NEBRASKA
FEDERATION OF FAMILIES FOR CHILDREN’S MENTAL HEALTH
Neb
Operations Manual
For Family Peer Support and
Family Navigation Services
Contract Attachment A
2011/2012
345 N. Minden Ave
P.O. Box 183
Minden, NE 68959
Table of Contents
Policy/Procedure Title
Provider Affiliate Agencies Responsibilities and Guidelines
Uniformity in Affiliate Organization Policiese
Fiscal Operation
Service Quality and Quantity
Quality Assurance and Quality Improvement
Screening for Abuse and Neglect
Reporting Abuse and Neglect
Caseload Management
Reporting Standards
Protected Health Information Security
Confidentiality
Employee Availability
Safety
Collaboration with the Help Line
Insurance Coverage
Failure to Present
Suicide Prevention Data Collection
Clinical Consultation and Licensure
Hiring Family Members
Documentation
Grievances
Communication Tools
Communication Policy
Background Checks
Transportation Standards
Evidence-Based and Promising Practices
Capacity Planning and Expectations
Contract Management and Monitoring
Intake
Consultation
Discharge
Telework Policy
Satisfaction Survey
Family Review
Checkpoint Meetings
Provider Performance
Referral/Eligibility Criteria
CPA Audit
Program Outcomes
2 Nebraska Federation of Families
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Retainage and Outcomes
Signature Page
3 Nebraska Federation of Families
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Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
I.
Date issued:
10/1/2011
Reviewed: 9/23/11
By: SN
Last Revision:
7/6/2011, 7/11/2012
Section: Provider
Affiliate Network
Effective
Date:
10/1/2011
Subject: Provider Affiliate Agencies
Policy No:
FedP234
Responsibilities and Guidelines
POLICY
It is the policy of Nebraska Federation of Families/Family Navigation/Family Peer Support
Services that Provider Affiliate Agencies (referred to as Provider) to implement and follow
basic Nebraska Federation of Families Provider Affiliate Network procedural guidelines and
expectations as they relate to the Provider Agency’s involvement in the Nebraska
Federation Provider Affiliate Network and in the provision of services.
II.
PROCEDURE
All Provider Agencies must follow the guidelines below.
A. Provider Affiliate Agency Access / Functions.
1. Providers must notify the Nebraska Federation in writing of any of the
following changes within 5 business days.
a. Agency Name.
b. Business Address / Billing Address.
c. Telephone / Fax Numbers.
d. E-mail Address.
e. Federal Employers Tax ID (FEIN) Number.
f. Agency CEO / Director.
g. Ownership.
h. Board of Directors.
i. Program Contact(s).
j. Discontinuation of Agreed Upon Services.
k. Change of Insurance Carrier.
l. Termination of a Direct Service Provider.
m. Any other changes that may be associated with the expectations set
forth in the Agency’s Service Agreement (MOA) with Nebraska Federation
of Families.
2. All Providers/Affiliates must have a working business phone that identifies the
Affiliate Agency by name. For Providers that use a telephone answering system,
the system must identify the name of the Provider Agency and have the
capability to accept messages and service recipient inquiries during regular
4 Nebraska Federation of Families
business hours. In non-emergency situations, a call should be returned within 24
hours.
3. Providers must utilize the provided secure Federation E-mail account that
Nebraska Federation has provided to the Affiliate for use of ongoing
communication with the Nebraska Federation.
4. A Provider may use a P.O. Box as a billing address, but must also provide a
current business street address.
5. Providers are responsible for updating Agency Resource Guide descriptions for
the Nebraska Federation per contract expectations related to the Nebraska
Helpline, which will reflect changes in current community programs/services, as
well as service specific program contact names and telephone numbers.
B. Provider Agency/Staff Conduct Ethics.
1. All Providers and Direct Service Providers are to conduct themselves in a
respectful and ethical manner during the provision of services through the
Nebraska Federation Provider Affiliate Network. This includes treating
clients/families, other family members and other members of the Child &
Family Team in a respectful manner and providing the authorized
service/support in a timely manner. Providers should refrain from the use of
demeaning, insulting or other language and conduct that may be perceived
as offensive by the family or other team members.
2. Advocates must maintain family confidentiality and as such may not be
accompanied by individuals not directly employed by the Provider and
directly involved with the provision of the authorized covered
service/support. This includes individuals such as the Provider’s own
child/children, other family members, friends, interns, trainees or other
parties.
NOTE: If there is a justifiable reason that an Advocate would need to be
accompanied by another person during the provision of a service, the
legal guardian must consent in writing and the person accompanying the
Advocate must be an individual from the Provider Agency through which
the Advocate is employed.
3. Families may NOT accompany Advocates on personal business at any time.
5 Nebraska Federation of Families
C. Staff Service Guidelines.
1. Provider Agencies are limited to providing the services agreed to in the
current contract/agreement with Nebraska Federation of Families.
2. Providers that use volunteers to provide services may not seek
reimbursement for services provided to Nebraska Federation enrolled
youth/families by those volunteers. Volunteers working with Nebraska
Federation enrolled youth must be screened and oriented in the same
manner as a paid employee.
3. Providers must orient all Advocates and other appropriate agency staff to all
relevant Nebraska Federation of Families service descriptions, protocols,
policies and procedures during a staff’s initial orientation period and as
needed to all subsequent Nebraska Federation policy and procedural
changes.
4. Providers are responsible for maintaining an accurate list of Advocates
corresponding to the services/supports identified in the current
contract/Agreement.
5. The Nebraska Federation Provider Network must approve all Advocates
before they provide services/Supports to service recipients.
6. Criminal Background Checks must be completed PRIOR to the provision of
services and every 2 years thereafter.
7. A Department of Motor Vehicle Driving Abstract must be obtained prior to
the provision of services for all direct service providers who transport
youth/families. (NOTE: Staff may NOT transport families under the FPS/FN
contract). The Provider Agency is responsible for review of the Driving
Abstract to ensure that the provider has an acceptable driving record. In
addition to the Driving Abstract, a copy of a valid State of Nebraska Driver’s
License and summary of current automobile insurance must be maintained in
the Provider personnel file for all Advocates who transport youth/families.
D. Advocate to Family Ratio
1. Provider/Affiliate agencies are required to follow the contractual agreement
regarding the ratio of families to any one (1) Advocate. The ratio is as follows:
6 Nebraska Federation of Families
(a) Family Peer Support Services: One (1) Advocate can carry a family caseload
of no more than 25 families at any given time. Administrative exception may
be considered in rare circumstances, but must be funneled through the
Federation of Families who will consult with the Division of Behavioral
Health.
(b) Family Navigation Services: One (1) Advocate may carry a family caseload of
no more than 15 families at any given time. Administrative exception may be
considered in rare circumstances, but must be funneled through the
Federation of Families who will consult with the Division of Behavioral
Health.
E. Maintenance of Family Records/Case Notes.
The following guidelines are mandatory and must be implemented with regard to the
maintenance of Family records/case notes for Family Peer Support and Family
Navigation enrolled families receiving services through the Nebraska Federation of
Families Provider Network.
1)
2)
3)
4)
Providers must maintain a Family specific record for every Family Peer
Support/Family Navigation family receiving services from the agency.
Each family must have his/her own record, unless the agency is
providing one of more other services to one or more family members
of the Nebraska Federation family in which having a family record
would then be permissible. If the Nebraska Federation family alone is
receiving more than one service from the Provider, only one record
needs to be maintained on that family. Every family must have their
own record. Please Note: this record may be electronic.
Each Provider family record must clearly indicate the family name. If
the service recipient is a sibling/caregiver of a Nebraska Federation
family and the only person receiving services from the Provider, then
the identified Family’s name must also be clearly visible on the client
record.
The Family record must be maintained in an orderly and neat fashion
(i.e., separate record into sections such as Provider Referral
Form/Intake Information, Consents, Assessments, Plans of Care/Crisis
Plan, Progress Notes/Service Documentation, Other Correspondence,
Discharge/Closing Summaries, etc.). If serving more than one family
member, similar documents for each individual may be maintained
together in the applicable section.
The Progress Notes/Service Documentation section of the Family
record should contain “subsections” if the Provider provides more than
one service to a Family and/or if the Provider Agency provides more
than one service to a family. Subsection tabs would reference the
different services and corresponding notes provided to the individual
7 Nebraska Federation of Families
5)
and/or family. Plans of Care/WRAP Plans: Providers must have timeapplicable Plans in the record relevant to the entire time the service
recipient received services. The only exception is if the service
recipient/family did not consent to share the Plan with the Provider. In
this case, the Provider should place a note in the Plan of Care/WRAP
Plan section of the record indicating the service recipient’s/family’s
refusal to share the Plan with the provider.
Current/active records must be separated from dis-enrolled Family
records. Records must be maintained in a secure cabinet or room.
H. Provider Agency Referrals and Consent Form.
1. Provider Referral Form.
A NE-FFCMH program-specific “Referral Form” must be received on each service
recipient prior to the provision of service(s). A Provider may not be reimbursed
for services provided prior to the date of the Referral. The Referral Form must be
maintained as part of the service recipient record.
2. Consent for Service/Treatment.
Providers are required to obtain a “consent for services or treatment" for each
service provided to Family service recipient. The consent for services form must
be signed and dated by the service recipient (if a legal adult) or Family/service
recipient’s legal guardian prior to the provision of services. If a service recipient
is age 14 or older, they should also sign the consent form. The consent should
read that it is applicable for one year from the date of signing unless otherwise
indicated. If a service recipient is seen for longer than one year, a new consent
form must be signed. Evidence of a signed and dated consent form prior to the
provision of services will be monitored during the review/audit process.
I.
Service Delivery
1. Providers are responsible for the provision of covered services as identified in
the Nebraska Federation Service Descriptions and all applicable Federation
service related Policies and Procedures. Advocates are allowed to provide
services/supports as described in the service specific description and related
policies/procedures. Exceptions to this requirement can only be made based on
written permission from Nebraska Federation Administration prior to the
provision of the covered services.
J. Service Documentation.
1. All Providers are required to maintain supporting documentation related to
provided services/supports as outlined in the Service Agreement, Policies or
8 Nebraska Federation of Families
Procedures/Provider Bulletins and all applicable Federal or State Statutes in
effect at the time the service(s) was provided.
K. Provider Agency Billing and Reimbursement for Services.
1. Billing for services provided to Nebraska Federation and must be done in
compliance with the requirements of Nebraska Federation Agreement.
L. Business Practice Guidelines.
1. Federal and State regulations governing cost reimbursement contracts and
agreements require that allowable costs be supported by a general ledger
system. It is important that all Provider Agencies maintain a general ledger
accounting system to record and accumulate revenue and expense information
related to the Nebraska Federation Agreement.
2. Nebraska Federation recommends that Providers maintain separate personal
and business transactions and finances. It is important that the Provider
maintain a business checking account, separate from that used for personal
banking and finance. Whenever possible, the Provider staff should avoid using
personal credit cards or credit lines for business purposes.
M. Other Requirements.
1. Critical Incident Reporting.
All Providers are asked to report critical type incidents (i.e., physical injury,
serious criminal offenses to or by the family or employee, service recipient
suicide attempts/verbalizations, physical/sexual assault, etc.) to Nebraska
Federation management within 24 hours of the incident. Providers should be
documenting these incidents on agency-specific incident forms or they can use
the “Critical Incident Report Form” available on the Nebraska Federation website
under the Provider Forms area.
N. Provider Documentation.
1. It is the responsibility of the Provider to enter service documentation on
Pyramid within 24 hours of contact. FPS Monthly summaries shall be entered on
Pyramid by the 10th of each month for services rendered the month previous.
CFS Monthly summaries shall be entered on Pyramid by the 5th of the month, in
addition to being provided to NE-FFCMH in Word format by the 5th.
2. Case closure can occur at any time throughout the month. All Discharges must
be reviewed, approved and signed off on by the consulting clinician before being
submitted to the Federation. Discharge dates are based upon the final
9 Nebraska Federation of Families
Federation review. The Federation representative will sign off on appropriate
discharges and return the final document to the corresponding Provider.
O. Consultation.
1. Provider agencies will be responsible for entering into an agreement with a
licensed mental health practitioner within their region for the purpose of
program-specific clinical consultation. The role of the clinician will be to provide
recommendations regarding family needs and will be utilized in situations
approved by the Organization Director, and at minimum prior to discharge and
during a family crisis situation.
2. Additional consultation will occur in the form of case review. The Provider
agency will be responsible for ensuring that Advocates and other related staff
are available and present for scheduled staffing situations and that they come
prepared to review designated information regarding the family. This form of
consultation may have varied frequency based upon the changing system and
programmatic needs.
10 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
I.
Date issued:
10/2/11
Reviewed: 9/23/11
By: SN
Last Revision:
2/25/11
Section:
Administration
Policy No:
FedP200
Effective
Date:
10/1/2011
Subject: Uniformity in Organization Policies
POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all Affiliate
Family Organizations adopt and abide by the approved and finalized policy and procedures
developed for all services contracted for under the Federation of Families.
II.
PROCEDURE
Affiliate Family Organizations each have their own Organizational policies and procedures
which are approved and finalized by their Board. In addition, the Federation of Families is
required, through State contracts, to ensure uniformity in all program-specific services in which
it sub-contracts. Each Affiliate will ensure the following:
A. Affiliate Organization staff providing any services/supports under contract with the
Federation of Families will review, sign and abide by the policies and procedures
identified for that program.
B. Affiliate Organization administration will ensure that Federation signed policies and
procedures are kept in the employee’s personnel file and available for any state or
Federation site review.
C. Affiliate Organization administration will demonstrate their ability to maintain
fidelity to all policies and procedures and will hold all program specific staff
accountable to the policy and procedures identified by the Federation.
11 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s
Mental Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
III.
Date
issued:
10/1/2011
Effective
Date:
10/1/2011
Reviewed: 9/23/11 Section:
By: SN
Administration
Last Revision:
7/25/11
Subject: Fiscal Operations
Policy No:
FedP210
POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that standard
financial and accounting practices are employed internally and with all Affiliate Family
Organizations:
A.
B.
C.
D.
E.
accounting activities with accredited accounting agent
Annual audit of the organization’s financial documents
Board oversight of financial transactions
Banking activity with accredited and insured banks
Secure technology and data storage
The Federation’s Affiliate Family Organizations utilize the similar practices as the Federation,
although with their own local professionals. Invoicing and billing will be conducted via standard
procedures according to a timeline consistent with contract parameters. It is recognized that
each Affiliate will have varying processes and procedures related to fiscal operations, as
deemed appropriate by their board, however, it is the responsibility of the Affiliate to develop a
sufficient financial plan with their board that addresses the financial needs of their
organization. This plan shall be submitted to NE-FFCMH.
IV.
PROCEDURE
The Federation and Affiliate’s Fiscal operations maintenance and adherence will be to generally
accepted financial accounting practices. The Fiscal Manager/Agent (to be identified in the
Affiliate submitted financial plan) has overall responsibility for internal system of fiscal control,
reporting directly to the Executive Director and/or the board. Major areas of responsibility for
the Fiscal Manager include:
a. Preparing Requests for the purchase of materials and capital equipment
b. Preparing disbursements following approval from Executive Director
c. Cash management
d. Maintaining a fiscally viable budget
e. Management oversight for all fiscal-related positions
f. Check-preparation for signature of Executive Director and Federation Board
Member
g. Payroll management
12 Nebraska Federation of Families
h. Scheduling Audits and corresponding with the Executive Director, Federation
Board or other identified entities/individuals regarding the financial records.
The Fiscal Manager/agent will ensure that all finances are accounted for and will receive prior
authorization on all disbursements from the Executive Director, or designee, in times of
absence.
Each Affiliate will be responsible to have a check utilization approval process in place that has
been approved by the board. This process will not be amended with the financial institution
without prior board approval and amendments will require the signature of the Board
President.
Monthly bank statements shouldl be provided to the Affiliate’s board for review by the
Financial Manager/Agent, after initial review by the Executive Director. The Financial Manager
will provide documentation of expenses, payments and pre-approval, as requested by the
Board.
Fiscal management practices should be identified by each Family Organization and presented to
the Federation in a plan. It is the responsibility of each Affiliate to:
A. Provide the Federation with a Start-Up Budget
B. Provide the Federation with an updated budget on a quarterly basis. The budget will
include line items of direct and indirect services, budgeted amounts for the quarter and
year and the actual for the previous quarter’s reporting cycle.
C. Maintain all receipts and demonstration of the use of Federation funding in a secure
location that can be accessed by the Federation during a site review, or as necessary to
meet state contract requirements.
D. Provide the Federation with monthly financial updates, as requested.
E. Provide the Federation with accurate counts of families served by category, including
resource only services/supports and families served through specific service categories.
F. Develop a plan that the Affiliate Organization has an operations reserve that will cover
necessary expenses for a span of three months or another approved process that
demonstrates the Affiliates ability to ensure viability over periods in which payment
from the vendor is delayed for unexpected reasons.
G. Submit a plan to the Federation related to Affiliate Fiscal operations, including the
following:
a. Travel Reimbursement
b. Cell Phone Reimbursement
c. Insurance
d. Other payments to staff outside of payroll expenses
13 Nebraska Federation of Families
The Federation and its Affiliates will ensure integrity is foremost in all accounting practices and
that all costs be monitored by the Affiliate Executive Director AND the Affiliate’s Board.
Appropriate approval for spending constraints shall be implemented and practiced within each
Organization that ensures safeguards. These safeguards will be presented to the Federation in
a Fiscal Plan.
14 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s
Mental Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date
issued:
10/1/11
Effective
Date:
10/1/2011
Reviewed: 9/23/11 Section:
Policy No:
By: SN
Administration
FedP235
Last Revision:
7/25/11
Subject: Service Quality and Quantity
A. POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that services and
supports are made available to referred families in a timely manner and that those services and
supports are of the utmost quality. Services and supports will be provided within the
contractual designated timeframe and in the manner outlined within the quality standards of
Peer to Peer Support.
II.
PROCEDURE
Affiliate Family Organizations will ensure the following in regards to timely and quality services
and supports:
1. Advocates will make a minimum of three (3) attempts to contact a family within the
first 72 hours of referral. Attempts to contact a family will be measured and
supported by a consultation step level, which will include:
a. If Advocate is unable to make initial contact with a family within the first 24
hours of referral, a consultation with their direct Supervisor/Administrator is
required.
b. If Advocate is unable to make initial contact with a family within the first 48
hours of referral, a consultation with the Federation Program Manager is
required.
c. Inability to make initial contact with a family within the first 72 hours of
referral, despite consultation and additional attempts, will result in
notification to the Helpline and DHHS addressing the lack of contact.
d. Following inability to make contact with a family within the designated
timeframe from referral, a letter will be sent to the referred family and the
Helpline will attempt to make contact with the referred family (if Navigation
referral) to provide them with the option for service/support again and to
provide them with the assigned Advocate’s contact information.
2. Advocates will document all attempts to contact a family in Pyramid system.
15 Nebraska Federation of Families
3. Advocates will utilize the Service-specific Intake process and related forms when a
new family is referred for any Federation contracted service/support.
4. Advocates will complete the intake packet within 15 days of referral.
5. Affiliate Organizations will ensure that all documentation provided is of a quality
nature and that it all fields are completed.
6. Affiliate Organizations will ensure Advocates provide families with the “Failure to
Present” policy (FedP214) which outlines cancellation of appointments and the
process to be used.
7. Affiliate Organizations will adopt the various review tools utilized by the Federation
to review quality and quantity of work performed and will cooperate fully with all
reviews, including through file preparation prior to the site reviews.
8. Affiliate Organizations will ensure all services and supports provided to families is of
a quality nature and meets all programmatic expectations defined by the
Federation.
16 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s
Mental Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date
issued:
10/1/11
Effective
Date:
10/1/2011
Reviewed: 9/23/11
Section:
Policy No:
By: SN
Administration FedP205
Last Revision: 7/22/11
Subject: Quality Assurance and Quality
Improvement
I. POLICY:
The Nebraska Federation of Families and its Affiliate Family Organizations shall recognize and
promote adherence to professional standards pertaining to the delivery of advocacy and
support services in all regions of Nebraska. The Nebraska Federation of Families shall be
responsible for the implementation and administration of a Family Peer Support quality
assurance program. The quality assurance program shall provide for the periodic review of all
Advocacy services and supports, and shall include a performance improvement component.
The Federation of Family’s QA/QI Mission is to ensure quality Advocacy and Service Access
while promoting continuous quality improvement of Support and processes to meet the needs
of youth and families.
II. PROCEDURES:
A. Each Affiliate Family Organization will coordinate an internal quality assurance program to
determine the quality and consistency of the FN/FPS services provided and ensure that care is
delivered according to professional standards, policies, and directives.
B. Each Affiliate Organization will ensure that Clinical reviews will be conducted by a licensed
mental health professional. The review shall include a family review that examines the quality,
appropriateness and efficacy of the services delivered. Clinical reviews shall occur based upon
minimum expectations, including:
 Referral and intake to the Navigator/Peer Support service when identified unmet
Mental Health and/or Substance Abuse needs that need to be addressed promptly
 Emergency situations
 Ethical situations
 Discharge
1. The Federation of Families will determine the focus and methodology of the clinical
reviews.
2. The results of each clinical review will be discussed with the individual clinician and
trends will be discussed during the Continuous Quality Improvement Meetings within
each Organization’s Region.
3. Corrective action plans will be developed during the Continuous Quality Improvement
Meeting.
17 Nebraska Federation of Families
4. Each Affiliate Organization will have a quarterly Continuous Quality Improvement
Meeting to review the Administrator reports, statistical reports, clinical reviews, and any
other reports or issues that impact service delivery.
a. This review, along with previous corrective action plans, will be used to develop
a plan for improvement.
b. Minutes of each \meeting will be documented to include attendance,
participation, and any significant issues that are not documented in the
corrective action plan. The minutes of the meeting and all associated corrective
action plans will be reviewed and signed by the Affiliate Organization’s Executive
Director and Board President to indicate their awareness of the issues discussed.
c. The Federation of Families will conduct a comprehensive review of each
Organization’s FN/FPS service delivery system at least twice every twelve
months.
5. Administrative Audits will occur a minimum of annually and will include a review of the
Affiliate Organization’s Personnel files to ensure contact compliance related to
performance of background checks, exceptions, “Family Member” status and any
related performance issues and resolution related to each Advocate.
