Behavioral Health Standard 1.A – Leadership

1.A.1.a-b

The Organization identifies:

  1. It’s leadership structure.
  2. The responsibilities of each level of leadership.
  • Organization Chart

1.A.2.a.1-2

A person-centered philosophy:

  1. Is demonstrated by: 1. Leadership & 2. Personnel
  2. Guides the service delivery.
  3. Is communicated to stakeholders in an understandable manner.
  • Person Centered Plan Policy (APS 2.5)
  • Person First Training
  • Person Centered thinking Training (See personnel Charts)

1.A.3.a

The identified leadership guides the following:

  1. Establishment of the mission of the organization.
  2. Establishment of the direction of the organization.
  • Mission Statement
  • Strategic Plan

1.A.3.b

Promotion of value in the programs and services offered.

  • Website, promotional materials

1.A.3.c

Achievement of outcomes in the programs and services offered.

  • Outcome measures
  • Strategic planning

1.A.3.d

Balancing the expectations of the persons served and other stakeholders

  • Agency Executive Director’s Report (BH 1.M)

1.A.3.e

Financial Solvency

  • Agency Executive Director’s Report (BH 1.M)

1.A.3.f

Risk Management

  • Agency Executive Director’s Report (BH 1.M)

1.A.3.g

Ongoing performance improvement

  • Agency Executive Director’s Report (BH 1.M)

1.A.3.h

Development of corporate responsibilities

  • Agency Executive Director’s Report (BH 1.M)

1.A.3.i

Implementation of corporate responsibilities

  • Agency Executive Director’s Report (BH 1.M)

1.A.3.j

Compliance with:

  1. All legal requirements.
  2. All regulatory requirements.
  • Corporate Compliance Program p.5, paragraph 1

1.A.3.k

Review of the organization’s policies at least annually.

  • Executive team minutes
  • CQI meeting minutes (see meeting notebooks)

1.A.3.l

Health and Safety

  • Health and Safety plan

1.A.3.m

Succession Planning

  • Succession Plan

1.A.3.n

Strategic Planning

  • Strategic Plan

1.A.3.o

Technology Planning

  • Technology Plan

1.A.4.a-c

The leadership of the organization is accessible to:

  1. The person served
  2. Personnel
  3. Other stakeholders
  • Corporate Compliance Program p.10

1.A.5.a-b

The organization implements a cultural competency and diversity plan that:

  1. Addresses person served
  2. Addresses personnel
  3. Addresses other stakeholders
  4. Is based on the consideration of culture
  5. Is based on the consideration of age
  6. Is based on the consideration of gender
  7. Is based on the consideration of sexual orientation
  8. Is based on the consideration of spiritual beliefs
  9. Is based on the consideration of socioeconomic status
  10. Is based on the consideration of languages

1.A.5.c-d

The organization implements a cultural competency and diversity plan that:

  1. Is reviewed at least annually for relevance
  2. Is updated as needed

1.A.6.a.1-3

Corporate responsibility efforts include, at a minimum, the following:

  1. Written ethical codes of conduct in business
  2. Written ethical codes of conduct in marketing
  3. Written ethical codes of conduct in Contractual relationships
  • Corporate Compliance Plan

1.A.6.a.4-6

Corporate responsibility efforts include, at a minimum, the following:

  1. Written ethical codes of conduct in conflicts of interest
  2. Written ethical codes of conduct in use of social media
  3. Written ethical codes of conduct in service delivery, including
    1. Exchange of gifts
    2. Exchange of money
    3. Exchange of gratuities
    4. personal fundraising
    5. personal property
    6. setting boundaries
    7. witnessing of legal documents
  • Code of conduct of staff (APS 5.8)

1.A.6.a.7-10

Corporate responsibility efforts include, at a minimum, the following:

  1. Professional responsibilities
  2. Human resources
  3. Organizational fundraising, if applicable
  4. Prohibition of:
    1. Waste
    2. Fraud
    3. Abuse
    4. other wrong doing
  • Corporate Compliance Plan p.7, item 7

1.A.6.b

Written procedures to deal with allegations of violations of ethical codes, including:

  1. A no-reprisal approach for personal reporting
  2. Time frames that:
    1. are adequate for prompt consideration
    2. result in timely decisions
  • Corporate Compliance Plan p.7 & 8

1.A.6.c

Education of stakeholders on ethical codes of conduct for:

  1. Personnel
  2. Other stakeholders
  • Corporate Compliance Plan p.4 & 10

1.A.6.d

Advocacy efforts for persons served

  • Log of advocacy efforts

1.A.6.e

Corporate citizenship

  • Corporate Compliance Plan p.6, item 5

1.A.7

An organization in the United States receiving federal funding demonstrates corporate compliance through:

  • Corporate Compliance Plan

1.A.7.a

Implementation of a policy on corporate compliance that has been adopted by the organizations leadership

  • Corporate Compliance Plan p.3

1.A.7.b

Implementation of written procedures that address exclusions of individuals and entities from federally funded healthcare programs.

  • ???

1.A.7.c

Designation of a staff member to serve as the organization’s compliance officer:

  1. That is documented
  2. Who:
    1. Monitors matters pertaining to corporate compliance
    2. Conducts corporate compliance risk assessments
    3. Reports on matters pertaining to corporate compliance
  • Corporate Compliance Plan p.9

1.A.7.d

Training of personnel on corporate compliance, including:

  1. Role of compliance officer
  2. The organization’s procedures for allegations of fraud, waste, abuse, and other wrongdoing
  • Corporate Compliance Plan p.7 & 10

1.A.7.e

Internal auditing activities

  • Corporate Compliance Plan p.12

1.A.8

Leadership provides resources and education for personnel to stay current in the field in order to demonstrate program strategies and interventions that are based on accepted practices in the field and current research, evidence-based practice, peer reviewed scientific and health-related publications, clinical practice guidelines, and/or expert professional consensus.

  • College of direct support – Online learning
  • MCO Trainings
  • Conferences
  • Tuition Reimbursement for employees

1.A.9

To demonstrate accountability in an organization that engages in fundraising

  • N/A