CATHOLIC CHARITIES, DIOCESE OF TRENTON
POLICIES AND PROCEDURES MANUAL
ADMINISTRATIVE POLICIES AND PROCEDURES
TABLE OF CONTENTS
Section 1.00 Agency Manuals
AP-1.01
Purpose and Format of Manuals
AP-1.02
Policy on Revisions to Agency Manuals
Section 2.00 Health, Safety, and Quality Issues
AP-2.01
Policy on Handling Emergencies
AP-2.011 Policy and Procedure for Reporting an Unusual Incident
AP-2.012 Procedure for Handling Crises Involving Threats
Attachment to AP-2.012: Telephone Bomb Threat Report Form
AP-2.013 Procedure for Managing any Incident That is Likely to be Subject to
Inquiry by the Press
AP-2.02
Policy and Procedure on Loss Prevention and Control
AP-2.021 Policy on Employee, Client, Volunteer, Visitor, and Property
Accident/Injury Reporting
Attachment to AP-2.021: Accident/Injury Report
AP-2.022 Monthly Facilities Inspection Program
Attachment to AP-2.022: Monthly Facilities Inspection Report
AP-2.03
Policy and Procedure for Use of an Agency Vehicle
Attachment to AP-2.03: Driver’s Statement
AP-2.031 Policy on Prevention of Alcohol Misuse and Prevention of Prohibited
Drug Use in Agency Transit Operations
AP-2.032 Policy and Procedure Regarding Vandalized Employee Vehicles
AP-2.04
Policy on HIV/AIDS
Attachment to AP-2.04: Universal Precautions – Centers for
Disease Control
1
AP-2.05
Policy and Procedure on Airborne Pathogen Infection Control
AP-2.06
Policy and Procedure for Blood-Borne Pathogen Control
Section 3.00 Human Resources Issues
AP-3.01
Personnel Requisition Procedure
AP-3.011 Procedure for Staff Recruitment and Hiring
Attachment to AP-3.011: Notice of Position Vacancy
AP-3.012 Policy and Procedure for the Review of Agency Job Descriptions
AP-3.02
Policy on Licensing and Credentialing
AP-3.03
Criminal History Background Checks and Disclosure Policy and
Procedure
AP-3.04
Policy on Hiring Immigrants
AP-3.05
Policy and Procedure on Management Orientation
AP-3.051 Policy and Procedure on Division/Program/Department Orientation
Attachment to AP-3.051: Division/Program/Department
Orientation Outline
AP-3.06
Policy on Evaluations Involving Promotions
AP-3.07
Policy and Procedure on Employee Terminations
AP-3.08
Policy and Procedure for Evaluating the Performance of the Executive
Director
Section 4.00 General Policies and Procedures
AP-4.01
Policy on Retention of Legal Counsel
AP-4.02
Policy on Agency Services to Personnel, Consultants, and Members of
the Board of Trustees and County Advisory Boards
AP-4.021 Policy on Managing Employees and Volunteers Seeking Services from
Catholic Charities
AP-4.022 Policy on Financial Interest of Personnel and Paid Consultants
AP-4.03
Policy on Chain of Command
AP-4.04
Policy on Retention of Records
2
AP-4.05
Computer, E-Mail, and Internet Usage Policies
Attachment A to AP-4.05: Acknowledgement of Understanding
Attachment B to AP-4.05: Request for Internet Access
AP-4.06
Policy on Closings Due to Inclement Weather
AP-4.07
Policy on Unbudgeted Purchases Over $100,000 and All Real Estate
Transactions
Attachment to AP-4.07: Appropriations Request
Form for Unbudgeted Expenses Over $100.000
and All Real Estate Transactions
AP-4.08
Policy on Client’s Right to Privacy and Use of Audio Visual
Recording
Attachment A to AP-4.08: Authorization for Use of Client
Statements and Public Performances
Attachment B to AP-4.08: Authorization to Use Camera, Audio,
and/or Video Recording Devices.
AP-4.09
Policy on Expressions of Condolence or Get Well Wishes
AP-4.10
Policy and Procedure on Providing Monetary Support to Other Notfor-Profit Organizations
AP-4.11
Policy on Payment of Honoraria to Board Members
3
AP-1.01
Administrative Policies and Procedures
PURPOSE AND FORMAT OF MANUALS
The Catholic Charities, Diocese of Trenton Policies and Procedures Manual serves as a guide to
both the management and the employees of Catholic Charities. It is designed to assist
management in conveying to each employee what it expects from him/her and what each
employee can expect from management in return.
The Policies and Procedures Manual is divided into five sections: Administrative Policies and
Procedures, Clinical Policies and Procedures, Fiscal Policies, HIPAA Security Policies, and
Procedures, and Personnel Policies and Procedures. A complete copy of the manual is housed in
the office of each member of Senior Management and each Division Director. It is the
responsibility of Senior Management and the Division Directors to ensure that all policies and
procedures are known to staff. The Personnel Policies and Procedures section of the manual is
also published separately and is given to each employee at the time of hire. Policies and
Procedures are also available in the Public Folders under Administrative.
The Policies and Procedures Manual shall be reviewed annually using the procedures outlined in
AP-1.02.
Approved 10-01
Revised and approved 12-03
Revised 12-04
Approved 6-05
4
AP-1.02
Administrative Policies and Procedures
POLICY ON REVISIONS TO AGENCY MANUALS
The Catholic Charities, Diocese of Trenton Policies and Procedures Manual (Administrative
Policies and Procedures, Clinical Policies and Procedures, Fiscal Policies and Procedures,
HIPAA Security Policies and Procedures, and Personnel Policies and Procedures) will be
reviewed annually and revised when necessary to meet changes in agency operation and policy
or to meet legal standards of employment practices.
Once a year an ad hoc committee, chaired by the Executive Assistant, comprising no less than
five (5) staff members will meet to review the Administrative Policies and Procedures. The
committee will request and consider input from staff and management and will provide
recommendations to Senior Management.
Once a year an ad hoc committee, chaired by the Associate Executive Director/Program
Services, comprising no less than five (5) staff members will meet to review the Clinical Policies
and Procedures. The committee will request and consider input from staff and management and
will provide recommendations to Senior Management.
Once a year an ad hoc committee, chaired by the Associate Executive Director/Fiscal Affairs, or
his/her designee, comprising no less than five (5) staff members will meet to review the Fiscal
Policies and Procedures. The committee will request and consider input from staff and
management and will provide recommendations to Senior Management.
Once a year an ad hoc committee, chaired by the Personnel Director, comprising no less than
five (5) staff members will meet to review the Personnel Policies and Procedures. The committee
will request and consider input from staff and management and will provide recommendations to
Senior Management.
The Compliance Director will serve ex officio on all ad hoc review committees.
Updated manuals will be submitted to the Executive Director and the governing body for
approval.
Updated manuals and/or revisions (with changes indicated) will be distributed to Senior
Management and Division Directors for distribution to appropriate staff. It is the responsibility of
the Division Directors or the Human Resources Director (in case of Central Administrative
Services staff) to ensure that all revised policies and procedures are made known to all staff.
All new personnel will be provided with a copy of the current Personnel Policies and Procedures.
Approved 2-83
Revised and approved l2-92
Revised and approved 4-97
Revised and approved 10-01
Revised and approved 12-03
Reviewed 6-05
5
AP-2.01
Administrative Policies and Procedures
POLICY ON HANDLING EMERGENCIES
Policy
Each agency location will have an emergency preparedness plan in place. This plan will address
safety, evacuation, medical and psychiatric emergencies, and other specific emergencies.
An emergency situation is one in which there is an immediate threat to life or property.
Emergency situations encompasses a wide range of real and potential dangers. Because of the
nature of a particular program, the clients, and staff, some emergency situations may have a
greater likelihood to occur than others.
For every agency location it is the responsibility of the senior administrator to have in place a
series of plans to handle specific emergencies. The following list constitutes a number of
potential situations for which emergency plans are required. However, it is the responsibility of
the program administrator and division director to have procedural plans for the following
emergencies:
1. Evacuation and safety plan for clients and staff in case of fire.
2. Medical emergencies including life-threatening situations for clients and/or staff.
3. Psychiatric emergencies in which clients may be at risk of harming themselves, others or
property.
4. Other situations identified specifically by staff as posing a particular risk in specific settings.
Examples: a threatening abuser or batterer at program for abusers or victims; fire, flood, or
other adverse conditions at program location. (These examples are neither intended to be
inclusive nor descriptive of most program areas.)
Approved 10-83
Revised and approved 12-92
Revised and approved 7-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
6
AP-2.011
Administrative Policies and Procedures
POLICY AND PROCEDURE FOR REPORTING AN UNUSUAL INCIDENT
Policy
The Division Director will report all unusual incidents of serious nature to the Associate
Executive Director of Program Services and the Executive Director.
Occurrence of the following incidents should be reported to the Division Director immediately.
The Division Director shall submit a verbal report to the Associate Executive Director of
Program Services and the Executive Director immediately, followed by a written report within
24 hours.
1. Suicide of a client.
2. Death, serious injury on Agency premises.
3. Fires or other calamities that cause injuries to people or property.
4. Any incident that is likely to be subject to inquiry by the press.
Additionally, all reporting procedures required by law or legal contract should be followed.
Approved 10-83
Revised and approved 12-92
Revised and approved 7-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
7
AP-2.012
Administrative Policies and Procedures
PROCEDURE FOR HANDLING CRISES INVOLVING THREATS
Policy
Each site will have an Emergency Response Coordinator and a backup Coordinator who will be
responsible for handling all crises involving threats. On an annual basis, the Emergency
Response Coordinator or backup Coordinator will run an evacuation practice and hold an annual
safety awareness meeting at each site.
Threats may include but are not limited to, bomb threats, client threats, employee threats, and
community threats.
Division Directors shall appoint an Emergency Response Coordinator and a back up for each of
their facilities. The Emergency Response Coordinator shall be responsible for ensuring that
emergency services are called, directing appropriate shutdowns, and directing emergency
activities including evacuation of personnel. Additionally, the Emergency Response Coordinator
shall be responsible for developing an evacuation plan for his/her location and conducting, at
least annually, an evacuation practice and safety awareness meeting at that location. The
Emergency Response Coordinator shall confirm with the Division Director that the evacuation
practice and safety awareness meeting was held. Written evacuation plans shall be submitted to
the Safety Director at Central Administrative Services.
Procedures in Case of a Threat to Life or Property
Contact the police immediately (911) upon receipt of any threat to life or property. This
protocol applies whether threat is received via phone, mail, or in person.
Immediately remove employees, clients, and visitors from the area of danger.
In cases of a bomb threat:
Telephone Threat: Complete Telephone Bomb Threat Report Form (see attachment).
Written Threat: Preserve the original message B save for evidence.
Evacuation
Bomb threats shall result in immediate and total evacuation.
Evacuation order shall be given by Emergency Response Coordinator or designee (e.g.
manager).
Leave all windows and doors open.
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Designated point person shall be responsible for roll call at evacuation gathering place.
Shelter for inclement weather should be planned.
All staff shall receive training in evacuation once a year. This requirement may be increased if
required by DMHS or other regulatory agency.
Follow Up
The Emergency Response Coordinator shall interface with police, fire, and other emergency
responders in a threat situation.
Any inquiries by the press shall be referred to Central Administrative Services. (Consult AP2.023.)
The Division Director and Emergency Response Coordinator shall prepare a critique of the
incident, within 24 hours, for presentation to the Executive Director and the Associate Executive
Director of Program Services.
The Division Director and Emergency Response Coordinator shall hold a debriefing for all
involved staff within 72 hours.
Approved 10-01
Revised and approved 3-03
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
Attachment to
AP-2.012
Administrative Policies and Procedures
TELEPHONE BOMB THREAT REPORT FORM
Instructions
Be calm and courteous. Do not interrupt the caller. As soon as it is apparent that the call is a
bomb threat, alert Security (if available), Director, Program Manager, or Supervisor, without
alerting the caller of your actions. The easiest way to do this is to flag down your supervisor or
co-worker and point to this report form which will be posted by your telephone for easy
reference.
Date: __________ Exact time of call: __________ Caller ID: _____________________
Exact words of caller:___________________________________________________________
______________________________________________________________________________
Questions to ask
When is the bomb going to explode? ________________________________________________
Where is the bomb right now? _____________________________________________________
What kind of bomb is it? _________________________________________________________
What does it look like? __________________________________________________________
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Why did you plant a bomb? _______________________________________________________
Try to determine the following (circle appropriate features)
Caller’s Identity: Male
Female
Adult
Juvenile
Tonal Qualities of Voice: Loud
Soft
High Pitch
Low Pitch
Deep
Raspy
Pleasant
Intoxicated
Other _____________
Speech: Fast
Slow
Distorted
Stutter
Nasal
Slurred
Lisp
Grammar: Excellent
Good
Fair
Poor
Foul Other ____________
Manner: Calm
Angry
Rational
Irrational
Coherent
Incoherent
Deliberate
Emotional
Righteous
Laughing
Intoxicated
Background Noises: Office Machines
Factory Machines
Trains
Animals
Music
Quiet
Voices
Mixed
Airplanes
Street Traffic
Party
Tracing call
After completing the call, depress and release the receiver button. When you get a dial tone,
press *57 on your touch-tone phone. Listen for the confirmation announcement and hang up. The
number of the last call received will be reported to Verizon.
Additional Information: __________________________________________________________
Person receiving call: ____________________________
3-01
Reviewed 12-04
Approved 6-05
10
Number called: ______________
AP-2.013
Administrative Policies and Procedures
PROCEDURE FOR MANAGING ANY INCIDENT
THAT IS LIKELY TO BE SUBJECT TO INQUIRY BY THE PRESS
Policy
All incidents that are likely to be subject to inquiry from the press are channeled through the
Executive Director.
Interaction with the Press
All interactions with the press should be conducted by or cleared with the Division Director.
Press interviews in sensitive situations should be discussed with the Executive Director or the
Associate Executive Director/Community Affairs prior to the interview. When an incident occurs
that is likely to cause inquiry by the press, the Executive Director should be notified immediately
and the agency’s Crisis Management Plan implemented.
Appointing an Organization Spokesperson
When an incident that is likely to be subject to inquiry by the press occurs, all information is to
be channeled through the Executive Director. The Executive Director shall serve as organization
spokesperson should this be required.
Some crisis scenarios include:
 a client hurts another person
 an administrator is charged with fraud
 a staff person embezzles money from the agency
 suicide of a client
 death, serious injury on agency premises
 staff sexually harasses or molests a client or employee
Once the decision has been made that the Executive Director needs to be the spokesperson, all
staff should refer all media to the Executive Director politely but firmly.
The Associate Executive Director/Community Affairs is designated as a back-up spokesperson
in the event that the Executive Director is unavailable at the time of the incident.
Notification of Staff
Division Directors are responsible for notifying staff that they are not to respond to any media
inquiries and that they should politely, but firmly, refer all questions to the Executive Director.
Staff should tell the media that although they would like to help, they have neither the correct
information nor the authorization to respond to questions. Tell reporters that the most accurate
information is available through the Executive Director.
11
Reporting Information to Executive Director
All pertinent information must be reported to the Executive Director immediately. Division
Directors should also provide a list of phone numbers of staff and resource people who can
provide information relevant to the situation. It shall be the Associate Executive
Director/Community Affair’s responsibility to aid in the collection and reporting of the
information to the Executive Director.
The Executive Director shall respond immediately to all media inquiries, even if the answers
provided offer only interim or standby statements.
Appropriate Division Directors or others involved with the incident must provide regular written
updates on the situation and be available to answer media's questions, via the Executive Director.
Division Directors are responsible for gathering information from appropriate staff and relaying
it to the Executive Director or to the Associate Executive Director/Community Affairs, should
the Executive Director be unavailable.
Any written reports should be addressed to the agency attorney but sent to the Executive Director
in order to safeguard the agency in the event that legal action is taken against Catholic Charities.
Developing a Response Strategy
Once all the information is gathered, the Bishop, the Chair of the Board, and the Secretary to the
