22-105684 Service Policies-02.01.23
CCSWW SERVICE POLICIES & PROCEDURES
REVISION W.
Revised January 4, 2021
SECTION I GUIDING PRINCIPLES 1
1.0 INTRODUCTION FROM THE C LINICAL OVERSIGHT GROUP (COG) 1
2.0 CCS VISION, MISSION, BELIEF STATEMENT, & CORE VALUES 1
3.0 THE VALUE AND DIGNITY OF HUMAN LIFE 2
4.0 AGENCY SERVICE PHILOSOPHY 2
5.0 CODE OF ETHICS 3
6.0 CCS IS A FAITH-BASED ORGANIZATION 3
SECTION II QUALITY IMPROVEMENT 5
7.0 QUALITY IMPROVEMENT 5
7.1 Local Quality Improvement Committee 5
7.2 CCSWW Quality Improvement Committee 5
7.3 Clinical Oversight Group (COG) 5
8.0 OTHER POLICIES AND PROGRAM MANUALS 5
SECTION III STAFF AND VOLUNTEER POLICIES 6
9.0 WASHINGTON STATE PATROL/DSHS BACKGROUND CHECKS 6
9.1 Procedure 6
10.0 LEGAL REPRESENTATION 6
10.1 Legal Representation of Staff 6
10.2 Legal Representation of the Agency 6
10.3 CCS Providing Expert Witness Testimony 6
11.0 STAFF PRESSING CHARGES AGAINST CLIENTS 7
12.0 WHISTLE BLOWER PROTECTIONS 7
13.0 FAVORITISM IN USE OF AGENCY SERVICES 7
14.0 PAYMENT FOR REFERRALS 7
15.0 CONFLICT OF INTEREST 7
15.1 Prohibition Against CCS Employees Providing CCS Foster Care 8
16.0 SECONDARY EMPLOYMENT FOR EMPLOYEES WIT H A PRIVATE PRACTICE 8
17.0 GIFT CARD POLICY 8
18.0 VOLUNTEER STATEMENT 8
SECTION IV SERVICES 9
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19.0 ACCESS TO SERVICES 9
20.0 CLIENT RIGHTS 9
20.1 Client Rights and Confidentiality 10
21.0 (Part A) CONSENT TO SERVICES FOR REGULAR/NON-HIPAA SERVICE AREAS 10
21.1 (Part A) Use of Consent to Services (Regular/Non-HIPAA) Form 11
21.2 (Part A) Exceptions to use of Consent to Services (Regular/Non -HIPAA) Form in Regular Service Areas 11
21.3 (Part A) Consent to Services (Regular/Non -HIPAA) Form Elements 12
21.0 (Part B) CONSENT TO SERVICES FOR HIPAA-COVERED SERVICE AREAS 12
21.1 (Part B) Use of Consent to Services (HIPAA) Form 12
21.2 (Part B) Consent to Services (HIPAA) Form Elements 13
22.0 (Part A) SHARING CLIENT INFORMATION WITH OTHERS IN REGULAR/NON-HIPAA SERVICE AREAS 13
22.1 (Part A) Information Sharing by Regular/Non-HIPAA Covered Services in CCS 14
22.2 (Part A) Transfer of CCS Client Information across Discrete CCS Records 15
22.0 (Part B) SHARING CLIENT INFORMATION WITH OTHERS IN HIPAA-COVERED SERVICE AREAS 15
22.1 (Part B) Information Sharing by CCS HIPAA-covered Service Areas 15
22.2 (Part B) Transfer of CCS Client Information across Discrete CCS Records 16
23.0 CCS IS A HIPAA HYBRID ORGANIZATION 17
23.1 How is Confidentiality Different in CCS Service Areas that are Covered by HIPAA and CCS Service Areas
that are NOT Covered by HIPAA? 17
23.2 Notice of Privacy Practices for Service Areas Covered by HIPAA 18
23.3 Breach Notification for Information Protected under HIPAA in Covered Entity Service Areas 18
23.4 Breach Notification in Regular CCS Service Areas (Not Covered by HIPAA) 19
23.5 Documentation of Unauthorized Disclosures (HIPAA) 21
23.6 Client Request of Accounting for Unauthorized Disclosures of Protected Health Information (HIPAA) 21
23.7 Purchasing of Outside Services by CCS HIPAA-covered Entity Service Areas 21
