DESTRUCTION OF RECORDS
Corporate records are shredded based upon above timelines, and removed by an authorized document destruction service provider.  

ACCESS OF RECORDS
The CEO, CFO, VP of administration, controller, and director of administrative services are authorized personnel to have access to corporate records, with limited access by the corporate administrative coordinator for filing and retrieval purposes.
 

Network and Data Security

Information is considered an important asset of Mains’l Services, Inc., and restrictions are imposed for controlled data access.  Mains’l Services, Inc. considers it important to provide access to information to authorized users only. This operating procedure defines the processes to be used to protect the confidentiality, integrity, availability, and reliability of all information technology resources used to support the needs of our internal and external stakeholders, and to implement and enforce that level of security which will provide for the protection of data and information technology resources from accidental or intentional unauthorized disclosure, modification, or destruction by persons within or outside of Mains’l Services, Inc.

All Mains’l Services, Inc. technology equipment has up to date antivirus software installed, which automatically scans for viruses in real time.
                            

1.    Access to the Network – Local and Remote Access
Access to the Mains’l Services, Inc. intranet (agency network) is restricted.  Each user has a confidential personal identifier (user name and password.)  Personal identifiers are not to be shared with anyone for any reason.  Upon gaining access to the network, user’s access and ability to view, add or modify information is governed by permissions.  These permissions allow access to information which is appropriate to his or her job responsibilities.  Access rights are authorized by the executive assistant and chief financial officer and configured by the ITS/DSO.  Mains’l Services, Inc. Technology and Systems Use Policy and Procedure must be reviewed by all authorized users before intranet access will be given.

Mains’l Services, Inc. complies with all HIPAA data privacy requirements (see Notice of Privacy Practices for Employees, and Notice of Privacy Practices for Consumers.)

Supervisors of authorized users are responsible for immediately notifying the ITS/DSO upon termination, transfer, or resignation for the purpose of system access adjustment or termination.

2.    Access to the FTP site    

A.    Security of Mains’l Services, Inc.’s file transfer protocol (FTP) site is the sole responsibility of the ITS/DSO.  

• Access to the Mains’l Services, Inc. FTP site is restricted and governed by the ITS/DSO, under the requirements of the contracted services contract.  Upon approval by the chief financial officer, each user receives a confidential personal identifier (user name and password), assigned by the ITS/DSO.  The chief financial officer communicates the personal identifier information to the appropriate agency personnel.  Personal identifiers are not to be shared with anyone for any reason.  
• Upon gaining access to the site, user’s access and ability to view, add or modify information is governed by permissions.  These permissions allow access to information which is appropriate to his or her role.  Access rights are authorized by the chief financial officer and configured by the ITS/DSO.
• Mains’l Services, Inc. Technology and Systems Use Policy and Procedure must be reviewed by all employees who require access to the FTP site, before access will be given; in addition, employees will be required to review and sign any policies, procedures, and security agreement forms, as required by contracted entities.  
• Supervisors of authorized users are responsible for immediately notifying the chief financial officer upon termination, transfer, or resignation for the purpose of system access adjustment or termination.

B.    Data Handling

• All data transferred from contracted entities to Mains’l Services, Inc. is downloaded from the secure FTP site to the secure local area network.  Files are unencrypted and converted to the appropriate financial management system.   Data is processed as outlined by the contracted entity.  Once data is processed, it is uploaded to the secure FTP site.
• Again, only authorized users have access to files on the FTP site.

3.    Equipment 

• The information technology specialist/data security officer (ITS/DSO) and executive assistant are responsible for the purchase and installation of the computer software and hardware, and for maintaining the equipment.  In the event computer equipment must leave the facility for repair, hard drives are removed to ensure profile and, thereby, data security.  Prior to computer equipment being exchanged to another user within the agency, authorized users profile is deleted from computer to enforce data privacy.  Storage of company data in local hard drives is prohibited.  In the event computer equipment is leaving the facility to a non authorized user/entity, hard drives formatted to wipe out any traces of sensitive information.  The ITS/DSO is the only authorized personnel to complete the formatted and removal/disposal process.
• Confidential data may not be stored on any unencrypted mobile device, with the exception of the ITS/DSO.   Back up tapes are the only removable media allowed to store data for the sole purposes of back up.

4.    Physical/Site Security

• Mains’l Services, Inc. main headquarters is geographically located in a non-disaster related plain. The facility has strict security levels, governed by the vice president of administration and ITS/DSO. The data center is climate controlled (with its own cooling system), has strict security access, and is monitored for fire and security.  All network server equipment is housed in racks and cages for additional limited access.  All equipment is raised off the floor, at least ten (10) inches, to prevent water damage.  In addition, the headquarters is monitored for fire and security 24/7. 
• The ITS/DSO is responsible for site security and uses preventive measures necessary to minimize the risk of destruction, theft and other losses of equipment, software, and data. The ITS/DSO evaluates the physical location and conditions surrounding the site and take the necessary precautions to protect it.  The ITS/DSO annually evaluate the effectiveness of the site’s security and will report any new findings to contracted entities.  In addition, Mains’l Services, Inc. has an IT Disaster Recovery Plan, which is reviewed and revised, as necessary, minimally on an annual basis.
• It is the responsibility of the individual using the data to maintain appropriate confidentiality and the responsibility of the individual’s supervisor to ensure that the employee has adequate training on protection of information.

5.    Training and Agreement

• Supervisors are responsible for ensuring authorized users receive rules, policies, procedures, and guidelines on departmental information security.  All authorized users will sign a Training and Security Agreement
   

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.

 

Hardware and Software Authorized Users and Installation

End User Hardware

Computers are provided to those employees requiring such technology to perform day to day services and business at Mains’l Services and its subsidiaries.

Desktops are routinely provided to office personnel and 24-hour program site locations.  Laptops are provided to those employees whose position requires mobility. Employees who are authorized to use laptop computers are required to sign a “Portable Equipment Agreement” before equipment is authorized for use (see “Portable Equipment Agreement.”)  Use of personal computers is permitted with limited access to agency information via terminal servicers and website only; personal computers are not supported by IT personnel.

All computer hardware and peripherals, whether desktop or laptops, are owned by Mains'l and are set up and installed by information technology (IT) department personnel.  

Employees authorized to use computer equipment owned by Mains’l include those given possession of the computer (senior leadership team members, directors, senior managers, managers, office personnel, etc.)  Other employees who may operate the technology include support coordinators and direct support professionals; however, the accountability of the computer remains with those employees who have been given possession.  Any users of computer equipment owned by Mains’l are expected to comply with this Information Technology Use Policy and Procedure.  

People who receive services from Mains’l may use computers which are owned by the agency, at the discretion of the manager and their supervisor.  The manager is responsible for any and all computer use at their site.

Server Hardware

Mains’l Services currently uses Cloud technology to deliver database services, applications, e-mail, file storage, and public services.  See IT Plan for specifications.

Software

Mains’l complies with software copyrights and adheres to the terms of all software licenses to which the organization is a party.  Employees may not copy or duplicate any software for use in other Mains’l locations, or for their personal use, as it may subject Mains’l and/or the employee to civil and criminal penalties. In addition, only software approved by the IT department may be used on Mains’l computers. Software is installed exclusively by IT department personnel. Standard software installed includes Microsoft Office Suite:  Microsoft Word, Excel, and Outlook.  Other programs installed may include Access, Provider Pro, Publisher, internet access software, or other approved software.  If unauthorized programs are used on Mains’l computers, discipline, restitution, and/or employment separation may result.

Assistive technology needs are addressed on an individual basis.  Employees will discuss needs with their supervisor, who will notify IT personnel of any necessary adaptations.

Training, Use, and Care of Hardware and Software

Training

All authorized computer users will receive initial orientation/training from IT department personnel.  Employees will be directed to receive training on this policy and procedure within two weeks of receiving equipment.  Employees are expected to have general knowledge of computer technology.  Employees are also expected to independently obtain additional training classes appropriate to their level of competency/job description requirements.  Classes
may be provided by IT department personnel on an individual or group basis; outside coursework may be obtained independently by authorization of the employee’s supervisor.

Care of Equipment

All users are expected to treat agency computers as fragile and valuable property.  Users are expected to:

• Protect computers they use from theft, undue shock, or similar physical damage.  
• Extreme care is required with food and beverages, which cannot be permitted to spill onto or near computers or system components. 
• Contact IT department immediately if malfunction of equipment is suspected. 
• Notify IT department if desktop computer equipment needs to be removed for any reason.
• Not store laptops and other peripheral equipment in very hot or cold environments for extended periods of time, such as car trunk.

If equipment is damaged during the user’s possession, and it is the determination of the IT department that damage was caused by user misuse or neglect, the user is responsible to fully reimburse Mains’l for repairs.  The human resources and finance departments are responsible to ensure payment is received.

If equipment is lost or stolen, outside of a Mains’l owned facility/leased property; employee is responsible for the replacement costs.  The human resources and finance departments are responsible to ensure payment is received.  User will receive temporary equipment until the replacement can be procured.

Network and Data Security

Information is considered an important asset of Mains’l and restrictions are imposed for controlled data access.  Mains’l considers it important to allow access to information to authorized users only, with information being accessed only by those who need it.                            

1. Access to the Network – Office and Remote Access

Access to the Mains’l network permits the user to access their e-mail, automation applications, office (word processing, spreadsheet and presentation graphics), and any specialized applications which have been configured for their use, whether they are in the office or off-site.   Pre-determined security access rights to information (user groups) have been created based on position responsibilities.  Each user has a confidential password.  Passwords are not to be shared with anyone for any reason.  Those employees assigned a Mains’l computer have the authority to allow other users access to their computer.  However, a generic account is provided for their access; this Technology and Systems Use Procedure will be reviewed by the manager before computer access is given, and a signature record is completed and placed in their personnel file by the manager.
        
Password Security Policy

All Mains’l employees who access our network file system are required to change their password for security purposes, as dictated by domain services.  Employees are required to update their password every 90 days.    

The current password requirements are:

• At least six (6) characters long
• Include a combination of letters and numbers
• May not be reused for a period of two (2) years

Employees will not write down passwords.  Employees will not share passwords with others.  If access to information is required, and access is available only through another employee’s account, permission needs to be obtained by the employee’s supervisor.  Supervisor will contact the IT department for direction and assistance in obtaining necessary information.   Password will then be reset by IT department personnel.  If passwords or security is breached, or believed to be breached (stolen equipment, hackers/viruses may have compromised security, etc.), employee will notify the IT department immediately for protection resolution.

2.     Access to the Network – Wireless

Wireless access to the Mains’l network is protected by the Wi-Fi Protected Access II (WPA2) security protocol.  Employees/authorized users are provided access to the network according to their personal access limits. Guest users are provided wireless access to the internet only.  

3.    Permissions within the Network
Upon gaining access to the network, the user’s access and ability to view, add or modify information is governed by permissions.  These permissions allow access to information which is appropriate to his or her job responsibilities and/or on a need to know basis.  Access rights are configured by the IT department.

4.    Virtual Private Network
Communication between Minnesota and satellite offices exists through firewalls configured to communicate through the internet by using secure Virtual Private Network connections (VPNs).  All VPN connections are configured by IT department personnel.

5.    Firewalls
Mains’l Services uses Watchguard firewalls as the agency’s defensive barrier to unapproved ports.   IT department personnel are the only authorized employees to configure port access.

Mains’l adapts to HIPAA data privacy requirements (see Notice of Privacy Practices for Employees, and Notice of Privacy Practices for Consumers.)   Data is stored in appropriately apportioned folders within the Mains’l network. Data for people receiving services is not stored on external disks, with the exception of media for back up purposes.  All computers owned by Mains’l are configured to auto lock when not in use/are idle after ten (10) minutes. 

All information is permanently removed by an IT department professional, before any computer equipment is removed from agency use/inventory, including laptops, desktops, fax machines, smartphones, copier/scanner/multifunction units, etc.

HIPAA Business Associate Agreements
When Mains’l requires the services of third parties ("business associates") to conduct its operations, all business associates (BA) will complete and sign standard HIPAA BA agreements, as required by HIPAA.  Agreements for any information technologies services will be attained by IT department personnel, and will be filed by director of human services.

Please refer any questions concerning the necessity for a BA agreement in a particular situation to the director of human resources, who acts as the privacy officer. 

Back Up

Data is secured with a daily back up, performed by IT department personnel, or appointed designee.   Full backups are run on a daily basis; backup tapes are maintained offsite by IT department personnel.  Monthly backups are stored off site in a secure location.  All documents created by employees are saved and stored on the Mains’l server/intranet; documents are not to be stored on individual drives, as they are not backed up.

Document Imaging

Mains’l uses Fortis document imaging software to store and archive electronic documents and information.  Electronic filing provides for faster search and retrieval of documents, reduces lost or misfiled documents, and reduces the amount of physical space needed to store hard copy documents. Stored information is maintained in accordance with state and federal government guidelines.  The federal government guidelines supersede all state requirements.

Audit controls are built within the Fortis system, with the ability to track, with date and time, those persons who have viewed or modified documents, as stated by HIPAA. Access to view, print, and modify documents are determined by user groups.  User groups are authorized by the senior leadership team, are set up by the IT department, and administered by the support services specialist.                         

Electronic Filing/Scanning Process:
1.    Management personnel, including managers, directors, and senior leadership team members, receive training within three months of employment.  
2.    Employees authorized to electronically file documents will routinely manage the records from their department and scan as required.  Each person will scan their department documents when the document(s) are no longer active documents.
3.    Employees scan documents directly into the document imaging software at the main office.  After scanning is complete, employees preview the pages to ensure all documents are scanned appropriately and are legible.
4.    Employees add indexing requirements for each document type as required by each department’s guidelines, along with any additional information in the notes field on the indexing menu.
5.    Documents have to be admissible in court, and will remain in effect as the agency’s retention schedule dictates.

Anti Virus

The agency’s computer systems contain information significant to Mains’l.  Computer viruses endanger this information.  The agency has established the procedures and policies in this document to help reduce this risk.   In addition, all networked computers have software that helps the agency reduce the risk of viruses, automatically detects and deletes viruses, and is monitored by the IT department.   

Internet

Mains’l provides internet access at the office and program site locations.  If employees wish to work at home or away from the 24-hour site locations, internet access costs are incurred by the employee.

The use of the internet to gain access to external and internal resources should be carefully managed.  Access is based on appropriate business need.  Users may only download (copy) word processing documents, electronic spreadsheets, and text files.  User may never download program files, without authorization from the IT department.  This includes free software such as screensavers, wallpapers, toolbars, free antivirus, and performance enhancing software.  All internet configurations are set up and maintained by IT department personnel. 

E-Mail

All those authorized for computer use are assigned an e-mail address by IT department personnel.   All e-mail messages are the property of Mains’l and should be used for business related purposes only.   E-mail addresses become part of a global address list.  Other users will assume they can send e-mail to all persons in the global address list; therefore, each e-mail user should check regularly, and respond to e-mails within 24 hours.
Employees have access to their e-mail accounts without accessing the file system via the www.mainsl.com web site.

Viruses infiltrate the network through e-mail attachments from e-mail addresses with whom you typically are not familiar.  Employees receiving e-mails and/or attachments they believe are suspicious should forward the message (without opening the attachment) to IT department personnel.

Employees will use caution when transmitting internal e-mail.  E-mail messages will not contain offensive material. It is prohibited to transmit any inflammatory material; material with abusive language; sexually, culturally, or racially offensive or insulting material; or obscene, vulgar, or profane material.  If unacceptable use of e-mail is confirmed on Mains’l computers, discipline, restitution, and/or termination may result.

All users are responsible for managing a regular process of deleting outdated e-mail correspondence that is no longer of value to the organization.

E-Mail Encryption

Mains’l Services uses ZixCorp services for all outbound external e-mail transmissions, which automatically encrypts private information within text documents.  For those documents containing private information within non-text documents (PDF files), typing the word SECURE (in capital letters) in the Subject line will encrypt e-mail transmission, as well. Private information includes, but is not limited to, Personal Health Information (PHI), including dates of birth, addresses, social security numbers, etc.

Voicemail

Voicemail boxes within the Mains’l telephone system are issued to personnel who require a method for others to leave messages when they are not available.  Voicemail boxes should be protected by a PIN which cannot be the same last four digits of the telephone number of the voicemail box.  Employees will routinely delete saved voicemail messages that are no longer relevant.  Once voicemail messages are deleted, they are not retrievable.

Personal Communication Devices

Mains’l is committed to providing excellent service to both employees and customers.  In order to provide 24-hour communication, personal communication devices (PCDs) are issued to managers, directors, senior leadership team members, and other personnel as identified (nurses, maintenance, navigators, etc.)  PCDs are either cellular phones or smart phones, which enable users to access the internet, including e-mail.  Employees will meet with IT department personnel to receive a PCD during the first two weeks of employment.  

PCDs are issued for Mains’l business.  Employees are responsible for exercising good judgment regarding the reasonableness of personal use. 

All employees who are issued PCDs will protect their device, using passwords, patterns, and/or biometrics, depending on the individual device.

PCD invoices payable by Mains’l are monitored by IT department personnel and authorized for payment by the executive assistant.  

Mains’l’s current MN and CA cellular plan includes unlimited voice and text messages; and 360GB of data. Overage costs include downloads (i.e., ring tones), international calls, and application subscriptions.   All cell phone overages/charges over $5.00, for non-business purposes, will be paid by the employee.  The Systems Administrator will notify the employee of any necessary payment.  The employee will complete an Employee Payroll Telephone Deduction form and submit to the payroll department.  

Mains’l’s current cell phone contract renews every two (2) years.  At this time, employees are eligible for upgrades. All employees will receive a device of their choosing up to $100.00 dollars in value.  If employees choose to upgrade past the standard replacement device, employees will be required to pay the difference.  Additionally, employees are reimbursed for a phone case (up to $20.00 dollars) and a screen protector (up to $10.00 dollars)

Any expenses incurred by employees using their personal cellular phone or PCD are required to be authorized, in advance, and approved by the employee’s management supervisor. All Expense Reimbursement Procedures will be followed.

Utilizing PCDs while driving can be a safety hazard.  Texting, surfing the internet, or answering e-mail is illegal, even at a stop light.  Drivers should use PCDs while parked or out of the vehicle.  If employees need to use PCDs while driving, Mains’l recommends the use of hands-free enabling devices.

Care of Communication Devices

If communication devices are damaged or lost during the user’s possession, the user may be required to reimburse Mains’l for replacement. If the phone/line is eligible for replacement, employees will receive a standard replacement; if the phone/line is not eligible for an update at time of incident, employee is responsible for the replacement cost. A Portable Equipment Agreement will be signed by employee before receiving a PCD.

When an employee having possession of a PCD terminates employment from Mains’l, the communication device will be returned to the employee’s supervisor.  If the employee purchased their own device, the phone number and company data are removed and the device is returned to the employee.

Bluetooth

Hands-free enabling devices, such as Bluetooth, may be issued to authorized personnel.  Caution shall be taken to avoid being recorded when connecting Bluetooth adapters; Bluetooth 2.0 Class devices have a range of 330 feet.

Enforcement

Any employee found to have violated this policy and procedure may be subject to disciplinary action, up and to including termination of employment.

Disaster Recovery Plan

Mains’l has a Disaster Recovery Plan that is updated annually, at a minimum.  The Disaster Recovery Plan is built on the foundation that preparation and precautions are created and implemented to prevent disasters to the greatest extent possible.
 

Credits cards may be issued to employees, based on their position and supervisor recommendation, and meet the following criteria:
1.    Have been employed for at least six (6) months at Mains’l or based on supervisor’s recommendation.
2.    Have demonstrated competence in managing financial systems according to policy and procedure.

Eligible employees may be required to do one or more of following:
1.    Sign the Approval Credit Rating form authorizing a personal credit rating check.
2.    Sign a Credit Card Agreement.
3.    Complete training with a credit card program administrator.

Cardholders agree to:
1.    Limit purchases to items that are necessary and reasonable within the agency and department budgets.
2.    Not use credit card(s) for personal use.
3.    Submit statement for approval within five (5) days from receipt of statement.
4.    Notify the credit card program administrator immediately if the card is lost or stolen.

Statements for credit cards are mailed/emailed monthly to the cardholder for processing.
Card holders are required to code and submit statements for payment.
1.    Statement Coding: 

•  Accurately code purchases to the appropriate department and account number. 
• Attach proper receipts, for each item purchased, in the order they appear on the credit card statement
  • For paper statements paperclip (do not staple) statement with corresponding receipts/invoices to be submitted.
• Ensure that the total amount coded matches the total credit card statement balance.
• Any purchases larger than $2,500 will be considered as a capitalization.  See Mains’l’s Capitalization Policy.

2.    Statement Submission:

• Submit statement and corresponding receipts/invoices for review and approval by your supervisor within five (5) days. 
• The cardholder’s supervisor is required to approve the statement for payment within five (5) days of cardholder submission.
• Paper statements are due to accounts payable within 10 days from date received with proper coding and approval.

3.    Termination of corporate credit cards:

• Mains’l maintains the right to revoke corporate credit cards at any time.
• When an employee holding a corporate credit card terminates employment from Mains’l, the card is returned to the supervisor.
• The supervisor is responsible for notifying credit card program administrator of any terminated employment.
   

Procedure
When an item is capitalized, it shall be added to the FAS and depreciated over the expected useful life per the table in this policy.  Personnel must maintain the equipment and keep it in good working order.
 

1.    Payment processing requirements:

• Payments are made for approved invoices that are submitted to Accounts payable. The cutoff time to submit approved invoices/payment requests is 12 p.m. on Wednesday of each week.  
• Vendor payment checks/direct deposits are processed on Friday of each week.  
• Vendor payments that are not received by the weekly cutoff are paid the following week unless a priority or exception can be justified.  
• A vendor direct deposit authorization form must be completed if a vendor needs direct deposit
• A voided check or a note from the bank  with routing and account number must be submitted with the direct deposit authorization form
• Accounts Payable determines if a check is required for emergency or priority items.
• Submit invoices/payments within five (5) business days of receipt.

2.    Preparing payments/invoices:

• Invoices or payment requests should be reviewed and prepared prior to submitting them to AP.
  • Review invoices for accuracy.
  • Use an authorized vendor stamp on the invoice without covering invoice details.
  • Complete the authorized vendor stamp information. 
  • Sign or obtain proper approvals/signatures.
  • Payment requests over $100 require approval from the employee supervisor.

b.    If an invoice doesn’t exists and a payment is required:

• Complete a Payment Request Form.
• Attach any supporting documentation.
• iSign or obtain proper approvals/signatures.
• Payment requests over $100 require approval from the employee supervisor.

3.    Recurring payables: 

• Recurring payables are payments made to the same person(s)/payee(s), for the same amount, with a consistent due date.  Typical types of recurring payables are rent, leases, and contract payments. 
  • If an approved payment meets the recurring criteria, you may submit a recurring payment request to AP with the department supervisor’s approval.
  • Once approved by the supervisor, signatures are not needed for the recurring payment to be processed.
  • If the recurring payment amount stops or changes the supervisor should contact AP to stop or make appropriate changes.

A representative payee can be appointed by the Social Security Administration to receive the Social Security or SSI benefits for a person who can’t manage or direct the management of his or her benefits.  Mains’l does not charge a monthly fee from Social Security benefits and/or Supplemental Security Income (SSI) benefits, but charges may apply depending on the business relationship between Mains’l and the person requesting representative payee services. 

• When the person requesting representative payee services also receives participant directed services, Mains’l charges and receives a monthly fee through the person’s Medicaid waiver. 
• When the person requesting representative payee services also receives traditional waiver services and is requesting the service in order to ensure payment to Mains’l for other services, representative payee services are provided at no charge. 

A representative payee’s main duties are to use the benefits to pay for the current and future needs of the beneficiary, and properly save any benefits not needed to meet current needs. A payee must also keep records of expenses. 

Establishing Mains’l as a Representative Payee

The following steps are to be followed to establish Mains’l as Representative Payee:

1. The person requesting representative payee services informs their manager and provides the person or representative with the contact information of the person designated at Mains’l to be representative payee. 
2. The manager contacts the person designated to be representative payee at Mains’l to inform him or her that a request to perform representative payee services has been made.
3. The representative payee, after being contacted by the person or their representative, plans a meeting. 
4.  A meeting is held to determine if the person would like to choose Mains’l as rep payee. If so, next steps are identified to determine when and how paperwork will be completed.
5. After paperwork is completed, Mains’l begins performing representative payee services. 

Fulfilling Representative Payee Responsibilitie

1. Required Duties: The person assigned at Mains’l as a representative payee works with the person receiving services and their support team to ensure his or her day to day needs are being met by performing the following duties:
   • Determine the beneficiary’s needs and use his or her payments to meet those needs;
   • Save any money left after meeting the beneficiary’s current needs in an interest bearing account or savings bonds for the beneficiary's future needs;
   • Report any changes or events which could affect the beneficiary’s eligibility for benefits or payment;
   • Keep records of all payments received and how the money was spent and saved;
   •  Provide benefit information to social service agencies or medical facilities that serve the beneficiary;
   • Report to the Social Security Administration  any changes that would affect our performance or our ability to continuing as payee;
   • Complete written reports accounting for the use of funds; and
   • Return to the Social Security Administration any payments to which the beneficiary is not entitled.
   • Mains’l completes the annual Representative Payee reports from Social Security for each person we provide rep payee services for, as requested by Social Security.  
2. Monthly Process
   • Mains’l collects the social security benefits each month and deposits the funds into each person’s rep payee account in QuickBooks.  
   • By the 5th of each month, the rep payee checks the account balance of each person they are payee for to ensure there are enough funds in the person’s account to process payments for the month.
     •  Payee pays bills for each person, as needed before the due dates. 
     • Payee issues a personal needs check by the 5th of each month

All utility accounts managed and payable by Mains’l will be set up by the senior manager or manager.  All invoices will be mailed either to the main office or to the individual program site.  Each invoice should reference the address where service is provided.  