Secretariat for Social Justice and Social Services shall be briefed and asked for input. Before
fielding any press calls, the Crisis Management Committee consisting of the Executive Director,
the Associate Executive Director/Community Affairs, the public relations coordinator, and legal
counsel shall confer to devise the appropriate response strategy.
This strategy shall include deciding how to release the pertinent facts and circumstances
surrounding the incident, bearing in mind that it must include answers to the five basic questions:
who, what, where, how and why. All information pertinent to the incident and legally
permissible should be shared.
The response strategy should focus on pointing out the positive aspects of the incident, i.e. how
we helped to remedy the situation, how we are assisting the victims, and what we will do to
prevent this from happening again.
The Crisis Management Chairperson shall outline the response strategy for the Executive
Director. A decision shall be made by the Executive Director on whether a press conference is
appropriate. A press conference should be called if the issue has a major impact on the
community and there are ongoing developments. The press conference should not be called until
the situation is somewhat under control and the Executive Director can say honestly that the staff
has done A, B, C, to rectify the situation.
Ongoing Incidents
For ongoing incidents, at least one meeting per day should be held with the Crisis Management
Committee to update them of the situation. Communication is vital.
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Handling Phone Calls from the Media
All phone calls from the media should be answered in the order received. However, it is also
important to consider which media has the greatest power in disseminating the correct
information. The goal is to get correct information to as many people as quickly as possible.
A log should be kept by the Community Affairs Department of all callers with media affiliation,
questions and telephone numbers. Quick response and a willingness to assist will contribute to an
accurate portrayal of the incident.
Guidelines for Answering Questions
The following are general guidelines for answering questions:
1. Answer hostile or negative questions as directly and briefly as possible.
2. Focus on a positive aspect – how the organization handled the incident, what it is doing to
prevent the situation again and how qualified employees are to handle the situation.
3. Stick to the facts.
4. Remember that everything is on the record.
5. In the event that the Executive Director cannot answer a reporter's question, he/she should
say we will check that particular fact and will quickly respond with accurate information.
The appropriate Division Director or other staff member should be contacted, the information
gathered, and relayed back to the media. Response must be quick, preferably within 10
minutes.
6. Respond to every media question, preferably within 10 minutes.
7. The confidentiality of our clients must not be violated.
8. Don’ts:
 Don't stonewall.
 Don't lie.
 Don't speculate.
 Don't show indifference to suffering.
 Don't attempt to cover-up a story.
 Don't search for someone to blame.
Access to Site
Designate one room for the press. The room should have easy access and be as far as possible
from the executive offices and site of incident.
If the crisis involves a particular site, determine whether the media will be allowed access. Media
should always be accompanied. A designated Division Director or designee should be the point
person for any uninvited media and will escort them out.
13
Preparation of Press Release
A press release should be prepared as soon as possible by the Associate Executive Director of
Community Affairs or designee that details the incident and the agency's response to that
incident. This serves as another avenue to disseminate our understanding of the story.
The release should be sent to all appropriate media. Copies should be kept on hand at the Central
Administrative Services so that it can be given to any reporter who comes to the main office.
Reporters who show up at any other Catholic Charities site should be referred to Central
Administrative Services.
The release should be accompanied by other information on Catholic Charities, providing
background on the agency and the people it serves. This should include the annual report,
agency overview, and service directory. Any changes in the situation warrant the creation of a
new release.
Approved 12-92
Revised and approved 8-96
Revised and approved 7-97
Revised and approved 3-03
Revised and approved 12-03
Revised 12-04
Approved 6-05
14
AP-2.02
Administrative Policies and Procedures
POLICY AND PROCEDURE ON LOSS PREVENTION AND CONTROL
Loss Prevention Policy
The concept of loss prevention is based on the principal of preventing injuries to persons,
conservation of property, and controlling the effect of both on the financial well being of the
individual and the agency.
No phase of administration or operations is of greater importance than safety and loss
prevention. Accidents which result in personal injury and damage to property represent needless
waste. Therefore, it is the policy of Catholic Charities to maintain all property free of
unnecessary hazards and to conduct all operations safely, thereby avoiding injuries to persons
and damage to property.
Planning for loss prevention shall start with the design and continue through purchasing,
operation and maintenance of all agency facilities and locations. All practical steps must be
taken to maintain safe and healthful buildings and properties.
In addition, loss prevention measures shall be integrated at all times with operating functions. All
supervisory personnel must accept responsibility for the prevention of losses on operations under
their direction.
Loss Prevention Responsibilities
The responsibility for loss prevention is rested in agency management with each level of
management being accountable to its superior for its performance in this vital area.
At the same time, each employee has a responsibility not only for his/her safety but also for the
safety to fellow employees, clients, and visitors.
Loss prevention responsibilities include the following:
Executive Director
The Executive Director has the ultimate responsibility for the loss control program and his
participation as follows, is most important:
1. Place safety and loss control on his agenda when having periodic meetings with his Senior
Management.
2. Ensure that each level of agency management carry out their loss control responsibilities.
3. Use safety performance and loss control as one important consideration in the annual
evaluation of subordinate’s performance.
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Associate Executive Director/Program Services
1. Place safety and loss control on his agenda when having periodic meetings with his Division
Directors.
2. Ensure that each level of agency management carry out their loss control responsibilities.
3. Use safety performance and loss control as one important consideration in the annual
evaluation of subordinate’s performance.
Division Director
For loss prevention to be effective, the Division Director at each agency location must be
involved and must carry out these responsibilities:
1. Ensure that each level of management reporting to him/her carry out their loss control
responsibilities.
2. Use safety performance as one important consideration in the annual evaluation of
subordinates performance.
3. Perform all work in as safe a manner as possible.
4. Be familiar with and abide by all agency safety rules and regulations.
5. Act on potential loss control issues expeditiously.
Each Employee
1. Report all unsafe acts and unsafe conditions to higher supervisor, in writing.
2. Report all accidents and injuries immediately.
3. Perform all work in as safe a manner as possible.
4. Be familiar with and abide by all agency safety rules and regulations.
Approved 7-97
Revised and approved 03-03
Reviewed 12-04
Approved 6-05
16
AP-2.021
Administrative Policies and Procedures
POLICY ON CLIENT, VOLUNTEER, STAFF, VISITOR, AND PROPERTY
ACCIDENT/INJURY REPORTING
Policy
Incident reports will be completed for all occurrences that effect employees, clients and visitors
or that cause property damage, or have significant risk of affecting the quality of care or services
provided by the provider, the provider site or staff member. Client, visitor, employee, and
property damage incident reports will be completed and submitted to the Program Director
within 12 hours of the incident. A copy of the incident report form and the follow-up
documentation is to be forwarded to the Division Director, the Quality Improvement
Representative, the Facility Management Director, and the Safety Officer within 24 hours of the
incident. In addition, all incidents involving property, employee/client/visitor injury and
automobile incidents are to be forwarded to the Director of Human Resources within 24 hours of
the incident.
Definition of an incident/occurrence
Any event that has the potential to cause or has caused injury to an employee, client or visitor
and/or has caused property damage or has a significant risk of affecting the quality of
care/treatment/service provided by the provider, provider site or staff member; or care or
treatment or service that is not routine and is inconsistent with the standards of practice, or the
operations of the facility and that has resulted in injury or potential harm to an employee, client,
volunteer or visitor.
Procedure
1. Employee/client/visitor reports to the Supervisor any occurrence. That staff involved in or
witness the event should initiate the incident report. If the incident/accident was not
witnessed, then the supervisor to whom the incident/accident was reported would initiate the
incident report. If the incident/accident was witnessed, then the supervisor will interview the
witnesses. This will be documented on the accident/incident report.
2. An incident report is to be completed on any potential incident or any incident where first aid
is not required. The report is sent to the Supervisor/Program Director for review.
3. An incident report is to be completed on any actual incident where first aid is required. The
report is sent to the Supervisor/Program Director for review.
4. Those occurrences that require medical attention shall be sent to the Nurse where applicable.
Photographs of the injury are to be taken as applicable.
5. If additional services are required, documentation of such services will be completed.
6. The following incidents must be treated by a physician:
6.1 all back and head injuries
6.2 needle stick
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6.3 blood borne pathogen exposures
6.4 human bites.
7. All incident reports will be forwarded to the Program Director within 12 hours of the
incident. The report is then forwarded the Division Director with a copy to the site QI person
within 24 hours.
8. Any incident report that has the potential for litigation must be faxed to the Associate
Executive Director of Program Services with a brief note from the Division Director.
9. Medical emergencies or incidents involving a client are to be documented legibly in the
client’s file and are to include the date and time of the incident and a summary of the
incident.
Accountability
1. Program Director
2. Division Director
3. Quality Improvement Representative
4. Safety Officer (if applicable)
5. Facility Management Director
Incident Review
Every incident report shall be reviewed by the Program Director. Proper recommendations and
actions are to be taken to prevent recurrence. Information tracked will include:
1. Type of incident
2. Number of incidents per period
3. Incidents to be classified as client, visitor, staff, and/or property
4. Predominant cause of incident
5. Recommendations to prevent recurrence
6. Attention to incident repeaters
7. Trends (time of day, day of week, seasonal effects, location etc.)
8. Opportunities for improvement
9. Number of incidents requiring referral to physician and/or emergency room
The QI representative or designee will compile the incident review report and this will be
18
presented to the site QI committee and the Agency wide Safety Committee. The Agency wide
Safety Committee will report and make recommendations to the Agency wide QI Committee.
Approved 7-97
Revised and approved 03-03
Revised and approved 12-03
Revised 12-04
Approved 6-05
19
Attachment to
AP-2.021
Administrative Policies and Procedures
Catholic Charities
Staff, Client, Volunteer, Visitor, Property Accident/Incident Report
Division: __________________________
Program: _____________________________________
Date of Incident: ________ Time of Incident: ________ am/pm
Day of week: ______________
1. Location of occurrence: ______________________________________________________________
2. Nature of injury/damage:_______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. Facility/Equipment involved: ___________________________________________________________________
4. How did the accident/injury/damage occur? _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_____________________________________________________________________________________________
5. Interview/statement of injured party: ___________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6. Witness names and statements: ________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. Property Damage: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Was medical attention needed? Yes No Offered? Yes No Accepted? Yes No
9. Was medical attention available? Yes No
Action taken:_______________________
If yes, please explain:__________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________
Signature of client, staff, visitor, volunteer ____________________________________________________
Print name: _____________________________________________________________________________
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10. Intervention taken: _________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
11. What corrective actions will be taken and when? __________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
12. Signature of client, staff, visitor ________________________________________________________________
Print Name:________________________________________________________________________________
13. Signature of person completed form: ____________________________________________________________
Print Name: _______________________________________________________________________________
14. Supervisory Investigation and comments: ________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
15. Supervisory Signature: ____________________________________________ Date: ______________
16. Program Director Review and Signature _______________________________ Date:______________
17. QI Representative Review and Signature: ______________________________ Date: ______________
Additional comments: __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Original: Program Director
Copy: Division Director
Copy: Site QI Representative
Copy: Site Safety Officer
Approved 07-97
Revised and approved 03-03
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
21
AP-2.022
Administrative Policies and Procedures
MONTHLY FACILITIES INSPECTION PROGRAM
Policy
At least once a month, supervisory personnel must insure that an inspection is conducted of all
buildings and grounds at each agency facility. The purpose of the self-inspection is to detect and
correct unsafe conditions or unsafe acts before an accident occurs.
Inspections and training are essential if the following accident causes are to be detected:
1. Obvious Hazards: These are conditions such as a hole in the parking lot or a stairway with
insufficient lighting or without a handrail or an uneven sidewalk; conditions which are
dangerous because of their very existence.
2. Conditions which at the moment may not be hazardous but which could easily be converted
to a hazard (e.g., a downspout emitting water when it rains; it becomes a hazard when the
water freezes)
3. Employee action that is hazardous to the employee involved (e.g., an employee stepping on
the upper most step of a step ladder).
4. Employee actions which may not be hazardous to the individual at the moment but in which
he/she is creating hazard to others (e.g., employee recklessly driving a vehicle).
A monthly report (that indicates the deficit and the corrective action taken or planned) must be
made (using the Buildings and Grounds Monthly Inspection Report, Attachment C) and kept on
file on such inspections. In addition, a copy must be forwarded to the Human Resources
Department and the Facilities Management Director. The Facilities Management Director will
review the current and previous reports to ensure that corrective action is completed and
sufficient.
It is suggested that the monthly inspection be performed by a designated staff member in each
location. That person would be responsible for completing the inspection report and signing it
off. The completed report would then be reviewed by the Supervisor and Division Director,
signed and then placed on file with a copy to the Human Resources Department.
At larger locations the inspection process could be divided into different parts with employee
safety committees performing the inspections, (i.e.: parking areas, sidewalks and grounds,
buildings, etc.)
Examples of hazards that should be covered during an inspection are as follows:
1. Housekeeping that results in tripping or slipping or in fire hazards.
2. Aisles and Walkways should not be blocked and should not present slipping or
tripping hazards such as missing tiles.
22
3. Ladders, Scaffolds and Walkboards: such equipment may be improperly placed or used
unsafely.
4. Hand trucks: should be in good condition and safely stored.
5. Condition of Floors, Platforms, Railings and Stairs: broken or loose tiles, carpeting,
handrails, etc.
6. Lighting - is it adequate and working?
7. Ventilation - are there any problems such as units out of action, fans with guards?
8. Dust, Fumes and Gases - are there any problems with indoor air quality?
9. Condition of Rest Rooms - cleanliness, water temperature
10. Exits - clear and well marked?
11. Any Unsafe Acts performed on the premises?
12. Condition of Safety Signs and Equipment
13. Electric Generators condition - are there periodic tests?
14. Condition of Emergency Lights, Smoke and Heat detectors and fire alarm systems
