FSCC Description of Organizagtion

FSCC – Description of Organization 2015

Fresh Start Comprehensive Center

Description of Organization

At Fresh Start Comprehensive Center (FSCC) we believe in the new disease concept for treating our clients. This concept offers a framework through which we can meet the needs of our clients by strategically integrating the resources of multiple formal (professional) and indigenous helping institutions. Multiple problem clients have become the norm in addiction treatment agencies across the country and Baltimore City is no different. These clients, many with long and complicated service histories, have not done well in our current categorical segregated service systems. Clients often complain about service exclusion, service extrusion, premature service disengagement, repeated episodes that were at the most harmful and at the least unbeneficial. At FSCC we believe addition, mental health and other acute and chronic disorders (co-occurring) can be treated best by integrated models of care for the multiple problem client/family. Integrated Services FSCC will offer our clients integrated services to address their mental health, substance abuse and somatic are needs. Our staff, partner agencies and consultants will use their expertise and direct client care experience to help the population we serve to help better understand and manage their conditions. Our state-of-the-art program will use the latest assessment tools, clinical interventions and treatments to provide outpatient services. We use through and accurate documentation of client’s progress using a problem-oriented record system. Each client’s treatment team plan reviews are developed and their progress is recorded. We educate clients diagnosed with a variety of illnesses to better understand and manage their conditions (including pregnant addicted women). We use discharge planning skills to promote independence, maximize function and return clients back to optimum health (both physically and mentally). We will assist our clients by offering services that will meet their needs within our facility and outside agencies we have partnered with. Once clients have met as many needs as they can we will offer them referrals to outside agencies recommended by our treatment team and follow-up to ensure services were received.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

Victims of a Disorder We as treatment professionals and community leaders can no longer view the addict as an irresponsible moral agent who perpetrates acts of self-destruction on themselves, their families and their communities, but as victims of a disorder that compromises their values and good intentions. Instead we have to look at whether ones choice to use or not is a direct result of their lack of skills to resolve problems as they develop. Addiction and recovery are best looked at in terms of degrees of diminishment or enhancement of voluntary control (aka as harm reduction). Once educated and given the tools, each person has a responsibility to:

 Recognize their vulnerability for A&D disorders,  Manage their own health,  Act proactively to prevent the onset of such disorders.  Recognize the presence of the disorders, and  Act decisively to arrest and manage the disorder.

Comprehensive Education At FSCC we give our clients these tools through education about: daily diets, work habits, exercise, sleep, stress management, psychoactive drug consumption, high risk behaviors, personal beliefs, social support, alternative support structures, alternative treatment approaches, and solo recovery experiences. We emphasize the responsibility of the individual to actively manage their health issues as a daily process of long-term recovery. In order for our clients to meet their recovery goals we will offer our clients a menu of professionally-directed interventions, recovery support services, mutual aid groups, indigenous healers/institutions, and self-engineered (potentially manual-guided) programs of recovery that individuals can select for personal and cultural fit. Individualized treatment plans of actions not one size fits all unlike programs have offered clients in the past. These choices will be ever evolving and the menu will be constantly upgraded to meet the needs of the individual client. At FSCC we incorporate the principle of chronic disease management that is used to understand and manage other chronic disorders. Evidenced based principles and techniques that are being successful used (evidence based) to manage addiction recovery. The focus will be on interventions that strengthen and extend the length of remission periods, reduce the number of relapse events, reduce the intensity and duration of relapse episodes, and reduce the personal and social costs associated with such episodes.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