1.    Utilities included, but not limited to, are:

• Basic cable services
• Electric utilities
• Gas utilities
• Water and sewer
• Lawn and snow removal
• Garbage disposal
• Telephone service
•  Maintenance

2.    Invoices mailed to the main office will be distributed, by the receptionist, to the appropriate manager’s mailbox.

3.    The manager will code the invoices for payment, using an authorized vendor stamp.

• Invoices are to be submitted to Accounts Payable within five (5) business days following the receipt of invoices.

4.    All invoices for people receiving services will be set up to be mailed to that person’s home.  Those include but are not limited to:

• Medical supplies
• Health club memberships
• Magazine subscriptions
• Personal phone services
• Cable services that are beyond the basic cable services

5.    Managers will ensure that the person receiving services pays for invoices for their personal services.

6.    Managers and/or senior managers are the only authorized persons to set up vendor accounts on behalf of Mains’l.

7.    Payment requests over $100.00 will be approved by the senior manager and/or manager.

8.    Grocery Accounts

• Grocery charge accounts will be managed by the manager
  •  A grocery report will be completed each month and signed by the manager
  • Summarize the purchases
  • Code the purchases to the appropriate account
  • Submit the signed and completed report to Accounts Payable by the fifth (5th) business day of each month.

9.    The manager shall notify Accounts Payable of changes to authorized personnel who can use charge accounts.

10.    No gift cards shall be purchased on grocery charge accounts. 

11.    Any purchases larger than $2,500 will be considered as a capitalization.  See Mains’l’s Capitalization Policy.
 

Mains’l Services will oversee the completion and filing of the following forms necessary to receive support for Room and Board services and collection of Room and Board Payments:

• CAF(Combined Application Form)

The CAF form will be filled out by the manager with assistance from guardian and/or case manager upon enrollment and is submitted to the county by the manager.  If the county representative requests to complete the CAF they will sign and date the R&B worksheet as the responsible party for these filings. This form must be completed in the month the person is admitted.  The county will then notify the person, rep payee and/or Mains’l Services the amount of GRH that will be paid for this person.

• Shelter Verification Form

The Shelter Verification form will be filled out by the manager and/or case manager at intake and submitted to the financial worker. If the case manager requests to complete the Shelter Verification Form (SVF) they will sign and date the R&B worksheet as the responsible party for these filings. This form will determine GRH eligibility

• Room and Board Worksheet and Financial Agreement

The Room and Board Worksheet and Financial Agreement is completed at intake by the manager and guardian/case manager and is put in the person’s file on the “M” drive. 
This form is to acknowledge the financial responsibility as representative payee of the person’s funds. 

Collection of Room and Board Charges

Payments received by Social Security and GRH are received monthly and applied to the monthly Room and Board invoice.

1. On the 10th of each month a reminder will be sent to each manager via email to let them know Room and Board payments are due for the people they support.  This reminder is for CRS (Community Residential Services) residents who receive their own Social Security and those who pay cost of care toward their Room and Board.  The manager will initiate payment to Mains’l Services out of the person’s funds and deliver payment to the Finance Department.  Payments are made within 5 days of person’s social security being received.
2. By mid-month the Finance Department will send out statements to anyone with outstanding balances which are the responsibility of the person to reimburse Mains’l Services.
3. By month-end the Finance Department will send out the Room & Board aging report after review from the Finance Department.  
4. After 90 days of past due balances, a letter will be sent out by the Finance Department to the guardians and representative payee with copies to the manager, senior manager and director of services as needed, that the account is past due and unless paid immediately further actions may be taken.
5. If payment is not received after the past due letter notification, the manager, senior manager and director of services as needed, will meet and all documentation will be reviewed to develop a plan of action for the person

Room and Board Training

All managers are required to complete Accounts Receivable training with Finance within six months of hire.
 

In the course of your time with Mains’l and in your personal life, you will be performing behavior interventions and people will be performing them on you. The procedures below provide definitions and examples of what we can’t do, what we can do and what we should do when it comes to intervening in someone else’s behavior. Let’s start with the bad and end with the good. 

The things we cannot do (also known as prohibited procedures)
The following are not allowed as a replacement for proper supervision or staffing, to reduce or stop a behavior, as punishment, or for staff convenience:

Chemical restraints Mechanical restraints Manual restraints Time out Seclusion Any other aversive or deprivation procedure In summary, we do not do these things.  Not only do they make people unhappy, they generally do not work well to help people appropriately get their wants and needs met. Prohibited procedures may stop a behavior, but they do not teach a person what to do differently the next time. Prohibited procedures may also make a behavior worse. In addition, prohibited procedures can result in mental or physical injuries.  We have better options for you, so please keep reading. We will cover the things you can’t do first and end with the good stuff, positive supports.  Here are the simplified and technical definitions of prohibited procedures along with some and examples.  1.    Chemical restraint: A chemical restraint is giving someone a drug or medication that has not been prescribed by their doctor to treat the behavior you are trying to avoid.    An example of chemical restraint is giving a person Xanax when they start yelling so they don’t become physically aggressive but Xanax is prescribed for the person to take when they have panic attacks. If Xanax is given for physical aggression and not a panic attack, this would be a chemical restraint.  Technical definition: The administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s medical or psychological condition.  2.    Mechanical restraint: A mechanical restraint is using an object to limit or stop a person from freely moving a part of their body or have access to a part of their body An example of a mechanical restraint is taping gloves onto a person’s hands so they cannot scratch themselves, but they would not choose to wear the gloves on their own.  Mechanical restraint does not include the following:  (1) devices worn by the person that trigger electronic alarms to warn staff that a person is leaving a room or area, which do not, in and of themselves, restrict freedom of movement; or (2) the use of adaptive aids or equipment or orthotic devices ordered by a health care professional used to treat or manage a medical condition. Technical definition: The use of devices, materials or equipment attached or adjacent to the person’s body, or the use of practices that are intended to restrict freedom of movement or normal access to one’s body, to prevent injury with a person who engages in self-injurious behaviors, such as head-banging, gouging, or other actions resulting in tissue damage that have or could cause medical problems resulting from the self-injury. Mechanical restraint also includes the use of practices that are intended to restrict freedom of movement or normal access to one’s body or body parts, or limits a person’s voluntary movement or holds a person immobile as an intervention precipitated by a person’s behavior.  3.    Manual restraint: A manual restraint is using your body to limit another person’s ability to move their own body. An example of a manual restraint is pinning someone to the ground to stop them from going somewhere.  Technical definition: Physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint.  4.    Seclusion: Basically, seclusion is making a person go somewhere or leave somewhere against their wishes and then not allowing them to leave.  An example of seclusion is forcing a person to be separated because they were pinching the staff by putting them in a locked room while attending a birthday party.  Technical definition: Removing a person involuntarily to a room from which exit is prohibited by a staff person or a mechanism such as a lock, a device, or an object positioned to hold the door closed or otherwise prevent the person from leaving the room; or otherwise involuntarily separating a person from an area, activity, situation, or social contact with others and blocking or preventing the person’s return.  5.    Time out: A time out is making someone go to an area and it is experienced as a negative consequence. It differs from seclusion in that the person is not stopped from leaving the area they were sent to, but it is still not allowable for a staff to tell a person receiving services that a consequence of their behavior/actions is that they have to go to a designated area.  Time out does not mean voluntary removal or self-removal for the purpose of calming, prevention of escalation, or de-escalation of behavior; nor does it mean taking a brief break or rest from an activity for the purpose of providing the person an opportunity to regain self-control. An example of a time out is sending a person to their bedroom after an argument, when they do not want to go. Another example is requiring someone to sit on a chair for a specified amount of time, but not physically forcing them to stay in the chair.  Asking someone to ‘take a break’ to ‘cool down’, but not requiring them to do so, is not considered a time out.  Technical definition: The involuntary removal of a person for a period of time to a designated area from which the person is not prevented from leaving.  6.    Any other aversive or deprivation procedure: Aversive procedure: An aversive procedure is doing or saying something during or right after a behavior that will cause a strong feeling of stress, anxiety, dislike or disgust in order to get the person to stop or reduce the behavior.   An example of an aversive procedure is to wash someone’s mouth out with soap if they swear in the hope that they will not swear again.  Technical definition: The application of an aversive stimulus based upon the occurrence of a behavior for the purposes of reducing or eliminating the behavior. Aversive stimulus: Typically, an aversive stimulus is an unpleasant thing that punishes or limits a person. The thing that is used to try to stop the behavior is the aversive stimulus. The thing or situation itself does not have to be aversive on its own. It can be how it is used that it becomes aversive to the person.  Examples of aversive stimulus are heat, cold, noise, a food or an event that is unwanted or unpleasant that is presented to stop someone or suppress a behavior.    Technical definition: An object, event, or situation that is presented immediately following a behavior in an attempt to suppress the behavior.   Deprivation procedure: A deprivation procedure involves taking away or not allowing someone to have something or do something they like, want, or need in order to get the person to stop or reduce the behavior. An example of a deprivation procedure is to take away someone’s dinner because they hit someone or not allow the person to go to the dance because they hit themselves.  Technical definition: The removal of a positive reinforcer following a response resulting in, or intended to result in, a decrease in the frequency, duration, or intensity of that response.  Often times the positive reinforcer available is goods, services, or activities to which the person is normally entitled. The removal is often in the form of a delay or postponement of the positive reinforcer. The things we can only do in certain circumstances (also known as restricted procedures) A restricted procedure is something that should not normally be done, but may be allowed in very specific circumstances if it is done properly and for acceptable reasons. Some restricted procedures include: 1.    Procedures identified in a positive support transition plan  A positive support transition plan is developed by the person’s expanded support team to implement positive  support strategies to:  Eliminate the use of prohibited procedures  Avoid the emergency use of manual restraint and  Prevent the person from physically harming self or others Phase out any existing plans for the emergency or programmatic use of restrictive interventions that are prohibited.  Employees working with a person who has a positive support transition plan receive training before working unsupervised. In Minnesota, Mains’l develops a positive support transition plan on the forms and in the manner prescribed by the commissioner of DHS for a person who requires intervention in order to maintain safety when it is known that the person’s behavior poses an immediate risk of physical harm to self or others.  The positive support transition plan forms and instructions will supersede the requirements in Minnesota Rules, parts 9525.2750; 9525.2760; and 9525.2780.   2.    Emergency Use of a Manual Restraint:  Emergency physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint. This means using a part of your body, such as your arms, hands, legs, or your entire body to stop the movement of another person.  An example of an emergency use of a manual restraint is to use a wrist side hug procedure to move a person away from someone they are trying to assault.   A restricted procedure (one approved in a positive support transition plan or an emergency use of a manual restraint) cannot: 1.    Be implemented with a person in a manner that is sexual abuse, neglect, physical abuse, or mental injury. 2.    Be implemented in a manner that violates a person's rights. 3.    Restrict a person's normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, necessary clothing, or any protection required by state licensing standards or federal regulations governing the program; 4.    Deny the person visitation or ordinary contact with legal counsel, a legal representative, or next of kin; 5.    Be used for the convenience of staff, as punishment, as a substitute for adequate staffing, or as a consequence if the person refuses to participate in the treatment or services provided by the program; 6.    Use prone restraint, which means the use of manual restraint that places a person in a face-down position. Prone restraint does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, if the person is restored to a standing, sitting, or side-lying position as quickly as possible; 7.    Apply back or chest pressure while a person is in a prone position; 8.    Be implemented in a manner that should not be used (contraindicated) for any of the person's known medical or psychological limitations; 9.    Be implemented by a staff that has not completed training on the proper techniques to do an emergency manual restraint.  The things that we can do (also known as permitted actions and procedures) While these are not the first choice, or what we want to regularly have happen, the following can be used on an intermittent basis. Additionally, if addressed in a person service and support plan, these things can be done on a continuous basis. The reason for continuous use is to be included.  1.    Physical contact or instructional techniques must use the least restrictive alternative possible to meet the needs of the person and may be used: To calm or comfort a person by holding that person when they show no resistance to being held. To protect a person known to be at risk of injury due to frequent falls as a result of a medical condition;  To facilitate the person's completion of a task or response when the person does not resist or the person's resistance is minimal in intensity and duration; To block or redirect a person's limbs or body without holding the person or limiting the person's movement to interrupt the person's behavior that may result in injury to self or others with less than 60 seconds of physical contact by staff; or To redirect a person's behavior when the behavior does not pose a serious threat to the person or others and the behavior is effectively redirected with less than 60 seconds of physical contact by staff. 2.    Restraint may be used as an intervention procedure to: To position a person with a physical disability in a manner specified in the person’s service and support plan.  Assist in the safe evacuation or redirection of a person in the event of an emergency and the person is at imminent risk of harm.   Allow a licensed health care professional to safely conduct a medical examination or to provide medical treatment ordered by a licensed health care professional that is necessary to promote healing or recovery from an acute, meaning short-term, medical condition. 3.    Use of adaptive aids or equipment, orthotic devices, or other medical equipment ordered by a licensed health professional to treat a diagnosed medical condition do not in and of themselves constitute the use of mechanical restraint. The things that you should do (positive supports) Positive approaches should be used first and be the most commonly used approached to intervening in another person’s behavior. Positive support approaches include: Showing is often more effective then telling. Act the way you want them to act. Take the time to understand what the person is trying to  communicate with an inappropriate behavior and then teach                   appropriate behavior so they can get what they want or need.     Follow the guidance in the person’s Services and Support Plan,  their Person Centered Plan and if they have one, their Behavior Plan.  Shift a person’s focus by talking with them about a different activity or topic.  Reinforce appropriate behavior. When someone does the right thing, point it out! Offer choices, based on the person’s preferences, including activities that are relaxing  and enjoyable to the person. Give regular and specific positive feedback. Listen carefully to what the person is telling you and  validate their feelings; Create a calm environment by reducing sound, lights, and other factors that may bother a person. Speak calmly with reassuring words; consider volume, tone, and non-verbal communication. Simplify a task or routine or discontinue until the person is calm and agrees to participate. Respect the person’s need for privacy or physical space. By using positive support approaches, we show respect and honor the dignity of people. We are also more likely to see decreases in the behaviors we don’t want to see and increases in the behaviors we do want to see.   Responding to a challenging behavior When a person begins to engage in escalating disruptive behavior and it becomes obvious that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of self or others if not redirected, implement the following steps: 1.    If appropriate or possible, remove all people, whose safety is threatened, from the immediate area of the threatening person. 2.    Attempt de-escalation techniques.  De-escalation techniques include restructuring the environment (noise, crowding, proximity), maintaining calm posture and body language, re-direction, positive verbal praise, active listening, and/or prompting (verbal and gestural). 3.    If applicable, review the use of the person’s PRN (as needed) medication to address target mental health symptoms. 4.    If the person’s behavior continues to be disruptive, ask the person to remove themselves from the ongoing activity to a location where they cannot observe the ongoing activity – this is a voluntary time out. 5.    Follow through with the encouragement of the person’s absence from the ongoing activity with verbal prompts. Do not use physical intervention! 6.    Monitor the person’s behaviors while they choose to be in a voluntary time out.  7.    When the person stops the disruptive or threatening behavior, ask them if they want to return to normal activities. 8.    If immediate intervention is needed to protect the person or others from physical injury or to prevent severe property damage that is an immediate threat to the physical safety of the individual or others, call 911.     9.    If a behavior intervention that includes the police, PRN medication to stop a behavior, or , the staff who implemented the intervention:  •    Notifies their manager immediately; •    Calls the on-call administrative personnel to report the incident as well as the on-call nurse (if they have one) if there is an injury; •    Completes the Behavior Intervention Reporting Form (BIRF), and submits it to the manager before they leave work; •    If a PRN medication is given for target behaviors rather than mental health symptoms, staff completes the BIRF. 10.    If 911 was called, the staff responsible at the time of the incident: •    Completes an incident report and the BIRF. •    Calls the on-call administrative personnel to report the incident; •    Notifies the manager who notifies the case manager and the legal representative of the incident within 24 hours. The procedures listed above are not used to respond to challenging behavior with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated for a person. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning process. Staff Training a. Before having unsupervised direct contact with a person receiving service and annually thereafter, all employees who provide direct support receive instruction on prohibited procedures that address the following: 1.    what constitutes the use of restraint, time out, seclusion, and chemical restraint;  2.    staff responsibilities related to ensuring prohibited procedures are not used;  3.    why such prohibited procedures are not effective for reducing or eliminating symptoms or undesired behavior;  4.    why prohibited procedures are not safe  b. For the limited situations where the emergency use of a manual restraint may be allowed, before those staff may implement manual restraints on an emergency basis they must also be trained on the following within 60 days of hire: alternatives to manual restraint procedures, including techniques to identify events and environmental factors that may escalate conduct that poses an imminent risk of physical harm to self or others;  de-escalation methods, positive support strategies, and how to avoid power struggles; simulated experiences of administering and receiving manual restraint procedures allowed by the program on an emergency basis; how to properly identify thresholds for implementing and ceasing restrictive procedures; how to recognize, monitor, and respond to the person’s physical signs of distress, including positional asphyxia; the physiological and psychological impact on the person and the staff when restrictive procedures are used; the communicative intent of behaviors; and relationship building. the safe and correct use of manual restraint on an emergency basis

NEW CLIENT Clinicians add new client’s information into Therapy Notes and will send an email to Accounts Receivable (AR) department to check eligibility. The AR department emails clinician back with eligibility information. Once it is determined that the client is eligible to be seen; the clinician schedules an appointment with the client. The clinician will enter session information into Therapy Notes to be sent in for payment. 

CO-PAYS 

Clinician verifies in the client profile for co-pay in Therapy Notes. If applicable the Clinician asks the client to pay the co-pay at the beginning of the session.  Clinician collects the co-pay and provides a written receipt to the client.  If client is unable to pay at the time of service a statement will be generated within 30 days and sent to their address on file. Mains’l only accepts checks or money order.

CLAIM SUBMITTION 
Clinician enters in all private insurance information required for billing by Therapy Notes. Therapy Notes notifies AR on the billing screen that there are entries for payment submission. AR electronically sends claims through Therapy Notes.

 
REMITTANCE ADVICE
Once the 835 form is electronically submitted into Therapy Notes from the clearinghouse AR applies all payments to the client’s claims.  As payments are received and posted in Therapy Notes the AR department will add the date of payment, the amount of payment and payer into the spreadsheet located on the T drive/month end/Mental Health Payments for the general ledger account. A report is printed out for exceptions that the system is unsure of how to handle the reconciliation. The AR manager will research and resolve those exceptions.     
For clients using Medical Assistance (MA) once the state receives the files and processes the claims that were submitted for payment the State of MN DHS will create an 835 file to be downloaded and the remittance advice to coincide with the information in the 835 file.  AR will download the 835 file and print off the remittance advice to reconcile the payments.
If claim is denied for any reason AR corrects and/or investigates the denial reason and follows up, as necessary, with clinician. AR resubmits 835 form with correction to third party payer.   

REVIEWAL OF EXPENSE/REVENUE
At month end, the Finance Coordinator reviews the general ledger to ensure accuracy of proper revenue and expense recognition.
AR and Chief Financial Officer will review the aging monthly to review and research any and all outstanding billings that may have been denied.

SYSTEM UPDATES
System updates are performed regularly to be in compliance with any changes to the procedures, tasks, or responsibilities of Mains’l Services in billing.
 

Clinical employees and/or clinical trainees follow mandated reporting requirements according to their governing licensing board. Suspected maltreatment must be reported within 24 hours of confirmed suspicion by the clinical employee or clinical trainee. 
To report:

1. For Adults: Call 1-844-880-1574   or go to: mn.gov/dhs/reportadultabuse/ to report
2. For Children: Contact law enforcement or locate the local child welfare agency phone number by going to: http://mn.gov/dhs/people-we-serve/children-and-families/services/child-p... or for a child living in foster care call 651-431-6600

• Once a report has been made to the appropriate reporting agency the clinical employee and/or clinical trainee documents the report in the progress note section of Therapy Notes.    
• Clinical trainees will seek clinical supervision from their clinical supervisor to review the report and request feedback on what are the appropriate next steps. 

For clients who receive multiple services from Mains’l for example; Community Residential Services (CRS) and Psychotherapy the clinical employee and/or clinical trainee follows both the reporting requirements according to their governing licensing board and Mains’l’ s policy and procedure on Responding to and Reporting Maltreatment in Minnesota. This may result in one or two reports being made on the same incident due to potentially different reporting guidelines.
 

The criteria for determining whether a disclosure of information is warranted should be based on the following guidelines:

1. There is a clear risk to an identifiable person or group of persons
2. There is a clear risk of serious bodily harm or death and
3. The danger is imminent

Once it is determined disclosure of information is warranted, follow the procedures below for the identified harm.

Suicidal Clients
Whenever possible, Mains’l clinical employees will obtain the client’s voluntary agreement to seek medical assistance.

When a client is not willing to seek assistance, Mains’l employees have a duty to disclose a client’s active suicidal ideation and/or plan to commit suicide. The employee’s disclosure may include, without being limited to:

1. Notifying a family member, a physician or other appropriate person who can ensure the safety of the client
2. Contacting the police or a mental health crisis team with a request to escort the person to a hospital for a psychiatric examination (i.e., a voluntary or involuntary assessment).
3. Mains’l clinical employees report, as soon as possible, the suicidal intent to the behavioral and mental health senior manager and vice president of administration. 

Clients who present a clear risk of violence or harm to others

Mains’l clinical employees have a duty to warn the intended potential victims of threatened violence. 

1. Mains’l clinical employees report, as soon as possible, the threat to the identifiable person or group of persons.
2. The threat gets reported to the police when the intended victim(s) cannot be reached or in situations of immediate danger. 
3. The police will determine the most appropriate next steps, including whether there are grounds to detain the client for an involuntary assessment. 
4. Mains’l clinical employees report, as soon as possible, the threat to the behavioral and mental health senior manager and vice president of administration. 

Assaultive Partners
Persons who are assaultive may be seen on a voluntary basis. Mains’l remains obligated to initiate contact with the partner (or others threatened) where there is a risk of imminent harm to the partner. 

In all situations, Mains’l clinical employees document the situation, including 

• Their assessment of the risk of harm or death, 
• The information on which their assessment is based 
• Any actions taken, in the client file in Therapy Notes software system.
   

Referrals
Mains’l engages in conversations with the person requesting services.  We are committed to a collaborative approach when developing therapeutic supports for people.  

When a person contacts Mains’l about our services:

1. We gather basic information about the person, including therapeutic need/ presenting concern, funding type, personal information, availability, preferred characteristics and/or qualifications of therapeutic professionals.  
2. If during the conversation(s) it is determined Mains’l is a good fit for the person information sharing continues. The information gathered is used to assist with the development of the person’s therapeutic supports. Mains’l may ask for the following, as applicable/available:

• Person Centered Plan (Picture of a Life, MAP, Essential Lifestyle Plan, etc.)
• Support/program plan (i.e., Treatment Plan, Coordinated Service and Support Plan or Individual Program Plan)
• Personal Safety Plan (Individual Abuse Prevention Plan, Support/Program Plan)
• Individualized Education Program Plan – completed by school professional
• Medical and health care related information and/or assessments (psychological and/or psychiatric evaluation, diagnostic assessment, behavior assessment, physical therapy, dental, occupational therapy, audiology, etc.)
• Positive Support Transition Plan

1. If it is determined that the person and Mains’l are not a good fit and we are not going to provide services, the  therapeutic specialist will communicate the reason, give 3 possible sources for service and upon request provide written documentation of  the reason to the person, the person’s legal representative, and case manager. 
2.  When the person requesting services and Mains’l agree that we are a good match, 

a.    For waiver funded mental or behavioral supports the therapeutic specialist negotiates the service agreement with the case manager.  Upon receiving the service agreement, (or authorization that the agreement is in process), the therapeutic specialist begins developing services.

• For private health insurance funded mental or behavioral the therapeutic specialist provides the insurance information to the billing department to verify eligibility and check if for preauthorization of services is required. 

Enrollment for people using waiver funds 
When the person requesting services and Mains’l agree that we are a good match, the process of starting services begins. This procedure may vary, depending on the supports and needs of each person.

1. An enrollment meeting is scheduled by the therapeutic specialist, the person and/or their support team.  Meetings are held at a place agreed upon by the person and their circle of support. 

2. At the meeting, 

•  If a Person Centered Plan has not been created by/for the person, the team addresses who will be responsible to develop the plan, as appropriate.
•  All documents listed on the Enrollment Checklist will be reviewed and/or signed by the person and/or their guardian. 
• The therapeutic specialist offers a Mains’l Guidebook to Supports. The handbook includes policies and procedures on how we offer services. 
• A date when services will actually begin will be determined by the person and the support team
• The therapeutic specialist completes a Starting /Change of Service form to notify other Mains’l departments when services are starting.
• 3. The therapeutic specialist begins the process of developing a functional behavioral assessment, behavioral support plan and/or other assessments, as requested per referral. The requested document begins development as soon as possible (best practice 15 days but no later than 30 days after the initial starting services meeting) and is completed in the time frame agreed per team agreement (best practice no later than 150 calendar days from starting services date).

Enrollment for people using private health insurance 
When the person requesting services and Mains’l agree that we are a good match, the process of starting services begins.
An enrollment appointment is scheduled by the therapist. This appointment may include family members, care givers, significant others and/or legal representative.  

1.    At the enrollment appointment, 

• All documents listed on the Enrollment Checklist- private insurance will be reviewed and/or signed by the person and/or their guardian. 
• The therapist and person begin to develop the therapeutic relationship and treatment goals.  

2.    The therapist enters the person’s personal information into Therapy Notes and notifies the billing department when services are starting, when applicable. 

3.    The therapist begins the diagnostic assessment and/or treatment plan. These documents are developed within the first 2-4 meetings as appropriate to meet complexity of interrelated concerns and cultural needs.
 

In the course of your time with Mains’l and in your personal life, you will be performing behavior interventions and people will be performing them on you. The procedures below provide definitions and examples of what we can’t do, what we can do, and what we should do when it comes to intervening in someone else’s behavior. Let’s start with the bad and end with the good.