23.8 Annual HIPAA Compliance Checklist 22
23.9 Annual Confidentiality Checklist 22
23.10 Additional Information Regarding State and Federal Requirements Regarding Confidentiality 23
24.0 OBTAINING AUTHORIZATION TO USE AND DISCLOSE INFORMATION AND EXCEPTIONS TO
CONFIDENTIALITY 23
24.1 Use of Authorization to Use and Disclose Health/Service Information (AFD) 23
24.2 Who is Allowed to Sign the Authorization to Use and Disclose Health/Service Information (AFD) Form? 24
24.3 Consent for Audio and Video Recording 24
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24.4 Confidentiality Agreement with Professional and Vendor Associates 25
24.5 Subpoenas and Court Orders 25
24.6 Mandated Reporting of Abuse and/or Neglect 25
24.7 CPS (Child Protective Services) and APS (Adult Protective Services) Reporting by Attorneys who Work in
CCS Service Areas 25
24.8 Warning Potential Victims of Threat of Physical Harm 26
25.0 HOW TO TELL WHICH CONFIDENTIALITY FORM TO USE 28
26.0 DENIAL OF SERVICES 30
27.0 QUALITY MONITORING OF PURCHASED SOCIAL OR HUMAN SERVICES FROM OTHER AGENCIES,
ORGANIZATIONS, AND/OR PRIVATE PROVIDERS 30
28.0 FEES 30
29.0 GIFT CARDS 31
30.0 PROHIBITION OF CORPORAL PUNISHMENT/PHYSICAL DISCIPLINE AND AVERSIVE PROCEDURES 31
31.0 PROVISION OF SERVICES TO PEOPLE WITH SEXUAL OFFENSE HISTORIES 32
32.0 PRESERVING GOOD BOUNDARIES WITH CLIENTS 32
33.0 INCIDENT REPORTING 33
34.0 INVESTIGATION PROTOCOL 34
34.1 Investigation Policy and Procedure 35
34.2 Choice of Investigator 35
34.3 Timeline of the Investigation 35
34.4 Steps of the Investigation 35
34.5 Review of Results and Disposition of the Charges 36
35.0 CLIENT COMPLAINTS 36
35.1 Informal Complaint/Problem Resolution 36
35.2 Formal Complaint Resolution 36
35.3 Formal Complaint Procedure 36
36.0 TEXT MESSAGING 37
36.1 Destruction of Text Messages 38
37.0 WEAPONS STORAGE POLICY FOR CCS SHELTERS AND DAY CENTERS 38
37.1 Weapons Storage Protocol for Facility Based Shelters and Day Centers in Facilities Owned or Leased by
CCS 38
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37.2 Weapons Storage Policy for Community Based Shelters/Day Centers Hosted by Outside Groups 39
37.3 Weapons Disposal 39
38.0 RESPONDING TO LAW ENFORCEMENT OFFICIALS 40
38.1 Guidelines for Immediately Responding to Law Enforcement Officials 40
38.2 Guidelines for Immediately Responding to Law Enforcement Officials in Drug/Alcohol Treatment
Locations 41
38.3 How to Interact with Bail Bondsmen 42
39.0 Interactions with Immigration Agenci es 42
39.1 Procedures Regarding Access to CCS/CHS Facilities/Buildings 42
39.2 Procedures Regarding Immigration Agents’ Request for Access to CCS/CHS Records/Files: 44
39.3 Procedures Regarding Immigration Agents’ Request For Access to CCS/CHS I-9 Forms 45
SAMPLE JUDICIAL WARRANT 46
40.0 Research Statement 46
SECTION V MEDICATION 47
41.0 PRESCRIPTION PADS 47
41.1 CCS Prescription Drug Pads 47
41.2 Non-CCS Prescription Drug Pads 47
41.3 Quality Improvement 47
42.0 Medication Samples 47
43.0 MEDICATION ACCESS/STORAGE/PROMPTING POLICY FOR SHELTER AND HOUSING 48