In order to utilize the above techniques the relationship between the Substance Abuse Counselor (SAC)/Peer Recovery Coach (PRC) and the client must be a partnership of long term disease/recovery management. This partnership during its duration will create an organized metaphor for personal change for the client and help the SAC/PRC to learn from the ever-changing lessons of clinical and recovery experience. In addition, the movement to integrate the alcoholism and drug abuse treatment fields will help individuals in this field to re-examine and redefine the assets they brought to the helping process. It will also spur the need for new knowledge and skill development for both substance abuse and mental health counselors to operate effectively and FSCC hopes to be the catalyst to bring about this re-education/cross training. FSCC will train our mental health practitioners to identify the signs of substance misuse and our addiction practitioners to identify psychiatric symptoms. This cross training is relevant because of the important development of “co-occurring disorders” among the clients that we serve. In order for clients to receive effective care, mental health and addiction services must be integrated. To successfully do so we will train our staff to focus on the commonalities of the two illnesses. To successfully do so we will train our staff to focus on the commonalities of the two illnesses, the process of recovery, healing, and the community inclusion. For example, all FSCC staff will be cross trained to serve clients with substance abuse issues. They will be given a comprehensive understanding of the 12 Steps of Recovery and the ability to implement it into the treatment process of our clients. Personal and Individualized Process As helping professionals we must assist others in embracing the fact threat recovery is a personal and individualized process of growth that can take multiple pathways and phases. It is our responsibility to the clients that we work with to develop a coherent vision of recovery that can be useful to all involved parties. It is important that people in recovery are encouraged and allowed to be an active agent of change in their own lives—not passive recipients of care. Only they can make the important decisions, take critical actions, and discover healing resources within and beyond their selves. In addition, clients realize the role of family and peer support in helping them to achieve their recovery and as helpers we must use these rich resources to help our clients through the recovery process. Philosophy Our philosophy at FSCC is that clients want to manage or eliminate their symptoms, increase their capacity to participate in valued social roles and relationships, embrace purpose and meaning in their lives, and make worthwhile contributions to their communities. At FSCC we realize that recovery looks different for different people.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

Therefore, we use a developmental framework for matching the person’s point in the recovery process to appropriate interventions. As well as, the fact that recovery is not an outcome—no one ever recovers from the disease of addition—but a continuum and process. Vision It is our vision to help all of our clients through their Recovery Process by using the following two track formula:

Offer choice/encourage client

 Address client’s overall life, physical and mental health  Treatment/Peer Support  Family education

We recognize and embrace the fact that each person seeking recovery must be the central participant in his or her own recovery journey. The menu of services that FSCC and its partnering agencies will include 34 initiatives and programs as listed the program description section. What is Recovery? Recovery defined means having a dignified and gratifying life in the presence of an on- going disability. In order to obtain a positive and safe lifestyle one must reclaim a full, meaningful life within the community. At FSCC we place the primary responsibility for recovery clearly with the persons affected; the person/family themselves. As practitioners we will provide support, by enhancing the client’s access to a range of opportunities from which they may choose, that are most useful to the clients entering into and pursuing their own recovery process. This will include both clinical treatment and non-clinical resources and supports that clients need in order to recover –including helping them to deal with stigmas from society, alienation from loved one, poverty and employment, homelessness, social isolation, loss of identity and roles, loss of sense of self, community acceptance and purpose in life. As clinicians we realize that removing the symptoms from an unchanged life is not recovery. At FSCC we believe in the following quote: “TAKE CONTROL OF YOUR LIFE BY TAKING CONTROL OF YOUR HEALTH”.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

Program Description FSCC was established in 2014 with a mission to provide adults struggling with addiction, mental illness and co-occurring conditions in order to live a productive and healthy life. At FSCC clients will have access to services that meet their recovery needs. This will be achieved by providing a range of community based, intervention, treatment and support services. The services consist of the following :

1. Individual Counseling 2. Group Counseling 3. Behavioral Health Counseling 4. Pastoral Counseling 5. Family Counseling 6. Trauma Counseling 7. Substance Abuse Counseling and Treatment 8. Mental Health Assessment & Treatment 9. Grief & Loss Assistance 10.Domestic Violence Assistance 11.Veteran Assistance 12.Reunification Assistance 13.Housing Assistance 14.Recovery/Transitional Housing Assistance

17.Disability Assistance 18.Legal assistance 19.Financial Eligibility Assistance 20.Job readiness/Placement 21.Healthcare Access 22.Medication Assistance Treatment 23.AA/NA meetings 24.Peer Recovery Coaches 25. Intensive Case Management 26.Dental Care Access 27.HIV screening, testing & treatment 28.Needle Exchange Program 29.GED classes 30.Hotline Assistance (24 hours) 31.Acupuncture 32.Relaxation Techniques 33.Yoga 34.Community Outreach and Education Services

15.Residential Detoxification 16. Identification Obtainment Assistance

Training and Workshops Through special grants and contracts, FSCC will provide professional training, conferences, workshops and symposia to our staff and to the communities where our clients live, work and play. We realize how important the impact of the environment is to our client succeeding in their recovery process. It is imperative that the environment be a good fit for our clients and the interactions be positive ones. Our philosophy at FSCC is that clients want to manage or eliminate their symptoms, increase

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

their capacity to participate in valued social roles and relationships, embrace purpose and meaning in their lives, and make worthwhile contributions to their communities.