The things we cannot do (also known as prohibited procedures)

The following are not allowed as a replacement for proper supervision or staffing, to reduce or stop a behavior, as punishment, or for staff convenience:

Chemical restraints Mechanical restraints Manual restraints Time out Seclusion Any other aversive or deprivation procedure

In summary, we do not do these things.  Not only do they make people unhappy, they generally do not work well to help people appropriately get their wants and needs met. Prohibited procedures may stop a behavior, but they do not teach a person what to do differently the next time. Prohibited procedures may also make a behavior worse. In addition, prohibited procedures can result in mental or physical injuries.

We have better options for you, so please keep reading. We will cover the things you can’t do first and end with the good stuff, positive supports.

Here are the simplified and technical definitions of prohibited procedures along with some and examples.

1. Chemical restraint:
   

   A chemical restraint is giving someone a drug or medication that has not been prescribed by their doctor to treat the behavior you are trying to avoid.  

   An example of chemical restraint is giving a person Xanax when they start yelling so they don’t become physically aggressive but Xanax is prescribed for the person to take when they have panic attacks. If Xanax is given for physical aggression and not a panic attack, this would be a chemical restraint.

   Technical definition: The administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s medical or psychological condition.

2. Mechanical restraint:

   A mechanical restraint is using an object to limit or stop a person from freely moving a part of their body or have access to a part of their body

   An example of a mechanical restraint is taping gloves onto a person’s hands so they cannot scratch themselves, but they would not choose to wear the gloves on their own.

   Mechanical restraint does not include the following:  (1) devices worn by the person that trigger electronic alarms to warn staff that a person is leaving a room or area, which do not, in and of themselves, restrict freedom of movement; or (2) the use of adaptive aids or equipment or orthotic devices ordered by a health care professional used to treat or manage a medical condition.

   Technical definition: The use of devices, materials or equipment attached or adjacent to the person’s body, or the use of practices that are intended to restrict freedom of movement or normal access to one’s body, to prevent injury with a person who engages in self-injurious behaviors, such as head-banging, gouging, or other actions resulting in tissue damage that have or could cause medical problems resulting from the self-injury. Mechanical restraint also includes the use of practices that are intended to restrict freedom of movement or normal access to one’s body or body parts, or limits a person’s voluntary movement or holds a person immobile as an intervention precipitated by a person’s behavior.  

3. Manual restraint:
   

   A manual restraint is using your body to limit another person’s ability to move their own body.

   An example of a manual restraint is pinning someone to the ground to stop them from going somewhere.

   Technical definition: Physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint.

4. Seclusion:
   

   Basically, seclusion is making a person go somewhere or leave somewhere against their wishes and then not allowing them to leave.

   An example of seclusion is forcing a person to be separated because they were pinching the staff by putting them in a locked room while attending a birthday party.

   Technical definition: Removing a person involuntarily to a room from which exit is prohibited by a staff person or a mechanism such as a lock, a device, or an object positioned to hold the door closed or otherwise prevent the person from leaving the room; or otherwise involuntarily separating a person from an area, activity, situation, or social contact with others and blocking or preventing the person’s return.

5. Time out:

   A time out is making someone go to an area and it is experienced as a negative consequence. It differs from seclusion in that the person is not stopped from leaving the area they were sent to, but it is still not allowable for a staff to tell a person receiving services that a consequence of their behavior/actions is that they have to go to a designated area.

   Time out does not mean voluntary removal or self-removal for the purpose of calming, prevention of escalation, or de-escalation of behavior; nor does it mean taking a brief break or rest from an activity for the purpose of providing the person an opportunity to regain self-control.

   An example of a time out is sending a person to their bedroom after an argument, when they do not want to go. Another example is requiring someone to sit on a chair for a specified amount of time, but not physically forcing them to stay in the chair.

   Asking someone to ‘take a break’ to ‘cool down’, but not requiring them to do so, is not considered a time out. 

   Technical definition: The involuntary removal of a person for a period of time to a designated area from which the person is not prevented from leaving.  

6. Any other aversive or deprivation procedure:  

• Aversive procedure: An aversive procedure is doing or saying something during or right after a behavior that will cause a strong feeling of stress, anxiety, dislike or disgust in order to get the person to stop or reduce the behavior.
  

  An example of an aversive procedure is to wash someone’s mouth out with soap if they swear in the hope that they will not swear again.

  Technical definition: The application of an aversive stimulus based upon the occurrence of a behavior for the purposes of reducing or eliminating the behavior. 

• Aversive stimulus: Typically, an aversive stimulus is an unpleasant thing that punishes or limits a person. The thing that is used to try to stop the behavior is the aversive stimulus. The thing or situation itself does not have to be aversive on its own. It can be how it is used that it becomes aversive to the person.
  

  Examples of aversive stimulus are heat, cold, noise, a food or an event that is unwanted or unpleasant that is presented to stop someone or suppress a behavior.  

  Technical definition: An object, event, or situation that is presented immediately following a behavior in an attempt to suppress the behavior. 

• Deprivation procedure: A deprivation procedure involves taking away or not allowing someone to have something or do something they like, want, or need in order to get the person to stop or reduce the behavior.

• An example of a deprivation procedure is to take away someone’s dinner because they hit someone or not allow the person to go to the dance because they hit themselves.

• Technical definition: The removal of a positive reinforcer following a response resulting in, or intended to result in, a decrease in the frequency, duration, or intensity of that response.  Often times the positive reinforcer available is goods, services, or activities to which the person is normally entitled. The removal is often in the form of a delay or postponement of the positive reinforcer.

The things we can only do in certain circumstance ( also known as restricted procedures)

A restricted procedure is something that should not normally be done, but may be allowed in very specific circumstances if it is done properly and for acceptable reasons. Some restricted procedures include:

1. Procedures identified in a positive support transition plan A positive support transition plan is developed by the person’s expanded support team to implement positive support strategies to:

• Eliminate the use of prohibited procedures

• Avoid the emergency use of manual restraint and

• Prevent the person from physically harming self or others 

• Phase out any existing plans for the emergency or programmatic use of restrictive interventions that are prohibited.

Employees working with a person who has a positive support transition plan receive training before working unsupervised. In Minnesota, Mains’l develops a positive support transition plan on the forms and in the manner prescribed by the commissioner of DHS for a person who requires intervention in order to maintain safety when it is known that the person’s behavior poses an immediate risk of physical harm to self or others.  The positive support transition plan forms and instructions will supersede the requirements in Minnesota Rules, parts 9525.2750; 9525.2760; and 9525.2780. 

2. Emergency Use of a Manual Restraint:

• Emergency physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint.

• This means using a part of your body, such as your arms, hands, legs, or your entire body to stop the movement of another person.

• An example of an emergency use of a manual restraint is to use a wrist side hug procedure to move a person away from someone they are trying to assault.

1. Be implemented with a person in a manner that is sexual abuse, neglect, physical abuse, or mental injury.

2. Be implemented in a manner that violates a person's rights.

3. Restrict a person's normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, necessary clothing, or any protection required by state licensing standards or federal regulations governing the program;

4. Deny the person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;

5. Be used for the convenience of staff, as punishment, as a substitute for adequate staffing, or as a consequence if the person refuses to participate in the treatment or services provided by the program;

6. Use prone restraint, which means the use of manual restraint that places a person in a face-down position. Prone restraint does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, if the person is restored to a standing, sitting, or side-lying position as quickly as possible;

7. Apply back or chest pressure while a person is in a prone position;

8. Be implemented in a manner that should not be used (contraindicated) for any of the person's known medical or psychological limitations;

9. Be implemented by a staff that has not completed training on the proper techniques to do an emergency manual restraint.

1. Physical contact or instructional techniques must use the least restrictive alternative possible to meet the needs of the person and may be used:

• To calm or comfort a person by holding that person when they show no resistance to being held.

• To protect a person known to be at risk of injury due to frequent falls as a result of a medical condition;

• To facilitate the person's completion of a task or response when the person does not resist or the person's resistance is minimal in intensity and duration;

• To block or redirect a person's limbs or body without holding the person or limiting the person's movement to interrupt the person's behavior that may result in injury to self or others with less than 60 seconds of physical contact by staff; or

• To redirect a person's behavior when the behavior does not pose a serious threat to the person or others and the behavior is effectively redirected with less than 60 seconds of physical contact by staff.

2. Restraint may be used as an intervention procedure to:

• To position a person with a physical disability in a manner specified in the person’s service and support plan.

• Assist in the safe evacuation or redirection of a person in the event of an emergency and the person is at imminent risk of harm. 

• Allow a licensed health care professional to safely conduct a medical examination or to provide medical treatment ordered by a licensed health care professional that is necessary to promote healing or recovery from an acute, meaning short-term, medical condition. 

3. Use of adaptive aids or equipment, orthotic devices, or other medical equipment ordered by a licensed health professional to treat a diagnosed medical condition do not in and of themselves constitute the use of mechanical restraint. 

The things that you should do (positive supports)

Positive approaches should be used first and be the most commonly used approached to intervening in another person’s behavior. Positive support approaches include:            

Showing is often more effective then telling. Act the way you want them to act. Take the time to understand what the person is trying to communicate with an inappropriate behavior and then teach appropriate behavior so they can get what they want or need. Follow the guidance in the person’s Services and Support Plan, their Person Centered Plan and if they have one, their Behavior Plan. Shift a person’s focus by talking with them about a different activity or topic. Reinforce appropriate behavior. When someone does the right thing, point it out! Offer choices, based on the person’s preferences, including activities that are relaxing and enjoyable to the person. Give regular and specific positive feedback. Listen carefully to what the person is telling you and  validate their feelings; Create a calm environment by reducing sound, lights, and other factors that may bother a person. Speak calmly with reassuring words, consider volume, tone, and non-verbal communication. Simplify a task or routine or discontinue until the person is calm and agrees to participate. Respect the person’s need for privacy or physical space​

By using positive support approaches, we show respect and honor the dignity of people. We are also more likely to see decreases in the behaviors we don’t want to see and increases in the behaviors we do want to see.  

Responding to a challenging behavior
When a person begins to engage in escalating disruptive behavior and it becomes obvious that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of self or others if not redirected, implement the following steps:

1.    If appropriate or possible, remove all people, whose safety is threatened, from the immediate area of the threatening person.
2.    Attempt de-escalation techniques.  De-escalation techniques include restructuring the environment (noise, crowding, proximity), maintaining calm posture and body language, re-direction, positive verbal praise, active listening, and/or prompting (verbal and gestural).
3.    If applicable, review the use of the person’s PRN (as needed) medication to address target mental health symptoms.
4.    If the person’s behavior continues to be disruptive, ask the person to remove themselves from the ongoing activity to a location where they cannot observe the ongoing activity – this is a voluntary time out.
5.    Follow through with the encouragement of the person’s absence from the ongoing activity with verbal prompts. Do not use physical intervention!
6.    Monitor the person’s behaviors while they choose to be in a voluntary time out. 
7.    When the person stops the disruptive or threatening behavior, ask them if they want to return to normal activities.
8.    If immediate intervention is needed to protect the person or others from physical injury or to prevent severe property damage that is an immediate threat to the physical safety of the individual or others, call 911.    
9.    If a behavior intervention that includes the police, PRN medication to stop a behavior, or , the staff who implemented the intervention: 
•    Notifies their manager immediately;
•    Calls the on-call administrative personnel to report the incident as well as the on-call nurse (if they have one) if there is an injury;
•    Completes the Behavior Intervention Reporting Form (BIRF), and submits it to the manager before they leave work;
•    If a PRN medication is given for target behaviors rather than mental health symptoms, staff completes the BIRF.
10.    If 911 was called, the staff responsible at the time of the incident:
•    Completes an incident report and the BIRF.
•    Calls the on-call administrative personnel to report the incident;
•    Notifies the manager who notifies the case manager and the legal representative of the incident within 24 hours.

The procedures listed above are not used to respond to challenging behavior with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated for a person. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning process.

Staff Training
a.    Before having unsupervised direct contact with a person receiving service and annually thereafter,
all employees who provide direct support receive instruction on prohibited procedures that address the following:

1.    what constitutes the use of restraint, time out, seclusion, and chemical restraint; 
2.    staff responsibilities related to ensuring prohibited procedures are not used; 
3.    why such prohibited procedures are not effective for reducing or eliminating symptoms or undesired behavior; 
4.    why prohibited procedures are not safe 

b.    For the limited situations where the emergency use of a manual restraint may be allowed, before those staff may implement manual restraints on an emergency basis they must also be trained on the following within 60 days of hire:

1.    alternatives to manual restraint procedures, including techniques to identify events and environmental factors that may escalate conduct that poses an imminent risk of physical harm to self or others;
2.    de-escalation methods, positive support strategies, and how to avoid power struggles;
3.    simulated experiences of administering and receiving manual restraint procedures allowed by the program on an emergency basis;
4.    how to properly identify thresholds for implementing and ceasing restrictive procedures;
5.    how to recognize, monitor, and respond to the person’s physical signs of distress, including positional asphyxia;
6.    the physiological and psychological impact on the person and the staff when restrictive procedures are used;
7.    the communicative intent of behaviors; and
8.    relationship building.
9.    the safe and correct use of manual restraint on an emergency basis 

Training on any of these topics received from other sources may count toward these requirements if received in the 12 month period before the employee’s date of hire and valid documentation is provided to Mains’l.
 

 

The first step in determining work place exposure to blood borne pathogens is through the development of an Exposure Control Plan (see attached.)  The Exposure Control Plan is designed to eliminate or minimize employee exposure to blood borne pathogens.  The Exposure Control Plan must contain:

I.    Exposure Determination
II.   Schedule and Method of Implementation for:

• Methods of Compliance
• Hepatitis B Vaccine and Post Exposure Follow Up
• Communication of Hazards to Employees
• Record Keeping

III.    Procedure for Evaluation of Circumstances Surrounding Exposure Incidents

The Exposure Determination (see Exposure Control Plan - Section I) is a site specific document completed by the Manager with the assistance of the Senior manager.  Its purpose is to delineate all tasks and procedures which may present an occupational exposure.  Because the primary tasks of all employees of Mains’l Services, Inc. is to offer training, assistance, and supervision to the people we serve, tasks posing an occupational exposure are considered collateral duties and are not regarded as primary job assignments.  The completed Exposure Determination for each site is maintained in the policy manual at the site.   The entire Exposure Control Plan, including the Exposure Determination, is reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.The Exposure Control Plan also contains a Schedule and Methods of Implementation for A) the OSHA recommended methods of compliance including the concept of universal precautions, engineering and work practice controls, personal protective equipment and general housekeeping standards, B) Hepatitis B Vaccine and Post Exposure Follow Up, C) Communication of Hazards to Employees, and D) Record Keeping.

Using the Universal Precautions approach, Engineering and Work Practice Controls, Personal Protective Equipment and general housekeeping standards are in place in all sites as deemed necessary.  (see Exposure Control Plan - Section IIA.)   Information about the aforementioned topics is contained in the “Control of Infection and Communicable Disease” Training module and provided during the first 60 days of employment to new employees and immediately to current employees. 

The Infection Control Plan is found within the Mains’l Policy Manual as an attachment to the Exposure Control Plan and incorporates related procedures addressing the universal precautions of hand washing, use of gloves, general cleaning procedures, and laundry procedure. 

The Schedule and Methods of Implementation also pertain to the administration of the Hepatitis B vaccine and Post Exposure Evaluation and Follow Up.  Pursuant to the OSHA modification of Hepatitis B vaccination requirements, employees who have occupational exposure as a “collateral duty” need not be offered the vaccine until an exposure incident has occurred.  (An exposure incident is defined as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral (skin piercing) contact with blood or other potentially infectious materials that results from the performance of an employee’s duties).  Any unvaccinated person who has rendered assistance in any situation involving the presence of blood or other potentially infectious material, regardless of whether an actual exposure incident as defined by the OSHA standard has occurred, will be offered the vaccine.  The procedure following an exposure incident is delineated in the Exposure Control Plan - Section IIB.  New employees are instructed in the procedures during initial orientation and current employees are informed of the procedures during the training conducted by the Managers. 

The Schedule and Methods of Implementation also pertain to the communication of hazards to employees.  Warning labels and signs are not deemed necessary in the residential programs in which the employees of Mains’l work.  Occupational exposures only occur as collateral duties of employees and training is provided in infection control, universal precautions, personal protective equipment including the use of gloves, general work practice controls such as hand washing, and general housekeeping standards.

As mentioned throughout this procedure, comprehensive training is provided to all employees of Mains’l Services, Inc.  The training module includes all the elements recommended in the OSHA standard (see Exposure Control Plan - Section IIC.)   New employees receive training within the first sixty days of employment and the training will be reviewed annually for all employees, within one year of previous training.

Finally, the Schedule and Method of Implementation applies to record keeping (see Exposure Control Plan - Section IID.)  If an occupational exposure occurs, Mains’l Services will establish and maintain an accurate medical record for each employee with an occupational exposure.  The medical records will be confidential and will include all information as stipulated in the OSHA regulations.  Training records are maintained and contain all information as stipulated in the OSHA regulations.

The last component of the Exposure Control Plan is the procedure for evaluation of circumstances surrounding exposure incidents.  Following an exposure incident, the senior manager will review all documentation of the route(s) of exposure and the circumstances under which the exposure occurred and make recommendations to prevent future exposure incidents (See Exposure Control Plan - Section III).  The report will be reviewed by the Health Services Director who will make necessary changes or revisions to policy and procedure.

Private data includes all information on a person that Mains’l has gathered for the purpose of offering supports.

Notice of Privacy Rights

1. On the day services begin, and annually thereafter, the manager gives the Notice of Privacy Practices for Persons Receiving Service document to the person/legal representative and has the person/legal representative sign the Notice of Privacy Practices Acknowledgment of Receipt. 
2. The manager files this in the legal/consent section of the person’s Support Plan.

Sharing Information: Mains’l employees are allowed to share information with only the following persons or entities without a release:

• Person receiving services 
• The person’s legal representative 
• Mains'l employees and consultants on a need-to-know basis:
• Representatives of responsible federal, state, and local agencies; i.e. case managers, licensors, state or federal investigators.
• Representatives of responsible contracting agencies such as managed care organizations

A person receiving services or their legal representative has a right to access and review the individual record and may request copies of pages in their record.

Besides the person receiving services and their legal representative, the people identified above do not automatically have access to private data about a person receiving services or about other staff or agency employees.  Need-to-know basis means that the person must have a specific work reason requiring access to the information. Private data about a person is available only to those employees whose work assignments reasonably require access to the data; or who are authorized by law to have access to the data.

Any written or verbal exchanges about a person's private information by staff with other staff or any other persons will be done in such a way as to preserve confidentiality, protect data privacy, and respect the dignity of the person whose private data is being shared. As a general rule, if a person is unsure about sharing information regarding a person, they should contact their supervisor or reference this policy and procedure. 

Sharing Information with Other Parties
Information regarding a person receiving service from Mains'l may be released to outside persons/agencies only after the person or their legal representative authorizes the release by signing the Consent to Exchange Information. 

Obtaining Informed Consent and Authorization for Release of Information
Upon starting services and annually after that, the Mains’l manager or their designee will obtain informed consent and authorization to release information. There may be other times when a representative of Mains’l provides informed consent and requests authorization for release of information. The following procedures are to be followed at any time information is requested:

1. At the time informed consent is being obtained, the manager informs the person or the legal representative individual about the following:

• why the data is being collected;
• how Mains’l intends to use the information;
• whether the individual may refuse or is legally required to furnish the information;
• what known consequences may result from either providing or refusing to disclose the information, and with whom the collecting agency is authorized by law to share the data;
• what the person can do if they believe the information is incorrect or incomplete;
• how the person can see and get copies of the data collected about them; and any other rights that the individual may have regarding the specific type of information collected.

2. The manager maintains all informed consent documents in the person’s individual record.

    The following will be observed when completing the Consent to Exchange Information:

• The form is initially completed at the time services begin. It is updated annually thereafter (automatic one-year expiration). If additional information is to be released during the period of the authorization that is in addition to or other than that initially included, an additional or revised form will be completed.
• The type of information to be released, to whom, and for what purpose must be specified on the form in order for the authorization to be valid.
• If the person receiving service is under 18 but has been given the legal right of an adult (emancipated adult) they must sign the form.  If they are not, the legal guardian must sign the form.
• Informed consent must be obtained to validate the authorization to release information.  The senior manager or manager must review with the person or their legal representative what information is being requested and/or released, by whom, and the purpose for which it will be used.  It is advisable to have the person who is authorizing the release then repeat what has been explained to assure their understanding and ability to give informed consent.

Requesting Information from Other Licensed Caregivers or Primary Health Care Providers
Mains’l may need to request information about the person from other licensed providers. When this is needed, the manager will:

1. Complete a Release of Information form.  The manager will carefully list all the consults, reports or assessments needed, giving specific dates whenever possible.  Also, the manager will identify the purpose for the request.
2. Clearly identify the recipient of information.  If information is to be sent to the program's health care consultant or other staff at the program, include Attention: (name of person to receive the information), and the name and address of the program.

Release of Written Documents to Persons Receiving Service or Legal Representative

The following process is used when a person receiving supports or their legal representative wishes to obtain copies of written records:

•  A written request from the person or legal representative, which specifies the information requested, shall be given to the senior manager.
• The senior manager makes the requested material available within three (3) working days after the request.
• The senior manager is available to discuss the content and meaning of the data with the individual receiving service and/or the legal representative if this is requested.
• The person is informed that the agency is not required to release additional data within six (6) months of the first release of information.
• The person making the request signs a statement verifying the requested data was received and, if desired, discussed.
• If a person wishes to contest the accuracy of the information, they must notify the senior manager in writing.  The senior manager and director review the information and respond in writing to the person within thirty (30) days of the request for clarification.
• The person may submit additional written information to be placed in their data file at any time.

Release of photographs or video to other parties: Photographs or video of people supported by Mains'l are displayed or released to outside persons/agencies only if the person receiving service or their legal representative has authorized the release by signing an Authorization for Release of Photographs.

The following is observed when completing the release of photographs form:

1. The general nature of the photo/s to be used, to whom, and for what purpose is specified on the form in order for the authorization to be valid.  The authorization remains valid until the person requests in writing their desire to have the photo removed from future reproduction.
2. Informed consent is obtained to validate authorization.  The manager reviews with the person/legal representative what photograph/video is being requested/ released, by whom, and for what purpose it will be used.  
    

In addition to the behavior intervention policy and procedure, the following procedures are followed if and when it is necessary to perform the emergency use of a manual restraint.

Responding to Escalating Disruptive Behavior

When a person begins to engage in escalating disruptive behavior and it becomes apparent that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of others if not redirected, implement the following steps:

1. Attempt de-escalation techniques. 
   • De-escalation techniques include restructuring the environment (noise, crowding, proximity), maintaining calm posture and body language, re-direction, positive verbal praise, active listening, and/or prompting (verbal and gestural).
2. If applicable, review the use of the person’s PRN use medication to address target mental health symptoms.
3. If the person’s behavior continues to be disruptive, ask that the person to remove themselves from the ongoing activity to a location where they cannot observe the ongoing activity  – this is a voluntary time out.
4.  Monitor the person’s behaviors while they choose to be in a voluntary time out.
5.  When the person stops the disruptive or threatening behavior, prompt them to return to normal activities.
6.  If appropriate or possible, remove all people whose safety is threatened, from the immediate area of the threatening person.
7.  If the person continues to refuse to remove him or herself from the situation and the challenging behaviors continue or escalate, implement personal safety techniques as trained.
   • Personal Safety Techniques:

• ​Wrist release:  Place one foot slightly forward and bend knees.  Use your free hand to grasp the back of their own hand and pull up following the direction of the thumb of the restrained hand until hold is released. Then position your hand on the inside of the individual’s opposite arm and pull to a one-arm wrap around
• Bite release:  Gently apply pressure, pushing the body part being bitten into individual’s mouth making a seal.  Simultaneously using thumb and forefinger to squeeze nose and block air passage until individual opens mouth to inhale and hold is released.​
• Clothing release: Use the outside hand to stabilize the hand grabbing clothing.  Then use the inside hand to hold clothing and gently pull out of individuals grasp.
• Hair pull: Use one hand to stabilize the wrist of hand pulling hair, then use your other hand to gently peel individual’s fingers from hair
• Object removal (not to be used with dangerous items i.e. butcher knives, guns): As individual begins to attack, bend at the elbows bringing hand towards toward face, palms facing outwards as to block.  Then reach to grab object and/or wrists and attempts to peel object out of individual’s hands.
• Blocking Punches and kicks: As individual advances to kick or punch, shuffle back while simultaneously bending arms and bringing both hands in front of face, palms facing outwards.

8. If the person begins to engage in behavior that is continuous aggression, continuous self-injury, or high magnitude disruption that threatens the safety of themselves or others, emergency manual restraint may be implemented, as trained.  When implementing an emergency use of manual restraint start with the least restrictive procedure necessary to keep the individual and others safe.

• If a restraint is being implemented following a personal safety technique, following the implementation of the personal safety technique you may pull to a one-arm wrap around.

9. After implementing the manual restraint, attempt to release the person at the moment staff believe the person’s conduct no longer poses an imminent risk of physical harm to self or others and less restrictive strategies can be implemented to maintain safety.

Mains’l will not allow the use of a manual restraint procedure with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning required under section 245D.070, subdivision 2, for recipients of basic support services; or the assessment and initial service planning required under section 245D.071, subdivision 3, for recipients of intensive support services.

Manual Restraints Allowed in Emergencies

Below is a list of each of the manual restraints trained staff are allowed to use on an emergency basis when a person’s actions pose an imminent (it is about to happen) risk of physical harm to self or others and less restrictive strategies have not achieved safety. The list includes instructions for the safe and correct implementation of those procedures.

They are listed in order of least to most restrictive:

1. Wrist Side Hug Procedure:  Standing next to the individual, using your outside hand, grasp the individual’s wrist above or below the wrist bone, making sure to position their thumb on top of your wrist.  It is important to not grasp the wrist directly as this could cause pain and potentially injury to the person. With your inside hand, closest to individual, wrap your hand around the back of the individual and grasp their triceps on the opposite side of the individuals body, making sure to keep your fingers and thumb together and not grabbing at the individual to cause bruising or pain (This is only used to move an  individual out of harm’s way)
2. Wrap Around- Bear Hug Style:  standing next to individual, staff wrap both of their arms around individual using one hand to grasp their own wrist.

