DEVELOPING, WRITING AND MAINTAINING POLICIES, PROCEDURES AND FORMS

When a person identifies an issue, concern, or recommendation for a change or addition to Mains’l policy, procedure, or form please use the following steps.
1.    The Policy Team should be informed in writing of the issue, concern or recommendation. 

• Email to policyteam@mainsl.com

2.    The person responsible on the Policy Team for the identified policy area works with his or her strategic             partners to identify if a change should be made. 
3.    A written response is provided to the person who brought forward the issue, concern or recommendation, informing them of the decision of the policy team. 
4.    If it is determined that a change will be made, the procedures for developing and writing policies, procedures and forms should be followed. 

Developing and writing policies and procedures: The following steps should be followed when completing a revision or creating a new policy and procedure:
1.    The person responsible on the Policy Team for making the change works with his or her strategic partners to revise or create the new wording. 

• All applicable rules and regulations are checked to ensure compliance.

2.    The reason a policy and procedure is being revised or created and the wording changes are to be explained in an email to the Policy Team.  
3.    The Policy Team talks with people who would be impacted by the change to get feedback. 
4.    The Policy Team either approves or denies the proposed changes through email or a meeting.
5.    Policies and procedures that are in draft form, because they are new or being revised, should be saved in a separate folder titled DRAFT Policies and Procedures in the policy and procedure manual folder on the M Drive.

• Save the document with the policy and procedure title and the word DRAFT. 

6.    A date of any revision should be put on the bottom right hand corner of the last page of the document. Revision dates should be on the page itself, not in the footer. The format is Arial font size 9. The revision date should look like this: Rev. 11/6/15
7.    If the policy and procedure is new, it should list the date of creation. Creation dates should be on the page itself, not in the footer. The format is Arial font size 9. The creation date should look like this: Created 11/6/15
8.    Once a draft is approved, it is moved by the Policy Administrator to the official policies and procedures location. 
9.    Policies and procedures that are no longer valid given an end date are archived by the Policy Administrator up to seven years and then destroyed. 
10.    If a draft is not approved, the person who created it or the Policy Administrator delete the draft.
Format 
Mains’l policies and procedures are written and maintained following the format described below to ensure clarity and consistency:

a.    Body Text: Policy, procedure and internal controls should be typed in Arial font 11 with narrow 0.5” margins and single spacing with one space between paragraphs and two spaces between the end of the policy, procedure, and internal controls. 

• Headings should be bolded. 
• Sub-headings should be listed by letter and bolded if there is a title word or phrase such as the ones in this section. 
• Steps that are to be followed in a specific order should be listed by number. 
• Lists should be bulleted with the open circle bullet as seen within this policy. 
• When there is a heading that only applies to a subgroup of people who will be reading the policy or procedure, the heading should also have a bottom border that puts a solid line across the page.

b.    Header: The Header contains the Mains’l logo sized to 0.66 x 1.3 in the left corner and has a 0.1” margin. Centered on the page is the title of POLICIES AND PROCEDURES in bolded Arial font size 16. The header should look like the header on this policy and procedure. 

c.    Footer: The footer contains the title of the policy and procedure in caps, Arial font size 9, centered and the page number in the right corner and has a 0.3” margin. The footer should look like the footer on this page. 

d.    Policy: Policies tell what we do. Policies are clear, simple statements of how Mains’l intends to conduct services, actions and business. Each policy should:

• provide clarity for decision making,
• change infrequently and set a course of action for the foreseeable future,
• help ensure compliance with applicable laws and regulations, 
• reduce agency risk, and
• list the purpose of the policy our position, rules, regulations or directions that must be followed.

e.    Procedure: Procedures tells how we do things.  Procedures describe how each policy will be put into action and should be written in a format that is easy to follow, using numbers or bullets to list steps to be followed. Each procedure should outline:

• who will do what, 
• what steps they need to take,
• which forms or documents to use.

f.    Internal Controls: Internal controls help ensure that we do things the way we say we do them. They provide quality assurance and support people to be successful in knowing and following policies and procedures. 

Maintaining policies and procedures
The Mains’l web portal provides 24/7 access to policies and procedures for portal users, including all Mains’l employees, participant directed service recipients and their employees. The documents on the Mains’l web portal are the official electronic storage and access point for Mains’l policies and procedures. 

A folder on the agency M: drive, contains the word versions of each current and draft version of the policies and procedures. The M:drive is where individuals with approval to create and revise policies and procedures are to access and store the documents. 

To maintain an organized system of change control, and to ensure consistency, individuals should not keep separate copies or versions of policies or procedures in other locations. Instead, departments should forward policies and procedures, to be hosted on the website, to the Policy Administrator. 

Notification of changes to policies and procedures
The policy team determines when notifications of policy and procedure changes are issued, who will receive them, and the timeline for implementation of the change. Communication regarding changes is saved in the folder titled Communication of Changes within the policy and procedure on the M Drive. 

A member of the Mains’l policy team or their designee sends notification when a policy and procedure change occurs. Determining who should be notified is based on what in the policy or procedure has been changed and who is impacted by the change. Common recipients of change notifications include employees, people we support, and funders. 

a.    Minnesota notification requirements: 

1. We must provide a written notice to all persons or their legal representatives and case managers at least 30 days before implementing any procedural revisions to policies affecting a person's service-related or protection-related rights (found in 245D.04) and maltreatment reporting policies and procedures. 
2. We must provide an annual notice to all persons, or their legal representatives, and case managers for licensed services of any procedural revisions to policies required by 245D. 
3. All of the notifications must: 

• Explain the revision that was made. 
• Include a copy of the revised policy and procedure. 
• If not sent 30 days before implementing the change, explain the reasonable cause for not providing the notice at least 30 days before implementing the revisions.

4.    Before implementing revisions to any required policies and procedures, we inform all employees of the revisions and provide training on implementation of the revised policies and procedures.
5.    Upon request, Mains’l provides the person, or the person's legal representative, and case manager with copies of the revised policies and procedures.

b.    California notification requirements:

1. We provide a written notice to all persons or their legal representatives and case managers at least 30 days before implementing any procedural revisions to policies affecting a person's service-related or protection-related rights and maltreatment reporting policies and procedures. 
2. We provide an annual notice to all persons, or their legal representatives, and case managers for licensed services of any procedural revisions to policies required by statute. 
3. All of the notifications must: 

• Explain the revision that was made. 
•  Include a copy of the revised policy and procedure. 
• If not sent 30 days before implementing the change, explain the reasonable cause for not providing the notice at least 30 days before implementing the revisions.

4.    Before implementing revisions to any required policies and procedures, we inform all employees of the revisions and provide training on implementation of the revised policies and procedures.
5.    Upon request, Mains’l provides the person, or the person's legal representative, and case manager with copies of the revised policies and procedures.

Categories
Policies and Procedures are grouped by category and in alphabetical order by name. Each policy and procedure is assigned to one of the following categories. 
a.    Human Resources: Policies and procedures related to employees.
b.    Finance: Policies and procedures related to accounting, budgeting, and other financial functions.
c.    Services and Supports: Policies and procedures related to the services and supports provided by Mains’l.
d.    Medical: Policies and procedures related to the medical health and wellbeing of the people we support.
e.    Corporate: Policies and procedures that are of a general administrative or operational nature. 
f.    Participant Directed Services: Policies and procedures related to Financial Management Services and Participant Directed Services. 

Forms
Form development, maintenance, notification and categories follow a similar process to policies and procedures. The location of forms is dependent on the form itself. Forms are typically located in the Forms folder.