44.0 NALOXONE USE 51
45.0 USE OF OTHER MEDICATIONS 53
46.0 ADVANCE DIRECTIVES 53
47.0 PEER REVIEW FOR PRESCRIBING OF MEDICATIONS 53
SECTION VI RECORDS 54
48.0 CREATING SERVICE RECORDS 54
48.1 General Procedure 54
48.2 Record Content 55
49.0 RECORD SECURITY, QI REVIEW, AND RECORD STORAGE 55
49.1 General Record Security 55
49.2 Records Review 55
49.2.1 Procedure for Records Review 56
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49.3 Secure Storage of Service Records 56
50.0 (Part A) HANDLING CLIENT REQUESTS FOR SERVICE RECORDS IN REGULAR/NON-HIPAA SERVICE AREAS 56
50.1 (Part A) Client Requests for Access to their Service Records – General Information 56
50.2 (Part A) What the Client or Legally Authorized Representative May Access from the Record 57
50.3 (Part A) Requests for Records of Deceased Persons 57
50.0 (Part B) HANDLING CLIENT REQUESTS FOR SERVICE RECORDS IN HIPAA-COVERED SERVICE AREAS 57
50.1 (Part B) Client Requests for Access to their Ser vice Records – General Information 57
50.2 (Part B) What the Client or Legally Authorized Representative May Access from the Record 58
50.3 (Part B) Requests for Records of Deceased Persons 59
51.0 Destruction of Archived Records 59
SECTION VII TITLE VI PLANS 64
52.0 TITLE VI PLANS FOR VOLUNTEER TRANSPORTATION PROGRAMS 64
SECTION VIII FORMS 65
ANNUAL CONFIDENTIALITY CHECKLIST (Regular/Non-HIPAA) 66
ANNUAL HIPAA COMPLIANCE CHECKLIST SCORECARD – CCSWW CE Programs 68
AUTHORIZATION FOR ELECTRONIC COMMUNICATION 72
CCS AUTHORIZATION TO USE AND DISCLOSE HEALTH/SERVICE INFORMATION (AFD) 73
BUSINESS ASSOCIATE / QUALIFIED SERVICE ORGANIZATION AGREEMENT 74
CLIENT RELEASE FOR MEDICATION PROMPTING SERVICE 80
CONSENT TO SERVICES (Regular/Non-HIPAA Covered Services) 81
CONSENT TO SERVICES (HIPAA-Covered Services) 83
CONFIDENTIAL DATA LOSS INVESTIGATION FORM (NON-HIPAA SERVICE AREA) 85
CONSENT FOR AUDIO AND/OR VIDEO RECORDINGS OF THERAPEUTIC SESSIONS 88
DISCLOSURE LOG FOR UNAUTHORIZED RELEASE OF PROTECTED HEALTH INFORMATION 89
DUTY TO WARN ASSESSMENT & PLANNING 90
FORMAL COMPLAINT FORM 92
HIPAA BREACH INVESTIGATION FORM 93
IMAGE & INFORMATION CONSENT FORM FOR STAFF, VOLUNTEERS, AND CLIENTS 96
INCIDENT REPORT 97
INDEPENDENT CONTRACTOR AGREEMENT FOR HEALTH CARE PROVIDERS 99
LOCAL QUALITY IMPROVEMENT COMMITTEE ANNUAL PLAN 103
LOCAL QUALITY IMPROVEMENT QUARTERLY MEETING/ACTIVITY REPORT 106
MEDICATION DISPOSAL FORM 112
MEDICATION LOG FOR SHELTER AND HOUSING 113
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NALOXONE DISTRIBUTION PLAN 116
NOTICE OF PRIVACY PRACTICES (NPP) 117
NOTIFICATION OF BREACH OF UNSECURED PHI 120
QUARTERLY RISK MANAGEMENT REPORT 121
INTERNAL REQUEST FOR REVIEW OF INDEPENDENT CONTRACTOR RELATIONSHIP 128
SAMPLE MEDICATION DISTRIBUTION LOG 131
SAMPLE MEDICATION INVENTORY LOG 132
SIGNATURE AUTHENTICATION FORM 133
SYSTEM-WIDE QUARTERLY QUALITY IMPROVEMENT SCORECARD 134
TITLE VI PLAN FOR THE FEDERAL TRANSIT ADMINISTRATION AND WASHINGTON STATE DEPARTMENT OF
TRANSPORTATION 139
VENDOR CONFIDENTIALITY AGREEMENT 147
WEAPONS STORAGE LOG SHEET 149
WEAPONS TAG - SAMPLE 150