Conditions for Emergency Use of Manual Restraint

Emergency use of manual restraint must meet the following conditions:

• Immediate intervention must be needed to protect the person or others from imminent risk of physical harm;
• The type of manual restraint used must be the least restrictive intervention to eliminate the immediate risk of harm and effectively achieve safety.  The manual restraint must end when the threat of harm ends.
• A manual restraint is only allowed in an emergency when a person’s behavior poses an imminent risk of physical harm to them self or others and the less restrictive strategies have not achieved safety.
• Documentation must be provided to show that positive approaches have been tried and have been unsuccessful as a condition of implementing an emergency use of manual restraint.
• The program must monitor a person’s health
• Property damage, verbal aggression, or a person’s refusal to receive or participate in treatment or programming on their own, do not constitute an emergency.
• Within 24 hours of an emergency use of manual restraint, the legal representative and the case manager must receive verbal notification of the occurrence.
• The use of an emergency manual restraint has been approved in the person’s support plan.
• The employee performing the emergency use of a manual restraint has completed training and demonstrated competence in performing a manual restraint.

Restrictions When Implementing Emergency Use of Manual Restraint

Emergency use of manual restraint must not:

1.   be implemented with a child in a manner that constitutes sexual abuse, neglect, physical abuse, or mental injury;

2.   be implemented with an adult in a manner that constitutes sexual abuse, neglect, physical abuse or mental injury;

3.   be implemented in a manner that violates a person’s rights and protection;

4.   be implemented in a manner that is medically or psychologically contraindicated for a person;

5.   restrict a person’s normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, or necessary clothing;

6.   restrict a person’s normal access to any protection required by state licensing standards and federal regulations governing this program;

7.   deny a person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;

8.   be used as a substitute for adequate staffing, for the convenience of staff, as punishment, or as a consequence if the person refuses to participate in the treatment or services provided by this program;

9.   use prone restraint. “Prone restraint” means use of manual restraint that places a person in a face-down position. It does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, and the person is restored to a standing, sitting, or side-lying position as quickly as possible; or

10. apply back or chest pressure while a person is in a prone position, supine (meaning a face-up) position, or side-lying position,

11. be implemented in a manner that is contraindicated for any of the person’s known medical or psychological limitations.

Monitoring Emergency Use of Manual Restraint

Mains’l must monitor a person’s health and safety during an emergency use of a manual restraint. When possible, a staff person who is not implementing the emergency use of a manual restraint must monitor the procedure. The purpose of the monitoring is to ensure the following:

1.   only manual restraints allowed in this policy are implemented;

2.   manual restraints that have been determined to be contraindicated for a person are not implemented with that person;

3.   allowed manual restraints are implemented only by staff trained in their use;

4.   the restraint is being implemented properly as required; and

5.   the mental, physical, and emotional condition of the person who is being manually restrained is being assessed and intervention is provided when necessary to maintain the person’s health and safety and prevent injury to the person, staff involved, or others involved.

Reporting Emergency Use of Manual Restraint

The staff who implemented any form of manual restraint procedure:

1. Notifies the assigned manager immediately.
2. Completes the Behavior Intervention Reporting Form (BIRF) and submits it to the manager prior to leaving the shift.
   
   • Each single incident of emergency use of manual restraint must be reported separately. A single incident is when the following conditions have been met:
     • after implementing the manual restraint, staff attempt to release the person at the moment staff believe the person’s conduct no longer poses an imminent risk of physical harm to self or others and less restrictive strategies can be implemented to maintain safety
     • upon the attempt to release the restraint, the person’s behavior immediately re-escalates; and
     • staff must immediately re-implement the manual restraint in order to maintain safety.
3. If a PRN medication is given for target behaviors (chemical restraint) rather than for target mental health symptoms, staff completes the BIRF.
4. If 911 was called, the staff responsible at the time of the incident:

• Completes an incident report;
• Calls the on-call administrative personnel to report the incident;
• Notifies the manager, who notifies the case manager and the legal representative of the incident within 24 hours

The manager/designated coordinator:

1. Within 24 hours of an emergency use of manual restraint, the manager contacts the legal representative and the case manager to provide verbal notification of the occurrence.

• When the emergency use of manual restraint involves more than one person receiving services, the incident report made to the legal representative and the case manager must not disclose personally identifiable information about any other person unless the program has the consent of the person.

b. Within (5) working days of the behavior intervention, reviews and finalizes the Behavior Intervention Internal Review form.

Expanded Support Team Review of Emergency Use of Manual Restraint

Within 5 business days after the completion of the internal review, the manage or senior manager must consult with the expanded support team to:

1.   Discuss the incident to:

a.   define the antecedent or event that gave rise to the behavior resulting in the manual restraint;  and

b.   identify the perceived function the behavior served.

2.   Determine whether the person’s service and support plan needs to be revised to:

a.   positively and effectively help the person maintain stability; and

b.   reduce or eliminate future occurrences of manual restraint.

3.   Make the revisions to the person’s service and support plan when it is determined necessary.

The written summary of the expanded support team’ discussion and decisions will be documented on the Expanded Support Team Review Form and saved in the person’s plan file.

Internal Review of Emergency Use of Manual Restraint

a. Within 5 business days after the date of the emergency use of a manual restraint, the senior manager must complete and document an internal review of the report prepared by the staff member who implemented the emergency procedure. The internal review must include an evaluation of whether:

1.   the person’s service and support strategies need to be revised;

2.   related policies and procedures were followed;

3.   the policies and procedures were adequate;

4.   there is need for additional staff training;

5.   the reported event is similar to past events with the persons, staff, or the services involved; and

6.   there is a need for corrective action by the program to protect the health and safety of persons.

b. Based on the results of the internal review, the senior manager must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or Mains’l.

c. The corrective action plan, if any, must be implemented within 30 days of the internal review being completed

d. The original is filed in the person’s plan file and a copy is submitted to the director.

External Review and Reporting of Emergency Use of Manual Restraint

Within 5 business days after the completion of the expanded support team review, the senior manager must submit the following to DHS using the online behavior intervention reporting form which automatically routes the report to the Office of the Ombudsman for Mental Health and Developmental Disabilities:

1.   report of the emergency use of a manual restraint;

2.   the internal review and corrective action plan; and

3.   the expanded support team review written summary.

Positive Support Transition Plan

If an individual uses a positive support transition plan, the plan will be written by a Board Certified Behavior Analyst.  The plan will be written and phased out within 11 months form the date of plan implementation. The BCBA will use the DHS created and approved plan.

 

Once services have started, the person receiving services continues the discovery process with people they have chosen to support them.  The process and procedure may vary, depending on the supports and needs of each person.

 

Mains’l employees are trained in offering person centered services. If at any time a Mains’l employee feels they do not have sufficient information regarding person centered practices, skills or tools, they are encouraged and expected to seek out a Person Centered coach. A list of coaches can be found on the Mains’l employee portal under Person Centered Thinking.    

 

A variety of tools and skills are used to assist in recording the information learned, in order to develop a Support Plan.  Tools/skills may include, but are not limited to: Matching Tools (to gain insight on what staff characteristics are preferred) and Discovery Tools (Important To, Importance For, Rituals and Routines, Relationship Map, Good Day/Bad Day, Communication Chart, Learning Log).  These tools inform the person centered description (see Person Centered Description packet and forms.)

 

1.    The person receiving services and Mains’l staff work together to develop a Personal Description of the person.  Employees will document what they learned using the materials in the Person Centered Description packet within the first 30 days of starting services.  Information discovered from this process creates the foundation of how supports will be offered.  A one-page personal profile/description is created, based on the information learned (a snapshot of the person), and includes what’s important to the person, what others like and admire about them, and how to best support them.

2.    The person receiving services and their support team, including Mains’l staff, work together to balance what is important to and for a person, and how to best support them. Information from existing support plans (i.e., Coordinated Service and Support Plan, Individual Service Plan, and Person Centered Plan, if available) is included in the Support Plan, which the manager will develop within the first 30-40 days of service. The Support Plan reflects what services and supports are offered, as well as how, when, and by whom the services will be provided.

3.    Mains’l employees collaborate with the person receiving services when documenting information.  This is to ensure the person has input into what is being recorded about them.  The person has the right to not participate in this process, but it is recommended and is encouraged.  This applies to all initial and ongoing recorded information gathered throughout the time the person receives supports from Mains’l.

4.    If a Person Centered Plan is not already in place, the manager works with the support team to identify who is responsible to create the plan, as appropriate.

 

Throughout the year, the manager, along with direct support staff and other key people, collaborate on how to best meet the persons’ identified needs, interests, preferences and goals. The person’s Support Plan is updated when needed, at minimum annually, based on the discoveries from conversations and changes in what is important to and important for the person. 

Ongoing Collaboration and Conversations

Mains’l values collaboration and partnerships when offering supports.  We have ongoing conversations with the person receiving services and their support team, to continually learn about the person and their changing preferences, needs, and personal goals and outcomes. The process of “Nothing about the person, without the person” is maintained to the greatest extent possible.

 

Personal outcomes and goals are reviewed with the person receiving services on an ongoing basis, and at least every six (6) months. The Support Plan is updated as needed to reflect any changes, and support team members are notified as progress and changes occur, when applicable. Learning logs may be used to assist in using innovative, creative ways to overcome barriers or enhance the supports offered.

 

Meetings are scheduled throughout the year, as requested and/or needed. Meetings are scheduled by the manager and/or the person and their support team, and are held at the person’s home, or another place determined by the person and their support team.

                                                                                                                       

1.    Mains’l encourages a face to face meeting with the person receiving services and their support team within the first 30-45 days of starting services to review how things are going and to ensure all documentation Mains’l has created is acceptable to the person and their support team.  While the person can choose to not have a face to face meeting, we strongly encourage this practice.

2.See Meeting Checklist (by service and meeting type) for a list of documents to be reviewed and/or completed prior to the meeting, at the meeting, and after the meeting. 

3.    The focus of all meetings is to continue to address what is important to and for the person.  The person receiving services and the team talk about what’s working and what’s not working, what has been tried, and share ideas for better support delivery.  The person receiving services is coached and encouraged to lead the meeting.  They are also asked to assist in creating the agenda, including areas they want addressed (or do not want addressed) at the meeting.   Person-centered skills and tools are used to assist the person in creating the agenda, as well as facilitating the meeting, as desired.

4.    Meetings may begin by an opening round.  A relevant positive question may be asked for all members to respond, i.e., “What is one highlight from the last year (week, month, etc.) you can share with the group?” or “What is one thing you like or admire about the person?”

5.    If a person centered plan has been developed, the team reviews and updates as desired.  If a plan has not been created, the manager works with the support team to identify who is responsible to create the plan, as appropriate.

6.    The person receiving services, if so desired, follows the agenda and then reviews the most recent Support Plan, telling the group if changes are needed.  The manager helps facilitate as needed.

7.    The manager requests the person or appropriate team member to sign all documents, as required, listed on the Meeting Checklist.

8.    A satisfaction survey is completed at each person’s Annual Meeting. A paper survey with a return envelope is offered, to consistently receive feedback on how we might improve our services.

9.    The team identifies next meeting date/s and how often they want to receive written updates and reports, as appropriate.

 

Inspections and Code Compliance:

• All new sites are inspected by a fire authority within 12 months of opening and licensure.
• All sites are annually inspected by municipal building inspectors against building and fire codes.
• Some sites are also inspected by fire inspectors (larger metro areas)
• County foster care licensors inspect initially and annually all licensed sites against MSA 245D requirements (Issued then a Community Residential Setting CRS license.)
• We also complete a Home Safety Checklist before the CRS license is issued.
• Re-inspections can be ordered at any time by state or local authorities.

 

Physical Plant Requirements:

 

Common Areas:

• Living area with adequate furnishings for living and social activities
• Dining area to accommodate meals for all residents

 

Bedrooms:

• At least 80 square feet of floor space
• 120 square feet if double occupancy
• Minimally 7 ½ foot ceilings
• Separated from halls, corridors and other rooms by floor to ceiling walls (no openings)
• Do not serve as a corridor to another room
• Have lockable doors with key issued to the person (copy to Manager for emergencies) complying with MSA 245D.04.

 

Bedroom Furnishings:

• Separate bed of proper size and height for convenience and comfort
• Clean mattress in good repair (normally inner spring, person may choose other – documented in their file.)
• Clean bedding appropriate for the season
• Individual cabinet or dresser*
• Shelving*
• Closet*
• Storage for personal belongings*
• Mirror for grooming*
• Person may choose not to use or have these (documented in their file)
• May bring personal possessions into their room, providing neat, orderly and not a fire hazard

 

For Service:

• All new managers and support coordinators will receive site specific maintenance training within the first 90 days of hire.
• In turn the manager should review an abbreviated version of the Maintenance Policy and Procedure with their staff during the September Team Meeting.  The outline for this training is in the September Monthly Team Meeting folder on the M-drive.
• Maintenance takes routine calls (612-636-8080) from 6:30 a.m. to 6:30 p.m. Monday - Friday.
• After hours calls can be made to the maintenance tech (if a real emergency), vice president of administration (651-249-6097) or the on call administrator (612-598-5700).

 

Service Contracts:

• All homes use Xcel “Home Smart,” CenterPoint “Service Plus,” or other utility service contractors.
• Covers the furnace, air conditioning, water heater, dishwasher, and refrigerator.
• The furnace, air conditioning, and water heater must be covered.  The other appliances are optional (decided by the manager and senior manager).
• CenterPoint Tel. No. 877-477-1664.  They ask for a P-I-N (provided at the training).
• Xcel Tel. No. 866-837-9762 (No P-I-N).
• Some outstate sites use other companies

 

Emergencies – Gas Smells, Fires:

 

If you smell gas or spot/suspect a fire:

1. Don’t try the fire extinguisher unless tiny fire.  Smoke can overtake you quickly.
2. Evacuate everyone – get more than 75 feet away from the house
3. Don’t use cell phones or other electronic devices
4. Watch out for static electricity
5. Don’t use the automatic garage door opener
6. (All these devices can spark an explosion if the gas is concentrated enough)
7. Once outside and clear of the house, call 9-1-1 immediately – they call fire rescue, gas company, etc.
8. Call the on call administrator and follow the Responding to and Reporting of Incidents and Emergencies Procedure

 

Emergencies – Extreme Temps:

1. If your AC or furnace is out, call Xcel or CenterPoint immediately 24/7.
2. Call the maintenance tech during business hours to report the outage.
3. Have a contingency plan (nearby hotel), if extreme temps in the house
4. (Over 85F or below 60F)
5. Use of fans or oil filled space heaters can sometimes help.

 

Emergencies – Water Leaks:

1. Leaks – turn of valve at the source (under sink for small leak) or for the entire house if major leak like a burst pipe (water shut off from the street) Do not delay!
2. The manager or support coordinator must show each new staff working at the site where these shut off valves are.
3. Call maintenance tech to describe the problem.  Can call vice president of administration of no response.
4. Will attempt to get a plumber out there ASAP.

 

Emergencies – Extreme Water Temps:

 

If the water heater is malfunctioning (too hot – in excess of 120F)

1. Stop all bathing, showering and unattended washing immediately, no exceptions.
2. Call maintenance tech immediately
3. Call Xcel or CenterPoint immediately
4. Once repaired, run the hot water for about 20 minutes to evacuate the overheated water to reduce the temp with fresh cold water.
5. Measure the water temp before returning to use (must be below 120F).
6. Best to measure closest to the water heater (laundry sink).

 

If the repair to the water heater will be delayed for more than 24 hours call the maintenance tech or vice president of administration to report the delay.  Also call the manager and/or senior manager to develop a contingency plan (hotel) until the repair is made.

 

Power Outages:

• If the power goes out and the rest of the neighborhood appears to be out too, call your electrical provider.  Companies and numbers to follow:
• Don’t assume you don’t have to call because someone else in the neighborhood has—call.  If it appears that the power will be out awhile, call the senior manager during regular business hours or the emergency on call administrator after hours to report the outage.  When the power is restored, repeat those calls.  Again, there might be the need for a contingency plan.

 

Power Outages Numbers to Call:

• Anoka Municipal Utility:                      763-576-2750
• Chaska Electric:                                 952-448-4335
• Connexus Energy:                              763-323-2660
• Elk River Public Utiity:                                    888-606-4660
• Rochester Public Utility:                     507-280-9191
• Xcel Energy:                                       800-895-1999

 

Maintenance Requests – Phone App – this is being tested and will be finalized soon.

 

Non-Emergency – Service:

Whenever any service technician comes to the home to make a repair, always ask the tech for a copy of the work ticket and get that ticket to the maintenance tech.

 

Non-Emergency – Service Technicians:

• If Home Smart of Service Plus comes to your site twice within any six month period to fix the same appliance, call the maintenance tech—may be a sign of a problem not getting resolved.
• Maintenance tech can help and talk with the service tech.

 

Non-Emergency – Water Softener:

1. Check the water softener canister periodically.
2. Verify the salt and water level are up close to the top.
3. Otherwise can clog plumbing.

 

Licensing Preparation – Licensed Sites:

1. When anyone at the site first learns about a scheduled date for a foster care licensing inspection call the maintenance tech immediately.
2. The maintenance tech can assist with the preparation.  The tech needs ample notice.

 

Fall/Winter Check Lists:

1. These are emailed out each fall to the manager to complete as winter preparation projects described on the form are completed.
2. E-mail or fax the completed form to the vice president of administration

 

Support Coordinator’s Role in Maintenance:

1. Remain alert to problems
2. Report needs to the manager and maintenance
3. Monitor work requests (is the work getting done?)
4. Review inspection (Maintenance Committee) for direction
5. Support your manager
6. Train staff
7. Lead by example
8. Keep persons receiving services first (it’s their home)

Manager’s Role in Maintenance:

1. Back up the support coordinator
2. Supervise staff
3. Enforce policies
4. Purchase needed supplies (can delegate with Wells Fargo cards)
5. Train staff in maintenance
6. Perform tasks assigned by inspections
7. Assess progress on maintenance requests

 

Maintenance Committee:

1. Internal committee of your peers
2. Inspects in site roughly every six months
3. Called the Semi-Annual Maintenance Inspection
4. Rates the condition of all physical plants and housekeeping including offices and hubs
5. Rating: 1 – Poor, 2 – Meets Standards, 3 – Excellent
6. Rating of 1 – committee returns to the site within a month to bring up to standards
7. Deficiencies are added to the site budget

 

Landlords of Rental Properties:

• Before any planned communication with any landlord first confer with the maintenance technician.
• Generally the maintenance technician communicates with landlords unless otherwise specified.

 

 

 

Personal Funds and Property when Starting and Ending of Service

1. Mains’l initiates conversations with a person’s teams when they will be moving in or out, about expectations related to personal property, funds and moving expenses/responsibilities.
2. A Consent to Manage/Audit Finances Form is completed within five working days of service initiation and annually thereafter when Mains’l will be managing any aspect of the person’s funds.
3. The support plan indicates if assistance is needed related to finances and when applicable, the frequency of financial reports to be sent to the team.
4. The Financial Funds and Property When Starting Services Form is completed either on paper or electronically when a person is moving into a Mains’l owned or leased property.
5. The Financial Funds and Property When Ending Services Form is completed either on paper or electronically when a person is moving out of a Mains’l owned or leased property.
   
   1. This form serves as a receipt that lists all items and funds given, date given, to whom they were given and who gave them.
      
      1. The form is signed by both parties
      2. A copy is saved in the person’s file
      3. A copy is given to the person to whom the items were given
6. When a person is no longer living in a Mains’l owned or leased property for any reason, any funds and property owned by the person must be given to the person or the person’s legal representative, or given to the executor or administrator of the estate.
   
   1. Assessment and distribution of a person’s property is done by the manager or senior manager as soon as possible and no longer than 28 days of a person moving out.
   2. Assessment and distribution of Mains’l property is done by the current manager if still providing services in home. If services are no longer provided in the home, the corporate administrative coordinator completes assessment and distribution.

Any suspicions of fraud, abuse, and waste should be directly reported to our Public Funds Compliance Officer, the Director of Administration.

The Public Funds Compliance Officer will conduct an internal investigation. In the event that our Public Funds Compliance Officer, the Director Administration is suspected or alleged to be involved in fraud, the National Director of Human Resources will complete the investigation. The investigation will include at least the following:

1. Whether fraud, abuse, or waste occurred;
2. Whether written policies and procedures were adequate;
3. Whether written policies and procedures were followed;
4. Whether there is a need for additional staff training;
5. Whether there is a need for external reporting.

If it is determined after a thorough investigation that any employee has committed fraud, their employment will be terminated immediately.

If it is determined that a vendor, person receiving services, or other business partner has committed fraud, Mains’l reserves the right to end the relationship.

While Mains’l prefers that reports of suspected fraud and abuse are made internally, you have the right to report suspicions of Medicaid abuse or fraud to a state agency.

In California:      Department of Health Care Services/Health Care Programs at 800-822-6222 or

http://www.dhcs.ca.gov/individuals/pages/stopmedi-calfraud.aspx

Office of the Attorney General 800-722-0432

http://www.ag.ca.gov/bmfea/medical.htm

In Minnesota:    Department of Human Services Provider Fraud: 800-657-3750 Recipient Fraud: 800-627-9977

http://mn.gov/dhs/general-public/licensing/report-fraud/index.jsp

Mains’l will not discharge, discipline, threaten, or discriminate against, or penalize an employee, who in good faith reports or participates in an investigation of fraud, abuse, or waste internally or externally. However, failure to report suspicions of fraud, abuse, and waste will result in disciplinary action, up to and including termination.

(Rev.5/24/2019 CJ)

Referrals
Mains’l engages in conversations with the person requesting services and their support team to help identify what’s important to and important for the person.  We are committed to a collaborative approach when developing services for people, and a team of Mains’l employees work together to determine if service needs can be met.  Team members may consist of a customer service specialist, navigator, senior manager and/or manager.

When a person contacts Mains’l about our services:

1.    We gather basic information about the person, including service needs, funding type, personal information, preferred characteristics of support staff, and the type of housing or roommate preferences, as applicable.

2.    We will ask if a person centered description and/or Person Centered Plan have been created.  If so, we request the information.  If not, we offer resources to assist the person in this process.  The process may involve an outside person centered planner.  

3.    We meet with the person and their circle of support (those invited by the person they want involved) about what is important to and for them.  Most often we have a “meet and greet” at a place designated by the person and/or at a place with potential roommates.  “A Getting To Know You” form can be used to begin recording information about the person.

4.    If during these conversations/introductions it is determined that Mains’l is a good fit for the person and/or their circle of support, information sharing continues.  Mains’l asks for the following, as applicable/available:

a.    Important to the person: 
o    Person Centered Plan (Picture of a Life, MAP, Essential Lifestyle Plan, etc.)
o    Personal Description and/or Personal Profile
o    Support/program plan (i.e., Coordinated Service and Support Plan or Individual Program Plan)
b.     Important for the person 
o    Personal Safety Plan (Individual Abuse Prevention Plan, Support/Program Plan)
o    Individualized Education Program Plan – completed by school professional
o    Medical and health care related information and/or assessments (psychological and/or psychiatric evaluation, behavior assessment, physical therapy, dental, occupational therapy, audiology, etc.)
o    Positive Support Transition Plan

5.    If there are concerns regarding potential risk to the agency, the assigned manager meets with the Vice President of Administration to determine if the referral process can continue. Certain medical needs or behavioral or criminal histories may pose too great a risk for the person or Mains’l.  History of arson, assault, and sexual offenses, for example, require special consideration and may not match Mains’l’s ability to provide supports. When there appears to be a mismatch between Mains’l’s ability to provide supports and the supports that are likely needed, the referral must be reviewed and approved by the executive leadership team.  

6.    If it is determined that the person and Mains’l are not a good fit and we are not going to provide services, the  manager will provide documentation of  the reason to the person, the person’s legal representative, and case manager, upon request. 

7.    When the person requesting services and Mains’l agree that we are a good match, the manager negotiates the service agreement with the case manager.  Upon receiving the service agreement, (or authorization that the agreement is in process), the manager begins developing services.

8.    The manager meets with additional Mains’l staff when the supports requested require resources that extend beyond our current support options. Members may include the following: services director, human resources representative, nurse, therapeutic specialist, finance representative, and/or a housing representative.  The development team works together to ensure the person’s support needs can be met, and within the expected timeframe(s).  The team meets on a regular basis to communicate updates on progress to the person and their support team, as needed.

9.    Mains’l support team members and the person requesting services continue the discovery process to learn as much as possible about each other.  Mains’l uses a variety of person centered practices to assist in documenting the information learned. These tools/skills may include, but are not limited to: Matching Tools (to gain insight on what staff characteristics are preferred) and Discovery Tools (Important To/For, Rituals and Routines, Relationship Map, Good Day/Bad Day, Communication Chart, Learning Log).  Many of these tools are contained in the Person Centered Description materials packet. 

The information gathered is used to assist with the development of the person’s support plan.

Enrollment
When the person requesting services and Mains’l agree that we are a good match, the process of starting services begins.  This procedure may vary, depending on the supports and needs of each person.

1.    When new staff are needed, Mains’l partners with the person and their support team to recruit employees who are the right fit for the person and Mains’l.   

2.    If during the referral process it has been determined that the person requesting services is looking for a new place to live, the support team members determine the roles and responsibilities of each member in locating housing.  Depending on the supports identified, different levels of supports will be needed.
a.    In some cases, Mains’l may have an established home that provides up to 24 hours of support. If a roommate is desired by existing tenants of the established home, and this level of support is requested by the person, the manager will make arrangements for the people to meet and get to know each other.
b.    If the person has a criminal background which may affect roommates, the manager notifies the roommates and/or their guardians and case managers (i.e., is on a sexual predator registry.)  Also, the manager notifies the person requesting supports if one of the potential roommates is on a sexual predator registry.
c.    If everyone agrees the living arrangement is a good match for all, a move in date is scheduled by the manager, the person, and their support team.
d.    When new housing must be arranged before supports start, a move-in date is set when the person’s home has been secured (lease signed, roommates identified if needed, etc.)  The roles and responsibilities are assigned by the person and their support team, depending on the level of support requested.
e.    Once staffing and housing is established, as needed, an enrollment meeting can be scheduled.

