fire is extinguishable utilizing the Mental Health Center fire extinguisher that is located in the kitchen area or hallway, this plan should be executed. 3. The evacuating staff should call the Cherokee 911 emergency office requesting assistance with the fire immediately. 4. The BHC staff will meet in the office parking lot upon evacuation.
PURPOSE: Define procedure if a medical emergency occurs at the Mental Health Center STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: 02/03/00 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center will respond immediately to any medical emergency by notifying the proper authorities, EMS and/or police. 1. In the event a medical emergency occurs at the Mental Health Center the staff will call 911 and report this. 2. The Mental Health Center staff will perform whatever activities that they are skilled in until the EMS arrives. 3. The Mental Health Center Director will encourage training opportunities for all staff in the area of CPR or other emergency care.
PURPOSE: Define procedure for responding to a 911 disaster emergency STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: 02/03/00 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center has been designated as a member of the Cherokee 911 disaster team and will respond immediately upon notification. 1. The Mental Health Center receives a phone call from the Cherokee 911 office stating there is an emergency. 2. Whoever at the Mental Health Center that receives the call will notify the Mental Health Center Director and/or the rest of the Mental Health Center Staff. 3. The Mental Health Center Staff will follow office-closed policy and procedure and go with Mental Health Center Disaster Kit immediately to the area designated by the Cherokee 911 office. 4. The Mental Health Center staff will stay at the designated area until all civilians are gone.
PURPOSE: Define the Procedure for Cherokee Indian Hospital Morning rounds STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: A responsibility of the Mental Health Center is to provide inpatient consultation to the Cherokee Indian Hospital inpatient population. 1. Inpatient rounds attendance will be shared among the Mental Health Center staff on a rotational basis, which will be determined at the Mental Health Center staff meeting. 2. The assigned staff member will attend rounds, check the Mental Health Center mailbox, emergency room box and inpatient consult box. 3. If there is an inpatient consult the Mental Health Staff member will perform the consult or notify Mental Health Director or other staff, depending on availability another staff member will perform consult. 4. The completed inpatient consult form will be placed in the patient’s inpatient medical chart. A copy of the completed consult will be kept at the MHC office. If available, the referring medical doctor will be consulted verbally. 5. In the event that the assigned Mental Health Staff member is unable to attend morning rounds, they will request that another staff member assume their role in attendance. 6. If no one is available to attend rounds, a call should be made to the inpatient desk informing them and requesting that if a consult is made to please notify the Mental Health Center Office.
PURPOSE: Define Cherokee Indian Hospital Emergency Room Standing STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center will reserve a 9:00 A.M. appointment time on each working day in case the emergency room has a referral from the previous night. 1. The Office Coordinator will reserve a 9:00 A.M. appointment time with the Mental Health Center clinicians on a rotating basis and depending on staff availability. 2. The staff member assigned to Cherokee Indian Hospital morning rounds will check the Mental Health Center referral box located at the Cherokee Indian Hospital Emergency Room prior to morning hospital rounds. 3. If there is a referral form in the Mental Health Center referral box the staff member will call the Mental Health Center office to relay this information in the event the Cherokee Indian Hospital Emergency Room staff has not done this. 4. The Mental Health Center Office Coordinator will notify the Cherokee Indian Hospital Emergency Room referring staff member to let them know if the 9:00 A.M. referral kept the appointment or not. PURPOSE: Define Process for Petitioning to Commit an Individual
for an Evaluation for STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: August 31st, 2001 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Ordinance 72 Caseworker is available to facilitate a petitioner in completing the legal document to allow for an individual to be evaluated for involuntary hospitalization. 1. The Caseworker will inform the petitioner of how to complete the legal document. 2. The petitioner must have first-hand knowledge that the intended
patient is of imminent 3. The Caseworker will take the completed, notarized legal document to the Cherokee Tribal Court House for its execution.
Q. What is the process? A: Involuntary Commitment is a legal action which requires these specific steps: 1) Appear before Magistrate : Any person who believes
an individual is of 2) Custody Order Issued: If the Magistrate finds
reasonable grounds for 4) Transport: The law enforcement will then transport to the admitting hospital. 5) Second Evaluation: Within 24 hours of the person’s
arrival at the admitting 6) Treatment: If a person is held
for inpatient treatment, he or she has Health Division SUBJECT: Reporting Suspected Child or Disabled Adult Abuse or Neglect PURPOSE: Define Process for Reporting Suspected Child or Disabled Adult Abuse/Neglect STAFF GOVERNED BY THIS POLICY: Mental Health Center (MHC) EFFECTIVE DATE: October 01, 1999 DATE REVIEWED OR REVISED: April 1, 2004 APPROVED BY: Reva Ballew, Ph.D., Director, Mental Health Center DISTRIBUTION: Mental Health Center POLICY/PROCEDURE: The Mental Health Center follows state, federal, tribal mandates regarding reporting suspected child or disabled adult abuse and/or neglect. 1. When a Mental Health Center staff member suspects or has been told that there is possible child or disabled adult abuse and/or neglect they will report this to the Bureau of Indian Affairs Department of Social Services at 497-9131 extension 259. 2. Inform the Mental Health Center Director that you have made a report to the Bureau of Indian Affairs-Department of Social Services, preferably prior to the report, but if not as soon as possible. 3. It is not the role of the Mental Health Center to substantiate, nor investigate the suspicions/allegations, but to report the suspicions/allegations to the Bureau of Indian Affairs- Department of Social Services. 4. When the Mental Health Center receives the Department of Social Services’ follow-up report this should be placed in the patient’s record. 7A-517. Definitions. Note: The definition of caretaker has been changed by the passage
of G.S.7B-101(3) [formerly 7A-517(5)] and now includes any employee
of or volunteer in a division, institution, or school operated by
the Department of Health and Human Services. See Administrative
letters 7A-542. Protective services. 7A-543. Duty to report child abuse, neglect, dependency, or death
due to maltreatment. 7A-544. Investigation by Director; access to confidential information;
notification of person If the investigation indicates that abuse, neglect, or dependency
has occurred, the Director shall decide whether immediate removal
of the juvenile or any other juveniles in the home is necessary
for their protection. If immediate removal does not seem necessary,
the Director shall immediately provide or arrange for protective
services. If the parent or other caretaker refuses to accept the
protective services provided or arranged by the Director, the Director
shall sign a complaint seeking to involve the jurisdiction of the
court for the protection of the juvenile or juveniles.If immediate
removal seems necessary for the protection of the juvenile or other
juveniles in the home, the Director shall sign a complaint which
alleges the applicable facts to invoke the jurisdiction of the court.
Where the investigation shows that it is warranted, a protective
services worker may assume temporary custody of the juvenile for
the juvenile's protection pursuant to Article 46 of this Chapter. |