Services offered defined in further detail:

 SUBSTANCE ABUSE SERVICES: In response to the growing need for addictions treatment services FSCC provides medication assisted treatment for chemically addicted persons.  COUNSELING: All clients are offered supportive/behavioral health counseling (individual, group and virtual).  COLLABORATION WITH OTHER AGENCIES: FSCC has established shared service agreements with a number of human services and treatment programs throughout the city.  PUBLIC EDUCATION AND TRAINING: FSCC provides public and professional education and training on a wide range of topics including: trauma therapy. This program provides practical information on community resources. FSCC will offer professional training conferences, workshops and symposia.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

MISSION STATEMENT The mission of FSCC is to assist adults in the process of recovery on a broader scope with a repertoire interventions and supports in a community based context. Specifically, the goal is to support recovery processes by utilizing the basic commonalities between mental illness and addiction. The mission will be achieved by providing a range of community based, intervention, treatment and support services. The Guiding Principles of FSCC 1. We recognize and embrace the fact that each person seeking recovery must be the central participant in his or how own recovery journey. 2. To assist individuals in their endeavors to lead healthy and productive lives FSCC will partner with other agencies. These partnerships will consist of an established shared service agreement with all designated Baltimore city agencies that can provide the services our client seek. 3. Individuals should be treated based on their presenting and individual needs. 4. Individuals should have easy access to services and support, e.g. a clearly defined pint of entry and 24-hour availability. 5. Mental health and substance abuse professionals should be responsive, skilled 7. Individuals are entitled to timely evaluations and treatment of any somatic, psychiatric or substance abuse conditions, and there should be one standard of care 8. Service availability should include integration of services with the ongoing system, and there should be follow-up services to those who are served. 9. There should be an effective partnership with the community. 10.There should be an efficient use of all resources. 11.Effective service delivery and therapeutic efficient will be promoted through the establishment of coordination, consultation and cooperation with the community and other service providers. At FSCC we realize that recovery looks different for different people. Therefore, we use a developmental framework for matching the person’s point in the recovery process to appropriate interventions. In fact we strongly believe that recovery is not an and sensitive to the needs of individuals rather than the system. 6. Families and consumer should be involved in decision making.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

outcome—no one ever recovers from the disease of addiction—instead recovery is a process of continuum that includes an integration of services and support systems.

Clients Rights and Responsibilities

 As a client of FSCC, she/he can expect to be treated with courtesy and respect at all times.  The client has the right to expect that FSCC will put forth the best effort to provide competent consultation, evaluation and treatment.  The client has the right to expect confidentiality will be maintained in treatment and what he/she reports to FSCC except in the instance where there is the risk of imminent danger to him/her or others.  The client has the right to have his/her treatment explained in clear, understandable language. This explanation should reasonably inform him/her of the risks, benefits and possible side effects of any proposed treatment.  The client has the right to a treatment plan, to participate in the plan and to receive treatment in accordance with the plan.  The client has the right to treatment in the least restrictive setting possible, consistent with the nature of the particular crisis. This may take the form of other treatment agreed upon by the client and FSCC.  The client has the right to review his/her records upon request unless a physician determines it harmful. If the physician denies the client’s request, she/he is entitled to see a written or verbal summary of the records.  The client has the right to refuse treatment at any time.  The client has the right to be free from unwanted intrusions by the staff of FSCC. The staff will avoid coming to the client’s home unannounced and without prior approval whenever feasible.  The client has the right to express dissatisfaction with any aspect of the treatment services provided by FSCC and to have FSCC listen and respond in a timely, reasonable way.  The client has the right to request a change in the staff assigned to his/her case. FSCC will honor such requests to the best of our ability so long as it does not adversely interfere with the client’s treatment.  As partners in the delivery of the client’s care, the staff of FSCC anticipates the client’s active participation.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