3.    An enrollment meeting is scheduled by the manager, and/or the person and their support team.  Meetings are held at a place agreed upon by the person and their circle of support. 

4.    At the meeting, conversations continue to address what is important to and for the person.  These conversations help the manager record information that will inform the person’s Support Plan.  
a.    If a Person Centered Plan has not been created by/for the person, the team addresses who will be responsible to develop the plan, as appropriate.
b.    All documents listed on the Enrollment Checklist will be reviewed and/or signed by the person and/or their guardian. 
c.    The manager offers a Mains’l Guidebook to Supports.  The handbook includes policies and procedures on how we offer services. 
d.    A date when services will actually begin will be determined by the person and the support team.

5.    The manager completes a Starting Services form to notify other Mains’l departments when services are starting. 

6.    The manager begins the process of developing the person centered Support Plan (see How We Offer Supports and Services Policy and Procedure).  This document is developed as soon as possible (best practice 15 days but no later than 30 days after the initial starting services meeting) and is sent to the person and their identified support team
 

A representative payee can be appointed by the Social Security Administration to receive the Social Security or SSI benefits for a person who can’t manage or direct the management of his or her benefits.  Mains’l does not charge a monthly fee from Social Security benefits and/or Supplemental Security Income (SSI) benefits, but charges may apply depending on the business relationship between Mains’l and the person requesting representative payee services.

1. When the individual requesting representative payee services also receives consumer/participant directed services, Mains’l charges and receives a monthly fee through the person’s Medicaid waiver.
2. When the individual requesting representative payee services also receives traditional waiver services and is requesting the service in order to ensure payment to Mains’l for other services, representative payee services are provided at no charge.

A representative payee’s main duties are to use the benefits to pay for the current and future needs of the beneficiary, and properly save any benefits not needed to meet current needs. A payee must also keep records of expenses.

 

Establishing Mains’l as a Representative Payee

 

The following steps are to be followed to establish Mains’l as Representative Payee:

1. The person requesting representative payee services informs their manager and provides the person or  representative with the contact information of the person designated at Mains’l to be representative payee.
2. The manager contacts the individual designated to be representative payee at Mains’l to inform him or her that a request to perform representative payee services has been made.
3. The representative payee, after being contacted by the person or their representative, plans a meeting.
4. A meeting is held to determine if the person would like to choose Mains’l as rep payee. If so, next steps are identified to determine when and how paperwork will be completed.
5. After paperwork is completed, Mains’l begins performing representative payee services.

 

 

 

 

 

Fulfilling Representative Payee Responsibilities

1. Required Duties: The person assigned at Mains’l as a representative payee works with the person receiving services and their support team to ensure his or her day to day needs are being met by performing the following duties:

1. Determine the beneficiary’s needs and use his or her payments to meet those needs;
2. Save any money left after meeting the beneficiary’s current needs in an interest bearing account or savings bonds for the beneficiary's future needs;
3. Report any changes or events which could affect the beneficiary’s eligibility for benefits or payment;
4. Keep records of all payments received and how the money was spent and saved;
5. Provide benefit information to social service agencies or medical facilities that serve the beneficiary;
6. Help the beneficiary get medical treatment when needed;
7. Report to the Social Security Administration  any changes that would affect our performance or our ability to continuing as payee;
8. Complete written reports accounting for the use of funds; and
9. Return to the Social Security Administration any payments to which the beneficiary is not entitled.
10. Mains’l completes the annual Representative Payee reports from Social Security for each person we provide rep payee services for, as requested by Social Security. 

1. Monthly Process

1. Mains’l collects the social security benefits each month and deposits the funds into each individual’s rep payee account in QuickBooks. 
2. By the 5^th of each month, the rep payee checks the account balance of each person they are payee for to ensure there are enough funds in the persons account to process payments for the month.
   
   • Payee pays bills for each person, as needed before the due dates.
   •  Payee issues a personal needs check by the 5^th of each month

 

Suspending Services

a.    Reasons for temporary suspension of services: 

1.    A person may suspend services with Mains’l at any time. Some reasons a person might choose to suspend services are:

• Scheduling conflicts or lack of staffing.
• Times when services are not needed or wanted for a short period of time, such as trying a different living situation (less than 3 months).
• Temporary situations that change the person’s service needs such as a medical condition (less than 3 months). 
• Person receiving services does not qualify for the service or is not eligible under program rules for a short period of time (less than 3 months).

2.    Mains’l may also choose to suspend services. Temporary service suspension by Mains’l is limited to the following situations:

• The person's conduct poses an imminent risk of physical harm to self or others and either:

a.    positive support strategies have been implemented to resolve the issues leading to the temporary service suspension, but have not been effective and additional positive support strategies would not achieve and maintain safety; OR 
b.    less restrictive measures would not resolve the issues leading to the suspension.

• The person has medical issues that exceed our ability to meet the person's needs.
• Mains’l has not been paid for services. 

a.    This includes non-payment of waiver obligations, spenddowns, private pay, GRH, Medicaid and any other funding sources. 
b.    Medicaid or other funding being inactive or person is no longer eligible for services. 

b.    Actions taken before services are suspended: Mains’l requests that we be notified in writing if a person chooses to suspend their services. Before Mains’l gives notice of temporary service suspension, the manager documents actions taken to minimize or eliminate the need for suspension. 

1.    Action taken by Mains’l must include, at a minimum:

• Consultation with the person's support team or expanded support team to identify and resolve issues leading to the notice being issued; and
• A request to the case manager for intervention services identified, including positive support services, in-home or out-of-home crisis respite services, specialist services, or other professional consultation or intervention services to support the person.
• Prior to suspension due to risk of physical harm, the manager requests the assistance of agency positive supports staff to identify and document strategies/interventions that may delay or avoid service suspension.
• Prior to suspension due to medical issues, the manager requests the assistance of agency nurses and/or the person’s medical professional team to identify and document strategies/interventions that may delay or avoid service suspension.
• Prior to suspension due to non-payment, the person is sent written notification from Mains’l detailing the money owed and payment expectations. 

If, based on the best interests of the person, the circumstances at the time of the notice were such that the manager was unable to consult with the person’s team or request interventions services; the manager must document the specific circumstances and the reason for being unable to do so.

c.    Actions taken when suspending services: 

1. The manager notifies the person or the person’s legal representative and the case manager in writing of the intended temporary service suspension by completing a Notice of Temporary Suspension of Services.  

2. If the temporary service suspension is from supported living services or community residential services:

a.    In Minnesota, the senior manager must notify the DHS Commissioner in writing. DHS notification will be provided by fax at 651-431-7406. 
b.    In California, the senior manager must notify the Case Management Supervisor in writing. 

3.    The Notice of Temporary Service Suspension is given on the first day of the service suspension.

4.    The written notice of service suspension must include the following elements: 

• The reason for the action;
• A summary of actions taken to minimize or eliminate the need for temporary service suspension; and 
• Why these measures failed to prevent the suspension.

5.    During the temporary suspension period the manager must:

• Provide information requested by the person or case manager;
• Work with the support team or expanded support team to develop reasonable alternatives to protect the person and others and to support continuity of care; and
• Maintain information about the service suspension, including the written notice of temporary service suspension in the person’s record.

d. Returning to services after suspension: A person has the right to return to receiving services during or following a service suspension with the following conditions:

1.    Based on a review by the person’s support team or expanded support team, the person no longer poses an imminent risk of physical harm to self or others, the person has a right to return to receiving services. 

2.    If the support team or expanded support team makes a determination that is different than the recommendation of a licensed professional treating the person for the reason services were suspended, the manager must document the specific reasons why a different decision was made.

Ending Services

a.    Reasons for ending services: 

1.    A person may end services with Mains’l at any time. Some reasons a person might choose to end services are:

• The services are no longer in the best interest of the person receiving services.
• The person wishes to change to a different provider and/or is not interested in receiving supports by Mains’l. 
• Person receiving services no longer qualifies for the service or is no longer eligible under program rules.
• The person is not satisfied with the services being provided or does not feel that Mains’l is a good fit for what they need. 
• The person moving to a location where services cannot be or do not need to be provided.
• Person has successfully achieved their goals and no longer requires the support of Mains’l. 

2.    Mains’l may also choose to end services. Termination of service by Mains’l is limited to the following situations:

• The termination is necessary for the person's welfare and the person's needs cannot be met by Mains’l.
• The safety of the person; other people in the program, or staff is endangered and positive support strategies were attempted and have not achieved and effectively maintained safety for the person or others.
• The health of the person, others in the program, or staff would otherwise be endangered.
• Mains’l has not been paid for services.
• Mains’l no longer offers the service.
• The person has been terminated by the lead agency from waiver eligibility.
• If the person indicates through their behavior that they no longer wish to receive services by Mains’l (i.e., several missed appointments, not home when support staff comes to visit) and has not returned our phone calls or e-mails.)

b.    Actions taken before services are terminated: Mains’l requests to be notified in writing if a person chooses to end their services. Before Mains’l gives notice of service termination, the manager will document the actions taken to minimize or eliminate the need for termination.

    Actions taken will include, at a minimum:

• Consultation with the person’s support team to identify and resolve issues leading to the notice being issued; and
• A request to the case manager for intervention services, including  positive support services, in-home or out-of-home crisis respite services, specialist services, or other professional consultation or intervention services to support the person.
•  A request for intervention services will not be made for service termination notices issued because the program has not been paid for services.
• An individual agreement will be developed with the person, if it is believed that their commitment to receiving services from Mains’l is absent. 

If, based on the best interests of the person, the circumstances at the time of the notice were such that the manager was unable to consult with the person’s team or request interventions services; the manager must document the specific circumstances and the reason for being unable to do so.

c.    Actions taken when terminating services: 

1.    A written notice of an intended service termination, including those situations which began with a temporary service suspension, must be completed on the Notice of Service Termination form and given to the person, their legal representative, and the case manager before the proposed effective date of service termination. 
a.    For California services, and for intensive services in Minnesota, the notice must be provided at least 60 days before the proposed effective date of service termination.
b.    For all other services, the notice must be provided at least 30 days before the proposed effective date of service termination.
c.        If the service termination is from supported living services or community residential services:

• In Minnesota, the senior manager must notify the DHS Commissioner in writing. DHS notification will be provided by fax at 651-431-7406.
• In California, the senior manager must notify the Case Management Supervisor in writing within 60 days. 

2.    This notice may be given in conjunction with a notice of temporary service suspension.

3.    The written notice of a proposed service termination must include all of the following elements:

• The reason for the action;
• A summary of actions taken to minimize or eliminate the need for service termination, and why these measures failed to prevent the termination. A summary of actions is not required when service termination is a result of Mains’l no longer providing the service (ceasing operation);
• The person's right to appeal the termination of services under Minnesota Statutes, section 256.045, subdivision 3, paragraph (a); and 
• In Minnesota, the person's right to seek a temporary order staying the termination of services according to the procedures in section 256.045, subdivision 4a or 6, paragraph (c).

4. During the service termination notice period, the manager must:

• Work with the support team or expanded support team to develop reasonable alternatives to protect the person and others and to support continuity of care;
• Provide information requested by the person or case manager;
• Complete a Starting Service/Change Form and Employee Status Change or Termination forms as applicable and distribute within the agency as the forms direct.
• Assure that information about the service termination, including the written termination notice, is maintained in the person’s plan file. 
• Organize the person’s personal information according to the Record Retention Procedure, and scan the records for electronic storage.
   

Responding to All Incidents

When an incident as defined above occurs:

An employee who is working at the time of the incident: 

1. Immediately call 911 if there is a medical emergency or a physical or sexual assault in progress - Do not wait!  You do not need to call the administrative cell phone or your manager first.
2. Provide emergency first aid and/or CPR.  Location of the first aid kit:____________________
3. If hospital treatment is required bring the following information if accessible:

• Medical Assistance Card
• Information About Person Receiving Services Document
• Medication Sheet, if applicable
• Medication Administration and Emergency Medical Authorization Form

4. Call and report the incident to the on-call administrative personnel:  612-598-5700
5. As soon as possible and before leaving the shift notify the assigned manager or senior manager
6. Complete an Incident Report and any other related documentation
7. When an incident involves more than one person receiving services, employees do not disclose personally identifiable information about the other person involved when reporting to the legal representative and case manager, unless we have their consent.
8.    Medical emergencies require a direct call to the on call nurse 612-644-0615

Additional procedures for responding to specific incidents and emergencies are provided on the following pages. In addition, you will receive customized training, based on the unique needs of the person or people you will be working with.

Responding to a Power Outage

1. ​If structural damage or extended power outage occurs, call the on-call administrative person, at 612-598-5700, who will work with the senior manager to coordinate alternative housing if relocation is necessary.  Maintenance personnel will assess the reported damages, if any.  Call to notify the on-call administrative person when power is restored.  
2. If services need to be relocated for more than 24 hours, an incident report is completed and submitted by the manager.  The manager or their designee personnel notify the person’s legal representative or emergency contact 
   and case manager within 24 hours of the incident.  They also notify 
   licensing personnel as appropriate.
3. The location of the flashlight and battery radio is__________________________________________.
4. If the power should go out in the 7000 office building, the building is equipped with a roof top  mounted emergency backup generator which will power the server room and portions of the building. The generator panel is equipped with a monitoring instrument which notifies designated staff of the outage and backup power.  The monitoring instrument will a

Responding to Fire

 Depending on where you are at:

1.    Follow the site evacuation plan/evacuate the home.
2.    Lead people to the designated safe place, using the nearest exit away from the fire.  
3.    The designated meeting place for this person’s home is _____________________________________ 
      (at least 75 feet away from the home)
4.    Call 911
5.    Location of fire extinguishers at this person’s home is _______________________  
Do not attempt to use extinguishers on any fire larger than a small wastebasket.  
6.    Call to report to on-call administrative person:  612-598-5700.  
They will assist if relocation is necessary.
7.    The employee working at the time of the fire completes an incident report

Fire Drills: When we support people in community residential settings the manager initiates/assigns completion of fire drills according to the printed agency schedule and based on the services being provided.  The schedule is designed to vary the staff participating and the times of day the drill is conducted.  Actual simulation of a variety of fire locations and responses are practiced. Following the completion of a drill, the Fire Drill Report is completed and submitted to the assigned senior manager who evaluates the response and makes recommendations for additional safeguards as needed.

Responding to a Carbon Monoxide Alert

a.    When the carbon monoxide detector sounds, and people are showing symptoms* associated with carbon monoxide poisoning:
1.    Immediately evacuate the building as quickly as possible. The designated safe place is: ___________________________________________________________________________
2.    Call 911.  Do not reenter the building until it has been aired out and the problem has been corrected.
3.    Call the on-call administrative person for assistance and to report: 612-598-5700; call again to report when you are allowed to re-enter the home.  

b.    When the carbon monoxide detector sounds, and people are not 
Showing symptoms associated with carbon monoxide poisoning:

1.    Press the test/reset button.  
Note:  If dangerous levels are present, the unit will re-sound.
2.    If unit does not re-sound, you may remain in the home, but 
watch for any signs that the monitor is faulty or for other symptoms 
of carbon monoxide (above).
3.    If the unit does re-sound:  

    Evacuate the individuals from the home
    Turn off all appliances, vehicles, or other sources of combustion immediately.  These could include a furnace, water heater, vehicles, and other sources
    Immediately get fresh air into the home by opening doors and windows
    Call your service provider to make a report
    Do not restart appliances until the service provider, or maintenance personnel, has stated the problem has been corrected

4.    Call the administrative on-call person for assistance:  612-598-5700. 

Responding to Severe Weather/Tornado 
a.     National Weather Service alerts to possible tornado or severe storm developments.

Tornado or severe storm Watch - (Conditions are right for a tonrnado over the next 12 hours) Public warning issued on radio and television; there s no siren Stay tuned to radio or television for further information Be ready to move to a safe place in the home if radio or TV instructs Tornado Warning - (an actual tornado has been sighted inthe area) Public warning is issued over radio and television and a 3-5 minute steady warning siren sounds When the tornado sirens sound, move immendiately to the designated safe area of the home

b.    The designated safe area for severe weather/tornado at this home is:_______________________

Severe Weather/Tornado Drills: When we support people in community residential settings, during tornado season, at least two practice drills in response to severe weather/tornado occur.  The drills are initiated/assigned by the manager, according to the printed agency schedule.  Following the completion of the drill, a Tornado Drill report is completed and submitted to the assigned senior manager who evaluates the response and makes recommendations for additional safeguards as needed. 

Responding to Severe Winter Weather
a.    During the cold winter months, remain alert to changing weather conditions.  Regularly check the weather reports on TV, radio, or internet.  Also, advisories may be issued internally across e-mail.  
b.    When the National Weather Service announces an extreme cold or blizzard warning it means that these conditions will occur within 12 hours of the initial advisory.
c.    During actual blizzard warnings, no unnecessary transportation is permitted.  Necessary travel i.e., medical appointments, may occur only with the approval of the manager after consultation with the senior manager.
d.    Be aware and prepared for other closing that may affect the 
Schedule of the person you support and make necessary arrangements.
e.    Call 911 and report your position if there is an accident or the vehicle goes off the road during the winter months. Stay in the vehicle unless it is not safe to do so. 
f.    The location of flashlight and battery radio is_________________
g.    If structural damage or extended power outage occurs, call the on-call administrative personnel at 612-598-5700.  They work with the senior manager to coordinate alternative housing if 
relocation is necessary.  Maintenance personnel will assess the reported damages, as necessary.  
Also call to notify the on-call administrative person when power is restored.  
h.    If services need to be relocated for more than 24 hours, an incident report is completed and submitted by the manager.  The manager or their designee notifies the person’s legal representative or emergency contact and case manager within 24 hours of the incident.  They also notify licensing personnel as appropriate.

Emergency Evacuation and Emergency Sheltering/Relocation of Services
People may need to be relocated due to structural damage after a storm or fire, furnace malfunction (including carbon monoxide), gas explosion, power outage, or other physical plant concerns.

When there are concerns for the health and/or safety of the persons who live there the following steps should be taken:

1.    If additional staff is needed to meet the emergency, staff on duty should call the manager, senior manager, and/or on-call administrative personnel for assistance at 612-598-5700.
2.    If relocation is necessary, call the manager, senior manager and the on-call administrative personnel.  They will work together to determine where the individuals can go most immediately, as well as assist with a long term plan, if that is needed.  If relocation exceeds 24 hours, the manager completes an incident report.
3.    The on-call administrative personnel works with the manager and senior manager to notify all employees, agency maintenance personnel, insurance company, parents, guardians, case managers, and county satellite and state licensors.
4.    Maintenance personnel work with law enforcement to secure the property and assess damage and, if possible, complete needed repairs so people may return to their home as soon as possible.

Responding to a Mental Health Crisis
You have a few options:

1.    Call 911 if the concern is life threatening.
2.    Call a mental health crisis intervention team or 
line that you can search on the internet. 
3.    A person can also call their individual therapist, 
when the situation does not require an immediate 
911 emergency response. 

Responding to a Missing Person
No two missing people are the same. Consequently, it is vital to find out as much about the missing person as possible before initiating a particular response. 

1.    If a person is suspected missing, note the time and location 
when and where the person is expected to be.

2.    Check the persons Community Supports and Services Plan 
(Support Plan) and/or Personal Safety Plan for guidance and the 
length of time the person can be on their own.

3.    Attempt to locate the person by calling people or agencies 
he/she may be with, and search the immediate area and 
nearby areas of potential interest to the person.

4.    If the person cannot be located, immediately call the on-call administrative personnel at 612-598-5700.  The on-call administrative personnel provides direction for notifying the person’s legal representative or designated emergency contact, case manager, and police.

5.    The employee working at the time the person was determined missing completes an Incident Report and any related documentation, i.e., Health Care Progress Notes, communication notes, police report, etc.

6.    The manager or their designee follows up with the case manager and the person’s legal representative or designated emergency contact within 24 hours of the incident.  They also notify licensing personnel as appropriate.

Responding to Physical Aggression between People Receiving Services
1.    Follow the approaches you have learned in Behavior Intervention Policy and Procedure and your individualized training and seek assistance from other staff if available. 
2.    If injury to an individual has occurred or there is imminent possibility of injury to another person and:
a.     you have been trained in the emergency use of manual restraint, immediately implement emergency use of a physical intervention, likely a manual restraint.  (Refer to Emergency Use of Manual Restraint Policy and Procedure). 
b.    you have not been trained in the emergency use of manual restraint or it isn’t effective and you cannot make the situation safe for people, immediately call 911.
3.    After the situation is under control, question the people as to any injuries and look for any signs of injury.  If injuries are noted, provide necessary treatment, contacting medical personnel if needed.  
4.    Notify the manager and administrative on-call person (612-598-5700) as soon as everyone is safe and the individuals’ immediate needs have been met.  
5.    The staff that was most directly involved at the time of the incident completes an incident report before completing their shift.  If the incident involved emergency use of a manual restraint, a call to law enforcement or other first responders, emergency psychiatric hospitalization, or a prn psychotropic medication was administered, this staff completes a Behavior Intervention Reporting Form (BIRF) and submits it to the site manager prior to leaving the shift.  
6.    The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours of the incident.  They also notify licensing personnel as appropriate.

Responding to Sexual Exploitation or Assault
1.    If you witness what you think is sexual exploitation or sexual assault, talk to the persons involved in a calm manner and ask them to separate.  If there has been obvious force or intimidation, based on your knowledge of the individuals, physically intervene or call 911 if necessary. If the individuals are unclothed, provide them with a robe or other clothing, but they should not redress in the clothing they were wearing and they should not bathe or shower.  
2.    Talk to each of them separately, to the extent possible, to determine what led to the interaction and what happened.  Assess whether the person is experiencing any physical or emotional discomfort.  Ask what, when, where, and how questions.  Do not ask “why” questions.  Document your initial observations and the information provided by the persons as soon as possible after talking with them.

3.    In a respectful manner, look for any signs of physical injury (e.g. bruising, bleeding, etc.) and document your observations as soon as possible.  
4.    If medical personnel and/or law enforcement have been contacted, follow all instructions they provide.
5.    If it is determined unnecessary to involve medical and/or law enforcement personnel, the person(s) may resume their normal activities.
6.    Call the manager and the on-call administrative person at 612-598-5700 as soon as appropriate arrangements have been made to meet the person(s) needs.
7.    The staff most directly involved at the time of the incident completes an incident report before completing their shift.  If the incident involved emergency use of a manual restraint, a call to law enforcement or other first responders, emergency psychiatric hospitalization, or a prn psychotropic medication was administered, this staff completes a Behavior Intervention Reporting Form (BIRF) and submits it to the manager, before the end of the work day. 
8.    The manager or their designee will notify the case manager and the person’s legal representative or designated emergency contact within 24 hours of the incident.  They also notify licensing personnel as appropriate.

When Law Enforcement is Requested
1.    In the event staff have summoned law enforcement or fire department to the home (e.g. due to possible criminal activity, security/safety concerns, individual’s behavior, fire etc.) or to the site of an incident or emergency, staff will explain, in detail the reason for requesting them, upon their arrival.  Answer all questions asked of you and follow any instructions provided.  Document the event on an incident report as soon as possible after the fact, and notify the on-call administrative personnel immediately.  
2.    If law enforcement was requested for security/safety concerns or behavior this staff also completes a Behavior Intervention Reporting form (BIRF) and submits it to the site manager prior to leaving the shift.
3.    The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.

Unannounced Law Enforcement
1.    If law enforcement officers arrives unannounced to the home or the site of an incident or emergency, staff first ask for proper identifications as warranted (i.e., non-uniformed officer).  Ask how you can be of assistance and be cooperative with the official.  Answer all questions asked of you; offer additional information after the officer’s questions have been answered.  Before they leave, ask the official for his/her business card and a case number if one is being assigned.
2.    Document the event on an incident report as soon as possible after the fact.  
3.    Call the manager and on-call administrative person immediately.
4.    The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.
5.    Submit a photo or the front and back of the officer business card if a case number is being assigned to the vice president of administration.

Vehicle Crash
1.     If involved in a vehicle crash, provide all information requested of you and provide officials with the necessary insurance information.  Also, be sure to obtain insurance information from the other drivers involved. (See Accident Protocol posted at the site).  Always call the police- never leave the scene until given permission by law enforcement.
2.    Document the event on an incident report as soon as possible after the fact.  Notify the manager and on-call administrative personnel immediately.
3.    The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.

Contact with Law Enforcement in the Community
1.    If you have contact with law enforcement or the fire department while in the community, as a part of your work, follow the procedures described in “Requested Law Enforcement” or “Unannounced Law Enforcement” above, depending on who initiates the contact.  
2.    Document the event on an incident report as soon as possible after the fact.  Notify the manager and on-call administrative personnel immediately.
3.    The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.