6. Quality Assurance audits will occur a minimum of annually to review: quality of contacts,
services referral and access, family stressors decreases, protective factors increases,
completed releases, WRAP Plans review, strengths identification, etc. Random quality
audits will be performed on Pyramid.
7. Family Reviews will occur with each Affiliate Family Organization on an as needed basis.
The review time will be utilized to capture data and staff new families entering services,
as well as staffing issues and resolution prior to discharge.
8. Data audits will occur, as needed, to ensure that data is being adequately entered on
the Pyramid IT system and that the quality of the contacts is occurring, as necessary.
9. Organization Reviews will occur within each Affiliate Organization to satisfy the
Continuous Feedback Loop necessary for system improvements. During the regional
meetings, data will be presented to the Advocates and administrators of the
Organization, as well as families and other stakeholders involved with the contract. In
addition to data review and trend analysis, families and Advocates will be asked for
feedback, which may include anything from celebrations, strengths of the system, gaps
or new resources identified.
a. The Organization Director will ensure that the minutes of the meeting are
recorded on Pyramid.
b. Staff who are unable to attend the meeting will review and sign the meeting
minutes.
c. The following staff will be invited to the meeting, at minimum:
• Organization Director;
• Organization’s President of the Board
• Consulting Clinician
• Advocates
• Community Members and Stakeholders, which may include (but is not
limited to: Regional Administrator, Public Health administration, school
18 Nebraska Federation of Families
d.
e.
f.
g.
administration, family members, youth, child welfare personnel, therapists or
other community-based organizations that the Affiliate may come into contact
with during business.
At minimum, the agenda will include:
• New policies and procedures
• Issues that impact the delivery of Advocacy services;
• Issues that impact the delivery of behavioral health services;
• Issues that impact the delivery of Advocacy services;
• New or revised community resources
• Regional/community gaps
• Behavioral health statistical reports;
• Health services statistical reports;
• Communication issues;
• Performance improvement and corrective action plan(s).
The Affiliate Organization Director will ensure that meeting minutes are
produced and disseminated within 5 business days of the meeting. Staff unable
to attend the meeting will be required to read and sign the meeting minutes.
The meeting minutes and corrective action plans will be submitted within 5
business days of the meeting to the Federation Administrative Office.
Each Affiliate Organization will maintain documentation of quality assurance
activities by calendar year. No quality assurance documentation will be filed in
the Family File. Documentation of quality assurance activities will be readily
available for review by the Federation. The documentation will include, at a
minimum:
• Clinical reviews;
• Site visit reports;
• Comprehensive review reports;
• Monthly Statistical data;
• Corrective Action Plans; and
• Consumer Satisfaction Survey results
10. Corrective Action Plans The Federation establishes targeted levels of performance
based on historical data and/or best practices or industry benchmarks. After the
measurement is completed and results have been compared to the selected
performance target, a corrective action process is implemented if the performance goal
has not been met. Corrective action plans include assessment of root causes for not
meeting the target level of performance, steps planned to implement corrective actions
with implementation timeframes and completion dates, and interim goals. Corrective
Action Plans follow the PDCA quality improvement structure to ensure performance
improvement goals are met, tracked and trended. Once an Affiliate is asked to
complete a corrective action plan, the Affiliate must comply by the following
timeframes:
19 Nebraska Federation of Families
a. Forty-eight (48) hours to complete the initial Corrective Action Plan from the
date/time requested by the Federation.
b. If NE-FFCMH requests any revisions to the Plan, the Affiliate has twenty-four (24)
hours to make revisions and return to NE-FFCMH.
III. DEFINITIONS
Administrative audit: The Administrative Audit is designed to ensure compliance with the
Family Navigation and Family Peer Support contract through the Division in which the
Federation partakes, as well as the Affiliate Agreements in each region. The audit tool draft has
been created and will continue to evolve over time in order to continually reflect the quality
sought from each organization. Additionally, in an attempt to provide consistency across all
programs, the audit tool will be standardized for use in all services provided by the Family
Organizations.
Quality Review Audit: The QA audit is designed to review the quality of contact with each
family, whether services are being referred and accessed, whether family stressors have
decreased and protective factors increased as demonstrated through the documentation of the
Advocates, whether releases are completed timely and signed by necessary parties, whether
WRAP Plans address the specific and unique needs of the family, whether strengths are being
identified, etc. Similar to the Administrative Audit tool, the QA tool has been created to utilize
across all services.
Checkpoint Meetings: The “as needed” Family Review provides an opportunity to review all
new Family Navigation and Family Peer support referrals by a group of individuals. This review
does not replace or act as a clinical review, but rather focuses on ensuring that all first steps in
the process have been completed. This may include completion of the intake packet, creating
the first safety plan or WRAP Plan, getting releases and making initial contact with the family
within 72 hours. The reviews occur via webinar for each Region. The Advocates are asked to
block this period of time out to review their new family assigned, and to come to the review
with the information requested.
Organization Review: The Organizational reviews are designed to satisfy the Continuous
Feedback Loop necessary for system improvements. During the regional meetings, data will be
presented to the Advocates and administrators of the Organization, as well as families and
other stakeholders involved with the contract. In addition to data review and trend analysis,
families and Advocates will be asked for feedback, which may include anything from
celebrations, strengths of the system, gaps or new resources identified. This collected
information is an additional formation of qualitative data necessary for universal review of
program success and outcome measurement.
20 Nebraska Federation of Families
Clinical Oversight and Review: The Federation has chosen to utilize an individualized approach
to clinical consultation and oversight for this contract that will allow for the variances and
specific culture of each Region to be observed and honored through this service. Each
Organization has chosen a partnership strategy that best meets the financial and cultural needs
of their Region and will include variances within a standardized set of expectations. Clinical
supervision will follow guidelines as those established for licensed Mental Health Practitioners,
obtaining state licensure. The goal of clinical staffing will be to learn the Clinician’s
recommendations and next steps, both of which will be documented and added to the case file.
To ensure compliance with guidelines of clinical oversight, all clinical supervision meetings will
be entered into the data base and monitored.
Performance Improvement Activities: The Federation participates in performance
improvement activities as identified by the Division. These activities include performance
improvement projects, consumer surveys, and complaint trending. In addition to these
performance improvement activities, the Federation also takes action to ensure that its
contracted Affiliates have the necessary education/training/technical assistance, follow up
monitoring of performance standards as needed, notification of changes in process or forms, to
ensure success within each Affiliate’s quality management programs. The Federation assesses
the effectiveness of actions taken and maintains formal processes to effectively communicate
performance improvement information.
Family Rights and Responsibilities: Family rights and responsibilities are defined by the
Federation and its Affiliates and published in the Federation Family Handbook (currently under
construction). Updates to the Family Handbook are submitted to the Division for approval on an
annual basis. Distribution occurs as part of the Family Handbook distribution process annually.
21 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
V.
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/22/11
Section: Program
Policy No:
FedP201
Effective
Date:
10/1/2011
Subject: Screening for Abuse and Neglect
POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all staff and
Affiliate Family Organizations abide by and follow the Federation Screening for Abuse and
Neglect policy as indicated below. Screening for Abuse and neglect includes interactions
between Affiliate Organization staff and the families in which they provide advocacy, as well as
the screening completed by each Organization for the hiring of staff under any Federation
funded programs.
VI.
PROCEDURE
A. Mandated Reporting
Per the Child Abuse and Neglect Reporting Act, those adults working with children and youth
under the age of 19 years old having reasonable cause to believe a child known to them in their
professional or official capacity may be abused or neglected shall immediately report or cause a
report to be made to the Nebraska Department of Children and Family Services’ Child Abuse
Hotline (1-800-652-1999).
Mandated reporters include any and all personnel who work with children under the age of 18
years old.
B. Suspected Family Cases of Abuse or Neglect
All Affiliate Organizations and program sites must have a written procedure for reporting
suspected cases of abuse and neglect that take place during the provision of services/supports
affiliated with the Organization. Organizational policy shall include:
 Informing parents of the Organization’s/Advocate’s role as mandated reporter. This may
be included in orientation packets and information to parents;
 Identifying the person(s) on staff who will be responsible for filing such reports and
informing the parents;
 Identifying the roles and responsibilities of family members and volunteers in reporting
such cases;
 Documenting all such incidents in a family’s file;
 Identifying the person(s) responsible for following up on reports made to the Hotline
and with the family.
22 Nebraska Federation of Families
C. Suspected Organization Cases of Abuse or Neglect
All Affiliate Organizations program sites must have a written procedure that covers
expectations for the safe management of families by staff and program volunteers, as well as
handling cases of suspected abuse or neglect that may have occurred while the child/family is
on program site or involved with the Organization’s Advocate. The procedure must include:
 Supervision of staff in contact with parents, children and youth;
 Clearly established norms of behavior for staff, especially training and procedures for
handling children and youth with problem behaviors;
 A method for identifying, documenting, and reporting suspected cases of abuse or
neglect within the Organization; interim plans for the employee and child(ren) involved
in the report while such an investigation is occurring; disciplinary action
Mandated Child Abuse/Neglect Reporting and Staff Screening for employees in such cases
that are founded by NDHHS.
D. Screening of Adults Working with Participants
Affiliate Organizations must have written procedures for hiring and screening staff and
volunteers who work with children ages 19 and under. Each Organization site must complete
required background checks as outlined by the Federation of Families and include the process
to be utilized for staff, volunteers, and interns over 19 years of age. Liability insurance should
also cover adults working with children and youth.
E. Background Checks
Background checks are required for all Affiliate staff and volunteers who have one-on one
contact with any parent, child and/or youth. Funded programs are required to have a written
protocol on file requiring background checks, as well as evidence of their completion.
23 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/22/11
Section:
Administration
Effective
Date:
10/1/2011
Subject: Reporting Abuse and Neglect
Policy No:
FedP227
I. POLICY
NFFCMH and its Affiliates will inform families that they are required by Nebraska law, to report
abuse and neglect and will abide by Nebraska Revised Statute 28-711. “Nebraska Revised
Statute 28-711 requires any physician, medical institution, nurse, school employee, social
worker, or other person who has reasonable cause to believe that a child has been subjected to
abuse or neglect or observes such child being subjected to conditions or circumstances which
reasonably would result in abuse or neglect to report their concerns to the proper law
enforcement agency or to the Department of Health and Human Services.
II.PROCEDURE
In the event that NFFCMH and/or its Affiliates suspect abuse or neglect, they will contact the
Nebraska Child Abuse/Neglect Hotline and report all information that they have available. To
the extent available, NFFCMH and its Affiliates will provide the name, address and age of the
abused or neglected child, the name(s) of the alleged perpetrator(s), where and when the
alleged abuse or neglect occurred, the nature and extent of the abuse or neglect, and any other
information which may be helpful in establishing the cause of the alleged abuse or neglect,
including past history. In a life threatening or emergency situation, NFFCMH and its Affiliates
will call law enforcement (911) in the city or county where the child resides. Immediately
following any reports of abuse/neglect to the DHHS Hotline, NFFCMH and its Affiliates will
consult with local Supervisor and notify the NFFCMH.
It remains the responsibility of NFFCMH and its Affiliates to ensure that if there is an identified
safety threat and corresponding need, that support and/or services are being offered to the
assigned family after investigation has occurred and the CFSS has notified NFFCMH and its
Affiliates that they can proceed assisting the family related to the specific threat. All policy and
procedures will directly interface with state law and statute regarding abuse and neglect.
In the case of suspected abuse of an adult, the following steps shall be taken by NFFCMH and
its Affiliates: In cases where there is suspected or known sexual assault/abuse, serious physical
injury, or theft, law enforcement should be notified prior to notification of other sources.
24 Nebraska Federation of Families
For suspected abuse of a vulnerable adult, NFFCMH and its Affiliates will abide by Nebraska
Statue 28-372. “When any physician, psychologist, physician assistant, nurse, nursing assistant,
other medical, developmental disability, or mental health professional, law enforcement
personnel, caregiver or employee of a caregiver, operator or employee of a sheltered
workshop, owner, operator, or employee of any facility licensed by the Department of Health
and Human Services Regulation and Licensure, or human services professional or
paraprofessional not including a member of the clergy has reasonable cause to believe that a
vulnerable adult has been subjected to abuse or observes such adult being subjected to
conditions or circumstances which reasonably would result in abuse, he or she shall report the
incident or cause a report to be made to the appropriate law enforcement agency or to the
department. Any other person may report abuse if such person has reasonable cause to believe
that a vulnerable adult has been subjected to abuse or observes such adult being subjected to
conditions or circumstances which reasonable would result in abuse.”
25 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision: 7/22/11
Effective
Subject:
Date:10/1/2011
Section:
Policy No:
Administration FedP202
Caseload Management
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that caseload
sizes remain within compliance based upon the related contract with the Division of Behavioral
Health and/or Division of Children and Family Services. It is the responsibility of each Affiliate
Family Organization to ensure compliance with this expectation within their Organization.
II.PROCEDURE
A. Caseload sizes will remain within the parameters of the contract, which include:
a. Family Navigation only caseloads shall not exceed a maximum of fifteen (15)
families at one (1) time.
b. Family Peer Support only caseloads shall not exceed a maximum of twenty-five
(25) families at one (1) time.
c. A combination of Family Navigation and Family Peer Support shall not exceed a
maximum of twenty-five (25) families at one (1) time.
B. Caseloads may vary depending on the intensity, duration and frequency of each family’s
needs.
C. The average length of stay for Family Peer Support is approximately six months and 90
days for Family Navigation.
D. Advocates providing service and support under both program types may be granted
exceptions based upon their ability to manage the case load efficiently and effectively
for the maximum family benefit.
E. Exceptions for caseload capacity must be pre-approved by the Nebraska Federation of
Families prior to assignment of a family to an Advocate carrying the maximum caseload
capacity.
a. Affiliate Organizations must adequately demonstrate how the Advocate will
effectively and efficiently manage the caseload if it is granted for increase.
b. Affiliate Organization must complete form # F137-Caseload Maximum Exception
PRIOR to assignment beyond the maximum and submit to the Federation
Program Manager for review and approval.
i. Exceptions will be reviewed with a final decision within 5 days of
submission to the Federation.
ii. Exceptions, whether approved or denied, shall be placed in the
Advocate’s personnel file.
26 Nebraska Federation of Families
iii. Approved exceptions shall be approved based upon content and Affiliate
Organizations receiving approved exception shall be responsible for
ensuring the plan is followed, including regular reviews of the progress.
iv. Failure to ensure that approved exceptions continually allow for effective
and efficient service to families assigned to Advocate may be subject to
corrective action by the Affiliate Organization.
F. The Affiliate Organization shall independently determine minimum numbers of
identified FN/FPS families to be distributed amongst Advocates.
27 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/22/11
Effective
Date:
10/1/2011
Subject: Reporting
Section:
Administration
Policy No:
FedP203
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that mandated
reporting remains consistent and occurs in a timely manner. Reporting guidelines are outlined
in each Affiliate Organization’s Memorandum of Agreement. Each Affiliate Organization shall
abide by the set forth reporting expectations.
II.PROCEDURE
The Affiliate Family Organizations are responsible for reporting to the Federation on a monthly
and quarterly basis. The Federation may request reports that are in addition to required
reporting expectations, as necessary to meet contract obligations. The following standard
reports shall be provided the Federation:
A. The Affiliate shall complete monthly summaries on Pyramid by the fifth (5th) of
each month for CFS and the 10th of each month for FPS/FN for services/supports
provided the month previous.
B. The Affiliate shall ensure service documentation has been entered on the system
within twenty-four (24) hours of the contact.
C. Other documentation may be required to be securely emailed to NE-FFCMH on
an “as needed” basis to sufficiently satisfy the needs of the Division of Behavioral
Health.
D. The Affiliate will provide a quarterly report for the FPS/FN program, as well as a
budget to the Federation by the 10th day of the month following the end of the
quarter. The budget will include specific categorical services divided between
direct and indirect expenses and will include both budgeted amounts for the
fiscal year as well as the actual for the quarter being reported on.
E. The Affiliate will provide a quarterly report to the Federation on all Indirect
services provided within their Organization by the 10th day of the month (FPS/FN
only) following the end of the quarter , which should include, at minimum:
a. Identification of any activities performed during the quarter that relate to
the six Substance Abuse Prevention Strategies.
28 Nebraska Federation of Families
b. Identification of any community meeting attendance and/or involvement
that relate to improvement of Nebraska’s Systems of Care
c. Identification of all board related trainings that the Organization’s board
attended and/or participated in.
d. Identification of all support groups coordinated, including dates, times,
location and number of participants. This report shall include both
parent support groups and youth support groups.
e. Identification of how youth and families were involved in planning,
development and monitoring or projects, services and outcomes within
the Affiliate Organization.
f. Identification of all outreach activities, educational activities and
marketing activities.
g. Identification of all resource delivery that occurred within the
Organization that was reported administratively (not through assignment
to an Advocate or enrollment in services), including the number of hours
spent in this type of activity and the total number of unduplicated
families/individuals in which non-formal referral options were provided.
These activities shall be defined by:
i. Consultation to other professionals in community
ii. Quality Assurance activities within Organization
iii. Marketing/Newsletter production and distribution
iv. Family Service Evaluations
v. Community Consultation/Education
vi. Program Staffing
vii. Other activities that cannot otherwise be defined by direct service
delivery
h. Identification of other relevant reporting, which include:
i. Any changes to clinical supervision, including (but not limited to)
changes in consulting clinician and their licensure
ii. Any changes to insurance policy
iii. Any corrective actions requested and completed, including dates
of corrective action and result of the action.
iv. Updated resources (in designated format) within the Behavioral
Health Region the Organization resides, including removal of
services/supports no longer available, new providers and services
and any other changes to resources
v. Listing of all Case Load exceptions requested and granted
29 Nebraska Federation of Families
F.
G.
H.
I.
vi. Listing of all Exceptions to change assignment of an Advocate
requested and granted
The Affiliate will assure that all documentation provided adheres to a quality
standard.
The Affiliate will provide a quarterly and annual report.
FPS Quarterly report is due as follows; (NOTE: CFS reports are due on the 5th of
the month following the quarter’s end)
 October 1st –December 31st will be due January 10th
 January 1st- March 31st will be due April 10th
 April 1st- June 30th will be due July 10th
 July 1st-September 30th will be due October 10th
Should the Affiliate be delinquent in submitting monthly data or reports the
Affiliate may be responsible for corrective action that may equate or lead to
financial penalties as outlined in the contract or breach of contract, leading to
contract termination.
NE-FFCMH will utilize 5% retainage, as also required by DAS and NE-FFCMH
contract. In the event that the Affiliate meets a minimum threshold of 80% of
the overall Performance outcomes, the full 3% retainage will be added to the
month following the quarter’s end reimbursement. In the event that the
Affiliate meets a minimum threshold of 80% of the overall Quality Outcome
Measures listed below, the full 2% retainage will be added to the month
following the quarter’s end reimbursement. If measures are not met related to
services purchased and the overall performance and quality measures, the
retainage will not be eligible for reimbursement as it will be considered a penalty
for outcomes not reached. The retainage measurement will be verified with
quarterly data that is validated and reconciled from the database by the 5th of
the month following the fiscal quarter, by NE-FFCMH. The Affiliate will be
responsible for submitting the reimbursement request for retainage, quarterly.
30 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/22/11
Section:
Administration
Policy No:
FedP204
Effective
Date:
10/1/2011
Subject: Protected Health Information Security
I.POLICY
It is the policy of the Nebraska Federation of Families that minimum necessary access is allowed
to client/family specific protected health information (PHI). Protected health information is
defined in 45CFR Part 164.501 of the Standards for Privacy of Individually Identifiable Health
Information as “individually identifiable health information” that is transmitted by electronic
media; maintained in any medium as described in 162.103 of the subchapter or transmitted or
maintained in any form or medium (except education records covered by the Family Education
Rights and Privacy Act) will be maintained by the Nebraska Federation of Families and its
affiliates allowing “minimum necessary access” to the protected health information as outlined
in the HIPAA Privacy Standards. Nebraska Federation of Families administration will establish
and maintain protocols for allowing “Minimum Necessary Access” to protected health
information that is maintained in the Nebraska Federation of Families computer application and
database system.
II.PROCEDURE
A. Access to Pyramid
Access to Pyramid is by Agency and job related duties and includes, but is not limited to, the
following categories:
1. Nebraska Federation of Families Office Staff.
-- Administration
-- Finance
-- Enrollment
-- Quality Assurance
-- Information Technology
-- Nebraska Federation Affiliate Network
2. Business Associates/Advocates/ Other Contract Agency Staff.
-- Advocate/FN/FPS Supervisors and Leads
-- Advocates, Family Navigators, Family Peer Support Specialists
-- Clerical Support/Data Entry Staff
-- Administrative Staff
-- Clinical Consultants
-- Data Management affiliates
31 Nebraska Federation of Families
B. Requests for Access to Pyramid
1. Requests for a Login/User ID to access Pyramid (Federation data management system) are
made in writing and forwarded to the Federation Program Manager, using the appropriate
REQUEST TO ACCESS PYRAMID LOGIN I.D.
C. Verifying Appropriateness of and Creating Pyramid Login/User I.D.
 I.D. requests will be reviewed:
 All areas must be completed
 I.D. request must be signed
 An existing Affiliate Organization Supervisor or the Organization Director must have
signed the request.
 If information is missing, the I.D. request form should be returned to the user for follow
up.
D. Issuing Pyramid Login/User I.D.’s.
Staff who are issued a Login I.D. for Pyramid will be given (via fax or email) a copy of the
“INSTRUCTIONS FOR ACCESSING Pyramid”. The instruction sheet will include the following
information:
• The Login I.D.
• Instructions for accessing Synthesis.
• Information about the “temporary” password and instructions for creating a new
• Guidance on protecting passwords.
• Information on how to access Pyramid support staff.
E. Misuse of Pyramid Login/User I.D.
Reports of abuse of or misuse of Pyramid Login I.D.’s are to be forwarded to NE-FFCMH
Program Manager. Misuse/abuse may include:
• An individual with a valid Pyramid Login I.D. allowing other individuals to use the I.D.
to access protected health information maintained in Pyramid.
• Copying and reproduction of protected health information maintained in Pyramid
without the appropriate authorization or permission.