 Responsible participation in that care entails being truthful with the FSCC treatment team, compliant with treatment recommendations and remaining free of drug/alcohol and/or nonprescription drugs/medications wile at FSCC.  The client’s responsibilities also require that she/he take an active part in the formulation and implementation of his/her treatment goals, as well as providing feedback to the treatment team when goals have or have not been met.  Additionally, responsible participation in the client’s care calls for reporting any problems or concerns to the treatment team (when and if these problems or concerns arise). Role of the Counselor The primary responsibility of the Counselor is to ensure the maintenance of a safe, therapeutic and structured environment for clients. To support this goal, the following duties must be executed:  Effective monitoring and supervision of all clients.  Assessment of clients’ level of functioning, symptomology and response to treatment.  Effective substance abuse services.  Utilization of supportive counseling and non-violent intervention skills to assist clients in managing their behavior.  Documentation of all clinically relevant client information  Timely performance of assigned duties and appropriate utilization of program resources.  Regular contributions to the effective functioning of the program through teamwork and flexibility.  Maintenance of effective and appropriate communication with clients, FSCC staff and management, community agencies and the public.  Active participation in the organization’s professional development program which includes: regular supervision, clinical training seminars, professional development seminars, and agency-sponsored attendance at outside educational activities. In addition, all clinical staff are required to receive yearly training in cardiopulmonary resuscitation (CPR), and non-violent physical crisis intervention and to provide documentation of tuberculosis screening. It is the responsibility of the staff person to keep his/her training file updated.  Participation in program development activities.  Mandatory attendance to monthly staff meetings and group supervision meeting.  Performance of other duties as assigned.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

Confidentiality of Client Records

 Information pertaining directly or indirectly to the client shall be considered a part of the client’s medical record.  This information is protected under both Maryland State and Federal law.  Prior to the release of any client related information, FSCC staff must follow informed consent procedures and obtain the client’s written informed consent utilizing the Authorization for Release of Information. This is in accordance with State and Federal law.  Any disclosure of information (whether in person, over the telephone, by mail or by fax) shall be documented in the client’s record.  The medical records shall be electronically maintained along with a companion hard copy file. The hard copy will contain the following: a. Informed consent to treatment signed by the patient; b. Any requests for release of information shared with other entities signed by the patient; c. Any treatment plan or treatment plan update signed by the patient; and d. Any program agreements or patient/counselor behavioral contracts signed by the patient.  All patient records will be maintained for at least 3 years as required by Health-General Article, 4-403, and Annotated code of Maryland following discharge. Except for Medicaid patient records which will be maintained for at least 6 years following discharge. Exceptions to the Right of Confidentiality 1. If a client presents a danger to self or others, the staff’s obligation to ensure safety supersedes the client’s right to confidentiality. If a client is suicidal, we are obligated to take septs, e.g. institute a higher level of observations or initiate an emergency petition, to ensure the client’s safety. If a client makes a threat against a specific person and we do not institute any form of treatment, we then have a DUTY TOWARN under the Maryland law. The Duty to Warn may be satisfied by contacting the potential victim directly or by notifying the law enforcement authorities. In either situation the Administrator-On-Call and/or Medical Director should be consulted. 2. If a client disclosed information that suggested a history of child abuse (as victim or perpetrator) or child neglect, we are legally required to report this information to Child Protective Services. If you have reason to believe a client has been a victim of child abuse or child neglect, the following procedure should be followed:

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

a. Within 12 hours of the disclosure, the coordinator/supervisor would be notified.