15. Condition of Electrical Equipment - such as temporary wiring, junction box covers missing,
outlets smashed, etc.
16. Condition of Parking Lots - are there holes, ruts, metal projections from the surface or
damaged hazardous fences.
17. Spill Kits and First Aid Kits
Approved 7-97
Revised and approved 3-03
Revised and approved 12-03
Revised 12-04
Approved 6-05
23
Attachment to
AP-2.022
Administrative Policies and Procedures
MONTHLY FACILITIES INSPECTION REPORT
Date ______________________________
Facility ______________________________________________________________
Program _____________________________________________________________
Inspector _____________________________________________________________
The following conditions were noted: (indicate deficiency and corrective action initiated)
Facility Exterior
(sidewalks, grounds, building, entrances, etc.)
Facility Interior
(offices, reception area, carpet, tile, ceiling, walls, fire extinguishers, alarms, etc.)
Electrical and Mechanical Equipment
(heating, ventilation, air conditioning systems, leaks, air quality, scheduled maintenance, etc.)
Reviewed by ____________________________________________________
Supervisor
Approved by ____________________________________________________
Division Director
1. Copy for division file
2. Original to Facility Management Director
3. Copy to Facilities Management Director (CAS)
24
AP-2.03
Administrative Policies and Procedures
POLICY AND PROCEDURE FOR USE OF AN AGENCY VEHICLE
Policy
Insurance coverage requires that all Agency vehicles be driven only by individuals who have a
current driver’s license, and have been given permission by their supervisor to drive the vehicle.
This includes volunteers as well as employees of the agency.
Authorization to Drive an Agency Vehicle
To comply with this requirement it will be the responsibility of the Division Director to see that
the following steps are taken:
1. Each year, each, the transportation coordinator or designee will obtain a copy of the drivers
abstract from the Division of Motor Vehicles for each employee/volunteer who has been
given the authority to drive. This abstract must be submitted to the Division Director, or
his/her designee, at the local office. The abstract must clearly state that driving privileges are
in "good standing" and reflect a safe driving pattern before the employee will be allowed to
drive an agency vehicle.
2. Each Division Director must obtain a photocopy of the driver’s license of the person who has
been authorized to drive an agency vehicle. In addition each driver must sign a Drivers
Statement Form (see attachment) prior to being allowed to drive an agency vehicle.
This information is to be kept on file in each local office and a copy of each forwarded to the
Human Resources Department.
Personal Use of Agency Vehicle
It is the policy of Catholic Charities that employees, who are assigned a vehicle for use in
performing their duties and for commuting, are prohibited from using the vehicle for any
personal use other than commuting. Twice a year commuting use of an agency vehicle will be
reported to the Accounting Department, upon their request, for tax purposes.
Vehicle Maintenance
1. A valid insurance card, inspection sticker, and valid registration will remain in the vehicle
at all times. In addition, all vehicles will have the vehicle accident reporting guidelines in the
glove compartment.
2. All agency vehicles will be kept in state of good repair. It is the responsibility of the driver to
inform the transportation department as soon as possible of any mechanical problems.
3. All gasoline powered vehicles will have a lubrication and oil change with filter completed
at 3,000 mile or three-month intervals, whichever comes first.
25
4. All diesel-powered vehicles will have a lubrication and oil change with filter completed on
an interval as suggested by the manufacturer.
5. Smoking is prohibited in agency vehicles.
6. Vehicles must be locked at all times when not in use.
7. Agency/personal items should not be left visible in the car/van.
8. Use of cell phones is in accordance with state law - speakerphone or headset.
9. Smoking is prohibited in the vehicle.
Safety
1. Drivers shall not drive while taking prescription or over-the-counter drugs (e.g.
antihistamines) that may affect driving ability.
2. Seat belts and child restraint seats shall be in good working order and used at all times.
3. Minor clients should never be left unattended in agency vehicles. Adult clients should be
supervised unless otherwise deemed appropriate by the driver. (If adult clients are left
unattended in a vehicle, the engine should be turned off and the keys removed.)
4. All van/bus type vehicles will be equipped with a fire extinguisher (ABC Dry Chemical, 2.5
lb) and a first aid kit.
5. All sedan type vehicles will be equipped with a first aid kit, ice scrappers, flares, and vehicle
accident reporting guidelines.
Vehicle Accident Reporting
It is the responsibility of the operator of the vehicle to report an accident, no matter how
insignificant, to the Transportation Coordinator or other designated staff.
As soon as possible after the accident, a formal written accident report should be submitted. This
report should include, at minimum, the following information:
1. Name of driver, license number
2. Description of agency vehicle (plate number, damage, etc.)
3. Location of accident, time, and date
4. Other driver/vehicles involved including names, addresses, auto makes and models, license
plate information, insurance information, type of damage, drivers license number.
5. A description of the accident.
6. List of passengers/individuals with injuries, if appropriate.
26
7. Police department who responded and name of officer and township.
8. Where vehicles were towed.
9. Supervisor is to request a police report ASAP.
Approved 8-85
Revised and approved 12-92
Revised and approved 7-97
Revised and approved 12-03
Revised 12-04
Approved 6-05
27
Attachment to
AP-2.03
Administrative Policies and Procedures
DRIVER'S STATEMENT
I certify that my current driver's license is valid and that my driving record shows no limiting
conditions attached to my license.
I agree to inform the Agency of any changes concerning the status of my license that would
legally prevent me from operating a motor vehicle.
I agree that I will not drive while taking prescription or over-the-counter drugs (e.g.
antihistamines) that may affect my driving ability.
Signed ___________________________________________ Date _______________________
Name (please print) _____________________________________________________________
8-85
Revised and approved 12-03
Revised 12-04
Approved 6-05
28
AP-2.031
Administrative Policies and Procedures
POLICY ON PREVENTION OF ALCOHOL MISUSE AND PREVENTION OF
PROHIBITED DRUG USE IN AGENCY TRANSIT OPERATIONS
Policy
All drivers of agency vehicles requiring a Commercial Drivers License (CDL) will be required to
undergo a prohibited drug and alcohol-testing program, as specified under 49 CFR of the
Department of Transportation Rules and Regulations.
Procedure
1. Drivers will be required to have a pre-employment physical examination to include alcohol
and prohibited drug testing, which will be provided at the employer’s expense. Employment
will be contingent upon the successful passing of this exam.
2. Thereafter, a physical examination to include alcohol and prohibited drug testing will be
required for drivers covered under this policy on a biennial basis.
3. Drivers will also be placed in a statewide computer pool for the purpose of random drug
testing on a periodic basis.
4. The agency will assure that no driver shall perform transit operations under Part 49 CFR
while under the influence of alcohol and/or prohibited drugs.
5. This information is maintained in the Human Resource Department.
Approved 3-97
Revised 12-04
Approved 6-05
29
AP-2.032
Administrative Policies and Procedures
POLICY AND PROCEDURE REGARDING VANDALIZED EMPLOYEE VEHICLES
Policy
It is the Policy of Catholic Charities to maintain all agency owned and leased parking areas in a
clean, safe manner for use by all staff as appropriate. However, it is acknowledged that in today’s
environment there does exist the potential for acts of vandalism to be committed against parked
vehicles.
Catholic Charities will attempt to minimize the burden on staff members whose privately owned
vehicle suffers damage as a result of vandalism while parked on agency owned or leased property as
outlined in the following Procedure:
Procedure
1. If an employee’s vehicle is damaged while parked on agency owned or leased property, either
during working hours or in the conduct of agency business, the incident must be reported to your
Supervisor immediately and complete the incident report.
2. A determination will be made by the local Supervisor as to the cause of the damage. A Police
Report must be requested as soon as practicable.
3. Employees who have comprehensive coverage will be asked to submit the claim for repair to
their auto insurance provider.
4. Once repairs are complete the agency will reimburse the employee for the employee’s auto
insurance comprehensive deductible up to a maximum of $500.00.
5. The employee may be asked to provide a copy of their insurance policy indicating their
deductible amount.
6. All requests for reimbursement must have the approval of the employee’s Division Director prior
to submission.
7. Requests will be submitted in writing by use of a purchase requisition, approved by the Division
Director, with the program to be charged noted on the requisition.
8. Reimbursement will be made directly to the employee.
9. Reimbursement is not allowed for damage as a result of collision with another vehicle or
object, or if struck by another vehicle while parked.
10. In situations where an employee is parked away from agency owned or leased parking areas
while on agency business and their vehicle suffers damage as a result of vandalism, coverage
under this policy will be considered on a case-by-case basis.
Approved 12-03
Revised 12-04
Approved 6-05
30
AP-2.04
Administrative Policies and Procedures
POLICY ON HIV/AIDS
Policy
All Catholic Charities’ employees will safeguard and protect the confidentiality of all protected
health information. Information will only be released in accordance with all Federal, State, and
Accrediting requirements.
The Need for Confidentiality and Privacy
All Catholic Charities employees have a duty to maintain the confidentiality of information
regarding an individual's HIV status.
Clients, as well as employees have a right to privacy concerning disclosure of information
related to HIV status. The right to decide to whom information may be disclosed generally
belongs to the individual about whom the information pertains, not to Catholic Charities or its
employees.
Disclosure of information could result in the client or employee suffering loss of privacy,
harassment, and discrimination. Unauthorized disclosures by agency staff could lead to
individual liability including damages against Catholic Charities, and its personnel.
Information Covered By This Policy
All HIV-related information is confidential. HIV-related information means any information that
is likely to identify, directly or indirectly, someone as actually having HIV infection, antibodies
to HIV, AIDS, or related infections or illnesses. Access to or disclosure of this information is
governed by this policy, as well as Federal and State laws.
This policy covers the confidentiality of information pertaining to a specific individual that has
applied for, receives, or formerly received treatment, services, or benefits. This confidentiality
also applies to an individual's family and partner.
HIV-related information is confidential regardless of the source, including whether the
information is obtained intentionally or unintentionally; from the client, his family, or partner, or
from another source, or through oral, written or electronic communication.
Individuals Subject to This Policy
All individuals who work for or provide services through Catholic Charities are bound by this
policy, including, but not limited to: full and part time staff, independent contractors,
consultants, licensees, temporary employees, interns, volunteers and board members.
All of the individuals mentioned above are required to review this policy and sign a statement
that they understand its requirements, agree to follow its procedures, and understand that they
will be subject to disciplinary and other adverse actions for any violations.
31
Use of Universal Precautions
All Catholic Charities programs will utilize the Universal precautions, the assumption is made
that every individual with whom you have contact may have an infectious disease. Therefore,
protective gloves will be used every time there is any contact with another person's body fluids
(i.e. blood, vomit, etc.). Programs will inform clients of the precautions recommended by the
Centers for Disease Control as appropriate. See Attachment A: Universal Precautions B Centers
for Disease Control. Protective gloves will be available in a conspicuous location in every
Catholic Charities program. Using Universal Precautions in all instances helps to prevent the
spread of all types of infectious diseases, including AIDS. It also eliminates the perceived need
to know who is infected in order to prevent the spread of the infection. Please see Policy and
Procedure for Blood-Borne Pathogen Control (AP-2.07) for additional information.
Designated Staff Members
Decisions regarding the implementation of this policy within each program of Catholic Charities
will be addressed utilizing the existing supervisory channels. A system of designated staff
members will be utilized in order to ensure the appropriate implementation of this policy, and to
address problems as they arise. Refer to attached job descriptions for program and agency
designated staff members. Each Catholic Charities Division Director, or his/her designee will
assume the role of the program designated staff member. Catholic Charities' Executive Director,
or his/her designee will assume the role of the agency designated staff member. An HIV/AIDS
Policy Review Committee will be a resource for the designated staff members. The committee
will be comprised of the agency and program designated staff members and other individuals as
appropriate. The committee will meet at least annually to review the policy in relation to
problems with implementation, and to make recommendations regarding policy changes based
on new knowledge about HIV/AIDS or any changes in the law.
Competency and Informed Consent
Clients, or in appropriate circumstances, their legal representatives must give specific, written
informed consent to disclosure of HIV-related information. The only exceptions to this rule are
identified in Sections VII, VIII, and IX.
If the HIV-related information concerns a family member or partner, then the family member or
partner must give specific, written consent to any disclosures.
The Catholic Charities Authorization to Release Records form must be completed prior to the
release of any HIV information. The only exceptions to this are identified in Sections VII, VIII,
and IX.
Adults are presumed to be legally competent to give or deny consent to disclosure of
information, unless they have been adjudicated incompetent to make this type of health care
decision. If a substitute decision maker has been appointed to make such a health care decision,
specific, written informed consent must be obtained from that individual.
With the exceptions noted above, infants and children under 12 do not have legal authority to
consent to disclosure of HIV-related information. Only the parent(s), legal representative, or
others defined by N.J.S.A. 26:5c-9 generally have this authority. N.J.S.A. 26:5c-5 defines a
"minor" as a person under 12 years of age. A client age 12 and over thus must be regarded as an
32
adult whose HIV-related information cannot be disclosed to anyone (including parents) unless
the client gives the prescribed written consent. As to children under age 12 written consent by
their parents, guardians or other legal representative is required for any disclosure of HIV-related
information.
When consent is required for disclosure of the record of a minor who has or is suspected of
having AIDS or HIV infection, consent shall be obtained from the parent, guardian, or other
individual authorized under State law to act in the minor's behalf.
Clients have the right to disclose information about themselves to anyone they choose, including
other clients. Some clients, however, because of emotional or cognitive impairments, or age, may
not understand or appreciate the potential consequences of disclosure. Therefore, staff members
should counsel clients about the potential risks of disclosure.
Clients, or their legal representatives, shall be informed of the agency's policy concerning access
to and disclosure of information when admitted or upon application for services. The AIDS
Policy Statement form will be signed by every client upon intake, or by his/her legal
representative. This form is included at the end of this policy.
Clients, or their legal representatives, shall be advised orally and in writing that legal and
advocacy services are available, or will be made available if they want such assistance.
Documentation of any referrals will be made and maintained by the agency.
Access to and Disclosure of Information Within A Program and/or Within Catholic
Charities
Individuals covered by this policy cannot gain access to HIV-related information, nor disclose
this information to anyone else within the agency or the program, unless the client (or his/her
legal representative) has authorized access/disclosure by completing an HIV Consent To
Disclose form. Similarly, access to or disclosure of HIV-related information about a client's
family member or partner is prohibited unless consent is received from the family member or
partner. Disclosure will be made without written consent only to qualified treatment personnel
who are directly involved in addressing issues/services regarding the clients HIV/AIDS status.
Initially, treatment personnel will include the designated staff member, the employee who first
became aware of the clients HIV/AIDS status, and the employee's direct supervisor. Further
disclosures will be determined by the designated staff member.
If the HIV Consent To Disclose form is not completed, then no reference will be made in the
client's file regarding the client's HIV status.
For those clients who have not authorized disclosure of HIV-related information to program