• Other misuse such as improper handling of protected health information obtained
from Pyramid.
Reports of abuse or misuse of Pyramid Login I.D.’s will be reviewed and may result in one of the
following actions:
• Additional training on the HIPAA regulations.
• Written/verbal reprimand or other disciplinary action (as appropriate).
• Revocation of the individual Pyramid Login I.D.
32 Nebraska Federation of Families
APPLICATION FOR PYRAMID LOGIN I.D.
To request a Login in I.D. for Pyramid, complete the following application.
PLEASE PRINT LEGIBLY!
Affiliate Organization Name:
Phone No.
Ext.
Email:
Fax (if no email listed above):
Type of User: (Check one or more that apply)
Staff Name:
Advocacy ___Advocate/FN___ Lead ___ Supervisor ___ Clerical
Vendor Billing Staff ___ View Authorizations ___ Submit Invoices ___View Reports Only
Vendor Data Entry Staff ___Resource Guide Update ___Progress Notes __ Data Entry ___ Data
entry and approval
(Authorization Level is required only for Progress Report entry requests)
Other (describe)
Programs: (Check one or more that apply)
Family Navigation
Family Peer Support
Child Welfare Family Advocacy
The above named Affiliate Organization requests that a Pyramid Login I.D. be issued to the
above named staff at their organization. The staff receiving the Pyramid Login I.D. agrees to the
following terms regarding maintenance of the I.D. and access to confidential information in
Pyramid.
The agency requesting a Pyramid Login I.D. for the above named individual agrees to notify the
Federation Program Manager when this individual’s I.D. is to be inactivated because the
individual’s job responsibilities no longer require access to Pyramid or the individual is no
longer employed by the organization.
PYRAMID USER I.D. AGREEMENT
I agree to keep my Pyramid Login I.D. and password confidential and not to share it with any
other individuals within or outside my agency. I understand that information provided
through Pyramid is confidential and agree to protect this information, using it only as needed
to perform my job duties.
I agree to report to the Federation administration office (1-877-239-8880) any unusual activity
or inappropriate access to information that occurs while using Pyramid.
Staff Signature _______________________________________
Date Signed: ___________________
33 Nebraska Federation of Families
Authorized by (signature) ___________________________
Print Name: ____________________________
FAX/scan completed request to Federation Administrative office at: (866) 763-2649 or email
at: swonder@nefamilies4kids.org
Reviewed/Created by: _______________________________ Date: _______________________
PROTECTING YOUR PASSWORD
Include some type of punctuation of other non-alphabetic or numeric symbol in the password
such as a dash or pound sign.
Do NOT write your password down or display it in writing on or near your computer.
If you must write your password down – store it in a secure place (not under the keyboard,
telephone or other objects on your desk).
DO NOT share your password with co-workers or friends and if it is written down – where you
keep it.
DO NOT use the “auto complete” feature on your Browser. (Remembers and automatically fills
in your password for you.)
34 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
I.
Date
Reviewed: 9/23/11
Section:
issued:10/1/11 By: SN
Administration
Last Revision:
7/6/2011
Effective Date: Subject: Confidentiality
10/1/2011
Policy No:
FedP221
POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all
client/family information (written/electronic or verbal) remains confidential. Client/family
identities and client/family specific information, whether stored in hard copy format or
electronically, shall be considered confidential and may only be given/received/shared with
authorized persons with the express, written, informed consent of the parent/legal
guardian and youth/client. Client/family identities and client/family specific information
(whether it be the actual hard copy record or electronic files) are not to be removed from
the Family Organization and/or its satellite offices, except as deemed necessary by job
responsibilities.
II.
PROCEDURE
A. Authorization for Release of Information.
1. Client/family identity and client specific information may only be discussed with or
released to the individuals/agencies that are listed on the signed AUTHORIZATION FOR
RELEASE OF INFORMATION form. Information that is released must be limited to the
minimum necessary information required to comply with the request as identified on
the signed Authorization to Release Information form. This form must be completed
and signed by the appropriate parties before any information can be
given/received/shared.
B. Re-release of Information.
If a document specifically states that it “May Not be Re-released”, Nebraska Federation
of Families and its affiliates will comply with that request.
(a) No personally identifiable information in treatment records may be rereleased by a recipient of the treatment record unless re-release is specifically
authorized by informed consent of the subject individual, by this chapter or as
otherwise required by law.
(b) Any disclosure or re-release, except oral disclosure, of confidential
information shall be accompanied by a written statement which states that the
information is confidential and disclosure without patient consent or statutory
authorization is prohibited by law. No personally identifiable information in
treatment records may be re-released by Nebraska Federation and its affiliates
unless the re-release is authorized by the client/guardian.
35 Nebraska Federation of Families
Written disclosures of information must be accompanied by a written statement
that the information is confidential and disclosure without patient consent or
statutory authorization is prohibited by law.
(c) All employees and affiliates will review and sign the (attached) Standards for
Ethical Conduct.
36 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/25/11
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP206
Employee Availability
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that the ability
to provide services and supports to referred families be available on a 24 hour basis, 365 days
per year. Affiliate Family Organizations shall ensure ability to provide this access to services as
a shared responsibility for and a commitment to positive outcomes.
II.PROCEDURE
Affiliate Family Organizations will ensure services and supports are provided in a timely manner
as defined in the service-specific contract. Affiliates shall:
B. Ensure 24 hour, 7 days per week, 365 days per year availability to respond to new
referrals.
C. Shall ensure coverage within their Organization to ensure this access can be
maintained
D. Shall notify the Federation of any staff changes that will impact ability to provide
services/supports within the designated timeframe.
E. Will provide one on-call number to the Federation for the purposes of relaying
referrals.
F. Will provide the Federation a copy of the Affiliate procedure for ensuring 24 hour
availability.
G. Will ensure all staff/Advocates providing on-call duties are adequately trained to
provide crisis responses.
H. Will ensure that initial phone contact is made with referred families within 24 hours
of the referral.
I. Will ensure initial face to face contact is scheduled with referred families within 72
hours of the referral.
37 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/2011
By: SN
Last Revision:
7/25/11
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP207
Safety
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that safety of all
Federation and Affiliate employees, as well as families served, are paramount in the delivery of
services and support. All Federation and Affiliate employees will complete the initial Safety
training and demonstrate competency in the understanding and practice of safety procedures.
II.PROCEDURE
The Federation and its Affiliates will ensure safety precautions are taken at all times, both at
the office and out in the field and will observe and manage all personal and employer liabilities.
At a minimum, the Federation and Affiliates will recognize, plan for and manage the following
safety related issues:
A. All employees working with families and/or children are considered mandatory
reporters and will notify families of this status during the intake phase.
a. All employees will report abuse/neglect to the Nebraska Child Abuse Hotline
or to local law enforcement. (as outline in FedP227)
B. Affiliates will ensure all employees receive initial Safety training upon hire and
ongoing training related to specific needs within the organization.
C. All Affiliates will have an Organization Safety Plan in place that has been reviewed
and approved by their Board and the Federation.
D. All Affiliates will conduct appropriate background checks as outlined in the
Federation contract on all staff hired to provide services under this contract.
Exceptions may be requested of the Federation, but should be done so prior to
employee being given access or contact with families.
E. Affiliates will have adequate process in place for warning employees of any potential
hazards.
F. Affiliates will have adequate processes in place for face to face contacts with families
in their homes or other community locations, specifically related to ensuring
38 Nebraska Federation of Families
G.
H.
I.
J.
K.
personal safety. Each Affiliate will be responsible for monitoring this safety on a
regular basis and putting any corrective measures in place, as needed.
Affiliates will ensure that all employees are equipped with adequate tools to protect
themselves in an unsafe situation, which may include a cell phone or other
communication devise. Affiliates that do not provide cell phones must demonstrate
how they will ensure safety of their employees in the field in other manners.
Affiliates should assign a “Safety Monitor” within their organization that is
responsible for the oversight of safety, including knowing the whereabouts of all
Advocates that make visits in the community, the time they left and the time they
return, and a plan of action if concerns arise. This plan and the name of the
designated office safety monitor must be provided to the Federation, along with any
changes that may occur.
Each Affiliate shall have a policy and procedure in place regarding weapons in the
workplace.
Affiliates shall utilize the format and processes identified by the Federation for
Incident Reporting, and ensure that all employees are provided access and
knowledge regarding this process.
Affiliates will ensure that they have the contract designated insurance coverage in
place for their organization and that the coverage meets the qualifications necessary
to be in compliance with the DHHS contracts. Affiliates will notify the Federation
prior to any changes to insurance coverage and will provide a written copy of the
policy changes.
39 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s
Mental Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date
Reviewed: 9/23/11
Section:
Policy No:
issued:10/1/2011 By: SN
Administration
FedP209
Last Revision:
7/25/11
Effective Date:
Subject: Collaboration with Helpline
10/1/2011
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all Affiliate
Family Organizations collaborate and partner with the Nebraska Family Helpline to ensure
appropriate communication and access to services for referred families occur on all levels.
II.PROCEDURE
A. The Federation and the Affiliates will ensure that communication with the Helpline is
addressed in Organizational procedure and includes the appropriate level of contact.
Referrals from the Helpline shall be sent directly to:
a. Nebraska Federation of Families Program Manager through secure
Federation Email
b. Nebraska Federation of Families Executive Director through secure
Federation Email
c. Affiliate Family Organization Executive Director through secure Federation
Email
B. The Affiliate Family Organization will communicate directly with the Federation Program
Manager on all referrals or contact with the Helpline regarding referrals of families
served. The Helpline will have a single point of communication with the Federation for
services provided under contract. Exceptions to direct communication with the Helpline
include:
a. Assisting family with contacting the Helpline for immediate services when
deemed appropriate by Affiliate Organization Supervisor/Director.
b. Returning a call from the Helpline for a specific purpose
B. The Affiliate Family Organization will work collaboratively with Federation to gather
information requested from the Helpline. All requested information will be funneled
through the Federation for the purpose of sharing with the Helpline.
40 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/29/11
Effective
Date:
10/1/11
Subject:
Section:
Administration
Policy No:
FedP212
Insurance Coverage
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all Affiliate
Family Organizations obtain and maintain the insurance required by the State of Nebraska and
the Nebraska Federation of Families. All insurance changes will be pre-approved by the
Federation of Families to ensure standards have been adequately met regarding contract
requirements. Approval of the insurance by the Federation and the State does not limit, relieve
or decrease the liability of the Affiliate.
II.PROCEDURE
Each Affiliate Family Organization is required to obtain and maintain the following insurance:
A. Workers’ Compensation Insurance: The Affiliate shall take out and maintain during the
life of the contract the statutory Workers’ Compensation and Employer’s Liability
Insurance of all of the Affiliate’s employees to be engaged in work on the project under
the contract with the Federation.
B. Commercial General Liability Insurance and Commercial Automobile Liability insurance:
The Affiliate shall take out and maintain such Commercial General Liability Insurance
and Commercial Automobile Liability Insurance as t shall protect them in performing
work covered by the Federation contract(s) for claims for damages for bodily injury,
including death, as well as from claims for property damage, which may arise from
operations under the contract(s). The amounts of such insurance shall be no less than
the limits included hereinafter.
1. Commercial General Liability Insurance shall be written on an occurrence
basis, and provide Premises/Operations, Products/Completed Operations,
Independent Contractors, Personal Injury and Contractual Liability coverage.
2. The policy shall include the State and the Federation of Families, as
additional insured.
3. The policy will be primary, and any insurance or self-insurance carried by the
State or the Federation of Families shall be considered excess and noncontributory.
41 Nebraska Federation of Families
4. The Commercial Automobile Liability Insurance shall be written to cover all
Owned, Non-Owned and Hired Vehicles.
C. The following are the required Insurance Coverage Amounts:
1. Workers’ Compensation and Employer’s Liability
Coverage A
Statutory
Coverage B
Bodily Injury by Accident
$100,000 each accident
Bodily Injury by Disease
$500,000 policy limit
Bodily Injury by Disease
$100,000 each employee
2. Commercial General Liability
General Aggregate
$2,000,000
Products/Completed Operations Aggregate
$2,000,000
Personal/Advertising Injury
$1,000,000 any one person
Bodily Injury/Property Damage
$1,000,000 per occurrence
Fire Damage
$50,000 any one fire
Medical Payments
$5,000 any one person
3. Commercial Automobile Insurance
Bodily Injury/Property Damage
$1,000,000 combined single limit
4. Umbrella/Excess Liability
Over Primary Insurance
$1,000,000 per occurrence
D. Each Affiliate must furnish the Federation of Families a certificate of insurance coverage
complying with the above requirements. The certificates shall include:
a. Name of Affiliate Family Organization
b. Policy numbers
c. Effective dates
d. Dates of expiration
e. Amounts and types of coverage
E. Notice of cancellation of any required insurance policy must be submitted to the
Federation of Families when issued and a new coverage binder shall be submitted
immediately to ensure no break in coverage.
42 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/11
By: SN
Last Revision:
7/25/11
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP214
Failure to Present
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all Affiliate
Family Organizations adopt the practice of providing families with the Failure to Present policy
and to ensure families have contact information of the assigned Advocate if they have a need to
cancel a scheduled appointment.
II.PROCEDURE
Families will be presented with the policy during the Intake phase. The policy present will
include the following guidelines:
A. Families are asked to make telephone contact at least 24 hours before an
appointment to notify Advocate if they are unable to attend.
B. Advocates will make telephone contact at least 24 hours before an appointment to
notify family if they are unable to attend.
C. If a family fails to present for the appointment three consecutive times, the
Advocate and/or Supervisor will contact NE-FFCMH in consultation regarding next
steps.
D. Advocates shall ensure due diligence in making contact with a family. A family’s
failure to present shall be investigated fully by the Affiliate to ensure the family does
not wish to access services and supports.
E. The Affiliate Family Organization will utilize a formatted letter that describes their
role in the services/supports provided and will provide a contact number to the
family in this correspondence. The formatted letter will be sent to a family following
consultation with the Federation following a family’s failure to present three
consecutive times.
43 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed: 9/23/2011
By: SN
Last Revision:
8/8/2011
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP217
Suicide Prevention Data Collection
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all Affiliate
Family Organizations collect the required data sets related to the State Suicide Prevention
grant, as determined appropriate by the Federation.
II.PROCEDURE
C. The Federation and the Affiliates will complete the Initial Suicide Screen (SBQ-R) on
all youth considered to be “Identified”.
a. SBQ-R is: Suicide Behaviors Questionnaire-Revised.
b. SBQ-R 6 to 12 Years: the initial screen to be used on all identified youth ages
6 to 12 years. (Form # F117)
c. SBQ-R 13 years and up: the initial screen to be used on all identified youth
ages 13 years and up. (Form # F119)
d. Identified youth are those that have parents/caretakers receiving Advocacy
Services from the Family Organizations due to the family requesting assisting
in accessing service and/or supports related to that specific child’s behavioral
health needs.
D. The SBQ-R will be completed only on youth in the Family Peer Support Program,
initially. Further implementation of the tool will be revised at a later date, to be
followed by policy and procedural changes.
a. The SBQ-R for 6 to 12 year old youth OR the SBQ-R for 13 years and older will
be completed on all “Identified” youth referred and accepted into the Family
Peer Support Program.
b. The SBQ-R will be completed with the family, for the identified child, within
15 days of the initial referral and will be considered part of the Intake packet
and process.
44 Nebraska Federation of Families
E. Once the Advocate has completed the SBQ-R, the Advocate will score the screen by
adding up the numbers of each response and totaling the number on the bottom of
the SBQ-R.
a. A SBQ-R score of 7 or more will determine next steps.
F. Scores of 7 or more on the SBQ-R will indicate a need to complete the EIRF
Immediate Follow-Up.
a. EIRF: Early Identification, Referral Form (Form # F138)
b. If a youth/child’s score on the SBQ-R is 7 or above, the EIRF Immediate
Follow-Up form is completed with the family and the Advocate assists the
family in accessing the identified services and supports necessary for the
situation.
c. If the Advocate has concerns regarding the initial screen on the child, the
Advocate should always error on the side of safety and make contact with
their Supervisor for consultation.
i. Each Affiliate Family Organization should have an adequate process in
place to manage such situations, including how to handle any
situation in which it has been determined, based upon the Advocates
opinion, that there is either an immediate or longer term safety
concern for the youth.
d. The Advocate will fill in all required fields of the EIRF with the family and
ensure that appropriate contact information on services and supports are
provided to that family at that time.
G. For each child that has completed the initial screen (SBQ-R) and the EIRF Immediate
Follow-Up, the Advocate will also complete a 90 day follow-Up (Form # F139) with
the child and his/her family.
a. The 90 day follow up will be completed within 15 days following the 90 day
timeframe. The 90 days begins the day the initial SBQ-R was completed. For
example, if the Advocate completed the SBQ-R on August 8th, the EIRFFollow-Up would need to be completed by November 23rd for the period
between August 8th and November 8th.
H. All data collected on the SBQ-R’s and the EIRF’s will be maintained in a secure and
confidential manner and reported to the Federation of Families.
I. All data collected will be entered into the Pyramid data system within 15 days of
collection.
45 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Effective
Date:
10/1/2011
Reviewed: 9/23/11
Section:
Policy No:
By: SN
Administration
FedP218
Last Revision:
7/29/11
Subject: Clinical Consultation and Licensure
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that Clinical
Consultation is provided for the purposes of treatment review, recommendations and
consultation of crisis situations involving children and families served under the Family Peer
Support and Family Navigation contract. Each Affiliate Family Organization is responsible for
the agreement and oversight of the Clinical Consultation obligation within their Region.
II.PROCEDURE
A. Appropriate clinical consultation will be obtained and maintained within each Affiliate
Family Organization. The Affiliate will ensure the utilized clinician meets required
licensing standards, which include one of the following licensures:
a. Licensed Mental Health Practitioner
b. Licensed Independent Mental Health Practitioner
c. Licensed Certified Social Worker
d. Psychologist
B. The Affiliate will ensure utilization and licensure maintenance
a. Licensure of the clinician will be maintained in the Affiliate office
b. Licensure or the clinician will be provided to the Federation
c. Updates of the licensure will be maintained by the Affiliate and provided to the
Federation
d. Any lapse in licensure by the clinician will require immediate notification of the
Federation and will institute a hold in clinical consultation from said clinician
until licensure is brought up to date.
C. The Affiliate will utilize the expertise of the clinician within their Family Organization for
prescribed tasks, at a minimum:
46 Nebraska Federation of Families
a. Clinical Consultant will review, provide recommendation and sign off on all
recommended discharges, prior to the actual discharge.
b. Clinical Consultant will be available to provide consultation on various situations
that arise to the level of “crisis” with a family, as defined by agreement of
terminology between the Affiliate and the Clinician.
c. Each Organization is responsible for identifying an alternate clinical consultant in
the event of a conflict of interest involving a family. The same process for
licensure and reporting to NE-FFCMH, as cited above, will be utilized for the
alternate consultant.
47 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/11
Reviewed:9/23/2011
By: SN
Last Revision:
7/29/11
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP220
Hiring of Family Members
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all
individuals hired to fulfill any positions within the agency, or within the Affiliate Network, meet
the definition of “Parent/Family Member”
II.PROCEDURE
The Federation recognizes two definitions and types of family member involvement that can be
observed in the hiring practices internally and with all Affiliate Family Organizations. Applicants
that do not meet the definition criteria shall not be hired to perform any role that would
potentially come into contact with family’s being served.
A. The Federation and all Affiliates shall maintain their status as a “family run organization”
for the purposes of providing any services and/or supports under contract with the
Federation and the State of Nebraska.
i. A family run organization shall be defined as: a private, non-profit
501(c)(3) organization that hires employees and volunteers that are
family members and that understand the challenges associated with
being of that status. Family members mentor families experiencing some
of the same struggles they themselves have faced, recognizing youth,
parents and caregivers are the experts when it comes to their family’s
needs. A family organization is a network of advocacy, support,
education, and resource referrals designed to strengthen families and
empower them as they become stronger advocates for their children.
B. The Federation recognizes two definitions for family member, based upon the variances
in populations served under the different contracts.
i. A “Family Member” is defined as the biological or legal parent, sibling, other
relative, legal guardian, caregiver and/or other primary relations to the child
whether by blood, adoption, legal relationships. This definition applies only
to the CFS contract.
ii. A Family Navigator/Family Peer Support Specialist is defined as a family member
or a person who is/was a primary caregiver for a child, youth, or adolescent who
48 Nebraska Federation of Families
has experienced a serious behavioral health challenge.” This definition is
required for all Advocates providing services under the FPS/FN contract.
This parent/family member must demonstrate standards of practice and competencies to
include, but not limited to, the ten domains of knowledge, skills and abilities described by the
National Federation of Families for Children’s Mental Health, which include: knowledge, skills
and abilities, ethics, confidentiality, effecting change, current information on children’s
behavioral health prevention and treatment, education/IDEA information, communication,
parenting resiliency, advocacy across systems, empowerment, wellness and natural
supports. The parent/family member preferably holds a Bachelors or Masters degree, but it is
not required. The Federation believes the professional skill set valued for this position is the
knowledge gained by the experience of raising a child with behavioral health needs. Parents are
the experts!
49 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed: 9/23/2011
By: SN
Last Revision:
7/22/11, 7/11/2012
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP232
Documentation
I.POLICY
It is the policy of Nebraska Federation of Families that all family related activities provided by
Advocates be documented in Pyramid (Nebraska Federation’s IT system). The Contact Note, as
defined in Pyramid, consists of the date of the note, the note text and the pertinent data points
required by contract.
II.PROCEDURE
A. All Contact Notes must be completed and finalized in Pyramid within twenty-four hours
of the contact. A hard copy of the contact notes are no longer required to be kept in the
family file, as we move to a more electronic record.
B. Each family served shall have a completed Monthly Summary on Pyramid by the 5 th of
each month for the CFS contract and the 10th of the month for the FPS/FN contract,
reflecting progress from the month previous.
C. All required domains on Pyramid shall be completed. Intake information on new
families shall be entered in Pyramid within fifteen (15) days of intake. This includes all
mandatory Pyramid fields, including (but not limited to): Identified child’s Social
Security Number, Identified child’s name, Identified child’s date of birth, Intake
questionnaire (contact information, diagnosis, demographics, background, stressors/risk
factors, strengths, Caregiver Strain, SBQ-R (for FPS only). As Pyramid continues to be
developed, additional requirements will be added and it is the expectation that all
required fields be entered.