Reporting Incidents and Emergencies

When an incident occurs:
a.     The employee who is supervising at the time of the incident:
o    Immediately calls 911 if there is a medical emergency or a physical or sexual assault in progress;
o    Immediately (before leaving the shift) notifies:
    The assigned manager or senior manager;
    The on-call RN, if the incident resulted in an injury to the individual; and
    The administrative on-call personnel
o    Completes an Incident Report and any other related documentation, i.e., Health Care Progress Notes, Entry Notes, communication book, and a BIRF, if applicable
b.    The manager:
o    Reviews each incident report and related documents the next working day for accuracy and thoroughness, to identify any patterns and to determine corrective action.  The manager will ask for the incident report to be rewritten if the content is not accurate or not written factually or professionally.  
o    The manager is responsible for completing the incident report and for any follow-up related to the incident, i.e. retraining, disciplinary action, etc.
o    Faxes or brings the incident report to the senior manager the next working day following the incident
c.    The senior manager:
o    Reviews the incident report for accuracy and thoroughness, returning it to the manager if changes or additions are needed.
o    They sign/initial the report, below the designated coordinator’s signature
o    Scans or e-mails the incident report to the “Incident Reports” e-mail address at Mains’l

d.    The manager, or senior manager in their absence, reports the incident to the person’s legal representative or designated emergency contact and case manager within 24 hours of:
o    An incident occurring while services are being provided
o    Within 24 hours of discovery or receipt of information that an incident occurred, unless we have reason to know that the incident has already been reported, or
o    As otherwise directed in a person’s Coordinated Services and Support Plan (Support Plan) or Coordinated Services and Support Plan Addendum
o    A copy of the incident report is sent to these persons, if requested
o    The senior manager sends a copy of the incident report to the county satellite licensor for any incident that involves serious injury, death, or change in health status that may affect continuation of services

e.    When the on-call administrative personnel receives the call from the employee:
o    They must verify whether the employee has reached the manager or senior manager to provide the notice to the legal representative or designated emergency contact and case manager, within 24 hours of the incident
o    Notify the following agencies as appropriate, within 24 hours:

    Death or Serious injury            Office of Ombudsman for Mental Health and
Developmental Disabilities FAX 651-797-1950
    AND
Department of Human Services, Division of Licensing FAX 651-431-7673

    Maltreatment                Minnesota Adult Abuse Reporting Center
(MAARC) at 1-844-880-1574 or online at mn.gov/dhs/reportadultabuse/ or for minors call law enforcement of the county Child Protection Agency Death, Serious Injury, or fire    County Satellite Licensor that causes structural damage or requires the fire department

f.    All employees receive ongoing training regarding emergency response procedures and responding and reporting incidents and emergencies. 
g.    When reporting a maltreatment incident, specifically, the person’s legal representative and case manager must be notified unless there is a reason to believe that either party is involved in the suspected maltreatment.  The information that must be disclosed is the nature of the activity or occurrence reported and the agency that received the report.
h.    The on-call administrative personnel notifies Chuck Jakway, vice president of administration, about any incidents report to MAARC, death, serious injury, police or fire rescue.  In the absence of the vice president of administration, John Jakway, shall be notified.  The vice president of administration, or his designee, initiates an internal review of incident reports of death and serious injuries that occurred while services were being provided and those that were reported by the program as alleged or suspected maltreatment, for identification of incident patterns, and implementation of corrective action as necessary to reduce occurrences.  The internal review will include an evaluation of whether:
1.    The policies and procedures were adequate
2.    Related policies and procedures were followed
3.    There is need for additional staff training
4.    The reported event is similar to past events with the persons or the services involve to identify incident patterns
5.    There is need for corrective action by the program to protect the health and safety of the persons receiving services and to reduce future occurrences
i.    Based on the results of this review, a corrective action plan is developed, documented, and implemented to correct current lapses and prevent future lapses in performance by staff or the agency, if any.  Internal Reviews are completed within 30 calendar days of the report.  
    When the initial reporter believes the incident was maltreatment, the on-call administrative personnel sends a Status of Report of Suspected Maltreatment letter to the initial reporter at their home address, with two working days.  
j.    The person conducting an internal review of maltreatment follows the Reporting and Responding to Maltreatment Policy and Procedure.
k.    The person conducting a review of emergency use of manual restraints follows the Emergency Use of Manual Restraint Policy and Procedure.

Record Keeping: 
1.    The review of an incident will be documented on the incident reporting form and will include identifying trends or patterns and corrective action, if needed.
2.    Incident reports will be maintained in the person’s record.  They will also be e-mailed/scanned into the incident report e-mail address ireport@mainsl.com.  Incident reports and corresponding documentation (MAARC reports, Internal Reviews, DHS determination letters, Status of Maltreatment Status Letters and Ombudsman Reports will be stored in this e-mail box.  

Critical Incidents

A critical incident is any incident that: involves illegal activity, results in significant injury to a person receiving services or staff, the death of a person or staff, has significant negative impact on a member of the neighborhood or community or is judged to potentially have a high level of risk/exposure for the agency.   

The procedure for managing critical incidents is as follows:
1.    Call 911 if appropriate.
2.    The staff present and most immediately involved in the incident calls the administrative on-call personnel.
3.    The administrative on-call personnel call the assigned senior manager; together they determine whether this is a critical incident. If it is determined to be a critical incident, the senior manager contacts one of the persons listed below in #4.  If the senior manager is not available, the administrative personnel will proceed to step # 4. 
4.    Critical Incident Lead-  Notify one of the following in the order listed:
 
In Minnesota:
Anne Roehl         612-597-9486 (c)
John Jakway        612-240-7642 (c)
In California:
Anne Silcher         530-723-2901 (c) Jamie Markey        530-723-0322 (c)
 
5.    When one of the above persons is contacted, they become the critical incident lead and the primary contact.  It is this person’s responsibility to direct all agency activity to the incident until it has been resolved. 
6.    Media Lead- When there is request or potential requests for comment from any external stakeholders or media agencies, only the following people should provide comments, in the order listed:
Corporate (Minnesota, California)
Tracy Hinkemeyer    612-987-3910 (c)
Anne Roehl         612-597-9486 (c) 
The media lead will work, together with the critical incident lead and senior leadership team, to respond to any media requests or questions.
7.    No other staff should initiate or respond to any contact from external stakeholders or the media unless specifically requested to do so by a member of the Executive Team.  Any written reports or correspondence are to be reviewed by the critical incident lead and media lead prior to release. 
8.    Critical incidents could occur at the Mains’l offices.  The Mains’l offices will keep a current emergency response contacts list of whom to call in case of specific kinds of emergencies such as damage (internal or external), disturbances, fire alarms, gas interruption, etc.  This list will be reviewed and updated at least annually by the vice president of administration. 

 

 

If you suspect, witness, or become aware of maltreatment of a vulnerable adult or a child, report immediately!

• Immediately call 911 if you observe or are aware of a physical or sexual assault in progress;
• Immediately (as soon as possible, but not more than 24 hours from initial knowledge) contact the Mains’l administrative on-call personnel. Mains’l does not release identifying information about the mandated reporter unless given permission by the mandated reporter, or as required by law. Only information about the suspected maltreatment or injury is reported;

Where to report maltreatment:

To Report to Mainsl, call the administrative on-call phone at 612-598-5700

If you choose to report outside Mainsl:

For Adults: call 1-844-880-1574 or go to:mn.gov/dhs/reportadultabuse/ to report

For Children: Contact Law enforcement or locate the local child welfare agency phone number by going to: http://mn.gov/dhs/people-we-serve/children-and-families/services/child-p... or for a child living in foster care call 651-431-6600

If you choose not to call the Mains’l administrative on-call person, you need to report directly to the Minnesota Adult Abuse Reporting Center (MAARC-for adults) or the local child welfare agency (for children) if you suspect maltreatment;

• Reports concerning suspected abuse or neglect of a child who lives in a home that is licensed as child foster care, should be made to the Department of Human Services, Licensing Division’s Maltreatment Intake line at (651) 431-6600.
• Reports concerning suspected abuse or neglect of a child who does not live in licensed child foster care should be made to the local county social services agency or local law enforcement. 

Suspected maltreatment must be reported.

You do not need to have proof that maltreatment has occurred.

How people learn about responding to and reporting maltreatment

Mains’l provides awareness and education to our employees and the people we support on responding to and reporting maltreatment.

1. All employees receive orientation training on their responsibilities as a mandated reporter, including online and in person training.  Review of this policy and procedure, statutes referenced in policy, the Service Questionnaire and Safety Plan and the Home Safety Plan also know as the Program Abuse Prevention Plan () is required when applicable, within 72 hours of first working in a direct care service and then participate in ongoing training each year. Training is documented for each employee.
2. All people receiving services and their guardian( s)  (when applicable) receive orientation to this policy and procedure, the Service Questionnaire and Safety Plan, and the Home SafeteySafety Plan, also known as the Program Abuse Prevention Plan (when applicable) within 24 hours of starting services with Mains’l. For a person whom would benefit more from a later orientation, the orientation may take place within 72 hours of starting services. This orientation is documented on the Orientation for Person Receiving Supports Form
3. This policy and procedure is made readily accessible to people by posting the critical information at each work location.

The who, what, where, why, and how for responding to and reporting maltreatment

Who is considered a vulnerable individual? In general, any person who needs assistance to adequately care for him or herself, and is therefore at a greater risk of maltreatment, is considered a vulnerable individual. Based on Minnesota laws, any person receiving services from Mains’l is considered either a vulnerable adult or child. The definition of a child for maltreatment reporting is a person who has not reached age 18.

Who is considered a caregiver? "Caregiver" means and individual or facility who has responsibility for all or a portion of the care of a vulnerable adult voluntarily, by contract, or by agreeement. Caregiver does not inlcude an unpaid caregiver who provides incidental care. 

What is maltreatment? For vulnerable adults, maltreatment is defined as abuse, neglect, or financial exploitation. For children, maltreatment is defined as physical abuse, sexual abuse, and neglect. Definitions of each type of maltreatment are provided below in the definitions section. For complete definitions, please see the Minnesota Statutes listed above.

Who is required to report maltreatment? While anyone can report, many people are required by law to report, including you.  A complete list of who is required to report can be found in the Statutes listed above. Some professionals who are mandated reporters are people who work in the following areas:

IF YOU SEE SOMTHETHING.....

• Care of vulnerable adults or minor children; including relatives and other paid and unpaid caregivers
• Healing arts
• Social  services
• Hospitals, medical clinics, and nursing homes                     
• Psychological or psychiatric treatment
• Child care  and education
• Law enforcement and corrections
• Vocational rehabilitation
• Medical examiner or coroner

What is required to be reported? Suspected maltreatment and any injury that cannot be explained must be reported within 24 hours of finding out.  Definitions of maltreatment are listed in this document.

For children, if you know or have reason to believe a child is being or has been neglected or physically or sexually abused within the past three years, you must immediately make a report to the child protection unit of the local social service agency.

Who do I report to? For the suspected maltreatment of a vulnerable adult, report to the Minnesota Adult Abuse Reporting Center (MAARC). For suspected maltreatment of a child, report to law enforcement or the local child welfare agency. We also ask that you contact the Mains’l administrative on-call personnel.

What happens at Mains’l after a report is made? When Mains’l has reason to believe that an internal or external report of alleged or suspected maltreatment has been made, we also report and respond.

1. When an internal maltreatment report is received, the Mains’l administrative on-call personnel is responsible for deciding if the report should be forwarded to the Minnesota Adult Abuse Reporting Center (MAARC) or local child welfare agency. If the administrative on-call person is involved in the suspected maltreatment, contact your senior manager, so they can take responsibility for deciding if the report should be forwarded to MAARC/child welfare.  When suspected maltreatment has occurred, the report must be sent to MAARC/child welfare within 24 hours.
2. If you have reported internally, you will receive, within two working days, a written notice that tells you whether or not your report has been forwarded to MAARC/child welfare.  The notice will be given to you in a manner that protects your identity.  It will inform you that, if you are not satisfied with the decision on whether or not to report externally, you may still make your own report to MAARC/child welfare.  It will also inform you that you are protected against any retaliation if you decide to make a good faith report to MAARC/child welfare.
3. An internal review is completed within 30 calendar days and corrective action is taken, if necessary, to protect the health and safety of vulnerable people.  The review includes an evaluation of whether:
   • the policies and procedures were adequate
   • related policies and procedures were followed
   • there is a need for additional straff training
   • the reported event is similar to past events with teh vulnerable person or the services involved; and 
   • there is a need for Mainsl to take corrective action to protect the health and safety of people

   Internal reviews are completed by Chuck Jakway, Vice President of Administration or a designated Senior Manager.  Mains’l documents completion of the internal review and will provide a copy to the commissioner immediately upon request.

4. Based on the results of the internal review, Mains’l develops, documents, and implements a corrective action plan designed to correct current lapses and prevent future lapses in performance by the agency or a specific person/group of people, if any.

What is the Minnesota Adult Abuse Reporting Center? The Minnesota Adult Abuse Reporting Center was established on 7/1/15 to replace the county based Common Entry Point system.  MAARC is the central location for receiving reports of vulnerable adult maltreatment.

What are local child welfare agencies? Each county in the state has a local child protection/welfare agency responsible for taking reports and investigating. The number for your local child welfare agencies can be found online and is included in orientation materials.

Who is the Mains’l administrative on-call personnel? The administrative on-call personnel is a group of employees at Mains’l who are extensively trained in maltreatment reporting. This team rotates an administrative cell phone for one week at a time in addition to their regular job duties. They are expected to answer the phone or return phone calls as soon as they can. With the caller, they walk through the steps required to complete maltreatment reporting and ensure the health and safety of the person who may have been maltreated.

How much time does a mandated reporter have to make a report? No longer than 24 hours from the time you believe or know that witnessed or suspected matreatment occured

Any person making a good faith report in a timely manner is protected from any civil or criminal liability that might otherwise result from their actions. 

What happens if I do not report suspected maltreatment? There are many things that can happen if you do not report including:

• the continuation of maltreatment to the person
• you being removed from your caregiver responsibilities
• you may be found guilty of a misdemeanor and liable for damages caused by the failure
• you may not clear a background study required for many jobs

If you are asked to not report something, you can explain to the person that you are required by law to report. You also do not have to inform the person that you are making a report, go ahead and make the report if you suspect maltreatment has occurred.

Will I be protected from retaliation if I make a report?  Yes, Mains’l will not retaliate against anyone for making a report in good faith (an honest report) and takes action to protect people who report. There are also laws in place to protect people who make good faith reports.

A person who intentionally makes a false report may be found liable in a civil suit for any actual damages suffered by the reported facility, person or persons and any punitive damages up to $10,000.00 and attorney’s fees.

What is therapeutic conduct? Some of the definitions reference therapeutic conduct. It refers to services and caregiver responsibilities that are provided in good faith and in the interests of the vulnerable individual where an accident or injury might occur that was not intended to harm.

What is considered an accident? A sudden, unforeseen, and unexpected occurrence or event which is not likely to occur, and which could not have been prevented by exercise of due care. It is also considered an accident if the occurrence or event happens when an employee or the person providing services is in compliance with the laws and rules relevant to the occurrence or event.

What is considered serious harm? An injury that requires medical treatment that cannot be immediately provided by the present caregiver may be considered serious harm. The act of going to the doctor when no medical treatment is received is not considered serious harm.

How do I know how to protect the person receiving services? Before you perform any caregiver responsibilities, you should review the person’s Service Questionnaire and Safety Plan that was written specifically for the person receiving services that addresses the vulnerable individual’s susceptibility to abuse, neglect, and financial exploitation, as well as other vulnerabilities. Review this document before services are provided so you are prepared. The individual receiving services participates in the development of this plan to the fullest extent possible. The plan is reviewed and if necessary, revised at least annually. If after reading the plan you have questions, please make sure to ask the person responsible for training you.

Maltreatment definitions for adults (See MN Statutes for complete definition and additional information) 

https://www.revisor.mn.gov/laws/2022/0/Session+Law/Chapter/98/2022-08-01...

Abuse: Abuse can be physical, emotional, verbal, or sexual. This includes but is not limited to:
1.    An act against a vulnerable individual that includes:

a.    assault 

b.    the use of drugs to injure or facilitate crime

c.    the solicitation, inducement, and promotion of prostitution

d.    criminal sexual conduct 

2.    Conduct which is not an accident or therapeutic, which produces or could reasonably be expected to produce physical pain or injury or emotional distress, including, but not limited to the following:

a.    hitting, slapping, kicking, pinching, biting, or corporal punishment 

b.    use of repeated or malicious oral, written, or gestured language or the treatment of a vulnerable individual which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing or threatening;

c.    use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable individual from other persons against their will.

3.    Sexual contact or penetration between a person providing services and a vulnerable individual. 

NOTE: It is not considered abuse when a vulnerable adult, who is not impaired in judgment or capacity by mental or emotional dysfunction or undue influence, engages in consensual sexual contact with a person providing services, when a consensual sexual relationship exists; or for a person, including a facility staff person, when a consensual sexual personal relationship existed prior to the care giving relationship.

4.    The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult’s services will to perform services for the advantage of another. 

Caregiver:  Means an individual or facility who has responsibility for all or a portion of the care of a vulnerable adult voluntarily, by contract, or by agreement. Caregiver does not include an unpaid caregiver who provides incidental care. 

Neglect: Neglect means neglect by a caregiver or self-neglect. 
1.    “Caregiver neglect” means the failure or omission to supply a vulnerable individual with care or services, including but not limited to food, clothing, shelter, health care, or supervision, which is reasonable and necessary to obtain or maintain the person’s physical or mental health or safety, and is not the result of an accident or therapeutic conduct.

 2.    “Self-neglect “ means neglect by a vulnerable adult of the vulnerable adult’s own food, clothing, shelter, health care, or other services that are not the responsibility of a caregiver which a reasonable person would deem essential to obtain or maintain the vulnerable adults’ health, safety, or comfort. 
    
Financial exploitation/abuse: Occurs when a person misuses funds, assets, or property of a vulnerable individual. This includes but is not limited to:
1.     Failure to use the vulnerable individual’s financial resources to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable individual, and the failure results in or is likely to result in detriment to the vulnerable individual;

2.    Willfully using, withholding, or disposing of funds or property of a vulnerable individual without legal
authority;

3.    Obtaining performance of services by a third person/party for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable individual; 
4.    Acquiring possession of, control of, or an interest in, funds or property of a vulnerable individual through the
use of undue influence, harassment, duress, deception, or fraud; 

5.    Forcing, compelling, coercing, or enticing a vulnerable adult against his or her will to perform services for the profit or advantage of another.

Maltreatment definitions for children

Physical abuse: Any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child’s care on a child other than by accidental means, or any physical or mental injury that cannot reasonably be explained by the child’s history of injuries, or any aversive or deprivation procedures, or regulated interventions, that have not been authorized under section 121A.67 or 245.825.  
Abuse does not include:
1.    Reasonable and moderate physical discipline of a child administered by a parent or guardian which does not result in injury. Unintentional injury resulting from physical discipline is physical abuse.
2.    The use of reasonable force by a teacher, principal, or school employee as allowed in section 121A.582.
Actions which are not reasonable and moderate (so NOT allowed) include, but are not limited to any of the following that are done in anger or without regard to the safety of the child:

• throwing, kicking, burning, biting, or cutting a child
• striking a child with a closed fist
• shaking a child under age three
• striking or other actions which result in any non-accidental injury to a child under 18  months of age
• unreasonable interference with a child’s breathing
• threatening a child with a weapon
• striking a child under age one on the face or head
• purposely giving a child poison, alcohol, or dangerous, harmful, or controlled substances which were not prescribed for the child by a practitioner, in order to control or punish  the child; or other substances that substantially affect the child’s behavior, motor coordination, or judgment, or that results in sickness or internal injury, or subjects the child to medical procedures that would be unnecessary if the child were not exposed to the substances 
• unreasonable physical confinement or restraint, including but not limited to tying, caging, or chaining; or
• in a school facility or school zone, an act by a person responsible for the child’s  care that is a violation under section 121A.58, which states corporal punishment is not allowed including: 
• hitting or spanking a person with or without an object; or
• unreasonable physical force that causes bodily harm or substantial emotional harm

Sexual abuse: Is when a person who has a significant relationship to the child or is in a position of authority controls or forces a child into any act considered by law to be criminal sexual conduct. Sexual abuse also includes any act which involves a minor which constitutes a violation of prostitution offenses. Sexual abuse also includes threatened sexual abuse. Sexual contact includes fondling, touching intimate parts and sexual intercourse. 

Neglect: Occurs when a child’s health and safety needs are not being met. This includes;
1.    Failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical or other care required for the child’s physical or mental health when reasonably able to do so;    
2.    failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so, including growth delay, which may be referred to as failure to thrive, that has been diagnosed by a physician and is due to parental neglect;    
3.    failure to provide for necessary supervision or child care arrangements appropriate for a child considering factors as the child’s age, mental ability, physical condition, length of absence, or environment, when the child is unable to care for the child’s’ own basic needs or safety, or the basic needs or safety of another child in their care;
4.    failure to ensure that the child is educated; 
5.    prenatal exposure to a controlled substance; 
6.    medical neglect:
a.    nothing in this section shall be construed to mean that a child is neglected solely because the child’s parents, guardian, or  other persons responsible for the child’s care in good faith selects and depends upon spiritual  means or prayer for treatment or care of the disease or remedial care of  the child in lieu of medical care; except that a parent, guardian, or caretaker, or a person mandated to report pursuant to subdivision 3, has a duty to report if a lack of medical care may cause serious danger to the child’s health. This section does not impose upon persons, not otherwise legally responsible for providing a child with necessary food, clothing, shelter, education, or medical care, a duty to provide that care;
7.    chronic and severe use of alcohol or a controlled substance by a parent or person responsible for the care of the child that adversely affects the child’s basic needs and safety; or
8.    emotional harm from a pattern of behavior which contributes to impaired emotional functioning of the child which may be demonstrated by a  substantial and observable effect in the child’s  behavior, emotional response, or cognition that is not within the normal range for the child’s age and stage of development, with  due regard to the child’s culture.

Remember… Respond immediately if you suspect, see, or hear about maltreatment!

• Immediately call 911 if you observe or are aware of a physical or sexual assault in progress;
• Immediately contact the Minnesota Adult Abuse Reporting Center for maltreatment of a vulnerable adult or the local child welfare agency for maltreatment of a child. 
• We also ask that you immediately contact the Mains’l administrative on-call personnel at 612-598-5700

Thank you for helping to protect people from harm. 
 

 

The AWAIR Program is intended to:

1. Establish an executive policy statement (we’re committed to safety)
2. Develop strategies to reduce workplace accidents and injuries
3. Provide for the safety inspection of worksites
4. Establish enforcement strategies to insure compliance
5. Provide for a training program (blood borne pathogens)
6. Provide for the assessment and control of hazards

 

Strategies to reduce workplace accidents and injuries:

Once each year; CRS sites will conduct an exercise to list together 3-4 workplace conditions or behaviors that can cause accidents and/or injuries.  In turn the supervisor will elicit solutions from the participants to address these conditions or behaviors.  The results will be sent to the vice president of administration for review and any follow up action necessary.

 

Inspections of Work Sites:

Home Safety Inspection Checklists will be used by CRS site staff to identify potential conditions that might also cause accidents or injuries.  These checklists are to be completed once every two months and sent to the vice president of administration for review and any follow up actions necessary.

 

Enforcement Strategies:

Employees who fail to follow safety rules or requirements will be subject to employee discipline as described in HR policies.

 

Training:

The primary training for safety in the workplace is blood borne pathogens.  Otherwise CRS sites will acquaint employees with local safekeeping practices.

 

Assessment and Control of Hazards:

Mains’l prohibits use and storage of hazardous materials.

 

Safety Coordinator:

The safety coordinator for Mains’l is the vice president of administration.

 

Food and Food Safety:

The manager of each home is responsible for the coordination of:

1. Food served to those persons receiving services meets the special dietary needs of each person as prescribed by their physician or dietician,
2. Three nutritionally balanced meals each day are served or made available to each person along with nutritious snacks available between meals.
3. Written menus are developed and adequate along with appropriate groceries and purchased and available’
4. Food is handled and properly stored to prevent contamination, spoilage, or a threat to the health of the person with all left overs labeled with identifying the contents and the date stored.

 

Goods Provided by the Agency:

The manager of each home is also responsible to ensure that:

1. Individual clean bed linens appropriate for the season and the person’s comfort, including towels, washcloths, and window coverings on windows for privacy are provided for each person receiving services,
2. Linens and in good repair and functional to meet the daily needs of persons living in the home and communicate any linen needs to the senior manager.
3. Household items for meal preparation and cleaning supplies to maintain the cleanliness of the home are available on site.

 

The senior manager for each home checks to verify that each person has clean and adequate supply of linens in good condition during their scheduled quarterly site visits and documents such on the Site Visit Checklist.

 

Personal Items:

The manager for each home is responsible to assure that:

1. Each person has an adequate supply of hygiene items appropriate to their specific needs and supplies are replenished as needed,
2. Each person’s personal hygiene supplies are not shared with other persons,
3. Personal health and hygiene items are stored separate from other personal items in a safe and sanitary manner.

 

Pets and Service Animals:

The manager of each home is responsible to assure that:

1. Pets and service animals within the home are immunized and kept in good health as required by state and local laws,
2. A record of immunizations and veterinary visits is kept on file at the site for each animal,
3. A person and the person’s legal representative are notified, before admission, of the presence of and kind of pets in the home.

 

Control of Pests and Vermin:

All staff will remain vigilant keeping an eye open for any signs of insects or vermin.  If sighted or suspected, staff will immediately report that information to their supervisor.  The supervisor will evaluate the report, gather any additional information needed, conduct a site visit and report their findings to the senior manager or maintenance.

 

The senior manager with consultation with the vice president of administration will immediately summon an exterminator to report to the site within 24 hours.  Exterminators have protocols on treating homes and sites on addressing furnishings, furniture and household structures and environments.  This includes the extermination of bed bugs for which there is a specific protocol.

Service Recipient Records

Documents that are created or received by Mains’l that pertain to a person receiving services are saved in the person’s secure electronic record or paper file.  

For paper files, after a County Foster licensing review, information is removed from the individual’s medical and plan file and scanned into the Mains’l document management system.  At this time, information that has been summarized into another format (e.g. data into a progress review) may be discarded. Managers organize the information to be scanned as follows:

1.    Separate the documents into the categories of:

• Program
• Medical
• Financial

2.    Incorporate all documents from work books into the primary file and remove pages that are          duplicates or are general in nature and not specific to the individual.
3.    Prepare all documents for scanning:

• Within the categories above, arrange them in the order they appear in the plan file or medical file, according to the table of contents 
• Organize all pages chronologically and orient all pages within the pile the same direction
• Remove all staples
• Straighten all folded, curled edges at the top of the page

4.    Scan documents into the appropriate category within the Fortis  system.
5.    Once scanning is complete, verify that all pages have been scanned and are readable      before destroying the original.

Program Records

1.    The program services, support services and human resources departments are responsible for scanning these documents:

• Incident Reports        
• Contracts            
• Licensing documents        
• Policies and Procedures

2.    Prepare all documents for scanning as follows:

• Organize all pages chronologically and orient all pages within the pile the same direction
• Remove all staples
• Straighten all folded, curled edges at the top of the page

3.    Scan documents into the appropriate category within the document management system
4.    Once scanning is complete, verify that all pages have been scanned and are readable before destroying the original.