staff, a separate log will be kept to record all HIV-related information and interventions. This log
will be kept by the program designated staff member in a discrete, confidential location.
To avoid accidental disclosures, HIV-related information must not be discussed in common
areas, such as hallways and elevators, or in the presence of other clients, and records or computer
screens must never be left unattended.
33
Written records or computer files that are generally available to agency staff must not be labeled
or segregated in a manner that could lead to its identification as containing HIV-related
information.
Extra-Agency Disclosure of Information (i.e. outside of Catholic Charities)
Disclosure of HIV-related information to outside agencies or individuals requires the client's
specific, written consent, except if a) the client lacks the capacity to give informed consent, and
b) disclosure of HIV-related information is necessary to protect the client's health from imminent
harm, and the urgency of providing treatment precludes getting consent from a substitute
decision maker.
All written disclosures of HIV-related information will be accompanied by a written statement
prohibiting the person or agency from re-disclosing this information to anyone else without the
client's consent. All oral disclosures of HIV-related information will be accompanied by an oral
warning against re-disclosure, and a written notice against re-disclosure should be sent within
one working day. Use of the HIV Consent To Disclose form meets this requirement.
All disclosures will be noted in the client's records and will include the following information:
1) The date of disclosure; 2) contents of the disclosure; 3) recipient of the disclosure; 4) type of
authorization (i.e. whether the client gave specific, written consent or the disclosure was
statutorily mandated); and 5) an indication that notification against re-disclosure was made. The
client's signed HIV Consent To Disclose form authorizing disclosure must be included in his/her
record. Clients shall be informed of all disclosures made pursuant to medical emergencies or
mandatory disclosure provisions.
Notification of Sexual or Needle-Sharing Partners Reference Duty to Warn Policy
In an effort to assist clients and their partners in understanding HIV infection and ways to protect
themselves from contracting the virus, the agency will conduct HIV risk reduction educational
efforts for clients and their partners, as appropriate.
Staff members or others listed in Section III who learn that a client may be placing his/her
current sexual or needle-sharing partner at risk of contracting HIV must immediately contact the
program's designated staff member who will determine if a significant risk of transmission exists
after consulting with medical personnel and other individuals, as appropriate, who are qualified
to assess the situation. Consultation will take place with the agency designated staff member, as
appropriate. In these consultations, the designated staff member must not disclose the client's
identity unless the other individuals have access to HIV-related information through one of the
mechanisms described in Sections VII, VIII, and IX. The program's designated staff member will
meet with the client, if necessary.
If the program's designated staff member determines that a significant risk of transmission does
not exist, no further action is required.
If the program's designated staff member determines that a significant risk of transmission exists,
he/she will consult with the agency designated staff member and will:
1. Arrange for the client to receive appropriate HIV risk reduction education and training, and
counseling on (a) the need to cease engaging in risky behaviors, and (b) the necessity of
34
disclosing his/her HIV status to his/her partner (with subsequent confirmation by the
counselor).
2. Offer the client the option of having the counselor or someone else of the client's choosing
disclose, or assist the client with disclosure of the client's HIV status to the partner,
preferably at a joint counseling session. If the client chooses a staff member, and this course
of action is an appropriate role for the staff member, the client must give special permission
which will be noted in the file that states that the client asked the staff member to disclose, or
assist the client in disclosing, the client's HIV status to the partner.
If the client refuses to disclose or authorize disclosure of HIV status to his/her partner, or if
the agency designated staff member has reasonable grounds to believe that the client will not
inform the partner, then the agency designated staff member will consult immediately with
an attorney, as per agency policy, who can review the agency's legal obligations and options
available, and advise any future action.
Every step in this process will be noted in the client's records, if an HIV Consent To
Disclose form is signed. If this form is not signed, the information will be noted in a
separate log, not in the client's file. Documentation will include the reasons for the
chosen course of action, individuals with whom the designated staff member consulted,
and the procedures followed in making decisions.
Catholic Charities As An Employer
Discrimination
The New Jersey Law Against Discrimination (LAD) prohibits employment discrimination based
on physical or mental handicap or a perception of handicap. Any person infected with HIV is
considered "handicapped" under the LAD. Employees with identified HIV related medical
conditions that impair their health and ability to perform safely and effectively should be handled
in a manner consistent with other serious or life-threatening illnesses and the personnel policies.
Catholic Charities will not discriminate in any manner in hiring and job assignment practices
against known HIV exposed or HIV infected employees.
Scientific and epidemiological evidence reports that the kind of person-to-person contact that
generally occurs among workers and clients or consumers in the work place does not pose a risk
for the transmission of HIV. All employees who are HIV infected should be allowed to retain
their employment and benefits. All employees are encouraged to know their HIV status.
All HIV infected employees should, if they choose, continue to work to the fullest degree
possible as long as they are physically and mentally able to perform their job. The relevant
standard is job performance, which should be applied fairly and consistently to all employees.
If it becomes necessary to modify job assignments because of increasing disability, reasonable
accommodations should be undertaken.
35
Confidentiality
Medical records may not be disclosed without the consent of the subject employee, by order of a
court, or where disclosure is mandated by law. Any information relating to an employee's HIV
status will be considered to be confidential. Please refer to the Personnel Manual for further
information.
Directors, supervisors, coordinators, and other employees involved in making and implementing
personnel management decisions involving employees who reveal medical information about
themselves, including their HIV status, must strictly observe applicable privacy and
confidentiality requirements.
Education and Training
Catholic Charities, recognizing that education is one of the most effective means of preventing
the spread of HIV/AIDS and of dispelling fears associated with the disease, shall make available
to it's employees current, accurate and objective information concerning HIV/AIDS.
All Catholic Charities employees will receive mandatory training regarding the implementation
of this policy. Board members, volunteers, and interns will be encouraged to attend as well.
Employees will sign a statement indicating that they have received this training, understand the
policy, and agree to follow it.
Training sessions will be held prior to the initial implementation of this policy. Thereafter, all
new employees will receive this training individually as part of the orientation provided by each
program for new staff members. Information about this policy will also be presented at the
agency's orientation session for new employees.
Education and training regarding HIV/AIDS information and issues will be provided as needed
to all employees of Catholic Charities, as determined by the HIV/AIDS committee.
Leave Administration
Requests for leave shall be handled in a manner consistent with any request for leave that arises
from any medical disability.
Employee Conduct
1. In situations where employees express reluctance or refusal to work with HIV infected
clients or employees, management shall deal with these problems through appropriate
counseling and education.
2. If the employee continues to express reluctance or refusal to work with HIV infected clients
or employees and/or the employee's behavior threatens the safety, order or direction of the
work of the agency, the employee is subject to corrective/disciplinary action.
36
Penalties For Unauthorized Disclosure
Under federal and state law, the agency and any individuals covered by the Confidentiality
Policy are subject to civil liability, for breaches of confidentiality of HIV-related information.
Violations of any of the procedures required by this policy will be considered grounds for
disciplinary or other actions. Sanctions may include reprimand prohibition from further access to
HIV-related information, or termination of employment.
Program Designated Staff Members
Each Catholic Charities Division Director, or his/her designee will assume the role of the
program designated staff member.
These individuals will have the specific duties outlined below:
1. Coordinate the provision of HIV risk reduction education to clients and meet with HIV
positive clients if needed to coordinate services.
2. Disseminate up-to-date information regarding HIV/AIDS to staff members.
3. Address questions on access to and disclosure of HIV-related information.
4. Oversee the implementation of this policy within the program.
5. Consult with the agency designated staff member as needed when questions regarding this
policy arise which require further exploration or legal interpretation.
7. Keep a separate case log for each HIV positive client who has not authorized release of this
information within the program. The case logs will be strictly confidential records of each
HIV-related interaction/intervention. Entries will be made by the program's designated staff
member, or appropriate staff members (i.e. the staff person to whom the client disclosed their
HIV positive status).
8. Be a member of the HIV/AIDS Review Committee.
Agency Designated Staff Member
Catholic Charities' Executive Director, or his/her designee will assume the role of the agency
designated staff member.
This individual will have the specific duties outlined below:
1. Implement the personnel-related aspects of this policy and oversee the implementation of this
policy agency-wide.
2. Maintain the confidentiality of employees who disclose their HIV status.
3. Serve as chairperson of the HIV/AIDS Review Committee.
37
4. Act as a resource person, collecting and disseminating information to the program designated
staff members.
5. Coordinate as needed training of the staff in each county regarding HIV/AIDS.
6. Provide consultation to program designated staff members as needed.
8. Contact the agency's attorney when legal advice is required.
Approved 5-87
Revised and approved 1-01
Revised and approved 3-03
Revised and approved 12-03
Revised 12-04
Approved 6-05
38
Attachment to
AP-2.04
Administrative Policies and Procedures
UNIVERSAL PRECAUTIONS – CENTERS FOR DISEASE CONTROL
Since medical history and examination cannot reliably identify all patients infected with HIV or
other blood-borne pathogens, blood and body fluid precautions should be consistently used for
all clients. This approach previously recommended by Centers for Disease Control CDC (3, 4)
and referred to as “universal blood and body-fluid precautions” or “universal precautions” should
be used in the care of all patients, especially including those in emergency-care settings in which
the risk of blood exposure is increased and the infection status of the patient is usually unknown
(20). August 21, 1987.
Purpose: To prevent or minimize contamination and transmission of infection among clients, the
environment, and personnel by direct or indirect contact with infective blood or body fluids.
Policy: Blood and body fluids from all clients and personnel are to be considered potentially
infectious. When contact with blood or any other fluids is anticipated or actual, appropriate
barrier precautions must routinely be used by all personnel to prevent skin and mucous
membrane exposure.
Definitions
1. Barrier technique: The use of items to interrupt the transmission or organisms from one
source to another. Example: gloves, masks, gowns, goggles, sharp containers, etc.
2. Body fluids: Blood, feces, urine, semen, vaginal secretions, drainage from wounds, sputum,
etc.
Procedures
1. All workers should routinely use appropriate barrier precautions to prevent skin and mucousmembrane exposure when contact with blood or other body fluids of any patient is
anticipated. Gloves should be worn for touching blood and body fluids, mucous membranes,
or non-intact skin of all patients, for handling items or surfaces soiled with blood or body
fluids, and for performing venipuncture and other vascular access procedures. Gloves must
be changed after contact with each patient. When removing gloves, peel cuff down, keeping
the contaminated side inside, and place them in the designated, contaminated waste
receptacle. Hands must be washed after removing gloves. A vigorous 15 to 20 second
rubbing together of lathered hands under running water is recommended. If hands are visibly
soiled, more time may be required for hand washing. Hand washing is the single most
important means of preventing the spread of infection. Gowns or aprons should be worn
during procedures that are likely to generate splashes of blood or other body fluids. Soiled
gowns should be placed in the designated contaminated waste receptacle.
2. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated
with blood or other body fluids. Hands should be washed immediately after gloves are
removed.
39
3. All workers should take precautions to prevent injuries caused by needles, scalpels, and other
sharp instruments or devices during procedures; when cleaning used instruments; during
disposal of used needles; and when handling sharp instruments after procedures. To prevent
needle stick injuries; needles should not be recapped, purposely bent or broken by hand.
After they are used, disposable syringes and needles, scalpel blades, and other sharp items
should be placed in puncture-resistant containers for disposal; the puncture-resistant
containers should be located as close as practical to the use area. Large-bore needles should
be placed in a puncture-resistant container for transport to the reprocessing area. A certified
waste disposal company will pick up sharp containers and waste.
4. Although saliva has not been implicated in HIV transmission, to minimize the need for
emergency mouth-to-mouth resuscitation, mouthpieces, should be available for use in areas
in which the need for resuscitation is predictable.
5. Workers who have exudative lesions or weeping dermatitis should refrain from all direct
patient care and from handling patient care equipment until the condition resolves.
6. Contaminated waste should be collected by a certified waste collection agency.
7. Body Fluid Spills: Gloves must be worn for cleaning up body fluid spills. Dispose of paper
towels, etc. in contaminated waste receptacle. Clean area with hot water with detergent,
followed by wiping with a bleach solution. A solution of bleach and water in a concentration
of one part bleach to 10 parts water can be mixed at the time it is required to clean the area.
The solution must be discarded after use or within 48 hours. Spill kits are available at the
nurse’s office and/or supervisor’s office.
Implementation of universal blood and body-fluid precautions for all clients eliminates the need
for use of the isolation category of “Blood and Body Fluid Precautions” previously
recommended by CDC (7) for patients known or suspected to be infected with blood-borne
pathogens. Isolation precautions (e.g. enteric, “AFG” [7]) should be used as necessary if
associated, such as infectious diarrhea or tuberculosis, are diagnosed or suspected.
40
AP-2.05
Administrative Policies and Procedures
POLICY AND PROCEDURE FOR
AIRBORNE PATHOGEN INFECTION CONTROL
Policy
All employees in high-risk facilities will receive a Mantoux test within the first week of
employment and annually thereafter. All employees in high-risk areas will receive training on
TB.
The Agency Airborne Pathogen Infection Control Policy is designed to reduce the risk of
exposure to persons with infectious TB. These measures will include implementing effective
workplace controls, effective training and counseling, plus the screening of employees for TB
infection and disease. This policy will be based on risk assessment in all work areas and/or work
groups, and will apply to areas of the agency that are deemed to be at high risk regarding the
potential exposure to TB infection.
Procedure
Testing
All employees within high-risk areas will receive a one step base-line Mantoux tuberculin skin
test within the first week of employment. In addition, all employees who are exposed to a client
with active TB will be tested.
Re-testing of employees shall be done annually with a one step Mantoux test.
Employees shall be exempt from any testing if they present documentation of a prior reaction
following a Mantoux test, prior or present TB disease, or previous adequate preventive therapy.
Administration
The result of the employee Mantoux TB test will be maintained in confidential medical files. The
employee will be notified immediately of the results of the TB test by the appropriate nursing
staff. If positive, the employee will immediately be referred for chest x-ray to confirm the
diagnosis. The employee will be excluded from work until a diagnosis of active TB is ruled out
or confirmed, the employee treated and subsequent tests prove that the employee is no longer
infectious.
Employees with active TB pose a risk to clients and other employees and it is the policy of this
agency that these employees will be excluded from the workplace until the treating physician
certifies in writing that the employee is free from active disease.
41
High Risk Areas