D. All families served will have an initial Family Plan entered on Pyramid within 30 days of
intake (note: the initial plan of care is to be completed within the first 15 days of
service).
E. When an Advocate is on vacation, sick leave or a planned absence, a note referencing
this should be entered. The Note should indicate the dates the Advocate will be gone,
the name(s) of the person(s) who will be covering for him/her, and the coverage
person’s phone number. This contact note should be entered prior to the Advocate
going on leave, vacation, etc.
F. There must be at least one Family Team Meeting (FTM) held per month and this must
be documented in a contact note. The FTM includes individuals the family will identify
along with others such as the Advocate, Child Welfare Worker or Probation Officer,
teachers, therapists and other mental health providers. Identification of
50 Nebraska Federation of Families
G.
H.
I.
J.
natural/informal supports will also be documented. The FTM Progress Note cannot be
combined with any other type of Progress Note.
Contact notes must provide a description of what occurred during the course of the
contact (who was present and/or spoken to and their relationship to the youth and/or
parent, the content of the interaction/discussion, where the contact occurred, the type
of contact (i.e., phone, face-to-face, written) an impression (if any) that the writer may
have regarding the contact, and the outcome of the contact.
Contact notes must be written in a strength-based and professional manner and reflect
progress toward the Family Plan/WRAP Plan.
Documentation shall be reviewed and edited, as necessary to meet quality standards, by
Affiliate designee prior to due dates listed above.
Supervisor review is required by the Affiliate, prior to submission of monthly summaries
to NE-FFCMH (for CFS) and prior to final entry by the 10 th of each month for FPS/FN.
51 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed: 9/23/2001
By: SN
Last Revision:
8/17/11, 7/11/2012
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP236
Grievances
I.POLICY
The Nebraska Federation of Families for Children’s Mental Health and its affiliates will provide
for resolution of medical and non-medical grievances within thirty (30) calendar days while
maintaining confidentiality, in accordance with regulatory and contractual requirements.
The Nebraska Federation of Families for Children’s Mental Health is committed to assuring that
participants are satisfied with the service delivery or quality of care they receive. The
Federation has an established grievance process to address participants’ concerns or
dissatisfaction about services provided, provider of care, or any aspect of the Federation
program array or that of the Federation’s affiliate Family Organization array.
The Federation and affiliates will handle all grievances in a respectful manner and will maintain
the confidentiality of a participant’s grievance at all times throughout and after the grievance
process is completed and information pertaining to grievances will only be released to
authorized individuals.
Contract providers (affiliates) are accountable for all grievance procedures established by The
Federation. The Federation will monitor contracted providers for compliance with this
requirement on an annual basis or on an as needed basis.
Definitions:
A grievance is defined as a complaint, either written or oral, expressing dissatisfaction with the
services provided or the quality of participant care. A grievance may include, but is not limited
to:
 The quality of services a participant receives in the home, or any identified
designated location
 Waiting times on the phone.
 Behavior of any of the Family navigator or program staff;
 A violation of a participant’s rights
52 Nebraska Federation of Families
Representative means a person who is acting on behalf of or assisting a Federation participant,
and may include, but is not limited to, a family member, a friend, a Federation employee, or a
person legally identified as Power of Attorney for Health Care/Advanced Directive, Conservator,
Guardian, etc.
1. The Federation Executive Director has primary responsibility for maintenance of the
2.
3.
4.
5.
6.
7.
8.
procedures, review of operations, and utilization of any emergent patterns of
grievances to formulate policy changes and procedural improvements in the
administration of the plan.
The Federation and affiliates will continue to furnish the participant with all services
at the frequency provided in the current plan of care during the grievance process.
The Federation and affiliates will not discriminate against a Participant solely on the
grounds that a grievance has been filed.
In order to ensure participants have access to and can fully participate in the
grievance process, the Federation and affiliates will ensure the following:
a. If the person filing the grievance does not speak English, a bilingual staff
member will be available to facilitate the process. If a staff person is not
available, translation services/interpreter will be made available.
b. The Federation and affiliates shall maintain a toll-free number for the filing of
grievances
The Federation and affiliates will provide written information about the grievance
process to a participant and/or his/her representative upon enrollment, annually,
and upon request.
Grievances can be called into the Federation office or mailed to the Federation
office at:
a. Telephone numbers for the filing of by telephone via toll free number: 1-877239-8880
b. Location where written grievances may be filed: 345 N. Minden Ave, P.O. Box
183, Minden, NE 68959
Any method of transmission of grievance information from one Federation staff or
affiliate to another shall be done with strictest confidence, in adherence with HIPAA
regulations.
If the Federation is unable to distinguish between grievances and complaints, they
will be processed as grievances.
II.PROCEDURE
The Federation maintains a formal Grievance policy and practice that governs the handling of
all grievances affecting individuals or entities that are considered part of the contract
services/supports in some manner. Each affiliate Family Organization is expected to ensure
compliance with this policy and procedure as it relates to the services and supports provided
53 Nebraska Federation of Families
under any contract with the Federation. Families shall be provided the opportunity to file a
Grievance with the Federation if resolution, by all parties involved, cannot be found.
Each affiliate must demonstrate how they manage Grievances within their organization,
including documentation on each filed Grievance and documentation on the resolution of the
Grievance as outlined below. Review of this process will be done bi-annually during
Performance audits with each affiliate. The affiliate shall provide the Federation with a board
signed copy of their organization’s specific grievance policy. The affiliate policy shall, at
minimum, address the issues cited in this policy.
1. Filing of Grievances
a. A participant and/or his/her representative, may voice a grievance to the
Federation or affiliate program staff in person, by telephone or in writing to a
Federation/Family Organization location.
b. The Federation or affiliate staff will assist the participant and/or his/her
representative in filing a grievance in the event assistance is required.
c. The Grievance Report Form (Attachment #1) is available from the Family
Advocate within the affiliate Family Organization or the Federation staff will
provide the participant and/or his/her representative with a report form, when
requested in person, by telephone or in writing.
2. Documentation of Grievances
a. All grievances expressed either orally and/or in writing, will be documented on
the day that it is received or as soon as possible after the event or events that
precipitated the grievance, in the Participant Grievance Log (Contract
Attachment L).
b. Grievances submitted in writing are documented on the “Grievance Report”
Form (by the participant and/or his/her representative. The Federation program
staff person or affiliate will assist with the completion of the Grievance Report, if
necessary. Grievances received either in person or by telephone are
documented on the “Grievance Report” form by the Federation staff person or
affiliate.
c. Complete details of the grievance must be documented so that the grievance
can be resolved within thirty (30) calendar days. In the event of insufficient
information, the Federation staff or affiliate will take reasonable efforts to obtain
the missing information in order to resolve the grievance within the specified
timeframes.
d. All information related to a participant’s grievance will be held in strict
confidence and will not be disclosed to program staff or contract providers,
except where appropriate to process the grievance.
e. It is the responsibility of the Federation staff and affiliates to ensure
confidentiality is maintained, documentation is complete and accurate, and
54 Nebraska Federation of Families
grievance process is implemented and completed according to Policies and
Procedures.
3. Acknowledgement, Notification and Initial Investigation of Grievance
a. Advocates will notify the affiliate Family Organization Executive Director
within one working day of receipt of the grievance.
b. Affiliate Executive Directors will report all grievances to the Federation within
forty-eight (48) hours with a plan of action to resolve the grievance.
c. If the grievance is unable to be resolved within the affiliate organization, the
Executive Director will ensure the participant understands their right to
contact the Federation in order to file a grievance.
d. Affiliates should ensure that steps taken on the Federation level are
replicated in the affiliate Organization’s policy and procedure.
e. The Federation Executive Director is responsible for coordinating the
investigation, designating the appropriate staff member(s) to take corrective
actions, and reporting the grievance to the interdisciplinary team.
f. The Federation Staff will acknowledge receipt of the participant’s grievance
in writing, within five (5) days of receipt of the grievance. When necessary,
the Federation staff will acknowledge receipt of the grievance by telephone.
g. Federation staff notifies the management or supervisory staff responsible for
the services or operations which are the subject of the grievance.
h. Grievances related to medical quality of care will be immediately submitted
to the Federation Executive Director by staff for appropriate action.
i. When grievances related to services provided by a Federation contract
provider arise, the staff notifies the contract provider’s Quality Assurance
staff.
j. When a grievance involves a violation of a participant’s rights, the staff will
notify the Federation Executive Director immediately to begin investigation
of the grievance.
4. Resolution of Grievances
1. Grievances that are resolved to the satisfaction of the participant and/or his/her
representative by the close of the next business day after a grievance is filed are
exempt from the requirement to send written acknowledgements and written
responses to the participant and/or his/her representative. At a minimum, final
resolution must be documented in the Federation participant grievance log.
2. The Federation and affiliates will resolve grievances within thirty (30) calendar days
from the day the grievance is received. Staff will make reasonable efforts to contact
the participant and/or his/her representative by telephone or in person to advise
him/her of the outcome of the grievance investigation and determine his/her
satisfaction or dissatisfaction with the outcome of the investigation.
55 Nebraska Federation of Families
3. Staff and affiliates will send written notification of the resolution of the grievance to
the participant and/or his/her representative.
4. Staff and affiliates will document details of the grievance resolution in the
Federation Participant Grievance Log. This will include how the participant and/or
his/her representative was notified and, whether or not he/she was satisfied or
dissatisfied with the outcome.
5. In the event resolution is not reached within thirty (30) calendar days, the
participant and/or his/her representative will be notified in writing of the status and
estimated completion date of the grievance resolution.
5. Expedited Review of Grievances
1. In the event the grievance involves a serious or imminent health threat to a
participant, including, but not limited to, severe pain, potential loss of life, limb or
major bodily function or when a participant’s rights have allegedly been violated, the
Federation and affiliate staff will expedite the review process to a decision within 72
hours of receiving the Participant’s grievance.
2. The participant and/or his/her representative will inform the Federation or affiliate
staff of his/her requests either verbally or in writing. While the participant may file a
verbal grievance, he/she should be assisted, as necessary, by staff to document the
grievance in writing prior to resolution.
3. If the participant files an expedited grievance during weekend hours (4:30 p.m.
Friday to 8:00 a.m. Monday), Program Staff will immediately contact an authorized
supervisor of the program (Executive Director, Program Director) to investigate the
grievance with the participant and/or his/her representative. This individual will
notify Staff at the start of normal business hours of the status of the grievance.
4. As soon as possible, but no later than one business day after the participant files an
expedited grievance, Staff/affiliate informs the participant and/or his/her
representative by telephone or in person of the receipt of the grievance for
expedited review and describes the steps that will be taken to resolve the grievance.
5. The Federation staff or affiliate will expedite the internal review process to reach a
decision within 72 hours of receiving the grievance.
6. The Federation staff or affiliate will notify the participant and/or his/her
representative in writing of the resolution of the expedited grievance. The
participant will be notified verbally and in writing if resolution is not possible within
72 hours. The written notification for delay will include the reason for the delay and
the timeframe for when the grievance will be resolved.
6. Grievance Review Options
1. After a participant has completed the grievance process (as described above) or has
participated in the grievance process for at least thirty (30) calendar days and he or
she is dissatisfied with the resolution of the grievance, the Participant may pursue
56 Nebraska Federation of Families
other steps. Note: If the situation represents a serious health threat, the participant
and/or his/her representative need not complete the entire grievance process nor
wait thirty (30) calendar days to pursue to steps described below.
2. If the Participant is eligible for Medicaid only or for Medicaid and Medicare, he or
she is entitled to pursue the grievance with the Department of Health and Human
Services by contacting or writing to:
Ombudsman's Office
Room 807, State Capitol
P.O. Box 94604
Lincoln, NE 68509-4604
(402) 471-2035
Toll Free: (800) 742-7690
Fax: (402) 471-4277
7. Documentation, Tracking, Analysis and Reporting
1. All grievances related information shall be marked “confidential”.
2. All grievance information and details of verbal correspondence will be documented
by staff in the Participant Grievance Log and stored in locked cabinets in the
Federation/affiliate office.
3. Designated Federation/affiliate staff is responsible for maintaining, aggregating, and
analyzing information related to grievances. On a quarterly basis, this information
will be forwarded to Executive Director within each affiliate organization and sent on
to the Federation.
4. A written summary of grievances including number, type, location, and disposition
are reported to the Quality Assurance and Improvement Committee, and the Board
of Directors on a quarterly basis.
5. The Federation or affiliate designated staff will maintain, aggregate, and analyze
grievance data and identify any trends or patterns. This information will be used by
the Federation internal quality improvement program.
6. Records of all grievances will be held confidentially and made available as needed to
State and Federal agencies upon request.
7. The Federation and affiliates shall maintain in its files copies of all grievances, the
responses to them, and logs recording them for a period of 7 years from the date
the grievance was filed.
57 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed: 9/23/2011
By: SN
Last Revision:
8/17/11
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP215
Communications Tools
I.POLICY
The Nebraska Federation of Families for Children’s Mental Health will ensure appropriate use of
communication resources, including monitoring and maintaining productivity of
employees/Affiliate, in order to assist in prevention of harm to interests of the Federation and
its employees/Affiliates, and to prevent the violation of various state and federal laws.
The Federation’s communications tools, including Pyramid, are provided by the Federation and
made available to users for the purposes of the business. A certain amount of limited and
responsible personal use by users is also permitted. All use of Federation communications tools
is governed by the terms of this policy, and if Federation rules and procedures are not adhered
to, then use of tools may be curtailed or withdrawn and disciplinary/contract corrective action
may thereafter follow. Any breach of this policy may lead to disciplinary action/contract
corrective action being taken against employees/Affiliates and serious breaches may lead to
summary dismissal or contract penalties/breach.
Communication plays an essential role in the conduct of Federation business. How
employees/Affiliates communicate with people not only reflects on the employee/Affiliate staff
as individuals but also on the Affiliate Organization and NE-FFCMH as an organization. NEFFCMH values the employee/Affiliate’s ability to communicate with colleagues, families, and
other community contacts, and NE-FFCMH invests substantially in information technology and
communications systems which enable the work to occur more efficiently. NE-FFCMH trusts
employees/Affiliates to use them responsibly.
This policy applies to all individuals working for the Federation and affiliate Family
Organizations who use the communications tools, including Pyramid, whether
[directors/departmental heads/partners/consultants], full-time, part-time or fixed-term
employees, trainees, contract staff, temporary staff, or agency staff. Although the detailed
discussion is limited to use of email and internet facilities, the general principles underlying all
parts of this policy also apply to telephone communications, fax machines, copiers and
scanners.
II.PROCEDURE
Employees/Affiliates must use the Federation information technology and communications
tools sensibly [professionally], lawfully, and consistently with duties, with respect for
58 Nebraska Federation of Families
colleagues and for the Federation and in accordance with this policy and the Federation’s
other rules and procedures.
All information relating to Federation families and our business operations is confidential.
Employees/Affiliates must treat paper-based and electronic information with utmost care.
Many aspects of communication are protected by intellectual property rights which are
infringed by copying. Downloading, uploading, posting, copying, possessing, processing and
distributing material from the internet may be an infringement of copyright or of other
intellectual property rights.
Particular care must be taken when using email, organizational blog or internal message
boards as a means of communication because all expressions of fact, intention and opinion
in an email may bind you and/or the Federation and can be produced in court in the same
way as other kinds of written statements.
The advantage of the internet and email is that they are extremely easy and informal ways
of accessing and disseminating information, but this means that it is also easy to send out illconsidered statements. All messages sent on email systems or via the internet should
demonstrate the same professionalism as that which would be taken when writing a letter
or a fax. Employee/Affiliate must not use these media to do or say anything which would be
subject to disciplinary or legal action in any other context such as sending any discriminatory
(on the grounds of a person's sex, race, disability, age, sexual orientation, religion or belief),
defamatory, or other unlawful material (for example, any material that is designed to be, or
could be construed as, bullying or harassment by the recipient). If there is doubt about a
course of action, take advice from supervisors/managers [line manager/departmental
head/partner].
USE OF ELECTRONIC MAIL
It is good practice to re-read and check an email before sending. If Employee/Affiliate copies
an email to others, it may breach the Data Protection Act if it reveals all the recipients' email
addresses to each recipient (e.g. in the case of marketing and mailing lists). It can also breach
duties of confidentiality (e.g. in the case of internal emails to members of a staff benefit
scheme). Accordingly, it may be appropriate to use the 'Bcc' (blind carbon copy) field instead
of the 'Cc' (carbon copy) field when addressing an email to more than one recipient. If in
doubt, seek advice from your supervisor.
1. Expressly agree with the families that the use of email is an acceptable form of
communication bearing in mind that if the material is confidential, privileged or
commercially sensitive then un-encrypted email is not secure.
59 Nebraska Federation of Families
2. The Federation provides one secure email account to the Affiliate to utilize in the
communication of sensitive material/protected health information. Sending an email
from the Affiliate business email to an outside email or to the Federation email from the
outside account is not encrypted or secure. Employees/Affiliates will only utilize the
Federation email account to send emails (outside of their business email network) that
contain protected health information.
3. Each business email should include the appropriate Affiliate/Federation business
reference.
4. If the email message or attachment contains information which is time-critical, bear in
mind that an email is not necessarily an instant communication and consider whether it
is the most appropriate means of communication.
5. If employee/Affiliate has sent an important document, always telephone to confirm that
the email has been received and read.
6. In every instance, file a hard copy of any email (including any attachments) sent to or
received from the family before filing or deleting the electronic copy. The same applies
to all internal email transmissions concerning family matters.
7. In light of the security risks inherent in some web-based email accounts,
employee/Affiliate must not email business documents to personal web-based
accounts. Employee/Affiliate may send documents to a family’s web-based account if
the family’s express written permission to do so has been gained. [However, under no
circumstances should sensitive or highly confidential documents be sent to a family’s
personal web-based email account, even if the family asks you to do so.]
8. When employee/Affiliate needs to work on documents remotely they can be retrieved
over the internet [via the Pyramid website].
9. Pyramid is a web-based data management system that can be accessed where internet
is available. Employees/Affiliates should only access Pyramid in a location in which
others cannot see the screen (and corresponding information).
10. Employees/Affiliates utilizing Pyramid (especially outside of the secure office setting)
should take precautions to ensure that they are logged off prior to leaving the computer
unattended and that no one else has access to their log in information.
USE OF INTERNET AND INTRANET
1. The Federation trusts the employee/Affiliate to use the internet sensibly. Bear in mind
at all times that, when visiting an internet site, information identifying your PC may be
60 Nebraska Federation of Families
logged. Therefore any activity you engage in via the internet may affect the Federation
or the Affiliate.
2. Whenever there is access to a web site, the employee/Affiliate should always comply
with the terms and conditions governing its use.
3. The Federation recognizes the need for individuals to have to carry out some personal
tasks during working hours, e.g. for internet banking or on-line shopping, and this is
permitted subject to the same rules as are set out for personal email us. If these
activities require additional software to be installed onto the PC then employee/Affiliate
should submit a request to IT Support who may be able to arrange this for you.
4. Employees/Affiliates are strongly discouraged from providing the Federation/Affiliate
email address when using public web sites for non-business purposes, such as on-line
shopping. This must be kept to a minimum and done only where necessary, as it results
in the Affiliate and the Federation receiving substantial amounts of unwanted email.
MISUSE OF FEDERATION DATA SYSTEMS
Misuse of Federation data systems including, abuse of its telephone, email, or the internet in
breach of this policy will be treated seriously and dealt with in accordance with Federation
disciplinary procedure or contract compliance regulations. In particular, viewing, accessing,
transmitting, posting, downloading or uploading any of the following materials in the following
ways, or using any of the Federation data systems, will amount to gross misconduct capable of
resulting in summary dismissal (this list is not exhaustive) or breach of contract:
a. Material which is sexist, racist, homophobic, xenophobic, pornographic, pedophilic or
similarly discriminatory and/or offensive; or
b. offensive, obscene, derogatory or criminal material or material which is liable to cause
embarrassment to the Federation/Affiliate and any of its staff or its families or bring the
reputation of the Federation and any of its staff or families or customers (DHHS) into
disrepute; or
c. any defamatory material about any person or organization or material which includes
statements which are untrue or of a deceptive nature; or
d. any material which, by intent or otherwise, harasses the recipient; or
e. any other statement which is designed to cause annoyance, inconvenience or anxiety to
anyone; or
f. any material which violates the privacy of others or unfairly criticizes or misrepresents
others; or
61 Nebraska Federation of Families
g. confidential information about the Federation and any of its staff, families or customers
(DHHS);
h. any other statement which is likely to create any liability (whether criminal or civil), and
whether for Affiliate or the Federation; or
i.
material in breach of copyright and/or other intellectual property rights; or
j.
online gambling; or
k. Unsolicited commercial or advertising material, chain letters or other junk mail of any
kind.
l.
If the Federation has evidence of the examples of misuse set out above it reserves the
right to undertake a more detailed investigation in accordance with its disciplinary
procedures/contract requirements.
SYSTEM SECURITY
Security of Federation IT systems is of paramount importance. The Federation and Affiliate owe
a duty to all of families and customers (DHHS) to ensure that all work-related activities and data
are kept confidential. If at any time there is a need to rely in court on any information which
has been stored or processed using the Federation IT systems it is essential that the Federation
is able to demonstrate the integrity of those systems. Every time the employee/Affiliate use the
system responsibility is taken for the security implications of what is being done.
a. The Federation’s systems or equipment must not be used in any way which may cause
damage, or overloading or which may affect its performance or that of the internal or
external network.
b. Keep all confidential information secure, use it only for the purposes intended and do
not disclose it to any unauthorized third party.
c. Keep the employee/Affiliate system passwords safe. Do not disclose them to anyone.
Those who have a legitimate reason to access other users' inboxes must be given
permission from that other user. The Federation will provide guidance on how to do
this. If the employee/Affiliate have disclosed their password to anyone else (e.g. in
response to a request from Affiliate management or Federation management) ensure
that the password is changed once the staff no longer need it. Contact the Federation
for guidance on how to do this.
d. [If a document is highly commercially confidential or price sensitive,
employee/Federation should mark it as "private and confidential" and password-protect
the document itself.