    

                    (Rev. 1/8/19; SR
 

These rights are established for the benefit of persons receiving services. Mains’l will not require a person to surrender these rights as a condition of receiving services.  A guardian or legal representative or, when there is no guardian or legal representative, a designated person, may seek to enforce these rights.

Informing people about rights

1. On the day that services start, the manager provides a copy of the Service Recipient Bill of Rights to the person or the legal representative for them to keep. 
2. The manager provides an explanation of the rights to the person or their legal representative on that day or no later than five days after services have started. The person/legal representative signs an agency copy of the rights to document that the rights have been explained and that they received a copy.  
3. The manager files this form in the legal/consent section of the person’s data file. 
4. At each annual review meeting, the manager reviews the rights with the person and/or the legal representative, acquiring their signature(s) on the Service Recipient Bill of Rights form, which is then filed in the legal/consent section of the plan file. 
5. Reasonable accommodations are made by Mains’l to provide this information in other formats as needed to facilitate understanding of the rights by the person and their legal representative, if any. 

Implementing a rights restriction
Restriction of a person’s rights is allowed only if determined necessary to assure the health, safety, and well-being of the person.  Any restriction of these rights is documented in the person’s coordinated service and support plan. Mains’l support plan and must be approved by the person or their legal representative before the restriction is implemented. Approval may be withdrawn at any time, at which time the right must be immediately and fully restored. Restrictions are reviewed, minimally, semiannually and more frequently if requested by the person or their legal representative if any, and case manager.

1. The manager initiates discussion of the restriction in a meeting with the support team. 
2. If the person and the team agree to a specific plan to restrict a right, the manager completes a Rights Restriction Summary, signed and dated by the person or their legal representative and submits it to the senior manager and the Disability Rights of California Association (CA only)  
3. Following review, the senior manager submits to the persons support team who responds in writing to the proposed restriction to indicate approval and/or any recommendations.
4. The senior manager or manager documents the outcome of the conversations on the rights restriction form and returns the form to the manager. If approved, the manager may implement the restriction.
5. The completed Rights Restriction Summary is filed in the legal/consent section of the person’s plan file.
6. The support team reviews a restriction at least semi-annually from the date of initial approval, or more frequently if requested by the person, legal representative, or case manager.
7. Approval for a restriction may be withdrawn at any time; the right must then be immediately and fully restored. Withdrawal must be in writing from each member of the individual’s team. If the decision is made during a meeting, the decision will be reflected on the Meeting Minutes Summary, and all team members will provide their signature that they were present and agreed to the change/s.
    

Employees review safety plans and support plans of the people who use our services to determine level of care needed and required around assistive lifting devices to support the person. Based on the safety plans and support plans of the people who use our services, employees of Mains’l are trained by managers, nurses or other designated trainer(s). Employees lifting or transferring people who use our services do so in accordance with the person’s safety plan and support plan.

When there are new assistive lifting devices assigned, a designated representative from the vendor or manufacturer of the device will come out to the work location and do initial training on the new device. It is the responsibility of the supervisor/support coordinator to carry this training forward and to train all other employees that work at the particular work location on the device.  Whenever possible specific videos will be utilized for initial and refresher training.

Every effort is made to make assistive lifting devices and other equipment/aids accessible to employees. If an employee has identified that there is a need for an assistive lifting device and/or other equipment/aids to safely transfer, move or reposition someone; they communicate this need to their supervisor immediately. 

Employees inspect equipment prior to use to make sure it is functioning properly referring back to their training. Equipment that is damaged, broken, or not functioning properly is not used. Employees notify their supervisor if the equipment is damaged, broken, or not functioning properly to ensure that it is not used by other employees until the equipment can be repaired. When a piece of assistive lifting equipment is damaged, broken, or not functioning properly, and a person  who uses our services needs an immediate transfer, employees call for assistance which may include another nearby site or the supervisor up to point of calling local police or fire department to ask for assistance. In the event that there is a waiting period to repair/replace the equipment, the supervisor will contact a rental agency for temporary replacement. 

Mains’l Health and Wellness department is responsible for:

1. Supporting the implementation of this policy;
2.  Reviewing training documentation, in partnership with the supervisor/support coordinator at work locations with assistive lifting device(s) to ensure employees have completed specific training to the device(s);
3. Supporting the Mains’l culture of Safety;

If assisting with movement of people  that use our services, using lift equipment and other aids to prevent  physical lifting and movement of  people  who use our services, according to written safety and support plans. 

Supervisors/Support Coordinators/other qualified trainers of programs with assistive lifting devices are responsible for: 

1. Providing sufficient  equipment/aids to ensure safe movement of people who use our services;
2. Ensuring equipment/aids are well maintained and repaired in a timely fashion;
3. Supporting the implementation of this policy;
4. Supporting  the Mains’l culture of safety;
5. Ensuring employees complete training that is specific to the assistive lifting device and people who use our services; the completion of this training is documented in the medical data file;
6. Ensuring employees complete initial and  refresher equipment use training;
7. Report all employee injuries in accordance with Mains’l Workplace Injuries and Workers Compensation policy and procedure;
8. Using lift equipment and other aids to prevent physical lifting and movement of people who use our services according to written safety and support plans. 

Employees of Mains’l:

1. Follow this policy;
2. Complete training on site specific lifting equipment and other aids (if applicable to your work location);
3. Follow site specific training for safe use of lifting equipment, slings, and other equipment/aids (if applicable to your work location);
4. Use proper lifting  techniques, lifting devices, and other  equipment/aids;
5. Notify supervisor of any injury sustained to the employee or person that uses our services;
6. Report  equipment in need of repair to supervisor immediately;
7. Report an identified need for new or additional assistive lifting devices and/or other equipment/aids to safely transfer, move or reposition someone to supervisor;
8. Notify supervisor of need for  refresher training with any equipment and aids;
9. Use lift equipment and other aids to prevent  physical lifting and movement of  people  who use our services according to written safety and support plans;
10. Support  the Mains’l culture of safety
     

This attendance procedure establishes guidelines to provide clarity for excellent attendance and to address any concerns of employee’s attendance and punctuality.  

Definitions of terms used in this procedure:

1.     Scheduled Work Time: Any time an employee is scheduled to work, including scheduled attendance at orientation, required meetings, and training sessions.

2.     Approved Absence: When an employee notifies their supervisor, according to designated time lines, of any absence, lateness, or early departure from their scheduled work time for an acceptable reason. The supervisor approves the employee’s request prior to the absence.

3.     Unapproved Absence: An absence from the work site during scheduled work time that was not pre-arranged according to the timelines set forth in the policies on Paid Time Off – Salaried and Hourly Employees, or FMLA.

4.     Tardy: Any late arrival for a scheduled work time without the pre-approval of the supervisor.

5.     Occurrence: Any single instance of an unapproved absence or tardy.

6.     No Call, No Show: An absence that is not communicated to the supervisor in advance of the scheduled work time or at any time during the scheduled work time.

Guidelines

Employees at Mains’l receive scheduled work time that is created in partnership with their supervisor. Scheduled work time is defined as any time an employee is scheduled to work, including scheduled attendance at orientation, required meetings, and training sessions. Employees at Mains’l are expected to arrive on time and to be prepared for their scheduled work time Ongoing tardiness can result in separation of employment. Due to the variety of the roles and responsibilities within the work we do, schedules may be required to change.

Occasionally there will be times that an employee is unable to work their scheduled work time. This includes any needed absence, lateness, or early departure from their scheduled work time for an acceptable reason. In order for this to be an approved absence, an employee notifies their supervisor according to the designated time lines in the in Mains’l paid time off and unpaid time off policies and procedures. The supervisor must approve the employee’s request prior to the absence.   

Every Occurrence is recorded unless the Occurrence is the result of one of the following:

1. A situation recognized by the organization as unavoidable (i.e. car accident on the way to work verified by an accident or police report.)
2. The Occurrence is caused by a serious illness, where the illness is documented by a physician within one week of the absence.
3. The Occurrence is recognized as a verifiable permissible leave as defined by State or Federal Statute such as Family and Medical Leave Act.

A single occurrence of a No Call, No Show, as defined in this policy is considered a voluntary termination of employment. 

Supervisors or other designee will make available the schedule in advance of the pay periods noting the scheduled work times of all the employees.  If there is a significant deviation from the standard schedule, the supervisor will notify the effected employee(s) in advance of the deviation. We provide 24 hour services at certain locations, and as a result an employee may need to stay beyond the end of their shift if a replacement employee does not arrive.
 

A Background Study Form that provides all of the information required to run a background study is completed by the person for whom the study is being completed on. This form is completed when a person is being considered for employment at Mains’l. A background study is then submitted after the person has accepted employment with Mains’l. The procedures that follow are outlined below and vary slightly based on state and program. 
Minnesota

1. Traditional Services Employees: The HR Coordinator or another designee processes all background studies and fingerprint receipts for traditional services. In the absence of the HR Coordinator, the HR Generalist is responsible for performing responsibilities related to background studies. 

• A study authorization form is completed by the potential new employee during or after an interview or meet and greet. 
• The HR Coordinator or another designee enters the background study information in the DHS system; NETStudy 2.0. 
• The HR Coordinator or another designee ensures they have provided the study subject with the Department of Human Services (DHS) privacy notice prior to initiating the background study, that the study subject has been informed when a study subject’s background study may be transferrable, and that a Mains’l designee has verified the study subject’s identity by viewing one of the Acceptable Forms of Identification to confirm that the information that will be provided in the background study application is correct. 
• The HR Coordinator or another designee selects a provider from the drop down menu to affiliate the study subject with the appropriate entity. 
• Once all information has been entered (first name, last name, date of birth and social security number), the HR Coordinator or another designee will initiate the study and complete payment.
• The HR Coordinator or another designee will then fill in the applicant’s personal information (first name, middle name, last name, date of birth, address, race, sex, eye color, hair color, height, weight, place of birth, aliases and prior out of state addresses within the past 5 years). The personal descriptive information is required by the Minnesota Bureau of Criminal Apprehension (BCA) and Federal Bureau of Investigation (FBI) to conduct fingerprint-based criminal record checks. 
• Once completed NETStudy 2.0 will perform an automatic search of the Minnesota Nurse Aide Registry (NAR), the Minnesota Exclusion List, and the Federal Office of Inspector General List of Excluded Individuals and Entities (LEIE) to determine if there are potential matches to the background study subject in these databases. In addition, if the study subject has lived in any state other than Minnesota within the last five years and this information was recorded on the profile page, the system will provide links for any known professional licensing databases for those states. These registries are not required for the background study to be completed and the searches are manual.
  • In the event that there is a potential match to an individual on the Federal Exclusion List, the Minnesota Exclusion List, or the Minnesota Nurse Aide Registry, there will be a blue hyperlink in the Research Requirements column advising the user of a possible match.
  • It is the provider’s responsibility to determine whether the information is a match and if so, whether it affects the hiring decision. A match on one of these registries may not cause a background study disqualification. 
  • NOTE: NETStudy 2.0 performs automatic rap back-like searches on the federal List of Excluded Individuals and Entities (LEIE), the Minnesota DHS list of Excluded Individuals, and the Minnesota Nurse Aide Registry. As stated above, the information is only valid if accurate and complete identifying information was provided for the background study, including SSN, date of birth, and correct spelling of names.
• Based off of the results from the search of the applicant’s name on the Federal Exclusion List, the Minnesota Exclusion List, or the Minnesota Nurse Aide Registry, the study will continue.
  • A background study does not begin processing until the applicant is fingerprinted and photographed at a DHS authorized fingerprint and photo service location.
• The HR Coordinator or another designee will provide a copy of the Fingerprint Authorization form and receipt of payment for the fingerprints to the study subject. Background study subjects must show the fingerprint and photo technician a copy of the Fingerprint Authorization form prior to being fingerprinted. Study subjects may show a paper copy of the form or an electronic copy on a mobile device.
• Once the background study subject has gone to the designated fingerprint and photo location to get their fingerprints completed, the supervisor of the study subject will be contacted to schedule onboarding.
• Once the study subject is fingerprinted and photographed, DHS will notify the study subject and the program if the study subject must remain supervised while the background study is being completed, or if the study subject may provide unsupervised services.
• A Supervision Required status of:
  • “No”- means that the study subject does not require supervision while the determination is in process.
  • “Yes”- means that the study subject requires supervision while the determination is in process.
  • “Remove”- means that the study subject must be immediately removed from any position that provides direct contact services.
• The HR Coordinator or another designee will receive notification from DHS in regards to the study subject’s status throughout this time
  • For applicants with a status of Eligible: the study subject has cleared the background study.
  • For applicants with a status of disqualified: the applicant may request reconsideration. Mains’l will not continue to employ anyone that has been disqualified. 
• The HR Coordinator or another designee will contact the supervisor and let them know of the study subject’s status:
  • Study subject has passed and doesn’t require supervision at this time.
  • More time is needed to complete the background study and the entity may choose whether to allow the subject to work or volunteer while the background study is being completed. The entity is not required to provide continuous direct supervision.
  • More time is needed to complete the background study and the entity may choose whether to allow the subject to work. The subject must be under continuous direct supervision. 
  • For applicants with a status of disqualified: the applicant may request reconsideration. Mains’l will not continue to employ anyone that has been disqualified. 
• The HR Coordinator or another designee will close the study subject’s profile on NetStudy 2.0 once the subject’s status has been finalized. This will then add the study subject to the affiliated roster.
• The HR Coordinator or another designee will enter the date of clearance in ISS (ProviderPro).

2.    Participant Directed Employees: The director of participant directed services or the participant directed services (PDS) manager processes all background studies and fingerprint receipts for participant directed services. 

• Study authorization forms are completed by the new employee as part of their hiring packet given to them by their managing party.
• The PDS manager or director enters the background study information in the DHS system; NETStudy 2.0. 
• The study subject is provided with the Department of Human Services (DHS) privacy notice prior as part of their hiring packet, which includes information about when a study subject’s background study may be transferrable. The PDS manager or director verifies the study subject’s identity by viewing one of the Acceptable Forms of Identification to confirm that the information that will be provided in the background study application is correct. 
• The PDS manager or director selects the Fiscal Support Entity provider from the drop down menu to affiliate the study subject with the appropriate entity. 
• Once all information has been entered (first name, last name, date of birth and social security number), the PDS manager or director will initiate the study and complete payment.
• The PDS manager or director will then fill in the applicant’s personal information (first name, middle name, last name, date of birth, address, race, sex, eye color, hair color, height, weight, place of birth, aliases and prior out of state addresses within the past 5 years). The personal descriptive information is required by the Minnesota Bureau of Criminal Apprehension (BCA) and Federal Bureau of Investigation (FBI) to conduct fingerprint-based criminal record checks. 
• Once completed NETStudy 2.0 will perform an automatic search of the Minnesota Nurse Aide Registry (NAR), the Minnesota Exclusion List, and the Federal Office of Inspector General List of Excluded Individuals and Entities (LEIE) to determine if there are potential matches to the background study subject in these databases. In addition, if the study subject has lived in any state other than Minnesota within the last five years and this information was recorded on the profile page, the system will provide links for any known professional licensing databases for those states. These registries are not required for the background study to be completed and the searches are manual.
  • In the event that there is a potential match to an individual on the Federal Exclusion List, the Minnesota Exclusion List, or the Minnesota Nurse Aide Registry, there will be a blue hyperlink in the Research Requirements column advising the user of a possible match.
  • It is the provider’s responsibility to determine whether the information is a match and if so, whether it affects the hiring decision. A match on one of these registries may not cause a background study disqualification.
  • NOTE: NETStudy 2.0 performs automatic rap back-like searches on the federal List of Excluded Individuals and Entities (LEIE), the Minnesota DHS list of Excluded Individuals, and the Minnesota Nurse Aide Registry. As stated above, the information is only valid if accurate and complete identifying information was provided for the background study, including SSN, date of birth, and correct spelling of names.
• Based off of the results from the search of the applicant’s name on the Federal Exclusion List, the Minnesota Exclusion List, or the Minnesota Nurse Aide Registry, the study will continue.
  • A background study does not begin processing until the applicant is fingerprinted and photographed at a DHS authorized fingerprint and photo service location.
• The PDS manager or director will provide a copy of the Fingerprint Authorization form and receipt of payment for the fingerprints to the study subject. Background study subjects must show the fingerprint and photo technician a copy of the Fingerprint Authorization form prior to being fingerprinted. Study subjects may show a paper copy of the form or an electronic copy on a mobile device.
• Once the study subject is fingerprinted and photographed, DHS will notify the study subject and the program if the study subject must remain supervised while the background study is being completed, or if the study subject may provide unsupervised services. The PDS manager or director will receive notification updates from DHS throughout this process. The PDS manager or director will notify the employee and managing party when an employee may begin working or at any time if they must be removed or are disqualified. 
  • For study subjects with a status of Eligible: the study subject has cleared the background study and may begin working.
  • For study subjects with a status of disqualified: the applicant may request reconsideration. Mains’l will not continue to employ anyone that has been disqualified. Person may not work unless a disqualification has been set aside.
• A Supervision Required status of:
  • “No”- means that the study subject does not require supervision while the determination is in process and may begin working. 
  • “Yes”- means that the study subject requires supervision while the determination is in process and is not eligible to begin working.
  • “Remove”- means that the study subject must be immediately removed from any position that provides direct contact services.
• The PDS manager or director will contact the managing party and employee to let them know of the study subject’s status:
  • More time is needed to complete the background study and the entity may choose whether to allow the subject to work or volunteer while the background study is being completed. The entity is not required to provide continuous direct supervision. This person may begin working. 
  • More time is needed to complete the background study and the entity may choose whether to allow the subject to work. The subject must be under continuous direct supervision. This person may not begin working. 
  • For applicants with a status of disqualified: the applicant may request reconsideration. Mains’l will not continue to employ anyone that has been disqualified. 
• The PDS manager or director will close the study subject’s profile on NetStudy 2.0 once the subject’s status has been finalized. This will then add the study subject to the affiliated roster.
• The PDS manager or director will enter the date of clearance in the PDS background study tracking document.

Name Changes in Minnesota 
If an employee has gone through a name change, the employee is responsible for notifying Mains’l by completing an Employee Information Change Form and presenting necessary documents to show legal proof of change their name. 

The agency’s Sensitive Information Person and those with the Administrative Rights role have the ability to edit data in NETStudy 2.0. 

When an update is made to the last name or date of birth of the background study after the background study is submitted, whether the update is due to an error or a legal name change, the Background Study Profile Update Request must be submitted to DHS. The agency’s Sensitive Information Person or those with the Administrative Rights role are responsible for submitting the Background Study Profile Update Request. 

California

1. Traditional Services Employees: The HR generalist will process a pre-employment live scan fingerprinting for traditional licensed and non-licensed services. Background Studies for traditional services will be completed by the prospective employee immediately following the contingent job offer. 

• Once the live scan fingerprinting is conducted, the prospective employee will return the live scan form record to the HR generalist or designated representative.
• The live scan determination with be sent electronically to Mains’l via a SMSS electronic mailbox or posted on the licensure live scan fingerprint clearance website.
• A Criminal Background Clearance Transfer Request can be submitted for licensed facilities and substituted for a new live scan fingerprinting where applicable. The prospective employee must be active and clear in the licensing fingerprint system for the transfer to be possible. 
• Company policy is that all background studies are subjected to the Department of Social Services list of Non-Exemptible Crimes.
• The HR generalist or their designee will attach the original background study determination to the submission verification and file/scan into the personnel file.
• In the absence of the Generalist, another HR representative will be responsible for processing background studies and Criminal Background Clearance Transfer Requests.
• If clarification is needed regarding the background study process, the Human Resources Director will be responsible for interpreting this process.

2.    Consumer Directed Employees: Background checks for consumer directed programs are not required in California.
 

While impossible to detail every work situation and recommended appropriate behavior, the following are some examples of positive and role modeling behaviors that are expected of employees at Mains’l:

1. Arrive on time and to be prepared for their scheduled work time;
2. Using respectful and courteous language (abusive language is not acceptable behavior and doesn’t align with who we are as an organization);
3. Abiding by the Employee Pledge. Employees should be proud of their decisions and their actions. It is expected that employees are truthful in written documentation and statements;
4. Decisions and actions are aligned with Mains’l’s mission, vision, and core values;
5. Wearing clothing appropriate for the work being performed. All clothing should be of a business and/or casual nature; that is, covered midriffs and backs, skirts and shorts longer than finger-tip length. Appropriate footwear (no bare feet or open toed shoes) and concealed undergarments;
6. Complying with safety standards--use of transfer belts, back braces, proper assistive lifting devices, seat belts, wheelchair belts;
7. Maintaining work place cleanliness and orderliness;
8. Implementing Person Centered Practices;
9. Using work time efficiently and effectively so as to promote the best interests of the people served;
10. Restricting personal cell phone use to emergency situations.

Although it is not possible to list all forms of behavior that are considered unacceptable in the workplace, the following are examples of behavior that is not in alignment of who we are at Mains’l (this kind of behavior may result in written performance feedback, up to and including separation of employment):

1. Failing to follow any of the above mentioned positive and role modeling behaviors;
2. Theft, destruction, inappropriate removal, or misuse of Mains’l or person’s property;
3. Failing to report unethical, suspicious, or illegal conduct by other employees; 
4. Insubordination or other disrespectful conduct;
5. Possession of dangerous or unauthorized materials, such as explosives, firearms, or other weapons in the workplace. Physical assaults or threats to others;
6. Borrowing money or purchasing personal items from a person receiving services, selling merchandise or personal services to a person receiving services;
7. Working or being at work under the influence of alcohol or illegal drugs;
8. Possession, distribution, sale, transfer, or use of alcohol or illegal drugs or any prescribed drugs that could impair the ability to work in the workplace, while on duty, or while operating employer-owned vehicles or equipment;
9. Sleeping on the job during any time, except for those employees who work within an asleep overnight position;
10. Sexual or other unlawful or unwelcome harassment;
11. Conduct that is offensive, or discriminatory;
12. Violation of Mains’l policies or procedures;
13. Falsification or misrepresentation of information in applying for a position;
14. Failure or inability to complete all required training that is part of a job assignment;
15. Unsatisfactory performance or behavior;
16. Excessive absenteeism or any absence without notice;
17. Failure to obtain or maintain a current license or certificate required by Mains’l or by law;
18. Any other act that threatens the safety, health, or well-being of another person, or which is so serious that it disrupts work or discredits Mains’l in the community.
     

Employees disclose material or potential conflicts and any relationships, personal or professional, that may create the appearance of a conflict of interest to their supervisor as soon as they become aware of them so that safeguards can be established to protect all parties. 

The supervisor then reviews the situation with their senior leader and Human Resources to determine appropriate action.

The types of activities and relationships employees avoid include, but are not limited to:

1. Accepting or soliciting a gift, favor, or service that is intended to, or might appear to, influence the employee’s decision-making or professional conduct;
2. Accepting, agreeing to accept, or soliciting money or other tangible or intangible benefit in exchange for the employee’s favorable decisions or actions in the performance of his or her job;
3. Accepting employment or compensation or engaging in any business or professional activity that might require disclosure of confidential information or business secrets;
4. Accepting employment or compensation or engaging in any business or professional activity that is in direct or indirect competition or results in a possible or real negative impact on Mains’l’s business or customers; *
5. Accepting employment or compensation or any other activity that could reasonably be expected to impair the individual’s independent judgment in the performance of official duties.
6. Accepting employment or compensation or engaging in any business or professional activity that is in direct or indirect competition,*
7. Ownership by employee or family member in any outside agency that does or seeks to do business with Mains’l or is doing business in the human services field or,
8. Any other arrangements or circumstances, including family or personal relationships, which may dissuade the employee from acting in the best interest of the company.

 Rev. 10-08-2019
 

Reimbursable Employee Property
1.    Clothing, eye glasses, and wrist watches;
2.    Employee vehicles;
3.    Other personal property at the discretion of Mains’l.

*Damage to personal property resulting from negligence of the employee or violation of training protocols is not reimbursable. 

Reporting

1. Within two (2) working days of an incident in which personal property has been damaged, the employee completes the “Employee Property Damage Report” with the following information: 

• Date of incident; Description of incident;
• Item/article of damage;
• Type of damage;
• Cost of repair or replacement;
  • When there is damage to an article of clothing or a watch, the maximum reimbursement is $25.00.
  • Eye glasses are reimbursed at the actual cost of repair or replacement. The cost of an eye exam is not reimbursable.
• If applicable, name of person receiving service responsible for the damage.
• If the damage exceeds $250.00, 3 estimates are submitted.
• The supervisor analyzes the report, recommends necessary action, signs the report, and forwards it to the vice president of administration or HR designee who will investigate the incident and damage and make a determination.
• The vice president of administration or HR designee will request that a check is made payable to the store or repair center upon submission of a written estimate or invoice or to the employee upon submission of a paid receipt for the repair or replacement.
• The “Employee Property Damage Report” is maintained by the vice president of administration.