Residential programs
PACT programs
Substance abuse services
HIV programs
Partial care programs
Training
On an annual basis employees in a high risk facility will receive education provided by the
appropriate nursing staff or the Health Department, regarding TB infection, signs and symptoms
of TB and the possibility of re-infection, the potential for occupational exposure including
information on the prevalence of TB in the community.
Training will include discussion of administrative controls including management of clients with
infectious TB.
Education will be provided on infection control practices that reduce the risk for transmission of
TB.
Follow up
This policy will be reviewed annually to determine its effectiveness in dealing with TB infection
control.
Approved 7-96
Revised and approved 11-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
42
AP-2.06
Administrative Policies and Procedures
POLICY AND PROCEDURE
FOR BLOOD-BORNE PATHOGEN CONTROL
General Purposes
In accordance with OSHA regulations Catholic Charities is committed to protect those
employees who are at risk for exposure to blood-borne pathogens through the performance of
occupational tasks and to provide appropriate treatment and counseling should an employee be
exposed to blood-borne pathogens.
Policy
Catholic Charities is committed to minimize risk for exposure to blood-borne pathogens (BBP);
to provide ongoing training to all employees to reduce exposure to BBP and to establish
appropriate work practices. By doing so, a cohesive effort will help to prevent the occurrence of
work-related illness and injuries due to BBP exposure.
Hepatitis B - Caused by Hepatitis B virus (serum).
Contamination is usually spread by infected blood or blood products and
close interpersonal contact (sexual contact and/or sharing of toothbrushes,
razors). This is a more serious form of hepatitis and can be fatal. Onset of
this illness is usually insidious and may not be diagnosed in early stages.
Hepatitis C - Often called “Non-A, Non-B”. Hepatitis B, Hepatitis C and HIV are
spread through contact with contaminated blood or body fluids that
contain blood.
Parenteral - includes human bites that break the skin, any blood to blood,
blood to mucous membrane exchange (i.e. needle stick, handling of
infectious material with broken skin).
Procedure
Methods of Compliance:
1. Universal Precautions
Universal precautions must be observed throughout the agency to prevent contact with
possible hazardous material. All clients are to be treated as if they are infectious and any
contact with blood or body fluids may result in contamination. For more information on
universal precautions see Attachment to AP-2.05.
2. Engineering Controls
The following engineering controls are available and used throughout the agency:
43
2.1 Hand-washing facility: Each facility provides an antiseptic hand cleaner or antiseptic
towelette for proper hand cleansing following exposure.
2.2 Rigid leak proof containers, labeled with a biohazard warning sign, for placement and
disposal of contaminated needles and sharps are provided.
2.3 Vinyl or latex gloves are provided as personal protective equipment.
2.4 Gowns are provided as personal protective equipment (Reference: AP-2.05).
3. Work Practice Controls
3.1
Recapping, bending, or breaking contaminated needles is strictly prohibited.
3.2
All employees must wash hands immediately after removal of any Personal
Protective Equipment (PPE).
3.3
Following any contact of a body area with any infectious material, hands must be
washed. Mucous membranes are to be flushed with water if exposed to infectious
material.
3.4
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact
lenses is prohibited in work areas where there is a reasonable likelihood of exposure.
3.5
Food and drink must not be stored or kept in refrigerators where blood or potentially
infectious materials are kept.
3.6
Any work-surface area which may have blood exposure must be cleaned with a
bleach solution immediately after the exposure by the nurse or housekeeping
personnel. The first person to see spill should initiate this containment procedure.
3.7
Any employee with an exudative lesion or weeping dermatitis shall refrain from
client contact or handling patient-care equipment until the condition resolves.
3.8
Broken glassware may only be removed or cleaned up by use of a mechanical means,
i.e. dustpan and brush, vacuum, forceps, or tongs.
3.9
Contaminated laundry is handled as little as possible. Gloves must be worn when
handling contaminated laundry. Contaminated laundry is placed in contaminated
waste container.
3.10
Disposable gloves are not reused. Gloves are place in contaminated waste container.
3.11
Waste receptacles are cleaned and disinfected on an as-needed basis utilizing PPE.
4. Personal Protective Equipment
The following work practices help to utilize this equipment effectively:
44
Gloves are worn:
 Whenever hand contact with potentially infected material is anticipated (emptying
trash, handling soiled linen, etc.).