62 Nebraska Federation of Families
e. Copies of confidential information should be printed out only as necessary, retrieved
from the printer immediately, and stored or destroyed in an appropriate manner.
f. Whenever an employee/Affiliate loads onto the PC material from outside the
Federation/Affiliate via a disk, CD Rom or flash drive, they must be sure that it is from a
secure and safe source. If in doubt about any such material or if it is suspected that it
may contain a virus, always contact the Federation or Affiliate IT support beforehand
and get help. Please note that the employee/Affiliate may not load software on to any
Federation provided PC unless it has been authorized by the Federation Administration.
g. Employee/Affiliate should not download or install software from external sources
without having first received the necessary authorization from the supervisor.
h. No external device or equipment should be attached to Federation systems without the
prior notification to and approval of the Federation.
i.
Employee/Affiliate should always exercise caution when opening emails from unknown
external sources or where, for any reason, an email appears suspicious or when a
suspected virus is received. (The IT department/line manager/departmental
head/partner] should be informed immediately in such circumstances.
WORKING REMOTELY
This part of the policy and the procedures in it apply to use of Federation systems, to
use of Federation laptops, and also to use of personal computer equipment or other
computer whenever working on Federation/Affiliate business away from the premises
(working remotely). When working remotely the following must occur:
a. password protect any work which relates to Federation/Affiliate business so that no
other person can access the work; position so that work cannot be overlooked by any
other person;
b. take reasonable precautions to safeguard the security of laptop computers and any
computer equipment on which Federation/Affiliate business is done, and keep
passwords secret;
c. inform the police and the Federation (as appropriate) as soon as possible if either a
Federation laptop in employee/Affiliate possession or any computer equipment on
which employee/Affiliate do Federation/Affiliate work, even if this is a personal IT
facility, has been lost or stolen; and ensure that any work which is done remotely is
saved on Pyramid system as soon as reasonably practicable. PDAs or similar hand-held
devices are easily stolen and not very secure so employee/Affiliate must password63 Nebraska Federation of Families
protect access to any such devices used by which is stored any personal data of which
Federation/Affiliate is a data controller or any information relating Federation/Affiliate
business, clients or their business.
PERSONAL BLOGS AND WEBSITES
This part of the policy and procedures apply to personal blogs, websites and all other personal
web content (e.g. personal podcasts) even if created, updated, modified or contributed to
outside of working hours or when using personal IT systems. The Federation recognizes that in
employee/Affiliate own private time they may wish to contribute to online forums, such as
websites, blogs and message boards, or they may take part in podcasting, webcasting or forums
of a similar nature. For the avoidance of doubt, such activities are expressly prohibited during
work time or using Federation systems. If employee/Affiliate post any content to the internet,
written, vocal or visual, which identifies, or could identify, employee/Affiliate as a member of
Federation/Affiliate staff and/or discuss work or anything related to the Federation or its
business, customers or staff, the Federation expects employees/Affiliates, at all times, to
conduct themselves appropriately and in a manner which is consistent with the contract of
employment/service contract and with Federation policies and procedures. It should be noted
that simply revealing a name or a visual image of the employee/Affiliate could be sufficient to
identify as an individual who works for the Federation/Affiliate. If employee/Affiliate already
has a personal blog or website which indicates in any way that they work for the
Federation/Affiliate they should report this to their supervisor and the Federation. If
employee/Affiliate intends to create a personal blog or website that will say that they work for
the Federation/Affiliate or in any way could identify them as someone who works for the
Federation/Affiliate then they should report this to their supervisor and the Federation. If a
blog posting clearly identifies that the employee/Affiliate work for the Federation/Affiliate and
any idea or opinion is expressed then employee/Affiliate should add a disclaimer such as "these
are my own personal views and not those of the Federation”. The following matters will be
treated as gross misconduct capable of resulting in summary dismissal (this list is not
exhaustive) or Federation contract breach:
a. Revealing confidential information about the Federation in a personal online
posting. This might include revealing information relating to Federation
clients/families, business plans, policies, staff, financial information or internal
discussions. Consult supervisor or Federation if employee/Affiliate is unclear
about what might be confidential.
a. Using a personal blog or website to criticize or embarrass the Federation/Affiliate,
its clients/families, customer (DHHS) or its staff. The employee/Affiliate should
respect the [corporate] reputation of the Federation and the privacy and feelings
of others at all times. If employee/Affiliate has a genuine complaint to make about
64 Nebraska Federation of Families
a colleague or workplace matter the correct procedure is to raise a grievance using
the Federation grievance procedure.
b. Accessing or updating a personal blog or website from Federation/Affiliate
computers or during work time. If you think that something on the blog or website
could give rise to a conflict of interest and in particular concerns issues of
impartiality or confidentiality required by the employee/Affiliate role then this
must be discussed with your supervisor as well as the Federation.
c. If someone from the media or press contacts the employee/Affiliate about posts on
a personal blog or website that relates to the Federation the employee/Affiliate
should talk to their supervisor before responding and Federation Administration
office must be consulted. Personal blogs or websites which do not identify the
blogger as a member of the Federation staff and do not mention the Federation
and are purely concerned with personal matters will normally fall outside the scope
of the Federation communications policy.
MONITORING OF COMMUNICATIONS BY THE FEDERATION
The Federation is ultimately responsible for all business communications but subject to that
will, so far as possible and appropriate, respect employee/Affiliate privacy and autonomy while
working. The Federation may monitor business communications for reasons which include:
a. providing evidence of business transactions;
b. ensuring that Federation business procedures,
c. policies and contracts with staff are adhered to;
d. complying with any legal obligations;
e. monitoring standards of service, staff performance, and for staff training;
f. preventing or detecting unauthorized use of Federation communications
systems or criminal activities;
g. and maintaining the effective operation of Federation communication systems.
65 Nebraska Federation of Families
DATA PROTECTION
As a member of the Federation who uses our communications tools, employees/Affiliates will
inevitably be involved in processing personal data for the Federation/Affiliates, as part of the
job. Data protection is about the privacy of individuals, and is governed by the Data Protection
Act 1998. This Act defines, among others, terms as follows:
a. "data" generally means information which is computerized or in a structured hard copy
form;
b. "personal data" is data which can identify someone, such as a name, a job title, a
photograph;
c. "processing" is anything you do with data – just having data amounts to processing; and
d. "Data controller" is the person who controls the purposes and manner of processing of
personal data – this will be the Federation administration, in the case of personal data
processed for the business.
e. Whenever and wherever an employee/Affiliate are processing personal data for the
Federation they must keep it secret, confidential and secure, and must take particular
care not to disclose them to any other person (whether inside or outside the Federation
unless authorized to do so. Do not use any such personal data except as authorized by
the Federation, family or DHHS for the purposes of the job. If in doubt get help from a
supervisor or the Federation.
f. The 1998 Act gives every individual the right to see all the information which any data
controller holds about them. Bear this in mind when recording personal opinions about
someone, whether in an email or otherwise. It is another reason why personal remarks
and opinions must be made or given responsibly, and they must be relevant and
appropriate as well as accurate and justifiable.
g. For employee/Affiliate information, section 55 of the 1998 Act provides that it is a
criminal offence to obtain or disclose personal data without the consent of the data
controller. "Obtaining" here includes the gathering of personal data by employees at
work without the authorization of the employer. The employee/Affiliate may be
committing this offence without authority of the Federation: employee/Affiliate exceeds
authority in collecting personal data; employee/Affiliate access personal data held by
the Federation; to control it or pass them on to someone else (whether inside or outside
the Federation).
h. While the Federation is a data controller of all personal data processed for the purposes
of our business, the employee/Affiliate will be a data controller of all personal data
66 Nebraska Federation of Families
processed in any personal email which is sent or received. Use for social, recreational or
domestic purposes attracts a wide exemption under the 1998 Act, but if, in breach of
this policy, use of Federation communications tools for the purpose of a business which
is not Federation business, then employee/Affiliate will take on extensive personal
liability under the 1998 Act.
i.
To help employees/Affiliates understand and comply with Federation obligations as a
data controller under the 1998 Act employee/Affiliate may be offered, and may also
request, training. Whenever employee/Affiliate is unsure of what is required or
otherwise need guidance in data protection, employee/Affiliate should consult
Federation administration. The Federation’s privacy statements and information about
data protection policies can be found on the Federation employee site.
COMPLIANCE WITH THIS POLICY
Failure to comply with this policy may result in disciplinary action being taken against
employees or contract breach being pursued on Affiliate contracts under Federation
procedures, which may include summary dismissal, contract breach and/or in the withdrawal of
permission to use the firm's equipment for personal purposes. If there is anything in this policy
that is not understood, it should be discussed with a supervisor or the Federation.
Please note that the procedures and policies outlined in this policy, and in any related policy,
may be reviewed or changed at any time. The employee/Affiliate will be alerted to important
changes [and updates will be published on the intranet].
67 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed: 9/23/2011
By: SN
Last Revision:
8/17/11
Effective
Date:
10/1/2011
Subject:
Section:
Administration
Policy No:
FedP237
Effective Communication
I.POLICY
It is the policy of Nebraska Federation of Families that the Affiliate partnership will maintain
high degrees of communication, both internally and externally. Effective communication
includes basic skills in listening, speaking, questioning and sharing feedback. Each individual
involved within the Affiliate relationship has the responsibility to assert when they do not
understand a communication or to suggest when and how someone could communicate more
effectively.
II. PROCEDURE
A. Each Affiliate Organization is responsible for ensuring that communication flows both
downwards and upwards within their organization, as well as with the Federation and
other outside entities.
h. Downward Communication: Each Affiliate will:
i. Ensure every employee receives a copy of the strategic plan, which
includes the organization's mission, vision, values statement, strategic
goals and strategies about how those goals will be reached.
ii. Ensure every employee receives an employee handbook that contains all
up-to-date personnel policies, including the specific Federation program
policies.
iii. Develop a basic set of procedures for how routine tasks are conducted
and include them in standard operating manual.
iv. Ensure every employee has a copy of their job description and the
organization chart
v. Regularly hold management meetings even if there's nothing pressing to
report. If you hold meetings only when you believe there's something to
report, then communications will occur only when you have something to
68 Nebraska Federation of Families
say -- communications will be one way and the organization will suffer.
Have meetings anyway, if only to establish and affirm the communication
that things are of a status that there are no immediate problems.
vi. Hold full staff meetings every month to report how the organization is
doing, major accomplishments, concerns, announcements about staff,
etc.
vii. Leaders and managers should have face-to-face contact with employees
at least once a week. Even if the organization is over 20 employees (large
for a nonprofit), management should stroll by once in a while
viii. Regularly hold meetings to celebrate major accomplishments. This helps
employees perceive what's important, gives them a sense of direction
and fulfillment, and lets them know that leadership is on top of things.
ix. Ensure all employees receive yearly performance reviews, including their
goals for the year, updated job descriptions, accomplishments, needs for
improvement, and plan to help the employee accomplish the
improvements. If the nonprofit has sufficient resources (a realistic
concern), develop a career plan with the employee, too
i.
Upward Communication: Each Affiliate will:
i. Ensure all employees give regular status reports to their supervisors.
Include a section for what they did last week, will do next week and any
actions/issues to address.
ii. Ensure all supervisors meet one-on-one at least once a month with their
employees to discuss how its' going, hear any current concerns from the
employee, etc. Even if the meeting is chit-chat, it cultivates an important
relationship between supervisor and employee.
iii. Use management and staff meetings to solicit feedback. Ask how it's
going. Do a round table approach to hear from each person.
iv. Act on feedback from others. Write it down. Get back to it -- if only to say
you can't do anything about the reported problem or suggestion, etc.
v. Respect the "grapevine." It's probably one of the most prevalent and
reliable forms of communications. Major "movements" in the
69 Nebraska Federation of Families
organization usually first appear when employees feel it safe to venture
their feelings or opinions to peers.
B. Media Relations: Affiliates will ensure that communication with partners, staff,
stakeholders, funders, and families is clear and concise. Affiliates will consult with NEFFCMH prior to having contact with any media representative on any topic that may
directly or indirectly affect NE-FFCMH or DHHS.
C. Affiliates will utilize Message Mapping as a communication tool within their Organization
70 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP238
Background Checks
I.POLICY
It is the policy of Nebraska Federation of Families that prescribed background checks are
completed on all employees hired to perform services under this contract.
II.PROCEDURE
A. EMPLOYEE PRACTICES/BACKGROUND CHECKS. The Affiliate is responsible for following
designated hiring practices, including required background checks on all employees
prior to contact with families and every two (2) years following the hire date. Affiliates
will ensure:
a. All employees hired to perform services/supports under this contract will be
considered a “Family Member” as recognized by the NE-FFCMH definitions
provided in the Operations Manual. Documentation of “Family Member” status
shall be maintained in the personnel file and available during administrative
audits.
b. Affiliate will perform the following background checks prior to an employee
having contact with families:
1. Nebraska State Patrol Sex Offender Registry
2. Nebraska Child Abuse and Neglect Central Registry
3. Nebraska Adult Abuse and Neglect Central Registry
4. Nebraska State Patrol Criminal History Check
5. E-Verify Immigration verification check/attestation
c. If the individual has resided in another state (other than Nebraska) within the
past ten years, affiliate will additionally complete the following background
checks in the state(s) in which they resided:
1. State Patrol Sex Offender Registry
2. Child Abuse and Neglect Central Registry
3. Adult Abuse and Neglect Central Registry
4. State Patrol Criminal History Check
d. Affiliate agrees to complete all required background checks PRIOR to employees
having contact with families.
71 Nebraska Federation of Families
e. Affiliate agrees to notify NE-FFCMH of any and all newly hired employees to
provide services under this contract prior to authorizing the employee to have
contact with families.
f. Affiliate will notify the Federation of any and all discipline, termination,
suspension other related employee concerns.
g. Affiliate will provide all new employees with the organization’s grievance policy,
which shall include ability of employee’s to make contact with NE-FFCMH.
h. Affiliate shall maintain an individual personnel file for all employees and
volunteers. Based upon the policy within the Operations Manual.
i. Affiliates will coordinate with NE-FFCMH regarding regularly scheduled
Administrative and employee audits and allow full access to employee (providing
services under this contract) files.
j. Affiliate will demonstrate completion of all background checks prior to family
contact, and provide the records of completion to the Federation prior to
allowing the employee to have contact with families.
k. All background check documentation shall be maintained in staff personnel
records. This includes documentation requested and received from states other
than Nebraska.
B. Background Exceptions
a. If a potential employee is found to have a record in one or more of the
background checks, the Affiliate will not hire them unless an exception has been
submitted and approved by NE-FFCMH.
b. Requests for an exception shall be made in writing to NE-FFCMH and will include
the name and background information, along with supporting documentation as
to why they believe that such person does not pose a threat to children or
families. NE-FFCMH shall have 10 business days to respond to such a request.
c. All documentation related to the process is maintained in the Family
Organization’s staff personnel records, including record of approved or denied
exception.
d. If NE-FFCMH approves an exception, it will be the responsibility of the Affiliate to
closely monitor the employee. This shall include a plan by the Affiliate that
includes how the employee will be reviewed, at minimum, every month. A review
shall include a Supervisor/Manager/Director accompanying the employee to a
minimum of one family-related face to face meeting per month, doing staffing
with the employee to determine progress since hire, and development of an
assurance plan that the employee that was granted an exception is in no way a
risk to children or families.
72 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP213
Transportation Standards
I.POLICY
It is the policy of the Federation that any employee that provides services or supports to
families under this contract will NOT provide transportation to the family.
II.PROCEDURE
Affiliates may provide transportation to families outside of the realm of FPS/FN contract,
providing they can demonstrate adequate insurance coverage. Affiliates may not provide any
type of transportation of families under the FPS/FN contract due to insurance related issues
and contract expectations.
73 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP239
Evidence-Based and Promising Practices
I.POLICY
It is the policy of NE-FFCMH that, when at all possible and appropriate, Evidence-Based and
Promising Practices are utilized within the scope of family programming.
II.PROCEDURE
NE-FFCMH and Affiliates will utilize the following Evidence-Based Practices in their daily work
within the Family Navigation/Family Peer Support contract:
 WRAP (Wellness Recovery Action Plan) Plans
 40 Developmental Assets
 Family Centered Practice/Wraparound
 Caregiver Strain
 Systems of Care
In addition to the above listed practices, Affiliates may choose to add additional evidence-based
or promising practices into their programming. The following steps should be followed in order
for the Affiliate to begin utilizing a new model, practice or tool.
A. Request NE-FFCMH approval to utilize a new model, practice or tool by providing
the research regarding how the model, practice or tool rates on the National
Registry of EBPs on the NE-FFCMH designated format provided to the Affiliate.
B. Once approved by NE-FFCMH, the Affiliate may implement the new model. The
Affiliate shall clearly document usage, implementation and ongoing tracking of
the tool, model or practice and report quarterly on the success.
C. Any other parenting course, model, practice or curriculum must be approved
PRIOR to use with families under this contract to ensure consistency and model
integrity are monitored, measured and documented.
74 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP219
Capacity Planning and Expectations
I.POLICY
It is the policy of NE-FFCMH that Affiliate ensures families can be served that meet the program criteria.
Development of this capacity in each Affiliate region shall not be based upon monetary basis, but on the
needs presented within the region.
II.PROCEDURE
A. Capacity building, also referred to as Capacity Development, is a conceptual approach to
development that focuses on understanding the obstacles that inhibit people, governments,
international organizations and non-governmental organizations from realizing their
developmental goals while enhancing the abilities that will allow them to achieve measurable
and sustainable results. It refers to the process of enhancing an organization’s abilities to
perform specific activities. An Organizational capacity building approach is used to develop
internally so better fulfillment can become a defined mission. Steps to building organizational
capacity include:





Developing a conceptual framework
Establishing an organizational attitude
Developing a vision and strategy
Developing an organizational structure
Acquiring skills and resources
Organizations who focus on developing a conceptual framework, an organizational attitude,
vision and strategy are more adept at being self-reflective and critical, two qualities that enable
more effective capacity building.
C. Capacity building in organizations should first focus on intangible qualities such as:
B.

Conceptual framework--an organization's understanding of the world, "This is a
coherent frame of reference, a set of concepts which allows the organization to
make sense of the world around it, to locate itself within that world, and to make
decisions in relation to it."
75 Nebraska Federation of Families

Organizational attitude--this focuses on the way an organization views itself. Kaplan
asserts that an organization must view itself not as a victim of the slights of the
world, rather as an active player that has the ability to effect change and progress.

Vision and Strategy--this refers to the organization's understanding of its vision and
mission and what it is looking to accomplish and the program it wishes to follow in
order to do so

Organizational Structure--a clear method of operating wherein communication flow
is not hindered, each actor understands their role and responsibility.

Another aspect of organizational capacity building is an organization's capacity to
reassess, reexamine and change according to what is most needed and what will be
the most effective.
D. NE-FFCMH recognizes that there is a high expectation placed on both NE-FFCMH, as well as the
Affiliates to not only provide a quality product that assists families thorough marked outcomes,
but that also begins to develop capacity to serve additional populations through advocacy and
support. Each Affiliate is challenged to begin the capacity discussions and planning in order to
grow, develop and adapt to the changing infrastructure in Nebraska.
E. Capacity within each Affiliate Organization shall be monitored on a minimum of a quarterly
basis. The quarterly capacity is the total number of families served each month divided by the
three months of the quarter to provide a quarterly average number.
o Affiliates are responsible for serving families that are eligible for the service and have
been referred to their agency.
o Affiliate and NE-FFCMH shall continually monitor the average length of days of service
for families to ensure that families are receiving the full benefit of services. Though the
average length of stay may fluctuate over time, it has been calculated based upon the
first fiscal year of the FPS/FN contract to be approximately six (6) months for Family
Peer Support and ninety (90) days for Family Navigation.
 If an Affiliates average length of stay during a quarter drops under the statewide
average or below the contracted minimum capacity expectation, NE-FFCMH and
the Affiliate will conduct a more thorough review that may produce a change in
the contracted amount for services.
76 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP216
Contract Management and Monitoring
I.POLICY
It is the policy of NE-FFCMH that all contract deliverables are monitoring and measured to ensure
maximum benefit to families served as well as to the entity that is purchasing the services.
II.PROCEDURE
D. Contract management is the management of contracts made with customers, vendors,
partners, or employees, and within this specific contract- Affiliates. Contract
management includes negotiating the terms and conditions in contracts and ensuring
compliance with the terms and conditions, as well as documenting and agreeing on any
changes or amendments that may arise during its implementation or execution. It can
be summarized as the process of systematically and efficiently managing contract
creation, execution, and analysis for the purpose of maximizing financial and
operational performance and minimizing risk. A contract is a written or oral legallybinding agreement between the parties identified in the agreement to fulfill the terms
and conditions outlined in the agreement. A prerequisite requirement for the
enforcement of a contract, amongst other things, is the condition that the parties to the
contract accept the terms of the claimed contract.
E. Monitoring is the systematic, regular collection and occasional analysis of information to
identify and possibly measure changes over a period of time.
F. Evaluation is the analysis of the effectiveness and direction of an activity and involves
making a judgment about progress and impact. The main differences between
monitoring and evaluation are the timing and frequency of observations and the types
of questions asked. However, when monitoring and evaluation are integrated as a
project management tool, the line between the two becomes rather blurred.
G. NE-FFCMH performs various contract monitoring and management activities that
involve the contract held with DAS, as well as monitoring of the contracts held with NEFFCMH’s Affiliate Family Organizations. In order to ensure that the NE-FFCMH contract
77 Nebraska Federation of Families
deliverables are met, NE-FFCMH monitors the activities and deliverables of Affiliates.
Some monitoring and management tasks include, but are not limited to:
i. Administrative Audits
ii. Personnel File Audits
iii. Family File Quality Assurance Reviews
iv. Pyramid Quality Assurance Reviews
v. Affiliate Performance Reviews
vi. Satisfaction Surveys
H. Managing the contract is the ability to select and use appropriate performance
metrics to manage the progress and effectiveness of individuals, workgroups,
and the organization overall. Individuals with this competency use data to
measure success or failure, and they are skilled at interpreting performance
measures and explaining their meaning to others.
I.