b. Within 24 hours of the disclosure and after consultation with the appropriate administrative staff, the staff member who received the information should telephone Child Protective Services (410-361-2235) to provide an oral report. c. Within 24 hours of the disclosure, the staff member receiving the information should complete form D-470 (report of child maltreatment) ad forward it to the Program Administrator. d. Execution of the above steps shall be documented in the client’s chart. In addition, a copy of the written report shall be maintained in the client’s chart. e. If the client reports that he/she has been a victim of sexual assault (the assailant is not in a custodial or caretaker role), the client should be encourage to report the assault. However, under no circumstances should FSCC staff initiate the report of an incident of sexual assault. This would violate the client’s right to confidentiality. 3. While FSCC is responsible for the confidentiality of all client information, the client’s right to confidentiality does not supersede the responsibility to appropriately communicate all relevant information to FSCC treatment team members and/or management. 1. Unauthorized visitors to the program are not permitted. This includes friends and relative of clients and staff. 2. To the extent possible, any interface with friends or family while escorting clients in the community should be avoided. 3. In the event that interface with friends or family is unavoidable, FSCC staff will refrain from disclosing any identifying client information. In addition, the interaction should be as brief as possible.

Confidentiality in the Community

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

ADMISSION

Criteria

A person is considered to be appropriate for admissions into the Detox when she/he meets the following criteria:

1. Is at least eighteen years old. 2. Is a resident of Baltimore City and/or the surrounding counties

3. Is free of serious medical problems and not in need of immediate medical attention. 4. Is willing and able to take his/her prescribed medication, with assistance/observation by the Medical staff. 5. Is voluntarily accepting services, is agreeable to working towards a treatment and has indicated such by signing the FSCC consent for treatment. 1. Upon the FSCC staff bringing the client to the office welcome the client, begin to build a rapport, and attempt to make him/her feel comfortable. 2. The client will be assessed/evaluated. 3. The treatment planning and discharging planning is explained to the client. The admission process is completed with paperwork signed. The Counselors should orient the client to the facility and clearly explain the rules and regulations including ensuring that clients have not brought and weapons and contraband items into the facility. Medical Record The medical record or chart serves two function. It is the place where the client’s progress toward treatment goals is documented, and it is the avenue through which staff communicates with each other as well as with outside parties. The Addiction counselor is responsible for organizing the client’s chart upon admission. The following standards should be followed: Admitting Procedures Documentation

1. The order of the documents should be the same in all charts. 2. All sections should be clearly identified and contain specific documents.

3. The chart should be clearly labeled including the client’s name (last name, first name and middle name/initial), SAMIS (substance abuse management information system), and date of admission.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

When writing in the medical record, the following guideline must be observed:

1. Use black ink only. 2. Include the client’s name, date and time on all pages. 3. Sign everything you write. Your signature must be followed by your license, degree or position, e.g. Ray Jones, BSW or Ray Jones, CSC-AD. 4. When continuing a progress note onto a second page, indicate the continuation appropriately including: a. At the end of the first page write “Cont’d: and sign. b. At the beginning of the continuation page write, “Cont’d” and continue the note. Be sure to include the client’s name, social security, date and time on each page.

5. When indicating an error, follow these guidelines: a. Cross out the error using a single line. b. Write “error” or “delete” above the error. c. Note your initials above the error. d. Note the date of the correction above the error. e. Write the corrected information. f. Do not scratch or white out the error.

Treatment Planning

Upon admission all clients will have a treatment plan completed by an interdisciplinary treatment team. The team will meet with the client to: 1. Identify problems, needs and treatment expectations to be addressed during the treatment period. This must include a description of the individual’s current behavior, symptoms and/or level of functioning. 2. Identify client strengths and resources. 3. Establish goals that are:  Client driven  Defined in measurable and behavioral terms  Achievable within appropriate time limitations  Directly related to the stabilization and/or linkage of community services.  Outcome oriented  Inclusive of a plan for transition and discharge 4. Identify treatment strategies that are relevant to goal attainment. This must include:  Recommended modality and frequency of interventions  Designation of staff responsible for implementing the elements of the plan

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

 When appropriate, identification of, referral to, and collaboration with other services to support the individual’s treatment. 5. Establish target dates for goal achievement. The treatment plan should be signed by the client. Daily progress toward the goals will be documented in Progress and Contact Notes. The treatment plan should be viewed as a “living document”. Goals should be added or discontinued as deemed appropriate. The treatment plan should be reviewed by the treatment team within 3 days to determine the continued appropriateness of the goals. 24 hours prior to the client’s discharged, the treatment team will again review the treatment plan to determine which goals were or were not achieved. This information will be documented under the “results” section on the treatment plan.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

THERAPEUTIC ACTIVITIES

Individual Counseling

1. Addiction Counselors will provide supportive counseling as needed.

2. Addiction Counselors will assist client in identifying and developing a treatment plan. 3. Addiction Counselors will document services provided and treatment modalities utilized in client’s chart. 4. Addiction Counselors will assist client in discharge planning as needed.