Whenever a vascular access is performed (i.e., venipuncture, injection).

When working with, handling or touching a contaminated item or
work surface.
Post Exposure Plan
Even with the best adherence to exposure prevention practices, incidents can still occur. With
this in mind, Catholic Charities has established the following exposure evaluation and follow-up
plan.
Any exposure incident means a specific eye, mouth, or other mucous membrane, non-intact skin
or parenteral (piercing the skin or mucous membrane) contact with the blood, infectious waste,
or other potentially infectious material that results from the performance of an employee’s duties.
In the event an employee is involved with a blood-borne pathogen exposure, the following
procedure should be implemented:
1. A supervisor’s accident report will be completed and submitted to the Human Resources
Department within 24 hours of an exposure.
2. In the event of an exposure, the exposed employee will be offered to be serologically
evaluated for evidence of HIV, HBV. The source client will be asked to also be tested, upon
their consent.
3. Once this information is collected, the employee will be scheduled with a health care
professional to discuss the employee’s medical status. If the employee tests negative, the
employee will be re-checked in six weeks and then again periodically for six months to
determine if seroconversion has occurred.
4. If the source client is negative, no further follow-up will be required. However, if the client is
a high risk, a re-check should be done in 12 weeks.
5. Post exposure treatment and prophylaxis will be done in accordance with the current
recommendations of the Centers for Disease Control or Public Health Services.
6. The medical records of these employees will be kept confidential. We will not disclose a
report of this information, except as required by law, without the employee’s consent.
Blood-borne Pathogen Training
All employees are required to receive training on Blood-borne Pathogens yearly. Any employee
change in job classification will be given any additional training their new position requires, at
the time of the new assignment.
Approved 3-03
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
45
AP-3.01
Administrative Policies and Procedures
PERSONNEL REQUISITION PROCEDURE
The purpose of the Personnel Requisition Procedure is to improve the efficiency of recruiting
and hiring agency staff. The Personnel Requisition itself, is a four-part form that is maintained
by the Human Resources Department.
Care should be taken in completing the form. It is suggested that a photocopy of the form be
filled out as a rough draft prior to the completion of the requisition.
The following procedure must be followed when initiating a Personnel Requisition.
1. As vacancies that are to be filled occur, complete the upper half of the personnel requisition
form and forward it to the Human Resources Department. The form should be completed in
full as the information supplied will be used for payroll purposes and for posting job vacancy
notices throughout the agency. Please be sure to include the program number to be charged
and indicate the grade level along with the salary.
2. Upon approval of the requisition, the Human Resources Department will retain one copy and
return the approved requisition to the initiating department. The program then has permission
to recruit. If approval is not granted this will also be verified.
3. Verbal approval to recruit may be obtained from the Personnel Director in situations where
an employee has resigned and you are looking to replace that individual. Personnel
Requisition Form still must be completed.
4. When a final candidate is chosen, the request to hire portion of the form is to be completed
and submitted to the Human Resources Department with the application and/or resume, W-4
form and an I-9 form. Upon approval, a copy of the requisition will be returned to the
initiator verifying approval to hire. A copy of the approved form will also be forwarded to
the Payroll Department along with the payroll advice for their records.
Please also refer to AP-3.011, Procedure for Staff Recruitment and Hiring
Approved 2-83
Revised and approved 12-92
Revised and approved 3-97
Reviewed 12-04
Approved 6-05
46
AP-3.011
Administrative Policies and Procedures
PROCEDURE FOR STAFF RECRUITMENT AND HIRING
Policy
Maintaining appropriate staff levels through the recruitment, hiring and retention of suitable
personnel is the responsibility of the Division Director or the hiring manager designated by the
director. In the case of Central Administrative Services, the Executive Director or his/her
designee shall be the responsible party.
Procedure
1. When a vacancy occurs a Personnel Requisition shall be submitted to the Human Resources
Department (see AP-3.01, Personnel Requisition Procedure). Once the requisition is
approved, the Human Resources Department will prepare an internal Notice of Position
Vacancy to be posted in each agency office in a conspicuous location for a minimum of 5
working days. The initiating department may begin recruiting a staff replacement in
accordance with the following steps.
2. The Division Director should check the file of applications in the Human Resources
department for a list of possible candidates who meet the qualifications for the position
outlined in the job description. If no suitable candidates are available, the Division Director
will prepare an advertisement for publication and place the ads as deemed necessary.
3. The Division Director will review all resumes submitted in response to the ads and
correspond with the applicants as appropriate.
4. The Division Director will select those applicants who, by a review of the material they
submit, seem best qualified and arrange for an employment interview. On that date the
applicant must complete an Application for Employment and submit a resume as appropriate
to the position. Applicants will also be asked to sign a Consumer Report and Disclosure
Authorization form and be given a copy of the Summary of Rights Under the Fair Credit
Reporting Act.
5. Upon completion of all required paperwork and the interview process, the Division Director
will have sole discretion in selecting a candidate for hire. Prior to the offer of employment
the Division Director will check at least three (3) employment references. In cases where
employment references are not available, due to lack of experience personal references may
be substituted to reach the required three (3) references. In addition, the Human Resources
Department will conduct a verification of previous employment whenever necessary.
6. When ready to make an offer the Division Director must contact the Human Resources
Department to discuss a possible start date. When approval has been granted the Division
Director will make the tentative job offer and upon acceptance by the candidate proceed to
assemble all employment documentation.
47
7. Upon verbal acceptance of the position, prospective hires will receive a new hire letter from
their Division Director confirming their verbal acceptance and clearly stating the position,
department, grade, annualized salary or hourly rate of pay and start date. Applicants who are
rejected for any reason will receive a letter to that effect from the Division Director.
8. All pre-employment paperwork must be completed and submitted with the Personnel
Requisition to the Human Resources Department in a timely manner at least two weeks prior
to the applicant’s start date. Documents to be completed are: Employment application, I-9
Employment Eligibility Verification, W-4 form, signed Confidentiality Statement, signed
copy of Consumer Report and Disclosure Authorization form, signed copy of job description,
verification of employment references, 3 work related references, copy of original
degree/licenses, with signed verification forms as appropriate.
9. Upon receipt of the completed Personnel Requisition and pre-employment paperwork, the
Human Resources Department will run the following checks: Criminal background check,
credential, license and previous employment verifications. If these checks are favorable the
new hire will be processed and a hiring packet prepared for distribution to the respective
hiring manger. If the checks are not favorable the Division Director will be informed and a
decision made regarding the withdrawal of the offer of employment. New hires may not
begin employment until this process is complete.
The procedure outlined is only an outline and is, of course, not meant to restrict the Division
Director’s discretion in the ordering of events. It may be practical to schedule several of these
procedural steps for the same day or in different order. However, each of these steps is
considered essential and must be followed as a matter of procedural imperative.
Approved 2-83
Revised and approved 12-92
Revised and approved 7-97
Revised and approved 8-98
Revised and approved 3-03
Revised and approved 12-03
Revised 12-04
Approved 6-05
48
Attachment to
AP-3.011
Administrative Policies and Procedures
NOTICE OF POSITION VACANCY
Position: ______________________________________________________________________
Grade: _______________________________
Brief Description: _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Requirements:__________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Department or Program: _________________________________________________________
Date Available: ________________________
Contact: ______________________________________________________________________
49
AP-3.012
Administrative Policies and Procedures
POLICY AND PROCEDURE FOR THE REVIEW OF AGENCY JOB DESCRIPTIONS
Policy
It is the policy of Catholic Charities to review its job descriptions and selection criteria at least
every two years to ensure that:
1. Education and experience requirements are relevant and appropriate to the organization’s
programs, consumer needs, and specific services provided; and
2. Qualifications or credential are reasonably related to the level of competence required for the
tasks involved.
The Human Resources Department is responsible for the overall coordination of this review.
Procedure
Human Resources will maintain all current job descriptions in a central location, sorted by
division.
Each job description will be date stamped with the date of the last review not to exceed a period
of two years.
Job descriptions that require review will be forwarded to the appropriate Division Director, who
will determine if any changes to the job description are required. The changes will be made at the
Division level and then forwarded to the Human Resources Department for final review and
approval. The reviewed job description will then be placed in the centralized binder located in
the Human Resources Department.
New job descriptions forwarded to Human Resources that are part of a Personnel Requisition
will be reviewed, date stamped, and placed in the job description binder for future reference.
Job descriptions that are no longer current will be removed from the active list of job
descriptions and filed for a period of one year, after which they may be discarded.
All employees are required to sign their job description at time of hire. Any time a current staff
member changes jobs, or the job description changes he/she must sign a new job description
upon acceptance of the position.
Approved 12-01
Revised and approved 3-03
Revised 12-04
Approved 6-05
50
AP-3.02
Administrative Policies and Procedures
POLICY ON LICENSING AND CREDENTIALS
Policy
All professional staff shall maintain current license status and this status will be reviewed and
verified upon hire and every year thereafter. In addition, all staff will be required to present proof
of educational credentials upon their hire, as required by the position they hold.
Procedure
1. Licensure
1.1
All professional employees of Catholic Charities shall be licensed to practice that
profession when hired to a position that requires licensing.
1.2
All psychiatrists employed or otherwise engaged by Catholic Charities shall be
licensed to practice medicine in the State of New Jersey, and shall be Board certified
or Board eligible in at least one psychiatric specialty.
1.3
All nurses hired to perform nursing functions shall be licensed as such to practice in
the State of New Jersey.
1.4
All professional licenses shall be verified and documented at the time of hire by
viewing the original license of the applicant and completing the verification of license
form with the original signature of the appropriate supervisor who viewed the
documents. This form will then be forwarded to Human Resources for inclusion in
the employees personnel file.
1.5
In addition to the sign off form, the Human Resources Department will also conduct
primary source verification of all professional licenses. The completed verification
shall be placed in the employee’s personnel file.
1.6
The Human Resources Department will conduct an annual verification of all
professional licenses to ensure that they are valid.
1.7
Employees are required to notify Human Resources of any change in the status of
their professional license.
2. Education
2.1
All educational credentials required by the position shall be verified at time of hire for
all staff by viewing an original copy of the educational credential, and completing the
verification of education form with the original signature of the appropriate
supervisor who viewed the documents. This form will be forwarded to Human
Resources for inclusion in the employees personnel file.
51
2.2
The Human Resources Department will conduct primary source verification of
educational credentials for all professional staff. The completed verification will be
placed in the employees personnel file.
Employment may be offered contingent on the successful completion of this verification process.
Approved 7-97
Revised and approved 8-98
Revised and approved 12-03
Revised 12-04
Approved 6-05
52
AP-3.03
Administrative Policies and Procedures
CRIMINAL HISTORY BACKGROUND CHECKS AND DISCLOSURE POLICY
Policy
In carrying out its mission Catholic Charities includes a special and careful concern for the well
being of the client population it serves. In hiring employees and encouraging the participation of
volunteers, the agency understands the need for a thorough screening process to closely examine
the background of individuals who seek positions that have contact with vulnerable service
recipients. This policy establishes the background screening process that will be used for all
employees joining the organization and for those volunteers that have direct contact with
children.
Procedure
1. Criminal Conviction Disclosure
1.1 Catholic Charities shall require (at the time of application) all applicants for employment,
and volunteers, to disclose criminal conviction in writing as indicated on the
employment/volunteer application form.
1.2 Applicants under consideration for hire are required to complete the “Authorization and
release for the procurement of a consumer and/or investigative report” form.
1.3 The information provided by the applicant regarding criminal conviction disclosures will
be verified as follows:
2. Criminal History Background Check.
2.1 Prior to commencing employment the agency will conduct a criminal history background
check on each applicant who has been extended an offer of employment.
2.2 The background check will consist of a review of state criminal conviction records by an
independent contractor, who will then provide a report to the agency within 72 hours of
the date requested.
2.3 All offers of employment are contingent on the outcome of this review process.
2.4 Falsification of a criminal conviction record on the employment application will result in
the withdrawal of the employment offer and/or termination of employment.
3. Fingerprint Criminal History Background Check
3.1 Employees and volunteers, who are covered by the following definitions, are required to
undergo a fingerprint criminal history background check in addition to the criminal
records review screening process.
53
3.1.1
An employee who, by the nature of his/her job description or in actual
performance of duties, maintains substantial and direct interaction with children
on a consistent basis; or has, or could have, individualized contact with children.
3.1.2
A volunteer who provides uncompensated services to the agency who by the
nature of his/her assigned duties, maintains substantial and direct interaction with
children on a consistent basis; or has, or could have, individualized contact with
children.
3.2 In applying these definitions, these additional considerations should be kept in mind. For
employees or volunteers, if interaction with children is limited to a group setting and is
not longer than one or two hours per week, a fingerprint criminal history background
check is not required. However, if there is a potential for individualized contact,
particularly if the interaction with children will involve overnight activities, the
background check will be required.
3.3 Procedure
3.3.1
The New Jersey law on criminal background checks is based on a fingerprint
record check that has two parts: A New Jersey State background check; and a
Federal background check.
3.3.2
When an employee or volunteer affected by this policy is identified the
Supervisor will request a State and Federal fingerprint card from the Human
Resources Department.
3.3.3
The Human Resources Department will issue the appropriate fingerprint cards
with the required registration numbers filled in, to the Supervisor.
3.3.4
The Supervisor will instruct the prospective employee/volunteer to take the cards
to their local police department for fingerprinting. It is suggested that the local
police department be called in advance to obtain an appointment for
fingerprinting. A maximum of two weeks is allowed for this process.
3.3.5
The completed fingerprint cards must then be returned to the Human Resources
Department for processing and the preparation of all applicable fees, before
submission to the State Police.
3.3.6
Due to potential delays in the processing of fingerprint criminal history record
checks, an employee may begin work and a volunteer may begin to contribute
services each on a provisional basis while awaiting results.
3.3.7
The State Police Employee/Volunteer Review Operation will respond to the
agency in the form of a letter advising of the employee/volunteer’s eligibility
under the law.
3.3.8
The State Police will not qualify or disqualify an employee/volunteer. The State
Police will make a recommendation based on the law. The final decision to hire
an employee/volunteer rests with the organization that has requested the criminal
history check.
54
4. Disqualification of Employment
4.1 Evidence of conviction of a crime, in itself, shall not automatically disqualify an
applicant/volunteer for hire or terminate an employee/volunteer from his or her position.
Such determination shall be made on a case-by-case basis considering the relevancy of
the conviction to the nature of the position. Documentation of this must be filed in the
personnel file.
4.2 Prior convictions that may disqualify employment are as follows:
4.2.1
Offenses against persons (e.g. assaults, robberies, thefts, etc.);
4.2.2
Offenses involving drugs or controlled substances;
4.2.3
Offenses involving weapons, arson, or terrorist threats.
4.3 Convictions that are not included in the aforementioned categories may be subject to
review and not result in disqualification depending upon the factual circumstances. No
decisions to a disqualification should be made without consulting with agency counsel.
4.4 When evaluating criminal history records the agency may consider the following criteria:
4.4.1
Recency of and circumstances surrounding the conduct in question;
4.4.2
The age of the individual at the time of the offense;
4.4.3
Societal conditions that may have contributed to the nature of the conduct;
4.4.4
The probability that an individual will continue the type or behavior in question;
and
4.4.5
The individual’s commitment to rehabilitation and to changing the behavior in
question.
4.5 Convictions for crimes against children such as sexual abuse, rape, or other sexually
exploitive offenses constitute an unacceptable level of risk and will result in automatic
disqualification from employment.
5. Applicants Rights
Applicants have the right to be treated fairly and to have their privacy respected. For this reason
applicants should be given a chance to challenge the accuracy of the information the agency
receives. This can be accomplished by allowing the applicant to resolve any disputes with the
criminal justice agency from which the information was received. Until the agency receives a
correction from the criminal records depository, it will assume that the information already
received is correct. For employees/volunteers, the agency reserves the right to place the
individual on suspension pending the outcome of the dispute.
Approved 12-03 (Replaces 3.03, 3.031 approved 7-97)
Revised 12-04 approved 6-05
55
AP-3.04
Administrative Policies and Procedures