The contract management objectives fall into basic categories, listed below:
Objectives
1. Provide families with a voice in the support and service they access and involve them in all levels of programming
2. Build and maintain a statewide resource database that is inclusive of all services that families may need or want
to access
3. Create and maintain uniformity in process, policy and procedure for all affiliate Family Organizations in the
Network
4. Create accountability for family Organizations in each Region of the State
5. Provide valid and inclusive data that provides gauge for outcome measurement
6. Provide training and workshops to the community to enhance workforce knowledge on family centered
practice, recovery, resiliency, and systems of Care
7. Provide quality support and referral to services that meet the needs of families
78 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001,
7/12/2012
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP240
Intake
I.POLICY
It is the policy of NE-FFCMH that various levels of consultation be utilized in the provision of
support and advocacy for families. Consultation points are utilized in order to ensure best care
for families and their children with behavioral health needs.
II.PROCEDURE
Each Affiliate is responsible for ensuring proper intake procedures occur within the designated
timeframes. The minimum intake expectations include:
a. Referral: FN,FPS, and CFS referrals are managed in the same manner. The
Advocate has 24 hours to make initial contact with the family and up to 72 hours
to schedule or hold the first face to face meeting with the family.
b. The Affiliate is responsible for notifying NE-FFCMH with the name of the assigned
Advocate for intake.
c. The Affiliate is responsible for entering the initial contact and the initial face to
face contact in Pyramid, as well as all other required information.
d. Intake review: intake review consists of utilizing the provided standard review
format provided by NE-FFCMH, at minimum, and shall include
supervisor/Advocate discussion regarding the immediate needs of the family, the
child/youth’s behavioral health needs, parent stressors, strengths and risk and
protective factors, potential resources discussed with the family and next steps.
In addition, this level of consultation should consist of review of all intake
paperwork completed with the family, as determined by NE-FFCMH on the intake
checklist. The intake staffing notes shall be entered into Pyramid, as well as any
ongoing staffing notes.
79 Nebraska Federation of Families
e. The intake packet consists of:
Introduction to Family Navigation and Family Peer Support
F108
R
Confidentiality and Release/Exchange of Protected Health
Information (signature required)
F116
R
Caregiver Strain Questionnaire (Advocate completes with
family)
F110
R
Intake Questionnaire (Advocate completes with family)
F115
R
F117
F119
R
R
F138
R
WRAP Plan/Family Plan/Safety Plan
F140
R
Family Member Leader Enrollment (optional for parent)
Family Guidebook (leave with family)
Protective Factors Assessment (PFA)
Family Centered Practice and Life Domains
F147
F146
F148
F121
R
R
R
O
F112
O
F113
O

Information only-to leave with family
SBQ-R (Suicide Prevention Screen, Referral and Intake)
SBQ-R (6 to 12 years old)
SBQ-R (13 years old and up)
If scores over 7, also do the :
EIRF-Immediate Follow Up
(reminder SBQ-R used for FPS services only)
90 days after intake- the EIRF 90 day follow up should be
completed-F139)

Information only- to leave with family
Optional Tool
Support Map
Optional Tool
Functional Strengths and Needs Assessment
Optional Tool
f. The Intake packet shall be completed with the family, during a face to face
contact. Packets shall not be left with the family to complete.
g. The Intake packet shall be completed within fifteen (15) days of intake
h. The Information gathered in the intake packet shall be entered in Pyramid within
fifteen (15) days of the intake meeting with the family.
i.
The signed release, (including the release for NE-FFCMH) shall be placed in the
family file.
80 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/1/2011
Reviewed By: SN
Last Revision:
9/23/2001
Effective
Date:
10/1/2001
Subject:
Section:
Administration
Policy No:
FedP225
Consultation
I.POLICY
It is the policy of NE-FFCMH that various levels of consultation be utilized in the provision of
support and advocacy for families. Consultation points are utilized in order to ensure best care
for families and their children with behavioral health needs.
II.PROCEDURE
J. Each Affiliate is responsible for reviewing the case files and circumstances of
each family served. This review may have multiple facets, but the minimum
review expectations include:
a. Intake review
b. Monthly Review
c. Discharge Review
K. Other reviews will occur during the family’s time with the Affiliate, which may
include-but are not limited to:
a. When someone in the family experiences a “crisis” situation
b. When a child in the home is placed outside of the home
c. If a child in the home is made a state ward or begins working with
DHHS and/or Lead Agency in a voluntary case, OJS or 3b case.
d. When all resources, referrals have proven ineffective
e. When a new Plan of Care has been completed or updated
f. When the Advocate has concerns regarding the family or their
progress
L. Another form of consultation is clinical consultation with the Affiliate’s
contracted/consulting clinician. The Consulting clinician plays the role of clinical
81 Nebraska Federation of Families
educator for Advocates, as well as consulting clinician that reviews families
throughout the time with the Affiliate and prior to discharge. (see FedP218)
M. The final form of recognized staffing is that of Administrative Review with a
designated NE-FFCMH team member. This review is designated primarily for the
review of data integrity, quality and process development. Though the staffing
with the NE-FFCMH team member may include similar information that is
presented to the clinician or Affiliate supervisor, the review is primarily aimed at
aiding forward movement. This may include identifying additional resources,
providing guidance on process and helping Affiliates determine appropriate
strategies to transition families to an informal system in capacity discussions.
N. Affiliates are responsible for consulting NE-FFCMH on various topics, which
include (but are not limited to):
i. Hiring or dismissing staff that will provide services under this
contract
ii. When unfavorable background (any misdemeanors OR felonies)
comes up on a newly hired employee or any employee already on
staff.
iii. When the Affiliate changes office locations, contact information.
iv. When the Affiliate is experiencing difficulties within their
regional/service area environment.
v. When the media is involved
vi. When there are incidents that may, in any way, affect NE-FFCMH
in a negative manner.
82 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
Reviewed:
By:
Last Revision:
10/27/2011,
7/12/2012
Effective
Date:
Subject:
Section:
Administration
Policy No:
FedP229
Discharge
I.POLICY
It is the policy of NE-CCMH that Affiliates utilize a consistent process for the discharge of families from
the Family Navigation, Peer Support, and CFS Peer Support Services.
II.PROCEDURE:
NE-FCCMH and Affiliates will utilize the following process when considering a discharge.
A. The Affiliate Supervisor or designee will review the family situation/case file and the Advocates
proposal to discharge. This review will include the goals that the family set and whether they
were able to reach them, whether the family has been able to access appropriate services,
whether the family has gained skills, resources or other means available to meet the needs of
their child with a behavioral health challenge. The Supervisor will ensure that the Family Plan
has addressed these issues fully. The Supervisor will also review whether the Advocate has
helped connect the family to informal or natural/informal supports. The Supervisor should also
review situations in which the family has refused contact, is unable to be located or has
requested to close their services for one of the cited reasons provided in the discharge/closure
function on Pyramid. Those options for Discharge/Closure include the reasons listed below, as
well as whether the reason for discharge requires a verbal consultation with NE-FFCMH prior to
submission of discharge:
1. Goals Met: Family/Advocate have determined that the reason for Peer services
request has been achieved as demonstrated by set goal being reached.
2. CFS Involvement: The family has become involved with a CFS voluntary or court
case and no longer meets program requirements for FN/FPS.
3. Transfer FN to CFS: Family successfully (or unsuccessfully) completed FN
program due to CFS involvement. This option is only available for R1,R2, R3 and
R4 and must include a referral from CFS meeting eligibility requirements for CFS
Peer Support program.
4. Family Requested Discontinuation/Unable to Locate: Family initiated services
(including initial contact with Advocate) but determined they did not want to
83 Nebraska Federation of Families
continue receiving services, even if goals were unmet. Unable to locate family
after contact had been originally achieved.
5. Transfer FPS to CFS: Family successfully (or unsuccessfully) completed FPS
program due to CFS involvement. This option is only available for R1, R2, R3, and
R4 and must include a referral from CFS meeting eligibility requirements for CFS
Peer Support Program.
6. No Response from Family: Family never initiated services from Advocate (ie
never responded to attempts by Advocate to make contact).
7. Transfer FN to FPS: Family has reached 60 day limit in FN program or has
reached desired goals and wants to continue longer term support through FPS
program.
8. Family does not want service: Family was referred and one contact was made
with Advocate, producing response from family that they do not want to access
the service.
9. Family won’t provide required information: Family unwilling or unable to
provide required information such as DOB, SSN, child’s behavioral health
challenge, etc.
10. Transfer CFS to FPS: Family successfully (or unsuccessfully) completed the CFS
program via discharge from court AND DHHS/CFS. This option must include a
referral from family or other entity indicating voluntary involvement and that a
child in the family meets FPS eligibility requirements.
11. No longer eligible due to program/contract requirements: the family has been
enrolled in one of the available programs but is no longer is eligible for the
program based upon eligibility requirements set forth in the contract.
12. Other: reasons for family discharge that cannot be categorized within the
determined categories.
B. If the family cannot be located within a thirty (30) day period, does not return calls or will not
provide required information, the Advocate is to complete and mail a letter (in a pre- approved
format) to the family, offering the family a final chance to engage in services.
C.
If, after the 10th day since mailing the letter, the family does not respond, the Advocate will
consult with his/her Supervisor regarding proceeding with Discharge and Supervisor will
document this review and its results as a staffing note on Pyramid.
1. If the Supervisor agrees to proceed with the discharge, a discharge summary will be
completed that describes all types and frequency of contact or attempted contact and
reasons why the family would not engage or document family not taking calls, etc. The
only reason acceptable for an Advocate to continue with discharging a family without
working with the family to complete the discharge Caregiver Strain would be due to
84 Nebraska Federation of Families
not having contact. In this situation, the Advocate should attempt to answer as many
of the questions on the Discharge Questionnaire (on Pyramid) as possible.
2. In the event that a family cannot be contacted, and all attempts have been document
with supervisor review, the Discharge Summary shall be signed by the Advocate and
Supervisor, but a clinical consultant signature would not be required.
3. For families that have engaged and are discharging for any other reason than not
having contact, the Advocate must complete the both the Caregiver Strain and
Discharge Questionnaire with the family prior to recommending discharge to the
Federation.
D. Once the discharge paperwork has been completed along with the consultation with the
Supervisor or designee, the Supervisor or designee will schedule the discharge consultation with
their consulting clinician. The clinician will review the discharge paperwork with the Advocate,
supervisor and possibly the peer team, and will provide recommendations and sign the
discharge summary, if he/she approves of the discharge. The Supervisor will ensure that all
fields in the discharge paperwork have been adequately completed and will ensure that the
discharge summary is completed in full, including checking off the completion of all required
discharge documents.
E. The Supervisor, Advocate or designee will scan/securely email or fax the discharge summary
(signed by the Advocate, supervisor and clinician) to NE-FFCMH.
F. The Supervisor, Advocate or designee will enter a discharge date on Pyramid for the family,
which will generate an automated email to NE-FFCMH requesting discharge.
G. The NE-FFCMH designee will review all field on Pyramid and the submitted discharge summary
to determine final approval and will then sign off on the summary and return the signed version
to the Affiliate, via secure Federation email, for the Advocate to file. The NE-FFCMH designee
will review all data entered or not entered on Pyramid prior to making a final decision on
discharge and may choose to delay discharge proceedings until the appropriate fields have been
entered. Included in this review are the following items, at minimum:
1. Completed Intake and Discharge Caregiver Strain entered on Pyramid
2. Completed Intake and Discharge Questionnaire entered on Pyramid
3. Contact notes demonstrating a minimum of four (4) attempts to contact families
(for the corresponding discharge reason of not being able to make contact with
family).
4. All domains completed on Pyramid- including referral date, first phone contact,
first face to face contact (for all families except those not returning calls), family
85 Nebraska Federation of Families
contact information including Team Meetings, family demographics, family
background, diagnosis(if applicable), SBQ-R (for FPS families only),Family/Safety
Plan, and any other modules added to Pyramid and determined mandatory by NEFFCMH.
5. Discharge Summary appropriately completed with all relevant fields entered, valid
signatures from Advocate, Supervisor and Consulting Clinician- which is scanned
and securely emailed to NE-FFCMH. This includes completing the checklist on the
summary regarding ensuring family has been a part of (through Family Discharge
Meeting) and received:
1. Family Plan (which includes the Safety Plan)
2. List of resources specific to the family needs
3. Discharge Questionnaire
4. Discharge Caregiver Strain
5. Discharge Satisfaction Survey
H. CFS/LEAD AGENCY INVOLVEMENT: In the event that a family that is being served within the
Family Navigation or Family Peer Support Programs becomes involved with Child and Family
Services (CFS) or a Lead Agency (NFC or KVC), the following process should be observed.
1. Family Navigation and Family Peer Support services are specifically designated in
order to serve parents that have children with behavioral health needs. There are
situations in which a family that is being served under this contract becomes
involved with CFS/Lead Agency while working directly with an Advocate in this
program. Families that are being actively investigated by CFS, but have not been
accepted for ongoing CFS care and/or custody, are able to access Family Navigation
and/or Family Peer Support services.
2. In the event that CFS opens an ongoing (court OR non-court involved) case on the
family, the family becomes ineligible for the Family Navigation and Family Peer
Support Service and must begin the transition to discharge process.
3. Once an ongoing CFS/Lead Agency case has been opened on a family being served
by this contract, it is the responsibility of the Advocate and his/her Supervisor to
immediately notify NE-FFCMH of this involvement. Families involved with CFS or a
Lead Agency are NOT to be served under the Navigation and Family Peer Support
programs for anything other than a pre-approved transition period. Families can
access advocacy services from the Family Organization through referrals from CFS
in the Western, Central and Northern Service areas or through a Lead Agency in the
Eastern and South Eastern Service Areas.
4. Once it has been determined that a family is working with CFS/Lead Agency, The
Advocates role becomes to help link the family to the appropriate CFS worker or
Lead Agency worker and to help the family, if the family requests it, to obtain a
86 Nebraska Federation of Families
5.
6.
7.
8.
referral for Advocacy from the appropriate CFS/Lead Agency source and provide
service/support on a transition basis only. The goal of transition is to ensure that
families falling into this category have some level of continuity between providers
to ensure ultimate success for the identified child with behavioral health needs and
his/her family.
It is the responsibility of each Family Organization to have open discussions with
the CFS service area administration or the Lead agency administration in their area
regarding the communication process related to acquiring a referral. Assistance
may be provided by NE-FFCMH in instances where it is determined necessary.
The period of transition from FPS/FN to either the connection with the CFS/Lead
agency worker or to the new Advocacy contract is short term and has maximum
timeframes considered appropriate for effective transition. The Advocate may
provide transition services for a Maximum of:
1. 15 calendar days from the date of notification of CFS/Lead
Agency involvement OR
2. 3 face to face meetings with the family and his/her assigned
Caseworker or Lead Agency Worker where the Advocate has
effectively connected the family and child and fulfilled their
original purpose related the specific needs of the child identified
due to his/her behavioral health needs.
3. Any exceptions to this must be pre-approved by NE-FFCMH.
4. Emphasis is placed on the quality of the transition and not the
total number of contacts or total number of days. Advocates
should be diligent in their efforts to provide an appropriate
transition for the family and child.
The Advocate will staff all families falling into this category a minimum of once per
week, with NE-FFCMH, until the final discharge occurs.
At the point of reaching a maximum of fifteen days or three face to face
contacts/meetings with the family within that fifteen days, the Advocate will follow
the standard discharge procedure.
87 Nebraska Federation of Families
Nebraska Federation of Families
for Children’s Mental Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
10/3/2011
Reviewed: 10/1/2011
By: SN
Last Revision:
10/1/2011
Section: Provider
Affiliate Network
Effective
Date:
10/3/2011
Subject: Telework Policy
Policy No:
FedP242
I.POLICY
It is the policy of NE-FFCMH that designated positions and employees or Affiliate employees be eligible
to work at an alternate work site, usually their home, for all or part of their work week to promote
general work efficiencies. Telework may also support a reasonable accommodation under the
Americans with Disability Act (ADA).
II.PROCEDURE
A. General Provisions
1. NE-FFCMH or Affiliate is responsible to:
a. Designate positions for telework, and
b. Approve employees to telework
2. Telework is not work extension. Employees must take work home with them on occasion.
This is remote work, and not considered telework within the scope of this policy.
B. Conditions of Employment
1. Telework assignments do not change the conditions of employment. Work performed at
alternate locations is considered official state business. NE-FFCMH/Affiliates may establish
specific conditions that apply to employees working at alternate locations. Employees on
telework assignments are required to comply with all appropriate policies and procedures.
2. Affiliate or NE-FFCMH management and the employee should mutually agree to telework
arrangements. However, Affiliate/NE-FFCMH management may establish teleworki as a
condition of employment based on business need. This requirement should be included for
all new hires when the position is advertised and in correspondence offering employment.
3. An employee’s compensation with NE-FFCMH/Affilaite will not change as a result of
telework.
4. Attendance at Meetings: Supervisors may require employees to report to a cental
workplace as needed to attend work-related meetings or other events. Supervisors may
meet the employee in the alternate work location as needed to discuss work progress or
other work-related issues.
5. Worker’s Compensation Liability: Affiliates may be liable for work-related injuries or disease
occurring at alternate work sites. Affiliates should consult with the Department of
Administration, Health Care and Benefits Division, Worker’s Compensation Management
Bureau.
C. Hours of Work
1. The total number of hours employees are expected to work will not change, regardless of
work locations. Employees must agree to conduct state work and business during identified
work hours.
88 Nebraska Federation of Families
D.
E.
F.
G.
2. NE-FFCMH/Affiliate management must ensure procedures are in place to document the
work hours of employees who telework. Work hours must be documented in accordance to
the Nebraska wage and hour laws, and the federal Fair Labor Standards Act.
Use of Leave
1. Affiliate management may determine whether it is appropriate to offer telework as an
opportunity for partial or full return-to-work following sickness or injury based on Affiliate
policy and criteria normally applied to decisions regarding the approval of telework and
reasonable accommodations.
2. Telework is not intended to be used in place of sick leave, Family and Medical Leave,
Worker’s Compensation leave, or other types of leave.
Equipment and Materials
1. Normally, NE-FFCMH/Affilaite will provide equipment and materials needed by employees
to perform their duties effectively. However, telework agreements (see section H) may
require employees to use their own equipment.
2. NE-FFCMH/Affiliate-Owned Equipment
a. Employees are responsible for protecting NE-FFCMH/Affiliate-owned equipment from
theft, damage, and unauthorized use.
b. NE-FFCMH/Affiliate will maintain, service, and repair NE-FFCMH/Affiliate owned
equipment used in the normal course of employment.
c. The telework agreement should specify who is responsible for transport and installation
of equipment. The telwork agreement should also state how the equipment will be
returned to the central workplace for repairs and service or upon termination of the
telework agreement.
d. NE-FFCMH/Affiliate may use funds to provide utility equipment and services generally
available in the central work location. Examples include but are not limited to:
i. Pay for leased telephone lines in the alternate work location,
ii. Install, and provide basic telephone services in the alternate work locations, or
iii. Provide cell phones for use in the alternative work location.
e. If phones are not provided, NE-FFCMH/Affiliate may reimburse employees for businessrelated long distance calls made from their personal telephones.
3. Employee-Owned Equipment: NE-FFCMH/Affiliate will not assume responsibility for cost,
repair, or service when authorizing employees to use their own equipment unless approved
by management.
Costs Associated with Telework
NE-FFCMH/Affiliates may assume responsibility for operating, maintaining, or paying for other
costs incurred by employees in the use of their homes as telework alternate locations.
Integrity and Confidentiality of Work Information
1. Employees must safeguard NE-FFCMH/Affiliate information used or accessed while at the
alternate location.
2. NE-FFCMH/Affiliates must grant permission according to agency procedure for employees to
work on restricted access information or materials at alternate work locations. Employees
89 Nebraska Federation of Families
must agree to follow agency-approved security procedures regarding the protection and
security of sensitive data to ensure confidentiality and security of the data.
H. Agency Responsibilities
1. Establish Agency Policy
a. NE-FFCMH/Affiliate will establish internal policies and procedures related to
telework if they allow telework in their agency. Such policies should maximize the
appropriate use of telework without diminishing employee performance or service
delivery.
b. At a minimum, agency policy should:
i. Identify positions appropriate for telework.
ii. Require telework agreements between agency management and
employees.
2. Develop Telework Agreements:
a. Agency management and the employee must agree to the terms of telework before
an employee can work at an alternate work location. Both the employee and the
agency management must sign the telwork agreement.
b. At a minimum, agencies should include the following in the telework agreement:
i. The duration of the agreement;
ii. The work schedule and procedure for how will be determined (this is the
same as if they worked in the main office);
iii. How leave is to be requested and approved;
iv. Status of the employee during emergency and weather related closings
affecting the central or alternate workplace;
v. How routine communication between the employee, management, coemployees, and families will be handled;
vi. Employee performance plan or expectations;
vii. The equipment and/or supplies that will be used, and who is responsible for
providing and maintaining them;
viii. Any applicable data security procedures;
ix. Safety requirements to maintain safe work conditions and practice
appropriate safety habits;
x. Certification that the work location is free from hazards; and
xi. Authorization and a procedure for the employee’s supervisor to access the
alternate work location during normal work hours as defined by the
telework agreement.
c. NE-FFCMH/Affiliates may include additional conditions in telework agreements
requiring employees to:
i. Comply with all state and agency rules, policies, practices and instructions;
ii. Use agency-provided equipment and supplies only for business purposes,
and notify agency management immediately when equipment
malfunctions;
90 Nebraska Federation of Families
I.
J.
iii. Notify their supervisors immediately of any situation that interfere with
their ability to perform their jobs;
iv. Notify their supervisors immediately of any injury occurring while working;
v. Absolve the agency from liability for damages to real or personal property
resulting from participate in telework; and
vi. Be responsible for security of information, documents, and records in their
possession or used during telework, and not take restricted access material
home without the written consent of their supervisor.
d. The telework agreement must be:
i. Signed by the employee, immediate supervisor, and the next higher
supervisor;
ii. Reviewed and renewed at least annually;
iii. Reviewed and revised when there is a change in supervisor, job
responsibilities, change in work circumstances, or performance;
iv. Filed in the employee’s personnel file; and
v. Agencies may revise the agreement at any time.
Termination of Agreement
NE-FFCMH/Affiliates may terminate the telework agreement at its discretion. NEFFCMH/Affiliate management is encouraged, when feasible, to give employees 30 days advance
notice if a decision is made to terminate the telework agreement, but advance notice by
management is not required.