Group Counseling

1. Addiction Counselors will facilitate therapeutic group sessions. The goal of group therapy is to allow the client the opportunity to give and receive mutual support. Each client will be encouraged to determine his/her comfort level with self-disclosure, and participate in the group accordingly. The group facilitator will assist clients as necessary with maintaining appropriate boundaries. The ground rules will be reviewed at the start of each session. a. The designated group facilitator is responsible for calling the group to order, distributing materials (pencils, and daily goals/actions worksheet), leading the group and ensuring that group participation is documented in each client’s chart. These duties may be delegated as appropriate, but the designated group facilitator will be held accountable for seeing that these responsibilities are met. b. All staff is responsible for reinforcing the goals of the group and assisting clients in their efforts to implement action plans. c. Group facilitators will adhere to the structure described in the group outline. d. Each client’s participation in the group must be documented in a separate progress note. The group progress note is to be labeled with the name of the group. The note should include a description of the client’s level of participation in the group, attitude toward other group members (staff and clients), and the work that the client does in the group, e.g. goals, action plan, etc. In addition, the progress note should relate any relevant mental status information, e.g. rapid speech, psychomotor agitation, impaired concentration or memory, etc. It is the responsibility of the group facilitator to see that a note is written for each client.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

Group Rules for Group Activities

 Information shared in the group stays in the group.  Be courteous. Everybody takes turns. One speaker at a time.  All members have an equal right to speak in the group.  This is a time for mutual support and not making judgments of others.  Respect the right of others to have views that are different from your own.  Each member is responsible for determining his/her comfort level with sharing personal information.  The choice of any member to not disclose personal information must be respected.  Arrive on time so the group can end on time. Incident Reports The purpose of the Incident Report is to ensure the maintenance of both client and FSCC staff/Volunteer health and safety in the work and r treatment settings, as well as to establish guidelines to correct problems that threaten health and safety. 1. Any and all situations in which a client, FSCC staff/volunteer, or client family member/significant other experiences an incident that jeopardized or potentially jeopardized the person’s health or safety is considered a “reportable incident”. 2. Report incidents may consist of, but are not limited to: A. Aggressive/Threatening Behavior B. Assault

C. Medication Reaction D. Sexual Misconduct E. Personal Injury F. Property Damage G. Theft

3. In any of the above instances, an oral report is given to the Director as soon as possible, after the incident occurs. In some situation it may be appropriate to notify the Medical staff first. For example, if the incident is related to a minor injury, it would be appropriate to first contact the medical staff who can assess the situation by phone or in person. 4. In case of any injuries, the Doctor and the Director will also be notified to provide direction for dealing with an injury if steps have not yet been taken. 5. As soon as possible after the incident, and no later than twenty-four hours after the incident, staff involved or observing the incident shall complete a written incident report. 6. Once completed, the Incident Report should be taken to the Director’s office.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

FSCC – Description of Organization 2015

7. Because incident reports may contain information gathered in anticipation of litigation and pertinent to FSCC’s quality assurance review, incident reports will be maintained as confidential. UNDER NO CIRCUMSTANCES SHOULD AN INCIDENT REPORT BE CONSIDERED PART OF OR BE MENTIONED IN THE CLIENT’S MEDICAL RECORD. 8. The QA/I committee shall use the incident reports to tabulate and categorize reportable events for the purpose of identifying trends with the program. SURVEYS Surveys will be conducted monthly to determine client’s satisfaction or dissatisfaction with service delivery. These surveys will be anonymous and will be kept in a binder. The QA/I committee shall use the surveys to tabulate and categorize to ascertain how/if improvements to meet client satisfaction can be achieved.

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1 E Mt. Royal Ave., Baltimore MD 21202 Tel. 443-671-1414, Fax 443-671-1420

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