POLICY FOR HIRING IMMIGRANTS
Policy
Catholic Charities will check documents establishing the identity and eligibility to work at the
time of hire.
The Immigration Reform and Control Act of 1986 requires employers to check documents
establishing the identity and eligibility to work for all new employees, and to have a properly
completed I-9 form within three (3) working days from the date of hire.
If any of the above conditions are not met, an applicant is not eligible for hire.
Employees whose employment eligibility documents carry an expiration date, must renew the
document prior to expiration or face termination of employment.
Approved 12-86
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
56
AP-3.05
Administrative Policies and Procedures
POLICY AND PROCEDURE ON DIVISION DIRECTOR/DEPARTMENT HEAD
ORIENTATION
Policy
The Agency provides a comprehensive orientation program for Division Directors and
Department Heads. Administration and scheduling for the program is the responsibility of the
Human Resources Department.
The program consists of separate presentations for newly appointed Division Directors. The
orientation covers Agency policies and practices in detail. More than one day may be required to
complete the process.
Executive Offices
Executive Director
Division Directors will meet with the Executive Director to discuss the Agency's operations,
goals and objectives, and how agency policy is directed toward fulfilling them. Division
Directors will be oriented to their responsibilities and the specific line of Agency authority.
Executive Assistant
Division Directors will meet with the Executive Assistant to review the Administrative Policies
and Procedures Manual and to discuss other administrative services including the structure of the
Board of Trustees and the Advisory Boards.
The Executive Assistant will give the following material to the new employee:
 Annual Report
 Agency Service Directory
 Organization chart of the Diocese of Trenton
 Membership list of Board of Trustees
 Membership list of appropriate Advisory Board(s)
Community Affairs Department
Division Directors will meet with the Associate Executive Director/Community Affairs. An
overview of the services of the Community Affairs Department will be given along with the
procedures for using these services.
The Associate Executive Director/Community Affairs will give the following to the new
employee:
 Guidelines for printed material
 Guidelines for program-level and county-level development efforts
57
Fiscal Affairs Department
Division Directors will meet with the Associate Executive Director/Fiscal Affairs. An overview
of the services of the Fiscal Affairs Department will be given along with procedures for using
those services. In addition, there will be a thorough orientation on the budget process that will
include a detailed review of the current year's applicable program budget(s). The monthly Budget
Status Report will also be explained in detail. A review of funding contracts (as applicable) will
also take place. Program supervisors will receive a financial orientation from their Division
Director as appropriate.
The Associate Executive Director/Fiscal Affairs will give the following material to the new
employee:
 Copies of the current year's budget(s)
 Copies of the most recent Budget Status Report(s)
 Copies of applicable funding contracts
Human Resources Department
Division Directors will meet with the Personnel Director to discuss the new employee's own
benefits, salary, and other terms and conditions of his/her employment. The Personnel Policies
and Procedures will be reviewed. In addition, an overview of the services of the Human
Resources Department will be given, including a discussion of the new employee's supervisory
and managerial responsibilities in such personnel areas as performance evaluation, discipline and
grievances, and termination policies.
The Personnel Director will give the following material to the new employee:
 Personnel Policies and Procedures Manual
 Organization charts of all Agency programs
 Organization chart of entire Agency
 Directory of Division/Department staff
Approved 5-88
Revised and approved 4-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
58
AP-3.051
Administrative Policies and Procedures
POLICY AND PROCEDURE ON
DIVISION/PROGRAM/DEPARTMENT ORIENTATION
Policy
All new employees will receive a Divisional/Program/Department orientation using the outline
attached herein. All new employees will receive this orientation within 30 working days from the
date of hire.
Procedure
1. Each Division should designate an individual who will be responsible for ensuring that
orientation is provided to each new employee.
2. Upon completion of the orientation the employee will sign the attached form acknowledging
this fact. An original will then be forwarded to Personnel for inclusion in the Personnel File
of the employee.
3. As each item on the orientation is completed the person providing the orientation will check
off each item on the outline form in the box provided.
4. The employee sign-off of this form will also satisfy the sign-off requirement for the
HIV/AIDS training required of all new staff.
5. Completion of the training shall be certified by the appropriate Supervisory staff.
Approved 2-97
Revised and approved 12-03
Revised 12-04
Approved 6-05
59
Attachment to
AP-3.051
Administrative Policies and Procedures
DIVISION/PROGRAM/DEPARTMENT ORIENTATION OUTLINE
1. OVERVIEW OF AGENCY
Mission Statement
Agency overview, service directory, and organization chart
Annual report
Initial/date: _____
Initial/date: _____
Initial/date: _____
2. OVERVIEW OF DIVISION
Chart of Organization
Mission of the Division
Initial/date: _____
Initial/date: _____
3. INTRODUCTION TO WORK ENVIRONMENT
Tour of the Facilities
Department/Program Organization Chart
Introduction to Staff
Location of fire exits, alarms, extinguishers
Evacuation plan
Security/building access procedure
Parking
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
4. AGENCY AND DIVISION POLICY AND PROCEDURES
Confidentiality issues
Agency Policies and Procedures Manual
New hire packet - enrollment forms completion
Time sheets
Travel reimbursement
Time off requests/sick calls
Incident/accident reports
Service delivery issues
Customer satisfaction
Quality Improvement Program
Medical records policy
HIV/AIDS policy training
Divisional Communication procedures
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
5. EQUIPMENT
Telephones/voice mail
Copiers/FAX
Agency vehicles
Computers/e-mail
Initial/date: _____
Initial/date: _____
Initial/date: _____
Initial/date: _____
I _______________________________________________________ hereby acknowledge
(employee name)
that I completed the above orientation on ______________________.
(date)
Supervisor Certification ___________________________________ Date _________________
60
AP-3.06
Administrative Policies and Procedures
POLICY ON EVALUATIONS INVOLVING PROMOTIONS
Policy
Evaluations and/or requests recommending an employee for a promotion or for an additional pay
increase, other than the normal increment, must be cleared through the Human Resource
Department prior to any discussion with the employee involved.
Procedure
A memo outlining the request should first be submitted to the Human Resources Department.
When approved by the appropriate Associate Executive Director, a confirming copy will be
returned to the requester, who may then discuss the promotion and/or pay increase with the
employee.
Approved 10-80
Revised and approved 12-92
Revised and approved 4-97
Revised 12-04
Approved 6-05
61
AP-3.07
Administrative Policies and Procedures
POLICY AND PROCEDURE ON EMPLOYEE TERMINATIONS
Policy
This policy states the Agency's position with respect to termination of employees and provides
uniform guidelines for the administration of this policy.
Definitions
Definitions of the types of termination are as follows:
Layoff: A reduction in work force, either permanent or indefinite. Laid-off employees are
subject to recall at the Agency's discretion.
Discharge Due to Job Performance: Termination of employment on the initiative of the
Agency under circumstances generally related to the quality of the employee's performance,
whereby the employee is considered unable to meet the requirements of the job. In this case,
the employee is not eligible for re-employment.
Discharge, Disciplinary, Insubordination: Termination of employment on the initiative of the
Agency for reasons of misconduct, insubordination, job abandonment or willful negligence
in the performance of job duties such that the employee is not eligible for re-employment.
Retirement: Termination of active work by the employee at the age or under conditions as
set forth in the Diocesan Pension Plan, through which the employee receives retirement pay
and enjoys other benefits. Retirees are eligible for rehire.
Medical Disability Termination: Being no longer able to keep the employee's position open
while he/she is on disability leave. In this event a comparable position will be offered to the
employee, if available, when the disability ends. If no positions are available at that time,
then the employee will be eligible for unemployment compensation. Please refer to the
Manual of Personnel Policies and Procedures (section 7.051, Family Medical Leave Act, and
section 2.03, Americans with Disabilities Act) for further information.
Resignation: Termination of employment on the initiative of the employee. Employees are
expected to give notice in accordance with the policy on resignations as outlined in the
personnel manual. Employees who resign on the basis of "mutual agreement" must be further
identified to determine eligibility for unemployment compensation.
The termination of any employee for disciplinary and/or job performance causes must follow the
procedures as set forth in section 6.06 of the personnel manual. Nothing in this procedure is
intended to alter the at-will status of every employee, which means that Catholic Charities retains
the right to terminate an employee at any time for any reason.
62
Termination Procedures
It is the responsibility of the Division Director to ensure that the following is done:
1. Consult with the Human Resources Department prior to making a decision regarding an
involuntary termination. This will allow a full review of the situation to ensure that
Agency procedures have been followed and that supporting documentation is adequate to
support the termination. This is especially important in cases involving discharge due to
job performance or disciplinary reasons.
2. Obtain a letter of resignation from an employee who is leaving a position voluntarily.
Forward the letter to the Human Resources Department.
3. Notify the employee once a decision has been reached of the cause and date of the
termination.
4. Conduct an exit interview (when practical) with an employee who is voluntarily
terminating employment.
5. Prepare a memo stating the reasons and date of termination and forward this to the
Human Resources Department. In cases where an employee terminates his/her
employment without notice, inform the Human Resources Department immediately to
prevent possible overpayment of wages.
It is the responsibility of the Human Resources Department to:
1. Verify that Agency procedures have been followed in all termination decisions.
2. Provide the payroll office with information on the terminating employee through the use
of the payroll advice form.
3. Notify the IT Department of the termination via e-mail.
4. Ensure that letters of resignation are received for those employees terminating
employment voluntarily.
5. Provide appropriate unemployment compensation information and forms to employees
who are being laid off.
6. Conduct exit interviews (when practical) with resigning employees. Exit interviews must
be conducted with resigning employees at Grade 10 or above.
It is the responsibility of the Payroll Office to:
1. Verify that the terminating employee has no financial liabilities to the Agency.
2. Issue a final paycheck upon completion of all termination procedures in accordance with
the payroll advice form.
63
It is the responsibility of the Information Technology (IT) Department to:
1. Disable access to all Catholic Charities, Diocese of Trenton information, and e-mail
systems (upon notification from the Human Resources Department).
2. Provide appropriate manager with access to terminated employee’s e-mail for review
(prior to final deletion of the employee’s e-mail account and all e-mail contained therein).
3. At the request of the appropriate manager, inspect terminated employees computer
system(s) to ensure integrity of any stored information. This inspection will be conducted
with the assistance of the employee’s immediate supervisor.
Deviations from this policy require written approval of the Human Resources Department.
Approved 5-81
Revised and approved 4-97
Revised and approved 3-03
Reviewed 12-04
Approved 6-05
64
AP-3.08
Administrative Policies and Procedures
POLICY AND PROCEDURE FOR EVALUATING
THE PERFORMANCE OF THE EXECUTIVE DIRECTOR
Policy
The performance of the Executive Director will be evaluated by the Personnel Committee of the
Board of Trustees.
1. The Personnel Committee of the Board of Trustees will be responsible for initiating the
performance evaluation of the agency’s Executive Director on an annual basis.
Responsibilities will include:
1.1
Reviewing and updating a standard written evaluation tool.
1.2
Reviewing the Executive Director’s written job description at least every two years.
1.3
Conducting a market salary survey relative to the position at least every three years.
2. The Executive Director will submit a written self-evaluation, based on progress toward the
prior year’s goals, to the Personnel Committee Chair.
3. The Personnel Committee Chair, in collaboration with the Chair of the Board of Trustees,
will solicit feedback regarding the Executive Director’s performance from the President of
the Board of Trustees (the Bishop), members of the Board Executive Committee, and
members of the Personnel Committee. Individuals solicited will be given a copy of the
Executive’s self-evaluation and asked to provide input by submitting written feedback using
an appropriate evaluation form.
4. The Chair will share the written feedback and discuss compensation with the Personnel
Committee prior to meeting with the Executive Director.
5. The Personnel Committee Chair and the Chair of the Board of Trustees will make an
assessment of the Executive Director’s performance based upon their own judgment, the
Executive’s self-evaluation, and the feedback solicited. The Committee Chair and Board
Chair will determine the percentage salary increase to award the Executive Director based on
performance merit and market factors.
6. The Personnel Committee Chair and the Chair of the Board of Trustees will conduct the face
to face evaluation with the Executive Director at which time:
6.1
The Executive Director will be given a written summary of the performance
assessment, which he/she will sign along with the Chair of the Board of Trustees or
the Personnel Committee Chair.
6.2
The Executive Director will provide a draft of goals for the coming year. The
Personnel Committee Chair and the Chair of the Board of Trustees will confirm,
65
revise and/or add to the goals, which will be endorsed by the Executive Committee.
6.3
The Executive Director will be informed of the final compensation recommendation
of the Personnel Committee and Board Chair.
7. In order to finalize the process, the Personnel Committee chair will:
7.1
Forward a copy of the Executive Director’s signed performance evaluation, along
with the Executive Director’s finalized goals for the coming year, to the Human
Resources department for inclusion in the Executive Director’s personnel file.
7.2
Provide written authorization to the Human Resources department for adjustment to
the Executive Director’s salary.
7.3
Provide a brief, written committee report, which discloses the Executive Director’s
salary adjustment for inclusion in the packet of materials distributed prior to the next
board meeting.
7.4
Provide a brief oral summary at the next board meeting.
8. The Executive Director will present his/her goals to the Executive Committee within the first
quarter of the new fiscal year.
Approved 3-03
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
66
AP-4.01
Administrative Policies and Procedures
POLICY ON RETENTION OF LEGAL COUNSEL
Policy
Legal counsel is retained by Catholic Charities and is available for consultation and/or services
to all Division Directors.
Procedure
Division Directors should be advised by staff or program supervisors of any need for legal
counsel. In turn, the Division Director will consult with the Executive Director or, in his
absence, his designated representative prior to retaining counsel.
Approved 5-81
Revised and approved 4-97
Reviewed 12-04
Approved 6-05
67
AP-4.02
Administrative Policies and Procedures
POLICY ON AGENCY SERVICES TO
PERSONNEL, CONSULTANTS, AND MEMBERS OF THE
BOARD OF TRUSTEES AND COUNTY ADVISORY BOARDS
Policy
Catholic Charities, Diocese of Trenton prohibits favoring personnel, consultants, or members of the
Board of Trustees and County Advisory Boards in their application for or receipt of the services of
the agency. All services rendered by the agency are provided in an equitable manner and no person
connected with the agency has an advantage over any other person needing those services.
Approved 5-86
Revised and approved 4-97
Reviewed 12-04
Approved 6-05
68
AP-4.021
Administrative Policies and Procedures
POLICY FOR MANAGING EMPLOYEES AND VOLUNTEERS
SEEKING SERVICES FROM CATHOLIC CHARITIES
Policy
Catholic Charities will assist employees and volunteers seeking services appropriate to their
needs.
When employees seek services from Catholic Charities the following guidelines should be
followed. With the exception of number one the same guidelines should be followed for
volunteers seeking services.
1. Determine whether or not the employee has accessed services through the Employee
Assistance Program (EAP) contracted by Catholic Charities.
1.1
Determine appropriateness of such a referral.
1.2
If appropriate help facilitate a referral to EAP.
1.3
If the EAP is not appropriate, make referral to the most appropriate Catholic Charities
service or to an outside agency if appropriate service is outside the scope of Catholic
Charities’ services.
2. When possible the pre-intake should be conducted by supervisory personnel to ensure
confidentiality.
3. The criteria for admission to a program or provision of services should be the same as
those for the general public seeking the same service.
4. Other than provision for increased confidentiality, Agency employees and volunteers should
not be given special preference with regard to access, waiting list, fee reduction, and length
or intensity of service.
5. In order to reduce general staff access and enhance confidentiality employee and volunteer
clinical records should be kept separate from the other client records under the control of
supervising staff.
Approved 8-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
69
AP-4.022
Administrative Policies and Procedures
POLICY ON FINANCIAL INTEREST OF
PERSONNEL AND PAID CONSULTANTS
Policy
Catholic Charities, Diocese of Trenton prohibits personnel and paid consultants from having
direct or indirect financial interest in the agency’s assets, leases, business transactions, and/or
professional services.
Approved 12-01
Reviewed 12-04
Approved 6-05
70
AP-4.03
Administrative Policies and Procedures
POLICY ON CHAIN OF COMMAND
Policy
The Division Director/Department Head is responsible to establish a chain of command in
his/her absence.
Each Division/Department must maintain supervisory coverage at all times. It is the
responsibility of the Division Director (or in the case of Central Administrative Services, the
Department Head) to establish a chain of command whereby an appropriate staff member is
selected to act as designee to provide clinical and administrative coverage in his/her absence.
The Division Director is required to submit the coverage plan to the Human Resources
Department before his/her absence.
When the Agency Executive Director is absent, the Senior Management Staff has decisionmaking authority/responsibility.
Approved 5-86
Revised and approved 4-97
Revised and approved 12-03
Revised 12-04
Approved 6-05
71
AP-4.04
Administrative Policies and Procedures
POLICY ON RETENTION OF RECORDS
Policy
Records will be maintained in accordance with Federal, State, and accrediting agencies
requirements.
Maintenance of Records
Clinical Records
Please refer to CP-2.0.
Corporate Records
Articles of Incorporation, Bylaws, Minutes, Income, and Other Financial Statements are
maintained by Central Administrative Services and must be retained permanently.
Real Estate and Construction Records
Deeds, Land Surveys, Leases, Mortgages, Title Insurance (original documents) are maintained
by Central Administrative Services and must be retained permanently.
Tax Records
Tax records are maintained by Central Administrative Services and are to be retained as follows:

Travel Expense Vouchers - 7 years

Audits, Income Tax Returns, Annual Reports, Withholding Statements - permanently.
Business Office Records
Business office records (original documents) are maintained by Central Administrative Services
(unless otherwise noted) and are to be retained as follows:

Bank Statements and Deposits, Routine Correspondence, Budgets, Property and
Extended Coverage Insurance Policies, Purchase Orders - 5 years

Checks, Check Stubs, Check Registers - 7 years

Cash Receipts and Client Receipts - 7 years (Program copies kept 2 years)

Liability Insurance Policies - 19 years

Equipment Leases - 5 years after expiration
72

Resident’s Funds Records (maintained by program)- 7 years after death or discharge

Licenses, Permits, Written Contracts - permanently.

Depreciation Records, Journals and Ledgers, Vouchers for Capital Expenditures,
Equipment Purchase Records and Operating Instructions - 7 years.
Employee Records
Employee records (originals) are maintained by Central Administrative Services and are to be
retained as follows:

Applications, non-employees - 1 year

Withholding Certificates - 4 years

Unemployment Compensation Records - 5 years

Withholding Statements - 4 years after taxes are paid

Social Security Reports - 5 years after taxes are paid

Applications, Employees - 5 years after termination

Attendance Records, Work History, Time Cards - 5 years after termination

Payroll - 10 years

Benefit Programs, Earnings; Employee Handbook, Personnel Manuals, Job
Classifications, Time Sheets, Pension Program, Rate Card - permanently
Blackbaud Records
Accounts Payable and General Ledger records are backed up daily and at the end of the year and
a second back up is done when the year is finally closed. This information is in the network and
the disk can be transferred to tape, if necessary. These records are to be retained for a period of 7
years.
Destruction of Records
Records to be destroyed are shredded.
Approved 5-81
Revised and approved 4-97
Revised and approved 3-03
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
73
AP-4.05
Administrative Policies and Procedures
COMPUTER, E-MAIL, AND INTERNET USAGE POLICIES
This document sets forth Catholic Charities’ policies with regard to computer, e-mail, and
Internet usage, including access to, review or disclosure of e-mail messages sent or received by
Catholic Charities’ employees, and Internet access and usage. Catholic Charities reserves the
right to modify or update these policies at any time. Use of the computer system, e-mail system,
or the Internet in violation of these policies or other Catholic Charities’ policies is a serious
violation and can result in a loss of access, disciplinary action (including termination), or other
legal actions. All employees and volunteers will be required to read the Computer, E-Mail, and
Internet Usage Policies and sign the Acknowledgement of Understanding (Attachment A).
1. Use for Business Purposes Only; Catholic Charities’ Access and Review
1.1 Catholic Charities’ Computer Systems. The Catholic Charities computer system, e-mail
system, and Internet access are provided to approved employees at Catholic Charities’
expense solely to assist them in carrying out Catholic Charities’ business. The e-mail
system permits employees to communicate with each other internally and with selected
outside individuals and companies. Internet access permits approved employees to use
resources at appropriate Internet sites to help them perform their duties and carry out
Catholic Charities’ business.
Catholic Charities owns, maintains, and is responsible for the computer system.
Employees must limit use the computer system, including e-mail and access to the
Internet, to the business purposes of Catholic Charities and only to obtain and transmit
information in accordance with Catholic Charities’ policies and procedures.
1.1.1
In order to maintain the integrity and the security of Catholic Charities’
Information Technology (IT) infrastructure, software and databases, Internet
access will be used only for the business purposes of Catholic Charities’ business.
Access to Anasazi and Outlook e-mail is available to all Catholic Charities’
employees. Any staff member requiring access to the Internet beyond Anasazi and
Outlook e-mail will require justification and approval from the Program Director,
the Division Director/Department Head, and the IT Manager. (See Attachment B:
Request for Internet Access form.)
1.2 Access and Review of E-Mail Communications and Internet Usage.
Catholic Charities treats all messages sent, received or stored in the e-mail system as
business messages.
Catholic Charities has the capability to access, review, copy, and delete any messages
sent, received or stored on the e-mail system. Catholic Charities has the ability to access
deleted messages. Catholic Charities has the capability to monitor employees’ Internet
usage, including the time spent on-line and the sites accessed.
Catholic Charities reserves the right to monitor, access, review, audit, intercept, use, copy
or delete all e-mail messages of any kind for any purpose and to disclose them to any
party (inside or outside Catholic Charities). Catholic Charities reserves the right to
74
review files and communications to maintain system integrity and ensure that users are
using the system appropriately, responsibly and in accordance with Catholic Charities’
policy and procedures.
1.3 E-Mail Etiquette.
Employees should bear in mind that their e-mail messages may be read by someone other
than the person to whom they are addressed and may even someday have to be disclosed
to outside parties or a court in connection with litigation. Accordingly, employees are
directed to ensure that their messages are courteous, professional and businesslike.
E-mail messages, once sent, are usually irretrievable. Employees should be sensitive to
the fact that, in the absence of an explanation, e-mail messages may be ambiguous and
convey the wrong impression. This is of specific concern when a message is being
forwarded to multiple recipients. Rather than quickly sending messages without adequate
review, employees should consider printing the messages and reading them prior to
distribution to ensure that their content is completely appropriate. The
“everyone@cctrenton.org” is to be used for business purpose only.
1.4 E-mail and Confidentiality of Protected Health Information.
At no time should any protected health information of any clients be transmitted via
electronic mail outside of Catholic Charities network, unless it is encrypted. Due care
shall be used when transmitting private health information of any client by electronic
mail within Catholic Charities internal network, to prevent the transmittal and/or receipt
of such information to any staff member not authorized to have access to the information.
Staff member shall not forward to any third party outside of Catholic Charities any email
messages that contain any form of individually identifiable health information, unless
expressly authorized by the client on a signed authorization for use/disclosure of health
information form. Catholic Charities will incorporate e-mail messages sent or received
that concern the diagnosis or treatment of a client, or payment for treatment, into the
client’s chart and/or billing file and shall maintain such information with the same degree
of confidentiality as the remainder of the client’s chart and billing file.
1.5 Storing and Deleting E-Mail Messages.
Catholic Charities strongly discourages the storage of large numbers of e-mail messages
for a number of reasons. First, because e-mail messages may contain confidential
information, it is desirable to limit the number, distribution and availability of such
messages. Second, retention of messages consumes storage space on the network and
personal computer hard disks, can slow down the performance of both the network and
individual personal computers. Finally, in the event that Catholic Charities needs to
search the network server, back-up tapes or individual hard disks for important
documents, the fewer documents it has to search through, the easier the search will be.
Accordingly, employees should regularly delete any e-mail messages they send or receive
that no longer require action or are not necessary to an ongoing project. Employees
should audit their stored e-mail messages periodically to identify messages that are no
longer needed and should be deleted.
2. Permitted and Prohibited Uses
2.1 Use Limited to Catholic Charities’ Business Purposes.
The computer system, e-mail system, and Internet access may be used only to support
75
and promote Catholic Charities business objectives. The use of computers and Internet
access through the Catholic Charities’ system is a privilege, not a right, and may be
revoked. Use of the computer system, e-mail system, or the Internet in violation of these
policies can result in disciplinary action.
Therefore, for example, employees may not:
2.1.1
intentionally waste limited computer resources;
2.1.2
engage in activities that have the potential to disrupt the business environment of
the workplace;
2.1.3
engage in actions that damage computers, computer systems or computer
networks;
2.1.4
use the computer system for commercial purposes, for personal gain or profit, or
to engage in illegal activity;
2.1.5
use the e-mail system to copy and/or transmit any documents, software or other
information protected by the copyright laws;
2.1.6
use their Catholic Charities’ provided Internet address when communicating
personal viewpoints on the Internet, unless approved by Catholic Charities’
Senior Management; or
2.1.7
use the computer system to access, view, store or distribute obscene,
offensive, harassing, discriminatory or otherwise objectionable files.
2.2 E-Mail Use.
E-mail messages, whether created inside Catholic Charities or created outside Catholic
Charities and transmitted within Catholic Charities or from Catholic Charities to other
sites, can generate claims of defamation, harassment, and discrimination. Therefore,
employees may not:
2.2.1
use the e-mail system to engage in any communications that are in violation of
any policy; or
2.2.2
use the e-mail system to transmit or display defamatory, obscene,
intimidating, offensive or harassing messages or pictures, or messages that
disclose personal information without authorization.
2.3 Internet Use.
An approved employee accessing the Internet from a Catholic Charities’ site is
responsible for all on-line activities that take place through the use of his or her login and
password. When using another organization’s networks or computing resources,
employees must comply with the rules appropriate for that network.
Those employees with Internet access privileges may not:
76
2.3.1
access inappropriate websites, including those involving gambling,
pornography, or obscene materials;
2.3.2
obligate Catholic Charities financially to any commercial web-sites without
the express permission of the IT Manager; or
2.3.3
use the Internet from a Catholic Charities’ site to engage in the practice of
moonlighting or for any commercial purposes, advertising, or other similar
activities.
3. Computer System Security
3.1 Importance of System Security.
Catholic Charities is obligated to maintain the confidentiality of its own information, of
client information and of communications with clients. As a consequence, all users of the
computer system must take steps to ensure the security of the system and to maintain the
confidentiality of all information on the system or communicated through the use of the
system. Each employee is responsible for what happens under his or her log in name.
Violations of security policies are considered serious violations and can result in
disciplinary action.
3.2 System Access.
Password and User Logon Id’s are unique to each authorized user and will be assigned by
the IT Department. Passwords must be kept private. They should not be shared, coded
into programs or written down.
In order to protect against dissemination of confidential information, employees should
not access their e-mail messages for the first time in the presence of others. E-mail
windows should not be left open on the screen when the computer is unattended. E-mail
passwords (as well as other computer passwords) should be routinely changed every 6
months.
3.3 Computer Viruses.
Computer viruses can be injected into the system through the receipt of e-mails, e-mail
attachments or files from other systems. Exercise particular care when opening files
attached to e-mails from unknown senders. Employees must pay attention to and strictly
comply with all warnings and instructions of the IT Department relating to viruses.
Employees must immediately inform the IT Department of the presence of any virus on
any Catholic Charities computer. Any computer that is infected or suspected of being
infected must immediately be disconnected from the network to reduce the risk of
spreading a virus. Employees are prohibited from disabling or interfering with any virus
scanning software installed on their system.
3.4 Installing or Downloading Software.
The IT Department must approve and install all software on any Catholic Charities
computer. No employee may download software without the approval of the IT
Department. When and if authorized to download software, employees must comply
with all restrictions and procedures for downloading software, including mandatory virus
scanning and detection procedures. Employees must inform the IT Department of any
77
virus, configuration change or different behavior of a computer or application, especially
after the addition of new software to the environment.
All employees must obey and follow all licensing agreements and procedures with regard
to the use and installation of all software. The IT Department will inspect computers
periodically to verify that all software has been approved and licensed properly.
3.5 Remote Access.
All remote access to the computer system, whether via dial-up or Internet access, must
use encryption services to protect the confidentiality of the session. Information regarding
access to the computer system, such as dial-up phone numbers, is confidential. This
information must not be posted on electronic bulletin boards, listed in telephone
directories, placed on business cards or made available to third parties without express
authorization.
3.6 Confidentiality.
Users must keep confidential all references and resource labels of Catholic Charities’
computer system including but not limited to internal domain names, server names,
printer names, IP addresses and Directory services.
4. Confidentiality of Communications
4.1 Importance of Confidentiality.
Employees must exercise a greater degree of caution in transmitting information
through e-mail than they take with other means of communicating information (e.g.,
written memoranda, letters or phone calls) because of the reduced human effort
required to redistribute such information and the security considerations on the
Internet. Confidential information of Catholic Charities or its clients should never be
transmitted or forwarded to outside individuals or companies not authorized to
receive that information.
Employees should always use care in addressing e-mail messages to make sure that
messages are not inadvertently sent to outsiders or the wrong person within Catholic
Charities. In particular, employees should exercise care when using distribution lists
to make sure that all addressees are appropriate recipients of the information. Lists
may not always be kept current and individuals using lists should take measures to
ensure that the lists are current. Employees should refrain from routinely forwarding
messages containing confidential information to multiple parties unless there is a
clear business need to do so.
Employees may contact the IT Department with any questions concerning this policy or
procedure.
Approved 5-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
78
Attachment A to
AP-4.05
Administrative Policies and Procedures
ACKNOWLEDGMENT OF UNDERSTANDING
COMPUTER, E-MAIL, AND INTERNET USAGE POLICIES
I acknowledge that I have read and will abide by Catholic Charities’ policies regarding
computer, e-mail, and Internet usage. In particular:
1. I understand that Catholic Charities has the complete authority to monitor my computer
usage, e-mail communications, and Internet usage, and that Catholic Charities may monitor
on a routine and/or special case basis.
2. I will accept personal responsibility for all activities occurring under my password/login.
3. I will keep confidential my password/login and will not utilize another’s password/login to
access any system.
4. I will keep confidential all client information, regardless of the medium – computer, email,
etc.
5. I understand that the computer system, the e-mail system, and the Internet system are to be
used for business purposes only.
6. I understand that I cannot install or download software and/or programs, screen savers,
firewalls, etc. without written approval of the IT Manager.
7. I understand that any violation by me of Catholic Charities’ computer, e-mail, or Internet
policies may result in a loss of access, disciplinary action (including termination), or other
legal action.
______________________________________________
Signature
______________________________________________
Name (please print)
Original: Personnel file
79
______________________
Date
Attachment B to
AP-4.05
Administrative Policies and Procedures
REQUEST FOR INTERNET ACCESS
Name _____________________________________
Title _____________________________
Program ___________________________________
Division __________________________
Location _______________________________________________________________________
Date of Request _______________________
Justification for access to the Internet:
Program Director’s Signature ___________________________
Date __________________
--------------------------------------------------------------------Division Director/Department Head Review and Approval
( ) approved ( ) not approved
Signature ___________________________________________
Date ________________
--------------------------------------------------------------------IT Manager’s Signature _______________________________
Original: IT Office
Copy: Program Director
80
Date ___________________
AP-4.06
Administrative Policies and Procedures
POLICY ON CLOSINGS DUE TO INCLEMENT WEATHER
Policy
Decision to close due to inclement weather will be made by the Executive Director in Mercer
County and by Division Directors (in coordination and communication with the Executive
Director/Program Services) in Burlington, Monmouth, and Ocean Counties.
Procedure
During the winter months inclement weather may necessitate the closing of Agency offices. The
procedure outlined below is to be followed during these emergency conditions.
All Counties
Because consumers are the agency’s primary concern, it will be necessary for some programs
(e.g. Residential and PACT programs) to remain open and have staff working regardless of
weather conditions. Employees should refer to their program policy manual and/or consult with
their supervisor for details.
If on any given day, the offices remain open but an employee is unable to report to work, he/she
may use vacation, holiday, or comp time to be paid for the day. Otherwise, the day will be
without pay.
Employees who work evenings and elect to leave work early at the approval of their supervisor,
will not be paid for the time if there is no official closing. However, they may use vacation,
holiday, or comp time to be paid for the remainder of their workday.
Hourly, per case employees will be paid only for hours worked and therefore, are not eligible for
paid time during snow closings.
If during evening hours, conditions warrant an early closing, Division Directors, or their
designees, should use their own judgment regarding closing their own programs.
If offices are open, all employees are expected to make every effort to be at work at the start of
their workday. Employees are not eligible for comp time if it is necessary for them to leave
home early to arrive at work on time.
Mercer County
The decision to close Mercer County offices lies with Central Administrative Services. If this
decision is made prior to the start of the workday, an announcement will be made over
designated radio stations to the effect that Mercer County offices are officially closed. In this
event, the day will be paid as a snow day.
81
There will be an access number identified within the Catholic Charities phone system for snow
closing status in Mercer County.
In the event that a snow emergency occurs during the course of the workday, Central
Administrative Services will then approve a closing based on the existing conditions. The
remainder of the day will be an approved snow day. Agency offices in Mercer County are open
until an official snow closing announcement is made by Central Administrative Services.
Burlington, Monmouth, and Ocean Counties
Because of the outlying nature of these offices, the Division Director of each program is
responsible for determining if a snow closing is necessary.
Division Directors will collaborate prior to a decision in order to achieve uniformity across the
county. One Director will notify Central Administrative Services of the decision on behalf of the
county programs.
When the decision to close is made, each Director will take responsibility for notifying his/her
staff of the closing.
The policy regarding payment as a snow day will follow that of the Mercer County offices.
Approved 2-28-85
Revised and approved 4-91
Revised and approved 3-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
82
AP-4.07
Administrative Policies and Procedures
POLICY ON UNBUDGETED PURCHASES OVER $100,000
AND ALL REAL ESTATE TRANSACTIONS
Policy
No purchase of capital assets should be made without proper authorization. All unbudgeted
purchases over $100,000 and all real estate transactions must have prior approval from the Board
of Trustees. Board approval is required in order to ensure that compliance with budget
guidelines are followed and sound investment decision practices are observed.
Procedure
Upon approval from the Trustees, copies of the completed authorization form, Appropriations
Request Form for Unbudgeted Expenses over $100,000 and All Real Estate Transactions
(Attachment to AP-4.07) should be forwarded to the Fiscal Affairs Department to ensure proper
records are maintained. The original authorization form should be attached to the original
invoice at the time that request for disbursement of funds is submitted.
Approved 3-03
Reviewed 12-04
Approved 6-05
83
Attachment to
AP-4.07
Administrative Policies and Procedures
APPROPRIATIONS REQUEST FORM FOR UNBUDGETED EXPENSES OVER
$100,000 AND ALL REAL ESTATE TRANSACTIONS
Request Date ___________________________________________
Payment Request Date ____________________________________
Vendor Name _________________________________________________________________
Vendor Address _______________________________________________________________
_______________________________________________________________
Amount of Expenditure ___________________________________
Amount Budgeted for Expenditure __________________________
Description of Expenditure _______________________________________________________
_________________________________________________________________
Documents Attached ____________________________________________________________
_________________________________________________________________
Charge Code ______________________________
Division Director’s Signature _______________________________________________________
Executive Director’s Signature _____________________________________________________
Date Approved by Board of Trustees _______________________________________________
Approved 3-03
Reviewed 12-04
Approved 6-05
84
AP-4.08
Administrative Policies and Procedures
POLICY ON CLIENT’S RIGHT TO PRIVACY AND
USE OF AUDIO VISUAL RECORDING
Policy
Client statements expressing gratitude toward the agency may be used in agency releases or
public media only when they are given voluntarily and released with the client’s written consent,
as well as endorsement by the primary clinician. (See Attachment A to AP-4.08.) Public
statements to this effect are to be neither required nor encouraged by agency staff. Participation
in public performances against the wishes of the persons served or without the informed consent
of that person (and in the case of a minor, of both the person and the parent or guardian) is
prohibited. (See Attachment A to AP-4.08.)
Procedure
Any use of audio and/or visual recording devices, photographs or incorporation of any
identifying client information in agency promotional materials, shall be discussed in detail in
advance with the client. (See Attachment B to AP-4.08.) Informed consent of the client is
required.
All aspects shall be reviewed and permission must be authorized by the client as per the attached
form.
The Community Affairs Department is responsible for implementation and assurance that the
rights of clients are protected.
Revised and approved 3-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
85
Attachment A to
AP-4.08
Administrative Policies and Procedures
AUTHORIZATION FOR USE OF CLIENT STATEMENTS
AND PUBLIC PERFORMANCES
I hereby authorize* the use of my name, identification as a client, and use of my comments
regarding the
_____________________________________ program of Catholic Charities.
I hereby agree to participate in a public performance of _____________________________
for the ___________________________________ program of Catholic Charities.
Name (please print) __________________________________________________________
Signature _____________________________________________ Date _________________
Signature of parent/guardian (if person is a minor) __________________________________
Witness ______________________________________________ Date _________________
Endorsement by primary clinician _________________________ Date _________________
*This authorization may be rescinded at any time by written notification to the Community
Affairs Department by the client and/or primary clinician.
Approved 3-98
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
86
Attachment B to
AP-4.08
Administrative Policies and Procedures
AUTHORIZATION TO USE CAMERA, AUDIO AND/OR
VIDEO RECORDING DEVICES
I hereby authorize*:
the audio/video recording of my sessions at the ______________________________
program of Catholic Charities.
photograph of myself.
identifying case description of services provided at the
____________________________ program of Catholic Charities.
I understand that such recording will be used only for:
review and supervision.
Other use (specify) ________________________________________________
Name (please print) __________________________________________________________
Signature _____________________________________________ Date _________________
Signature of parent/guardian (if person is a minor) __________________________________
Witness ______________________________________________ Date _________________
Endorsement by primary clinician _________________________ Date _________________
*This authorization may be rescinded at any time by written notification to the Community
Affairs Department by the client and/or primary clinician.
3-98
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
87
AP-4.09
Administrative Policies and Procedures
POLICY ON EXPRESSIONS OF CONDOLENCE OR GET WELL WISHES
Policy
Executive Director will decide what is appropriate for Division Directors and Central
Administrative Services Staff in reference to condolences or get well wishes. Division Directors
are responsible for deciding what is appropriate for their staff and will charge the expense to
their program’s budget.
Division Directors and Central Administrative Services Staff
Flowers, fruit, plants, or Mass cards (whichever is appropriate for the occasion) shall be sent to
Division Directors and all Central Administrative Services staff in the name of the agency and
paid for by the agency in the event of:
1. Inpatient hospitalization of employee.
2. Death of employee or member of immediate family parent, spouse, child.
3. Birth of child to employee or spouse.
The Executive Assistant shall implement this policy.
Program/Division Staff
It is the responsibility of each Division Director to decide what is appropriate for his/her staff
members and to charge the expense to his/her program's budget.
Approved 12-88
Revised and approved l2-92
Revised and approved 4-97
Revised and approved 12-03
Reviewed 12-04
Approved 6-05
88
AP-4.10
Administrative Policies and Procedures
POLICY AND PROCEDURE ON PROVIDING MONETARY SUPPORT
TO OTHER NOT-FOR-PROFIT ORGANIZATIONS
Policy
All funds spent by programs of Catholic Charities should be spent for the direct or indirect
benefit of the program, division, and/or agency.
Procedure
The Division Director is responsible to decide which potential expenditures would benefit the
program/division and its clients.
If there is a direct benefit to be derived by supporting another not-for-profit organization, the
Division Director may approve the request.
If there is an indirect benefit to be derived by supporting another not for profit organization, the
Division Director must evaluate the request in terms of its importance to all other potential
expenditures, that could be made to benefit the program and its clients. If the request is seen by
the Division Director as a priority, it may be approved.
Approved 6-86
Revised and approved 4-97
Reviewed 12-04
Approved 6-05
89
AP-4.11
Administrative Policies and Procedures
POLICY ON PAYMENT OF HONORARIA TO BOARD MEMBERS
Policy
Catholic Charities, Diocese of Trenton prohibits payment of honoraria to members of its Board
of Trustees and county Advisory Boards.
Approved 5-86
Reviewed 12-04
Approved 6-05
90