Training Managers and Supervisors
NE-FFCMH/Affiliates may encourage the successful and appropriate use of telework by
encouraging or mandating training to supervisors and managers on how to manage teleworkers
effectively.
III. DEFINTIIONS : For the purposes of this policy, the following definitions apply:
Alternate Work Site: Approved work locations within Nebraska other than the employee’s central work
place where official NE-FFCMH or Affiliate business is performed. Such locations may include, but are
not necessarily limited to, employees’ homes or satellite offices.
Central Workplace: an agency’s place of work where employees normally are located.
Telework: a formal work arrangement in which agency management directs or permits employees to
perform their usual job duties away from their central workplace.
Telework Agreement: A written agreement between agency management and the employee detailing
the terms and conditions of and employee’s work away from the central workplace. Work agreements
are required for Telework.
Work Schedule: The employee’s hours of work in the central workplace or in the alternate work
locations.
91 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
I.
Date issued:
10/29/2011
Reviewed:
By:
Last Revision:
10/27/2011,
7/11/2012
Section: Evaluation
Effective
Date:
11/1/2011
Subject: Satisfaction Surveys
Policy No:
FedP243
POLICY
It is the policy of the Federation of Families that all services provided be continually evaluated for
quality and satisfactory provision.
II.
PROCEDURE
1. NE-FFCMH and each Affiliate Family Organization shall be responsible for ensuring quality services
are provided to children and families. One such mechanism that quality is measured is through the
use of evaluation tools, including the Family Satisfaction Survey. The Satisfaction Survey will be
utilized for both Family Peer Support and Family Navigation Services, as well as for CFS Advocacy
Services. There will be differences outlined between FN/FPS and CFS. All Family Organizations shall
participate in the completion of surveys for another Organization in return for that Organization
completing their surveys.
A. All Family Peer Support (including CFS contract) and Family Navigation families will be provided
an opportunity to participate in Satisfaction Surveys, which occur as follows:
a. At discharge from Family Navigation
b. At discharge from Family Peer Support
c. At discharge from Family Peer Support for CFS
d. This includes families that transition from one program to another internally
B. At intake, Advocates shall provide all families with a consent and release form that indicates the
family’s willingness to allow the assigned Family Organization completing the survey to do a
phone survey. If the family chooses not to sign the consent and release form, the Advocate
must consult with his/her supervisor and the Supervisor shall be responsible for approaching the
family prior to discharge to request release. If the family refuses to participate in the survey, the
affiliate is responsible for entering a contact note on Pyramid documenting such.
C. Advocates shall provide families with two options for completion of the Survey:
a. A Family Member from the assigned Family Organization can call the family and
complete the survey by phone, or
b. The Advocate can provide the family with the Survey to complete by hand and return in
the provided stamped, NE-FFCMH addressed envelope.
D. The Survey results shall remain confidential and shall NOT be connected to a particular family
member.
92 Nebraska Federation of Families
E. Family Members shall be informed of their rights, as well as that the Survey is confidential and
will not be tied to them in any way so that they can provide honest feedback in order to assist us
in continuing to provide quality services.
2. Phone Surveys
A. If the Family chooses to be contacted by a Family Member to do a phone survey, the Advocate
will indicate this by checking the appropriate box on the Discharge Summary and writing in the
phone number in which the family would like to be contacted, as well as the best time to reach
the family.
B. The Federation will forward the contact information to the assigned Family Organization in
addition to:
a. Federation ID Number
b. Program Type
c. Advocate Name
d. Discharge Date
e. Reason for Discharge
f. Parent Name
g. Child Name
h. Best time to contact the family to complete the survey
C. The assigned Family Organization will provide this information to their Family Member Surveyor
assigned to contact families to do the Surveys. During these calls, the Surveyor will document
the answers provided by the family on the survey form.
D. The Surveyor will collect all completed surveys in a confidential file until the designated date of
transmission to NE-FFCMH, which will be by the 5th day following each fiscal quarter for CFS and
the 10th day following each quarter for FN/FPS.
a. Included in the quarterly Fax or Scan/Email transmission (utilizing secure NE-FFCMH
email only) will be all surveys completed during the quarter.
b. The provided Survey Tracking form shall be utilized by the surveyor to track each survey
attempted and completed, as well as the results of each survey. The tracking form shall
be submitted to the Federation by the 5th day following each quarter for CFS and the
10th day following each quarter for FPS/FN.
E. The Surveyor is responsible for the following:
a. Ensuring that all information collected from the family remains confidential.
b. Ensuring the survey completed by phone is not copied or shared with any other parties
c. Ensuring that all attempts to contact families for phone surveys are documented related
to dates, times and number(s) called. The Surveyor will make a minimum of four
attempts to reach a family and will consult with his/her supervisor after the third
unsuccessful attempt.
d. Ensuring that all families contacted for surveys are treated with the utmost dignity and
respect.
e. Ensuring that, if a family has questions regarding why the survey is being done, or where
the information goes, the Surveyor provides accurate and clear response.
93 Nebraska Federation of Families
f.
Ensuring that the questions are read just as written on survey and that if a family
questions what the question means, the Surveyor will allow them to interpret it based
upon their presumptions.
g. Ensuring that the survey is completed with the parents (not the child) that worked
directly with the Advocate.
3. Hand Written Surveys
A. If the Family chooses to complete the Survey by hand, the Advocate will provide the family with
the stamped, NE-FFCMH pre-addressed envelope along with the actual survey. The Advocate
will ensure the family understands why the Survey (see Form #F146) is used and what is done
with the information collected, including that the information that the family provides is strictly
confidential and the Advocate will not see the results.
B. On a quarterly basis, NE-FFCMH will provide the aggregate results of the Survey to each
Affiliate Organization for surveys completed on families served the previous quarter. The
Federation will share the results with each of the Family Organizations and assist in creating
plans to address concerns that arose from surveys, as well as celebrate successes reported.
94 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
III.
Date issued:
12/6/2011
Reviewed:
By:
Last Revision:
Section: Evaluation
Effective
Date:
12/6/2011
Subject: Family Reviews
Policy No:
FedP244
POLICY
It is the policy of the Federation of Families that all referred and assigned cases be reviewed by the
assigned Affiliate within the designated parameters.
IV.
PROCEDURE
The Federation and each Affiliate Family Organization shall be responsible for ensuring quality
reviews of each family served. Macro and System Level reviews are further discussed in the
Federation Quality Assurance policies. Micro-Level reviews are further defined in this policy and
procedure.
Reviews occur on three levels:
a. Micro-Level: Individual family case review
b. Macro-Level: Organizational review encompassing all Affiliate families served
c. System-Level: Statewide Affiliates review of quality services as linked to broader system
Micro-Level Reviews, otherwise referred to as Family Reviews (or staffing), are to occur with
consistency within each Affiliate organizations infrastructure. It is the responsibility of each
Affiliate Family Organization to develop a consistent process that fully accommodate the quality
review of each individual family and that meets the minimum expectations of this policy. In
order for meaningful review to take place, adherence to the following concepts is essential:
a. The primary goal of review should reflect enhancing the quality of care for
children and families. Nonetheless, the review will increasingly address issues of
family-driven care. Affiliate Supervisors or Managers/Directors should be the
leader of these conversations.
b. Affiliate policies for family care should be established by Affiliates based upon
the evidence available balanced with sensitivity to local/regional/Organizational
needs and expectations.
c. The review should assess the quality of care and support rendered.
d. The end product of review should be improvement of child/family care through
Advocate education and system/Affiliate improvement. The conduct and
process of the review should seek to identify potential systematic
improvements that the organization could implement to reduce the chances of
mistakes or adverse events in the future. Though the end outcome relates to
system improvement, each family reviewed shall be considered vital to that end
95 Nebraska Federation of Families
outcome and shall be reviewed in great detail to identify best course of action
and support.
e. Affiliates conducting peer review should be afforded confidentiality, but the
evidence and decision making used in developing the review decisions should
be transparent and open to scrutiny.
f. Each family served by the Affiliate should be considered for their individualized
needs and goals.
1. Family Review minimum timeframe requirements for occurrence include:
a. Each family (regardless of program type) should be reviewed by the Affiliate within
the fifteen (15) days of referral. (It may be sometimes preferable to do the initial full
staffing/review after the first face to face contact has been made and information
can be ascertained from the family).
b. Family Navigation cases shall be reviewed a minimum of two times
ii.
Intake (within 15 days of referral)
iii.
Discharge (prior to discharge or transition to another Affiliate
program). All Discharge summaries must be reviewed, approved
and signed by the Affiliate’s Clinical Consultant (see related
policy/procedure).
c. Family Peer Support cases shall be reviewed at regular junctures, which shall include:
1. Intake (within 15 days of referral)
2. Monthly
3. Discharge (prior to discharge or transition to another Affiliate program).
All Discharge summaries must be reviewed, approved and signed by the
Affiliate’s Clinical Consultant (see related policy/procedure).
d. Child Welfare cases shall be reviewed at regular junctures, which shall include:
1. Intake (within 15 days of referral)
2. Monthly
3. Discharge (prior to discharge or transition to another Affiliate program).
All Discharge summaries must be reviewed, approved and signed by the
Affiliate’s Clinical Consultant (see related policy/procedure).
2. The Affiliate Organization should ensure each INITIAL family review consists of the following
discussion elements:
a. Reason for referral sited on documentation (either through the Helpline or other
referral source/types)
b. Reason for referral as described by the family (i.e. First contact)
c. Immediate needs of the family
d. Family Strengths (this includes involved parents and identified youth)
1. “The strengths perspective obligates workers to understand that however
downtrodden or sick, individuals have survived (and in some cases even
thrived). They have taken steps, summoned up resources, and coped. We
need to know what they have done, how they have done it, what they have
learned from doing it, what resources (inner and outer) were available in
their struggle to surmount their troubles. (Saleebey, 1992 pp. 171-172.)
96 Nebraska Federation of Families
2. In order to move to a strengths-based system, Affiliates and Advocates must
accept that:
i. All families have unique strengths based on their culture, ethnicity,
and community
ii. Absence of particular competencies is not a failure
iii. Families with problems are not broken and needing to be fixed
iv. Families are not out of compliance when a particular strategy may
not work
v. The goal of intervention is to create less dependency on
professionals (including Advocates)
vi. Professionals are not viewed as experts able to solve the family’s
problems.
3. Advocates will help the family identify “Functional” Strengths. Functional
Strengths = the depth of an individual and family’s capacity that enables
them to endure and cope with difficult situations, to bounce back in the
face of significant trauma, the ability to use external challenges as a
stimulus for growth, to excel despite the barriers they may be presented,
and the use of social supports, family rituals and traditions, as a source of
resilience. (Adapted from McQuaide and Ehreneich, 1997).
e. Developmental Assets of the youth
f.
Advocates will help the family identify Protective Factors.
i. Protective Factors are factors in a person's life that promote mental
health and wellbeing. Protective Factors also promote:
1. A sense of attachment and belonging
2. Supportive social networks (friends and family)
3. Good relationships with at least one parent
4. Sound psychological development
5. Life skills such as conflict resolution, anger management and problem solving
6. Parents modeling effective problem solving skills
7. Family cohesion and harmony
8. Good social skills
9. Positive coping skills
10. Opportunities for control
11. Access to appropriate levels of income
ii. Advocates will utilize the Protective Factors Survey to assist the
family in the identification of Protective Factors.
1. The PFS is a pre-post evaluation tool for use with caregivers receiving child
maltreatment prevention services. It is a self-administered survey that
97 Nebraska Federation of Families
measures protective factors in five areas: family functioning/resiliency,
social support, concrete support, nurturing and attachment, and knowledge
of parenting/child development.
g. Family Stressors (do not rely on the stressors identified in the referral- this should
be a discussion with the family to determine what they consider to be stressors
affecting their family)
1. A Stressor is a life event or transition that happens in the family. It can
be either positive or negative and can cause a change in the family’s
coping pattern. Examples of stressors could be an event like the birth of
a child, drought, death, or divorce. Other stressors could be a hardship
such as increased medical expenses because of a chronically ill child or a
normal change in a family member’s development, such as a family
member becoming a teen or turning 40.
h. Identification and documentation of what goals/outcomes the family would like to
work towards. This is the first step in developing the Family Plan with the family.
The initial Family Plan should begin development during the intake phase as all
actions revolve around plan development and should tie back to that specific and
individualized plan that the family creates.
1. NOTE: For Navigation cases the initial goal is pre-determined due to the
contract. That goal is “Access to Services” and activities with Family
Navigation should relate to how the Advocate assists the family in
navigating the system for appropriate services and supports to meet their
child’s needs.
2. Each family should be provided information about WRAP planning and be
provided an option to be assisted in the development of their own personal
WRAP Plan. This a plan that the family maintains and is not for the
Advocate to keep in their file unless the family asks for that to occur.
3. A family should never be expected to maintain more than one Plan. The
Advocate should help the family coordinate with any other entities that
have worked with the family to create a family plan, and ensure that the
plan meets their needs. This plan can be adopted an implemented as the
Family Plan for Affiliates, as appropriate.
i. Review of the Caregiver Strain results
1. NOTE: the Caregiver Strain Questionnaire should NEVER be left with a
family to complete, unless the family requests this. The Advocate should
utilize this questionnaire as a tool for discussion and becoming familiar with
the family and their needs, stressors, etc.
j. Review of Intake Questionnaire
1. NOTE: like the Caregiver Strain, this document should not be left with
families to complete unless requested. The Advocate should utilize the
98 Nebraska Federation of Families
document as tool for discussion and becoming familiar with the family and
their needs, history, etc.
k. Discharge Planning: discussion regarding the goals/outcomes set and expected
timeframes for completion to ensure that family is either discharged within 60 days
(per contract expectations) or transitioned to FPS program.
l. Intake Collection REVIEW: the initial review should also entail a review of the data
entered on Pyramid as well as a review of all forms required to be disseminated
and/or signed by the family at Intake. It is the responsibility of each Affiliate to
ensure that the intake process is being followed properly, including the assurance
that:
1. F108 Introduction to Family Navigation and Family Peer Support (leave with
family)
2. F116 Confidentiality and Release/Exchange of Protected Health Information
3. F110 Caregiver Strain Questionnaire
4. F115 Intake Questionnaire
5. SBQ-R (Suicide Prevention Screen, Referral and Intake), SBQ-R (6 to 12 years
old), SBQ-R (13 years old and up) and EIRF depending upon score of SBQ-R
6. F140 WRAP Plan/Family Plan/Safety Plan
7. F148 Protective Factors Assessment (tentatively effective 1/1/2012)
8. F147 Family Member Leader Enrollment (optional for parent)
9. F146 Family Guidebook (leave with family)
m. Data Review: The initial review shall entail a Pyramid review:
i. Forms that require signature shall be reviewed during the initial
staffing and kept in the family file.
ii. Forms that are translated into Pyramid shall be reviewed for
completeness and quality during the review- on Pyramid.
iii. Contacts with the family shall be reviewed on Pyramid, including
review of the initial response timeframe. (Initial contact with family
must be made within 72 hours though best practice is within 24
hours. First face to face meeting must be scheduled with the family
within 72 hours.
3. Discharge Family Review
a. All families shall be reviewed prior to discharge. Please reference the Discharge
policy for specifics on the discharge review process.
4. The Affiliate Organization should ensure each Monthly Family Review consists of the
following discussion elements for ongoing program cases (Child Welfare and Family Peer
Support):
99 Nebraska Federation of Families
a. NOTE: The review shall encompass the following items of discussion and shall
include a minimum of an Affiliate Supervisor/Manager/Director in addition to the
assigned Advocate.
b. Updated or additional Family Strengths (this includes involved parents and identified
youth)
c. Updated or additional Developmental Assets of the youth
d. Review of Protective Factors are being used to mitigate risk factors
e. Updated Family Stressors
f. Updated Goals/Outcomes
g. Review of referrals offered and utilized, direct services provided (see direct service
codes)
h. Review of contact notes/documentation that ensured a minimum of one face to face
contact per month with family. All contacts with the family should tie back to
outcomes/goals developed with the family. Family goals are individualized but
should relate to the reason they accessed the program and where they would like to
see progress.
i. Discharge planning: discussion regarding progress toward goals and determination
of where the family is at related to meeting goals and be discharged.
5. All reviews shall be documented by the Affiliate on Pyramid (Staffing Contact Note)
6. Involvement of the Federation of Families in the Review process is limited to the discretion of
the Federation. If the Federation determines that process is not being properly followed,
there are concerns with quality of care, completion of required tasks/contract expectations
related to service delivery are not accomplished, etc, the Federation may request
involvement in the Affiliate’s staffing or schedule an additional review to address concerns.
7. The Federation will review Contact Staffing notes as well as all other data elements and
contact notes on Pyramid a part of a regular quality assurance review process. The
Federation may contact the Affiliate at any time to report concerns, seek clarification or
request changes, amendments or corrective actions related to family care, documentation of
the family care or staffing of family care.
8. The Affiliate is responsible for ensuring that the above cited review tasks are managed
internally and shall not rely upon the Federation for initiation of such tasks. Responsibility
for quality of care is that of the Affiliate Family Organization providing direct advocacy and
support to families under contract with the Federation.
100 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
V.
Date issued:
12/6/2011
Reviewed:
By:
Last Revision:
Section: Evaluation
Effective
Date:
12/6/2011
Subject: Checkpoint Meetings
Policy No:
FedP245
POLICY
It is the policy of the Federation of Families that each Affiliate Family Organizations take part in a
Checkpoint Meeting to satisfy macro and system-related issues, as well as providing an opportunity
to review the micro-level family issues and progress.
VI.
PROCEDURE
The Federation and each Affiliate Family Organization shall be responsible for ensuring quality
reviews of each family served. Macro and System Level reviews are further discussed in the
Federation Quality Assurance policies. Micro-Level reviews are further defined in this policy and
procedure.
Reviews occur on three levels:
d. Micro-Level: Individual family case review
e. Macro-Level: Organizational review encompassing all Affiliate families served
f. System-Level: Statewide Affiliates review of quality services as linked to broader system
i.
ii.
iii.
iv.
v.
vi.
The Federation or Affiliate can schedule a Checkpoint meeting with the other to review
micro, macro and systems-related issues. The Federation will ensure a consistent time each
week is scheduled for this purpose.
The Checkpoint Meeting is for the sole purpose of administrative discussion and is not
considered a Family Review or staffing, but may entail discussion regarding specific families,
as appropriate to broader discussion.
The Affiliate will be responsible for ensuring that minimum attendance is reflected in the
checkpoint meeting, which shall include:
1. Affiliate Program Managers or Lead Advocate AND/OR
2. Affiliate Executive Director
The Checkpoint meeting is established to cover a gamut of related issues related to
provision of advocacy and support services under the Federation contract.
A standard agenda will be provided to each Affiliate Family Organization in advance that will
include ongoing items of discussion as well as any specific issues of concern posed by either
the Federation or the Affiliate.
At a minimum, the Checkpoint Meeting will cover:
1. Family Review schedule (agenda for Affiliate staffing) and any concerns, questions or
updates.
101 Nebraska Federation of Families
2.
3.
4.
5.
Organizational or Federation updates
Affiliate concerns, questions or input/comments
Federation concerns, questions or input/comments
Review of performance (when relevant)
102 Nebraska Federation of Families
Nebraska Federation of Families
for Children’s Mental Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
VII.
Date issued:
1/31/2012
Reviewed:
By:
Last Revision:
1/31/2012
Section:
Administration/Review
Effective
Date:
2/1/2012
Subject: Provider Performance
Policy No:
FedP246
POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that all Affiliate Family
Organizations will be subject to regular audits on quality, contract obligation adherence and
organizational adherence. The Provider Performance tools will be utilized to measure performance and
reported as described in this policy and procedure.
VIII.
PROCEDURE
A. Provider Performance Report
1. Objective
The objective of performance reporting is to provide a means whereby the caliber of the
service provider is assessed on the contract for service with NE-FFCMH. Performance
assessments during the course serve a means to help identify good performance as well as
matters that may need improvement. Performance reports assist in the assessment of
service providers for continued contract eligibility, reimbursement response evaluation and
in the event of termination for unsatisfactory performance under a contract.
2. Service Provider Performance Report (performance report) is a means for measuring
performance. The performance report format described in this guideline is used to assess
performance against established criteria. Agencies may provide additional performance
criteria for specialized services. Performance reports serve to minimize the risks associated
with poor performing service providers as well as recognize exemplary performance.
B. Management and suitability of project personnel
The service provider’s ability to assign appropriate staff to the project for the duration of the
project and then to achieve effective performance including:
 Appropriateness of skills and experience of personnel assigned to the work.
 Adequacy of the number of personnel assigned to the work.
 Efficient control of site personnel
 Application of proper administration of payments due.
 Consistency in the skills and experience of the staff assigned to the project with those
nominated in the bid for the work.
C. Standard of service
Standard of work will generally be measured against the technical, financial and reporting
requirements set out in the conditions of engagement. In particular, the following should be
considered:
 Compliance with the contract and operations manual
 Quality of work including conformance with specified performance criteria
 Adherence to budget
103 Nebraska Federation of Families





Achievement of contracted performance standards
Reviews and reports delivered in accordance with the operations manual
Amount of rework required from the service provider
Need to engage another service provider to undertake additional or remedial work
Extent of involvement required from NE-FFCMH to achieve the desired standard of the
service provider’s ability to coordinate and manage in-house staff responsibilities,
expectations, etc as well as outside systems to ensure effective performance including:
• Compliance with contractual obligations
• Timely completion of services and quality of service delivery
 Coordination of interfaces, including all indirect service related items
 Demonstration of adequate financial planning
D. Cooperative relationships
Assessment items include:
 Commitment and implementation of a management approach that fosters continuous
improvement, self assessment and general program monitoring
 Adoption and commitment to partnering principles with families, consultants,
contractors (NE-FFCMH) and system partners.
 Commitment to resolving issues through open and effective communication with nonadversarial approach.
E. Other categories
Other performance criteria may be included to meet specific performance requirements in the
contract.
F. Assessment of service provider’s performance
The service provider’s performance should be assessed against the performance criteria and
graded in accordance with the following definitions:
Unsatisfactory
Did not occur, poor
adherence, not
documented, poor
quality
Satisfactory
Met most contract
standards- but not all,
not documented with
frequency, poor to fair
quality
Good
Met contract standards,
above average quality
and frequency, good
adherence,
demonstrated
competency
Superior
Met contract standards,
excelled at quality and
frequency, superior
adherence and
competency, went
above and beyond to
demonstrate
effectiveness in service
and partnership
1. Overall performance
Assessment of overall performance should reflect the service provider’s performance against
the criteria stated in the contract documents.
2. Review and recommendations
The Reporting Officer and the Reviewing Officer (which may be the same individual) must make
every effort to ensure that comments are objective, accurate, can be substantiated and
104 Nebraska Federation of Families
supported by facts. The Reviewing Officer is to ensure that the report is objective and accurate
so that it can be used reliably for making decisions concerning continued funding/contracting.
3. Overall comment.
In completing reports it is important to report on good performance as well as unsatisfactory
performance. Performance reports form part of future contract evaluations; service providers
with good reviews should be noted. Assessment comments should be kept to the facts relating
to the contract at hand. Where it is considered necessary to give an opinion, the opinion should
be:




A first-hand opinion;
Recorded and signed by the Reporting Officer, and
About the service provider, not individuals and;
Be factual and preferably be supported with relevant documents. In particular,
comments should commence with ‘In my opinion’. For example
 ‘In my opinion, the service provider did not provide a suitably experienced leader of the
design team’, or
 ‘In my opinion, the management of the sub consultants was not satisfactory’.
Comments should refer to the weakness/failure of the service provider and not to
individuals. In reporting, do not use extreme language. For example
 ‘In my opinion, the service provider was totally (or completely) inefficient’.
It is easy to challenge such opinions, as there may be some area, no matter how small, where
the service provider was not inefficient and/or you are unable to substantiate the inefficiency.
Reasons for any opinion should be stated and should refer to the relevant evidence for that
opinion.
4. Unsatisfactory performance
a. An unsatisfactory service provider performance report
A service provider’s performance may be rated as unsatisfactory in one or more of the
assessment criteria or in the overall assessment. In most cases, an unsatisfactory overall rating
will lead to a recommendation that the service provider be assessed or regarded as unsuitable
for further work of a similar nature.
b. Review of performance ratings of ‘unsatisfactory’
Overall assessment satisfactory (but rated unsatisfactory in one or more assessment criteria in
one more performance reports)
The procedure below is to be used where the overall assessment is satisfactory but one or more
of the assessment criteria is rated as unsatisfactory, ie below 50%. The service provider must be
made aware if its performance is rated as unsatisfactory in any assessment criterion and be
given an opportunity to comment on the report in accordance with the following procedure:
1. The service provider is to be advised in writing of the assessment and requested to
respond in writing within a reasonable time, for example, 10 working days from the date
of transmission.
2. The Reviewing Officer considers the service provider’s response and the service provider
are advised if the unsatisfactory rating(s) is to be retained.
c. Overall assessment unsatisfactory
105 Nebraska Federation of Families
Where the overall assessment is unsatisfactory or the service provider is not recommended for
further work of a similar nature for the reporting agency, the following procedure applies:
a. A meeting between the service provider, the Reporting Office/Reviewing Officer is to be
convened.
b. At that meeting, reasons for the scoring seen in the performance report are to be
discussed and the discussions documented in minutes.
c. The service provider shall be given the opportunity to respond in writing i.e., 10 working
days of the meeting.
d. The service provider’s response may provide sufficient grounds that would allow the
performance report to be adjusted, however doing so is entirely at the discretion of the
original Reviewing Officer and the NE-FFCMH Executive Director. An adjustment must
be evidence based. The onus is on the Service Provider to produce the evidence.
e. If upon completion of steps 1 to 4 the service provider’s overall assessment remains
unsatisfactory, the service provider is to be informed that they can seek a further review
by the Agency which will be undertaken in accordance with the review process.
5. Review process for service provider performance report
If, after following the review process described, a performance report rates the service
provider’s overall performance as unsatisfactory or the service provider is not recommended for
further work of a similar nature the service provider must be given the opportunity to have an
independent review as follows:
a. The review will be undertaken within a reasonable time, for example, 10 working days
of receipt of an appeal by the service provider.
b. The officer(s) of the agency conducting the review must be senior management, and not
associated with the contract concerned. For works requiring prequalification or for large
engagements with fees over $100,000, the review should be carried out by a Review
Committee, of not less than 3 officers which should include an independent
representative, for example from another government agency. The review is to be
undertaken on the available evidence submitted by all parties and the reviewer or
committee may at its absolute discretion seek additional information from the service
provider, Reporting Officer or Reviewing Officer, either in writing or in person.
c. The service provider is to be notified of the outcome of the review within 10 working
days of the review. Where the performance report is changed as a result of a review, an
adjusted copy of the report is to be given to the service provider.
6. End of contract performance report
The end of contract performance report will be an important source of data for evaluation of
the performance of a service provider. For this reason, the final report should reflect the
performance of the service provider throughout the entire contract period. When performance
is unsatisfactory, concise supporting evidence and all relevant details of the unsatisfactory
performance must accompany the report. All performance reports must be accompanied by
documentary evidence supporting the reports, including minutes of meetings with the service
provider.
7. Service provider performance rating system
Performance criteria
Service provider performance ratings may be allocated points against the performance criteria
(for example, time management, quality of service etc) based on the rating scale below:
106 Nebraska Federation of Families
Better 10 points
Acceptable 7 points
Marginal 5 points
Unsatisfactory 0 points
a. Performance rating formula
The Reporting Officer determines the performance rating as a percentage using the formula:
A = Service provider’s point score x 100 Total maximum points
The service provider’s point score is the total of the points scored against the performance
criteria.
The total maximum points applicable is the number of criteria graded against x 10.
The total maximum points may vary from report to report, depending on the number of
performance criteria the service provider is graded against.
b. Performance grading
The assessment percentage (A) is then graded as follows:
 Better over 85%
 Acceptable over 63%
 Marginal over 50%
 Unsatisfactory below 50%
107 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
4/2/2012
Reviewed:
By:
Last Revision:
Effective
Date:
4/2/2012
Subject:
Section:
Administration
Policy No:
FedP247
Referrals and Eligibility Criteria
I.POLICY
It is the policy of Nebraska Federation of Families for Children’s Mental Health that eligibility of all
referred families be reviewed and documented by both the Family Organization and the Federation
prior to acceptance of the referral. Final determination of eligibility of Family Peer Support, Family
Navigation and CFS Family Peer Support referrals will be at the discretion of the Federation and will
follow set forth guidelines.
II.PROCEDURE
G. Family Peer Support Eligibility Criteria
Below is a list of the mandatory eligibility criteria for Family Peer Support referrals:
1. A minimum of one child in the family has a behavioral health challenge, as identified by the
family. (Behavior must be specific and not due to normal child development)
a. A diagnosis is not required as long as behaviors of the child can be clearly articulated. In
this situation, the referral should clearly define those behaviors. An example could be,
“12 year old John Doe has hallucinations on a weekly basis and tells his mother about
them. John is aggressive with other peers at school and has been suspended from
school due to his aggressive actions.”
b. If the child has a diagnosis, this should be included in the referral
c. Children diagnosed within the Autism Spectrum (including Aspergers) shall not be
eligible for Family Peer Support Services as Nebraska does not currently classify this
diagnostic category eligible for behavioral health funding.
d. Family Organizations may opt to a “resource only” consultation with families deemed
ineligible or may serve the family with other funding sources outside that of the
Federation.
2. The identified child being referred must be 18 years old or younger
3. The identified child must be living with the parent or caregiver being referred.
a. If one or more of the children in the family household are state wards or working with
CFS on a voluntary agreement, the family is NOT eligible for Family Peer Support due to
potential duplication of state funding. Referrals for any family involved with the
Department due to Abuse/Neglect should be obtained from CFS.
4. The identified child must be a documented United States Citizen and have an accurate and true
Social Security Number.
108 Nebraska Federation of Families
H. CFS Referral Eligibility Criteria
Mandatory Criteria: Below is a list of the mandatory eligibility criteria for CFS Family Peer
Support referrals. Both categories must be met for eligibility.
1. The referred family shall have a minimum of one child within their family unit that is placed
outside of the family home.
a. The out of home placement can include informal living arrangements and/or voluntary
placement agreements.
2. The referred family shall have a Permanency Plan of Reunification.
Additional Criteria: Below is a list of additional eligibility criteria for CFS Family Peer Support
referrals. A minimum of one is required for eligibility.
1. The referred family is court involved with the child welfare system due to Abuse/Neglect
2. The referred family in involved with Child Welfare due to Abuse/Neglect and has a Voluntary
Agreement
3. The referred family is involved with Child Welfare for the first time
4. The referred family has at least one child that is between the ages of zero and eight years of age
5. The referred family has been assessed by the Children and Family Services Specialist with the
Structured Decision Making Model and been determined to be a High Risk or a Very High Risk.
I.
Family Navigation Referral Eligibility Criteria
Family Navigation referrals are received only from the Nebraska Family Helpline and are
assessed for eligibility prior to being sent to the Federation and corresponding Family
Organization.
J.
Required Referral Information
Other Required Information on the referral is also mandatory and referrals received without all
domains completed are subject to denial.
1. Parent(s) Name
2. Identified Child’s Name (this is the child that the family is requesting services for and meets
the eligibility criteria).
a. There may be more than one Identified Child per family. However, for each
identified child there must be an intake and discharge, data collected and separate
narratives completed. The service is provided for the entire family unit, so the
purpose of identifying more than one child would be for the purpose of tracking
them separately- such as the SBQ-R.
3. Parent’s Address (which includes the identified child)
4. Parent’s Contact information
5. Identified Child’s Date of Birth
6. Identified Child’s Social Security Number
7. Identified Child’s gender
8. Assigned Advocate
9. Date of Assignment
10. Signature of Approving Family Organization Supervisor
109 Nebraska Federation of Families
K. Transmission of Referral
1. Referrals shall be submitted to Nebraska Federation of Families for Children’s Mental Health
by secure Federation Fax or by secure email.
a. Email that is outside of the Federation email server to or from another server is NOT
secure. In order to securely email referrals from a Family Organization, the
Organization should ONLY email referrals on their designated Federation email
account.
b. Referrals from outside of the Organizations should be either encrypted and
password protected when emailed to the Federation, or securely faxed.
2. Referrals can be made directly to the Family Organization as a secondary option. However,
if a referring party does submit a referral directly to an Organization, it is the responsibility
of that Organization to submit the referral to the Federation within 24 hours of receipt.
a. The contact timeframe begins at the date/time the referral is received first (either
to the Federation or to the Family Organization) and the Advocate has 72 hours to
make initial contact from that date/time.
L. Documentation of Referrals not meeting eligibility Criteria
1. In the event that the Federation denies a referral due to the family not meeting the
eligibility criteria, the Federation will respond directly to the Family Organization regarding
the reason the referral could not be accepted.
2. The Federation will maintain copies of all received referrals, despite acceptance.
3. The Federation will document all denied referrals
a. This information may be used at a later date to determine populations of families
that may benefit from Advocacy Services.
b. It is recommended that each Family Organization also maintain copies of all
referrals.
4. The Federation will review Referrals during audit proceedings to determine if the eligibility
criteria was met for all selected families in the audit.
110 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
6/7/2012
Reviewed:
By:
Last Revision:
Effective
Date:
7/1/2012
Subject:
Section:
Administration
Policy No:
FedP248
CPA Audit
I.POLICY
It is the policy of NE-FFCMH that fiscal accountability be paramount internally and with all Affiliate
Family Organizations. CPA Audits of the Affiliate Family Organizations must occur annually, at the
expense of each Organization. The purpose of the CPA audit is to assess the accuracy and reliability of
accounting processes and financial reports.
II.PROCEDURE
CPA Audits are due to NE-FFCMH no later than 120 days (4 months) after the close of the State
Fiscal Year.
The Affiliate shall submit an audit conducted by a Certified Public Accountant to NE-FFCMH.
Affiliate CPA audits are to include a two year comparison of expenditures after the second year
of funding. (One year comparison in the first contract cycle). Affiliate agrees that all revenues
for all Family Navigation and Family Peer Support Services (including Behavioral Health and
Children and Family Services contracts) must be reported in the financial CPA audit separately
from other programs and services provided by the Affiliate.
A. Exceptions to requirement for Independent CPA Audit:
 Affiliates funded under $50,000 providing any type of services for NE-FFCMH
may comply with one of the following methods to verify expenditure of funds:
1. An annual fiscal audit with revenue and expenditure details of
programs funded under this contract by a CPA firm; or
2. A fiscal year-end unaudited financial statement of revenues and
expenditures, including a use of funds statement and a statement of
fund balances for all fund sources for the specific service(s) fully or
partially paid with funds identified by contract.
B. Two hard copies of the Affiliate CPA audit are to be submitted to NE-FFCMH
C. Audits must be received by NE-FFCMH by no later than 9 months following the end of the
fiscal year.
D. The audit must be submitted to NE-FFCMH within one month of Affiliate’s receipt
E. The Affiliate shall not audit itself for any services paid with State or Federal funds, through
NE-FFCMH.
111 Nebraska Federation of Families
F. As a result of any finding, the agency may be required to take certain corrective steps that
include, but are not limited to:
1. File a plan of correction with NE-FFCMH within 30 days
2. File a revised reimbursement requisition for the months reviewed
3. In all instances, Affiliates will be given a reasonable length of time (typically 30 to 90
days), depending on the scope of deficiencies, to make the needed corrections and
submit follow-up documentation.
112 Nebraska Federation of Families
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
6/20/2012
Reviewed:
By:
Last Revision:
Effective
Date:
7/1/2012
Subject:
Outcome
Outcome: Resiliency
Participants care for their personal needs and
reduce strain associated with parenting a child
with behavioral health challenges.
Strategy/Indicator: Participants know
strategies that they can use to promote selfcare and wellness.
Outcome: Social Connections
Participants have a mutual support network of
friends, family and neighbors they use for
support and assistance, as needed.
Strategy/Indicator: Participants know and
utilize reliable, safe and appropriate friends,
family members and neighbors for support and
assistance when they need it.
Outcome: Concrete Supports
Participants with children with special needs
are aware of and know how to access
community resources and formal supports
available to them.
Strategy/Indicator: Service choices are offered
to families.
Outcome: Knowledge of Parenting and Child
Development
Participants understand the dynamics of their
child’s behavior as well as strategies to
effectively mediate the behaviors.
Strategy/Indicator:
Parents are offered individual or group parent
skill-building, which is clearly documented in
the Family Plan.
113 Nebraska Federation of Families
Section:
Administration
Policy No:
FedP249
Program Outcomes
Measurement
To be measured on a
quarterly basis
 Family Plan
documentation
 CGSQ intake vs
discharge
Data Element
80% of families will have a Family Plan with at
least one goal addressing overall wellness and
self-care.
To be measured on a
quarterly basis
 Family Plan
documentation,
including informal
support box that
shall include full
name of support
person and their
role as support
 CGSQ # 1,2,9,10
To be measured on a
quarterly basis
 Direct services
offered vs used
from contact notes
on Pyramid
 CGSQ #25
80% of Family Plans will document that each
family has a minimum of 3 informal family
supports within the first 30 days of care.
To be measured on a
quarterly basis
 Offered vs utilized
quarterly rpt. data
on Pyramid
 CGSQ#31
80% of families are offered individual or group
parent skill building.
80% of families are provided options for
services (service referrals on contact notesPyramid).
Affiliate provides the updated resource
directory a minimum of monthly, which
includes new changes in existing resources and
updates).
Nebraska Federation of
Families for Children’s Mental
Health
Family Navigation (BH)
Family Peer Support (BH)
Family Advocacy (CFS)
Date issued:
6/25/2012
Reviewed: 7/25/2012
By:
Last Revision:
Effective
Date:
7/1/2012
Subject:
Section: Fiscal
Policy No:
FedP250
Retainage and Affiliate Performance
I.Policy
It is the policy of NE-FFCMH that retainage will be utilized in Affiliate payment in order to
ensure appropriate and quality completion of all services purchased.
II.Procedure
a. Retainage is defined as: a portion of the agreed upon contract price deliberately
withheld by a principal (client or owner) until the work is substantially complete to
assure that all respects, satisfy its obligations and functioning satisfactorily according to
the contract.
b. NE-FFCMH will retain a percentage of the month’s set base rate each month that will be
considered retainage.
c. Retainage will be equal to a total of 5% withholdings each month from the Affiliate by
NE-FFCMH.
d. At the end of each quarter, the Affiliate’s performance will be reviewed to determine
how much of the total 5% retained for the quarter might be returned to the Affiliate due
to met outcomes. The retainage will apply to two sets of outcomes, which include:
e. The overall 5% retainage will be divided into two sub-categories:
i. Performance Outcomes
1. Performance Outcomes will be measured quarterly and must
demonstrate an overall quarterly average of 80% completion. These
outcomes will equal 3% of the overall 5% total withheld and eligible for
return to the Affiliate.
2. Performance Outcomes include:
ii. Performance Outcome Measurement: an 80% average over the assessed
quarter must be reached to be eligible for the total 3% retainage to be
reimbursed to the Affiliate following the quarter’s end. The four assessed
outcomes include:
1. Family Resiliency: Participants care for their personal needs and reduce
strain associated with parenting a child with behavioral health
challenges.
a. Indicator: Participants know strategies that they can use to
promote self-care and wellness.
b. Measurement A: 80% of families will have a Family Plan with at
least one (1) goal addressing overall wellness and self care.
114 Nebraska Federation of Families
c. Measurement B: Overall caregiver strain will reduce by a
minimum of 20% from intake to discharge.
2. Social Connections: Participants have a mutual support network of
friends, family and neighbors they use for support and assistance as
needed.
a. Indicator: Participants know and utilize reliable, safe and
appropriate friends, family members and neighbors for support
and assistance when they need it.
b. Measurement: 80% of Family Plans will document that each
family has a minimum of 3 family identified informal family
supports within first 30 days.
3. Concrete Supports: Participants with children with special needs are
aware of and know how to access community resources and formal
supports available to them.
a. Indicator: Community Service choices are offered to families.
b. Measurement A: 80% of families are provided options for
services (service referrals on contact notes-Pyramid).
c. Measurement B: Affiliate provides the updated resource
directory a minimum of monthly (new or changes in existing
resources)
4. Knowledge of Parenting and Child Development: Participants
understand the dynamics of their child’s behavior as well as strategies
to effectively mediate the behaviors.
a. Indicator: Parents complete individual or group parent skill
building – which is clearly documented in the family plan.
b. Measurement: 80% of families complete Individual or group
parent skill building. (offered/utilized quarterly report by org)
iii. Quality Outcomes
1. Quality Outcomes will be measured quarterly and must demonstrate
and overall quarterly average of 80% completion. These outcomes will
equal 2% of the overall 5% total withheld and eligible for return to the
Affiliate.
2. Performance Outcomes include:
iv. Quality Outcome Measurement: an 80% average over the assessed quarter
must be reached to be eligible for the total 2% retainage to be reimbursed to
the Affiliate following the quarter’s end. The four assessed outcomes include:
1. Families will experience quality continuity in care with all advocacy
services.
2. Measurement: 90% of families will maintain the same primary
Advocate, despite any changes in Advocacy service types.
115 Nebraska Federation of Families
3. Measurement: 90% of Families will receive initial contact from their
assigned Advocate within 72 hours of Referral.
f.
If an Affiliate fails to reach the desired Performance or Quality Outcomes at an 80%
average quarterly rate, NE-FFCMH will not return the retained funds, otherwise
considered an Affiliate penalty.
i. Penalties are defined in this contract as the Affiliate not receiving the 3%
retainage for performance outcomes and/or the 2% retainage for quality
outcomes after outcome measures are assessed following the quarter’s end to
determine if the 80% threshold was met.
g. Services Purchased: NE-FFCMH contracts with Affiliates to provide Advocacy services to
a designated population of families as further defined through eligibility criteria. In
order for an Affiliate to successfully provide the purchased service of Advocacy for Peer
Support and Family Navigation, milestones must be reached consistently on a monthly
basis. These milestones are measured through Pyramid and are defined as follows:
i. One Face to Face Meeting occurs each month per family (as documented on
Pyramid)
ii. One Family Team Meeting occurs each month per family (as documented on
Pyramid)
iii. One “Other” contact occurs each month per family (as documented on Pyramid)
iv. One Monthly Summary is completed by the 10th of each month per family,
which includes (as documented on Pyramid):
o Updates to goals and strategies
o A monthly summary narrative
o Updates to strengths and informal support
h. NE-FFCMH completes a minimum of one Organizational Audit annually. During these
audit proceedings, services purchased are reviewed in comparison to what the Affiliate
reports in the monthly reimbursement request related to total number of families
served for the month being reported.
i. If NE-FFCMH finds that the total number of families served for any given month
does not sufficiently meet the criteria for Services Purchased, a penalty may be
imposed to reclaim funds allotted to the Affiliate for those services during the
month(s) in question.
ii. Penalties will be assessed based upon the overall number of families reportedly
served and the overall average number of families that did not meet the
standards laid out in the Services Purchased definition, up to a maximum of 5%
of the month’s reimbursement paid to the Affiliate.
iii. Affiliates will be provided an opportunity to challenge these findings by
providing substantial and adequate documentation supporting that the family
met the Services Purchased definition.
116 Nebraska Federation of Families
iv. NE-FFCMH will make final determinations, with all information provided,
regarding the penalty.
117 Nebraska Federation of Families
Verification of Understanding and Implementation in Practice
By signing below, I agree that I have thoroughly read each of the policies and procedures
provided in the NE-FFCMH Operations Manual for Family Navigation and Family Peer Support
Services and that I fully understand all expectations herein. I understand that the Family
Organization that I am employed by may have additional policies for the Organization, as a
whole, or for other programs outside of this contract. I understand that it is my responsibility
to utilize the processes and policies related to Family Navigation and Family Peer Support, as
outlined in this manual.
_________________________________________________
Name of Affiliate Staff-PRINT
___________________
Date
_________________________________________________
Name of Affiliate Staff-Signature
___________________
Date
Note: This signed document shall be placed in the Employee Personnel file and will be
considered verification of the Operations Manual training for the employee, which is subject to
Personnel File Audits.
118 Nebraska Federation of Families