Mains’l supports a workplace that is free from the effects of drugs, alcohol, chemicals, and abuse of prescription medications. This Drug and Alcohol Free Workplace Policy and Procedure is provided to all employees in orientation and is available for employees to view on the portal at any time. 
Behavior Expectations 

• All employees must be free from the abuse of prescription medications or under the influence of a chemical that impairs their ability to perform their job responsibilities. 
• In almost all circumstances, the consumption of alcohol is not allowed while working. Consuming alcohol is never allowed while directly responsible for a person receiving services, in our vehicles, using machinery, or using equipment (owned or leased), and will result in corrective action up to and including termination. 
  • Exceptions to the possession or consumption of alcoholic beverages are allowed only for special events/functions expressly approved by a member of the senior leadership team. However, if you choose to consume alcohol at such events, you must do so responsibly and maintain your obligation to conduct yourself properly and professionally at all times.
• Being under the influence of a controlled substance, alcohol, or illegal drugs in any manner that impairs or could impair an employee’s ability to perform their job, is prohibited and will result in corrective action up to and including termination.
• In almost all circumstances, the use of a controlled substance is not allowed while working. The sale, manufacture, distribution, or possession of a controlled substance while working, while on our property, in our vehicles, using our machinery, or equipment, is never allowed and will result in corrective action up to and including termination.
  • Exceptions to the possession or use of doctor prescribed controlled substances are allowed only for expressly approved by a member of the senior leadership team. 
• Any employee convicted of criminal drug use or activity must notify their supervisor and human resources no later than five (5) days after the conviction. Criminal conviction for the sale of narcotics, illegal drugs or controlled substances will result in corrective action up to and including termination.
• Mains’l will notify the appropriate law enforcement agency when we have reasonable suspicion to believe that an employee may have illegal drugs in his/her possession while on duty during work hours. Where appropriate, we will also notify licensing boards.
• If any employee has reasonable suspicion that any of the situations noted above have occurred, they are required to immediately contact Mains’l as follows:
  • Call the supervisor of the employee who you suspect is not meeting the expectations above.
  • If the supervisor cannot be reached, contact the supervisor’s supervisor or human resources. 
  • If you cannot reach the above parties, contact the on call administrative personnel. 
  • The supervisor and/or the on call administrative personnel notify the director of human resources or the human resource generalist immediately to receive direction about the appropriate next steps and expectations. 

Voluntary Treatment
Mains’l encourages employees who may have a substance abuse problem to seek voluntary treatment. Employees who need assistance may obtain evaluation and/or counseling through the various private and public agencies that are available. The decision to seek diagnosis and accept treatment is the employee's responsibility. When requested, human resources will provide information regarding any available drug counseling, rehabilitation and employee assistance programs that an employee may enter through his or her health insurance.

Costs associated with any treatment or rehabilitation program may be covered by the employee's health insurance. However, costs not covered by the employee's health insurance, and that are not otherwise required to be paid by any applicable plan, are the employee's responsibility.

Requests for leave are handled in accordance with the Mains’l general leave policies and any applicable medical leave or disability discrimination laws. Except as otherwise required by law, Mains’l cannot guarantee that the employee is reinstated to the same or a comparable position upon return to work. 

Employees who voluntarily come forward to request assistance with a substance abuse problem or request a leave of absence to participate in treatment are not subject to disciplinary action for making the request. However, voluntary requests for assistance do not prevent disciplinary action for violations of this or any other policy or performance expectations. Employees may not escape discipline by requesting assistance and/or a leave after being selected for testing or violating this policy or other rules of workplace conduct. Employees who voluntarily seek treatment must still continue to meet all Mains’l job performance expectations and conduct standards. Mains’l may take disciplinary action up to and including termination of an employee who fails to meet our standards.

Drug, Alcohol, or Chemical Testing

• Reasonable Suspicion Testing: To protect against drug, chemical, and alcohol abuse in our workplace, testing may be required. The method of testing shall be determined by Mains’l and the company it uses for drug testing. The testing methods may include, among others, a breath test, saliva test, blood test, and/or urine test. 

Mains’l may test an employee for drugs and alcohol when there is a reasonable suspicion that the employee: 

• Is under the influence of drugs, alcohol or chemicals that may impair their ability to perform their job;
• Has violated rules prohibiting the use, possession, sale or transfer of chemicals, drugs, or alcohol while working, while on Mains’l premises, or while operating Mains’l vehicles or equipment.

It is strongly encouraged that whenever possible, at least two (2) supervisory employees agree that there is reasonable suspicion for a drug test. 

• Treatment Program Testing: Mains’l may require an employee to undergo drug, alcohol, and chemical testing with or without prior notice:
  • If the employee has been referred for chemical dependency treatment or evaluation, 
  • While the employee is participating in a chemical dependency program. 
  • For up to two years following completion of any prescribed chemical dependency treatment program.

Treatment program testing may include a return-to-work duties test to ensure the employee is able to perform their job responsibilities. 

Actions Taken for Positive Test Results 
Employees who receive a positive test result on a drug or alcohol test, refuse to undergo a required chemical, drug and alcohol test, or engage in other conduct that violates this policy are subject to discipline, up to and including termination.
Mains’l will not automatically terminate the employment of an employee for having a positive test result if;

• It is the first time the employee has had a positive test result and,
• The employee is meeting all other performance and conduct expectations with the agency and,
• The employee participates in an appropriate drug and alcohol counseling or rehabilitation program while maintaining employment. The employee is solely responsible for the cost of any such counseling or rehabilitation program, unless otherwise covered by the employee's health insurance plan.

Any employee who refuses to participate in a required drug and alcohol counseling or rehabilitation program, fails to successfully complete the required program, is also not meeting other performance and conduct expectations, or subsequently receives a second positive test result, will face discipline up to and including termination.

When an employee returns to work after a voluntary or required leave of absence, Mains’l attempts to reinstate the employee to his or her former position, if possible, provided the employee is still qualified to properly perform the requirements of the job. However, Mains'l cannot guarantee that the employee can return to the same or a comparable position upon return to work.    

Rights and Protections
Mains’l requires employees to undergo chemical, alcohol, and drug testing in the above circumstances. However, it is important that employees understand that they have the following rights and protections under this Drug and Alcohol Policy:                       

1. Right to Refuse Testing: Employees have the right to refuse to undergo chemical, drug, and alcohol testing. However, failure to undergo testing is treated as a failure to comply with this Policy and may result in termination of employment. A refusal to undergo testing includes attempting to or actually substituting, adulterating, tampering with a specimen or otherwise interfering with the collection or testing process.
2. Opportunity to Explain Positive Test Result: Within three working days after receiving notice of a positive test result on a test, the employee may submit information to the medical review officer (MRO), director of human resources, or human resource generalist  to explain the test result. 
3. Right to a Retest: If an employee receives a positive test result, the employee may request a retest (a second test) of the original sample at the employee’s own expense to confirm the positive test result. If the retest does not confirm the original positive test result, then no action will be taken against the employee based on the original sample. If the employee wishes to exercise this right, then the employee must notify the director of human resources, or human resources generalist in writing within five working days after receiving notice of the positive test result. The employee is responsible for paying the cost of the retest before the test is performed.
4. Right to Receive Test Results: Any employee or applicant has the right to obtain from Mains’l a copy of the test result report on any chemical, drug, or alcohol test. The request must be made in writing and submitted to the director of human resources, or human resource generalist.
5. Confidentiality of Test Results: Unless Mains’l receives the employee’s prior written consent, or as otherwise provided by law, neither Mains’l nor its testing laboratories discloses test result reports and other information acquired in the drug or alcohol testing process:

• to another employer, 
• to any third-party individual, 
• to any government agency,
• to any private organization. 

Evidence of a positive test result on a confirmatory test may be used without the individual's consent in a judicial, administrative, or arbitration proceeding; as required by federal law, regulation, or order; for the purpose of evaluation or treatment of the individual to a substance abuse treatment facility; or as otherwise authorized by law.

6. Access to Employee Medical and Personnel Files: Employees are allowed access to any and all information in the employee’s medical or personnel file relating to 

• positive test results,
• other information acquired in the drug and alcohol testing process, and
• conclusions from and actions taken based on the preceding.

     
Rev. 8/25/2020, HR Policy Team
 

Eligibility
Eligible employees are regularly scheduled (full time or part time), have successfully completed their training requirements and have been employed by Mains’l for a minimum of six (6) months prior to the course.

Eligible employees are in good standing with the agency, and have had no written performance feedback conversations within the last six months.

Educational opportunities eligible for assistance are those which develop the employee’s competence in his/her current position, or prepare them for a position to which they may be interested within Mains’l. 

Eligible courses for education assistance are those that require attendance during off-work hours.

Eligible courses for education assistance are provided by:

1.    Accredited colleges or universities;
2.    State or public school systems, adult education systems;
3.    Vocational or trade schools;
4.    Institutions offering seminars, programs, or conferences.

Funding
Mains’l will reimburse staff up to a maximum of $300 per course up to maximum of $1200 per 12 month period. 

Employees will secure a passing grade of “C” or above to receive any reimbursement. Expenses are validated by receipts and a copy of the final grade or certification presented to human resources prior to reimbursement. 

Covered expenses include tuition, fees and books required to satisfactorily complete the coursework. Other miscellaneous expenses such as, but not limited to parking, supplies, athletic fees and day care are not reimbursable. Mains’l will not reimburse any expenses covered by any other financial aid that does not have to be repaid (i.e. GI Bill, scholarships, and grants). 

Applications are approved quarterly (end of March, June, Sept & Dec.)

Approval does not entitle the employee to automatic, ongoing assistance. Each time an eligible employee would like to receive education assistance they need to apply for it.

How to Apply
Applicants complete the Education Assistance Application. Application forms are available on the Mains’l website through the employee portal. 

Submit the completed application to the Human Resources Department. Applications and grades submitted later than one year after the date of the course will not be reimbursed.

Interpretation
The Human Resources Department is responsible for interpreting the Educational Assistance Policy and Procedure. Deviations to this policy and procedure must be approved by the Human Resources Department. 
 

Definition and Explanations
Fair Labor Standards Act Job Classification: Refers to the standard by which an employee is paid and their eligibility for overtime. The three (3) categories of employee status at Mains’l. are:

1. Salaried Exempt: paid a predetermined salary and are exempt from overtime pay based on Fair Labor Standards Act. 
2. Salaried Non-Exempt: paid a weekly salary that equates to at least minimum wage for all hours worked and is entitled to overtime pay in addition to the salary. 
3. Hourly Non-Exempt: paid an hourly wage for every hour worked and are eligible for overtime pay for hours worked based on State and Federal wage and hour laws. The Mains’l work week is the seven (7) day period from Sunday at 12:01 am to Saturday at Midnight. See Payroll Policy/Procedure for your state regarding information on how overtime is calculated. 

*See Payroll Policy and Procedure for your state for more information.

Status 
Refers to the number of hours an employee is scheduled to work. There are three (3) categories. Hours picked up by employees that are not regularly scheduled or guaranteed to them in the future do not count towards time classification 

1. Full Time: Employees whose regular, predictable schedule is 35 hours or more per work week. Full time status is lost if the employee does not maintain this schedule for two consecutive pay periods. 
2. Part Time with Benefits: Employees whose regular, predictable schedule is between 30-34 hours per work week. Part time with benefits status is lost if the employee does not maintain this schedule for two consecutive pay periods. 
3. Part Time: Employees whose regular, predictable schedule is less 30 hours per week (Employees whose status is “on call” are categorized as part time).

Eligibility for Insurance
Refers to an employee’s eligibility to participate in the group medical, dental, vision, and life policies offered by Mains’l.

1. Eligible: Achieved under two (2) conditions:

• Employees hired for a regular schedule of 30 hours or more per work week. Upon completing the necessary paperwork, insurance is effective on the first of the month following sixty (60) days of employment. (See Insurance Benefits Policy/Procedure)
• A current employee whose regular, predictable schedule is increased to 30 hours or more per work week. Upon becoming eligible and choosing to participate in the group insurance program, the insurance is effective on the first of the month following sixty (60) days of eligibility. (See Insurance Benefits Policy/Procedure)
• Employees who work in our Participant Directed Services program are eligible for group medical only

2. Ineligible: 

• Employees hired to work less than 30 hours per work week based on a regular, predictable schedule. If an eligible employee’s scheduled hours fall below 30 per work week for two (2) consecutive pay periods, the insurance is ended and the employee is given the opportunity to continue insurance benefits in accordance with COBRA. (See Insurance Benefits Policy/Procedure)

The above classifications do not guarantee employment for any specific length of time. Employment is subject to the employee’s and the company’s respective rights to end the employment relationship at any time. Accordingly, unless expressly agreed to otherwise in writing, signed by the CEO, or the Corporate Human Resources Director. 
 

Coaching and Development Conversations

Coaching and development conversations describe a process by which Mains’l Services helps encourage employees to maintain accountability within their work performed and to support their development. 
Coaching and development conversations are intended to assist employees with their career development while helping the agency retain a high performing workforce of people engaged in work that has meaning and purpose. It is the policy of Mains’l to provide employees with ongoing support through continuous coaching and development. 

When a supervisor identifies areas for improvement within an employee’s job responsibilities, typically the first step is coaching and development conversations with the employee. As a guideline the conversation may include:

• The supervisor expressing what is working and not working with the employee’s execution of their job responsibilities;
• Identification of any additional training or support is identified, if needed;
• The employee and supervisor collaborate and partner to seek solutions to reach the needed improvement
• A summary of this meeting is captured and stored in a manner that can be produced at a later time. 

If coaching and development conversations are not successful, the employee may be engaged in a written performance  feedback process. The drafted written performance feedback (Success Plan) is reviewed by Human Resources before it is provided to the employee. The supervisor schedules a meeting with the employee and presents it to the employee.  The document includes the following information: 

1. The areas of improvement are described with specific dates and supporting data;
2. The needed outcomes for obtaining the expected performance is developed by the employee in conjunction with their supervisor. 
3. The success includes criteria that can be measured and quantified;
4. The supervisor and employee both sign the document;
5. A date is scheduled for the supervisor and employee to follow-up on progress within the plan;
6. The written performance feedback document will be filed in the employee’s file.

Management may vary from this procedure if circumstances demand. Although not the desired outcome of Mains’l, immediate separation of employment may be needed depending on circumstances.

90 Day Feedback

Employees may receive a written performance feedback evaluation after 90 days following the date of hire. In the case of a job transfer or change in job classification, an evaluation may be conducted 90 days after the change. Managers are responsible for initiating and conducting 90-day evaluations and completing them within two weeks of the due date. The manager and the employee will review different aspects of the employee’s job including the core responsibilities, training and documentation, and team work. The manager and the employee will review together what is working and not working and if there is further improvement needed. The employee can then set personal goals they would like to achieve before their annual feedback. 

Annual Review

Employees may receive an annual review at the anniversary of their hire date. Managers initiate and conduct these evaluations annually or bi-annually depending on the job title or as needed. During an annual review, the employee will review themselves and discuss what people like and admire about them, what they have accomplished within their work and what is working and not working related to their position. The supervisor will provide their comments as well with the employee. Together, the employee and the supervisor will discuss developmental areas that the employee may be interested in to grow within their role. The employee receives a copy of their review as well. 

360 Degree Feedback Tool (Internal and External)

360 Degree Feedback is a tool also available for all managers, senior managers, vice presidents and senior leadership team as supervisor or employee discretion.  A director, vice president or senior leadership team member may use the 360 degree feedback tool to determine progress after a performance issue has been addressed or prior to a promotion. The employee provides names of people to be contacted – which may include people receiving services, parents, county and district stakeholders, colleagues, etc.  The supervisor reviews the list and may add to it.  The manager e-mails the 360 Degree Feedback forms, collects the data, and summarizes what is learned to share with the employee.  There may be improvement or development goals resulting from the 360 degree feedback.
 

The primary method for soliciting employee feedback is through survey. The methods Mains’l uses to solicit feedback are in person meetings, paper surveys, or digital mediums. Additionally, employees are also able to provide comments directly through the Mains’l website or employee portal. 

These feedback requests are administered at times or intervals determined by Mains’l. The person requesting the information from an employee is also typically the designee for collection of the feedback. Additionally, exit surveys may be administered by, a human resources representative or supervisory level employee. 

Participation in the exit survey is voluntary. The responses remain confidential where possible. The responses will be used to identify circumstances around an employee’s exit from Mains’l. 

Questions may include:     

1. Why are you leaving?
2. What could we have done differently?
3. Would you refer someone you know to work at Mains’l?
4. Other questions as requested.

We ask that in any and all feedback you provide throughout your employment, that you do so honestly and truthfully. We thank you in advance for your feedback as it assists Mains’l in learning what is working and not, and allows us to improve as an organization.

     
 Rev. 10-09-2019
 

Employee files will be maintained on all active Mains’l employees by human resources. The following information generally is contained in all personnel files:

1. Employment application;
2. Letter confirming employment and work location;
3. Employee evaluations and performance records;
4. Any licenses, professional affiliations, or certificates;
5. Documentation of changes in employment status;
6. Documentation of changes in wage or salary status;
7. Written communication between Mains’l and the employee;
8. Employee training records and documents;
9. W-4 forms;
10. References;
11. Orientation Checklists and Log;
12. Copy of automobile insurance coverage, if applicable;
13. Any other pertinent data as determined by the employee's supervisor and/or human resources.

The following documentation is maintained in a separate file or document imaging file, due to the private nature of the information:

1. I-9 Employment Verification;
2. Benefit information;
3. Medical information including documentation relating to the Americans with Disabilities Act;
4. 401K Information;
5. Workers’ Compensation.

Employee files may be kept in paper form in a locked cabinet or in electronic form in a password protected document management system. Keys for these cabinets are kept by human resources staff. The following classifications are permitted to view employee file records as it pertains to their work:

1. Managers;
2. Senior Managers;
3. Directors;
4. Executive Team members;
5. Human Resources staff;
6. Finance staff.

Access to the files for viewing can be obtained by contacting human resources. For control and security purposes, the files can only be viewed in a designated location in the office and in the presence of human resources staff. The only exception to this policy will be at the request of licensing or other officials who have legal authority to access these records. 

No files or documents are removed from human resources files.

If a current or former employee personally requests a copy their own employment information, Mains’l requires a signed release; when the employee requests information via telephone or email, the requested information may:

1. be mailed directly to the employee’s home address, 
2. picked up by the employee in the main office, or 
3. faxed to the employee as requested.
    

The following steps should be followed when an employee has a job-related problem, question or complaint:

1. Under normal conditions, Mains’l employees talks to the person with whom you have the job-related problem, question or complaint. The simplest, quickest and most satisfactory solution often will be reached at this level. 
2. If you are not able to resolve the complaint, problem, or get your questions answered directly to the person, the next step is to go to your supervisor or the supervisor of the person you spoke to that did not resolve the issue with you. 

If an employee feels they have been treated unfairly or if they disagree with the decision of their supervisor, an employee may have their questions or concerns addressed by the process outlined in this procedure. The employee initiates the grievance within ten (10) calendar days of the event.

The employee submits written documentation describing the problem and the efforts attempted to resolve the complaint to their supervisor’s supervisor. If the grievance involves a suspension or separation of employment, the grievance is submitted to the Human Resources Generalist. 

The supervisor’s supervisor or Human Resources Generalist will respond, in writing, as soon as possible after the grievance is received. A meeting between the concerned individual(s) may be utilized to assist in the recommendation or decision. Documentation of any meetings or conversations is the responsibility of the person with whom the grievance was submitted.

This action will not prejudice the employee's interest in any manner.

Process:

1. The employee writes up and submits a report describing why they believe they were treated unfairly. The report includes any documents or statements to support the grievance.
2. The employee submits their report to their supervisor’s supervisor or Human Resources Generalist within ten (10) days of the event first giving rise to the grievance.
3. The supervisor’s supervisor and Human Resources Generalist will conduct an investigation into the allegation(s) and provide feedback to the employee.
    

The following set forth the periods of retention: 

Personal Data Category	Longest Retention Period	Laws/Regulations Requiring Retention
Recruitment, Hiring and Job Placement Records  * Employment applications  * Resumes  * Other job inquiries sent to     employer  *Employment referral records  *Applicant identification records  *Help Wanted advertisements	2 years or the duration of any claim or litigation involving hiring practices	Title VII FEHA ADA ADEA GINA
Payroll Records *Name, employee number,   address, age, sex, occupation *Individual wage records *Regular hourly rate *Hours worked (daily and weekly)  * Weekly overtime earnings *Daily or weekly straight time earnings *Deductions from or additions to wages * Wages paid each pay period *Payment dates and periods * Time cards * Shift schedules *Employment tax records	7 Years	FLSA Unemployment Insurance Codes Labor Codes IRS  FMLA ADEA
Employment Eligibility Forms Verification (I-9 Forms)	The later of 3 years from hire date or 1 year after termination.  Note: I-9 for currents employees are never destroyed	Immigration Reform and Control Act (IRCA) Immigration and Nationality Act (INA)
Child Labor Certificates and Notices	3 years	FSLA
Employee Personnel Files *Disciplinary Notices  *Promotions or demotions  *Performance evaluations  *Discharge, layoff, transfer and recall files  *Training and testing files  *Background checks  *Applications	3 years after employee has been terminated	Title VII ADEA FEHA ADA
Affirmative Action Programs and Documents	5 years	Title VII HRA
Employee Health Records  *Health Assessment  *Benefits applications/changes  *Physician statements  *Worker’s compensation records (except exposure records)  *Drug and alcohol test records  *OSHA Records	5 years	ADA ERISA OSHA
Work related safety/health exposure records	30 years	OSHA
Family Medical Leave (FMLA)	3 years	FMLA
California Family Rights Act (CFRA)	2 years after the files are created or received or 2 years after an employment action is taken	FEHA CFRA
Employee Benefits Data  *Summary plan descriptions  * Plan changes COBRA  *Beneficiary designations/changes  * Earnings	6 years	ERISA COBRA
401(k)  * All documents related to 401(k)	Indefinitely	ERISA
Unlawful Employment Practices, Claims, Investigations and Legal Proceedings Records *Personnel and payroll records about complaining parties *Personnel and payroll records about all others holding or applying for similar positions	Until disposition of case	Title VII FEHA ADEA ADA FLSA HRA

 

Internal

Two conditions may apply if an employee is interested:

1. If an employee is interested in a current job opening, and the opening is in addition to the current position the following apply:

1. The scheduled hours of the new position plus those of the current position must not exceed forty (40) per week;
2. The employee will notify their manager that they are interested in picking up more hours.
3. Human Resources or manager will connect with the supervisor of the new program and shares with them the employee’s interest in the position;
4. The employee provides full disclosure of his/her current schedule;
5. The supervisor of the new program will connect with the employee to discuss the job opening further (this may include a formal/informal interview, conversation, and/or meet and greet with key people).
6. The employee lets the current supervisor know that they are interested in taking on a secondary position at another location.
7. The supervisor lets HR know that an employee is taking on a second position and what their new status, department, secondary manager will be through a PSCF- Payroll Status Change Form.  

 

2. If an employee is interested in a new job opening, and the new opening will replace what the employee is currently doing, the following details apply:

1. An employee should be in their current position for a minimum of six (6) months to be eligible for a transfer.

• Note: Employees may be promoted if in a position for less than 6 months if in the best interest of the agency and/or people receiving services.

1. The employee completes an Internal Application and forwards to Human Resources.
2. Human Resources will connect with the supervisor of the new program and share that there is a current employee interested in the opening.
3. The supervisor of the new program will connect with the employee to discuss the job opening further (this may include a formal/informal interview, conversation, and/or meet and greet with key people). If the employee is hired for the new opening, we ask that the employee submit a 30-day written notice to the current supervisor (If agreed to by all parties, shorter notice may be allowed.)
4. If an employee accepts a new position, the supervisors will mutually agree on a transfer date based on the needs of the people receiving services, team, and schedule. In addition there may be a transition plan that the employee and supervisor complete to support a successful transfer.

In both of the above situations, the current supervisor shares information regarding the employee’s work performance, training record, dependability, flexibility, and other skills and attributes. The human resources department provides access to the personnel file for review by the new supervisor upon request. Selection is based on the preceding factors and the needs of the person or people in the new program, work location or team.

If the employee has received written performance feedback within the last six months, they will not be able to transfer until the employee has shown sustained improvement that is documented by the existing supervisor and employee.

 

External

Job openings at Mains’l are advertised on the company website by position type, in newspapers, at job fairs, college career centers, Workforce Centers, and/or the internet. Applicants proceed through the following process:

1. The applicant completes an application or submits a resume.
2. The applicant is pre-screened by human resources or hiring supervisor.
3. When an applicant meets the basic qualifications, the applicant will be invited to meet with the supervisor to have a discovery conversation in hopes that Mains’l may find out if the applicant is a good fit for Mains’l and if Mains’l is a good fit for the applicant.
4. The applicant may be invited to go and visit the person or people that they be working with (if applicable).
5. The applicant for a Personal Supports position in the Participant Directed Services program is interviewed by the family/person receiving services. Any assessments or reference checks are conducted at the discretion of the family/person receiving service.

Employment at Mains’l is dependent on successful completion of all State and licensing requirements. The offer of employment letter will specify all requirements.

The content of orientation and annual trainings are based on:

1. Job duties at Mains’l
2. Applicable licensing and contract requirements 
3. Requirements of the program the employee is working in
4. Mains’l policies and procedures
5. State and federal laws

Employees are paid for trainings when they are required by Mains’l. If an employee chooses to take additional training beyond what is assigned, the employee will not be paid by Mains’l for that time. 

Orientation training is completed by all new employees and current employees transferring to a new position or department within Mains'l. Additionally, all employees are encouraged, and in some cases required, to participate in ongoing annual professional and educational training. Mains'l provides information to employees on important conferences, workshops, and training opportunities. When attendance at training is required by Mains’l, the agency covers the cost of training and pre-approved expenses. Supervisors may consider certain trainings required or optional based on the unique experience and role of each employee. Employees are notified if training is required or optional. 

Training and development may be conducted by members of the human resources teams, administrative team, supervisors, senior supervisors, directors, people receiving services, parents and other stakeholders, and direct care employees. Employees may receive online training, classroom instruction and competency testing, site specific instruction and competency testing, and on the job training and coaching. Some training may be completed over the phone if approved by the supervisor. 

What are my training expectations?
Each Mains’l employee is expected to demonstrate the knowledge and skills needed to be successful in his or her role. Employee training and development involves building skills and knowledge that enhances the employee’s skills, knowledge and abilities, both personally and professionally. Training instructions and expectations are given to the new employee at their first day- Welcome Aboard. 

Orientation Training and Development
There are six (6) parts to Mains’l orientation process:

1. First Day – Welcome Aboard
   • First day orientation is the employee’s welcome to Mains’l. New employee paperwork is reviewed with the supervisor or other designee and completed by the employee. This is the employee and employer opportunity to learn about each other and begin to establish their working relationship. Expectations for how and when to complete the rest of orientation are provided. 
2. Orientation to the Individual (for direct support services)
   • Orientation to the Individual is the process of getting to know the person with whom the employee will be working with by reviewing documentation and information from the person and his or her support team. After completing Orientation to the Individual, the employee should have a good understanding of the support and service needs of the person and your role and responsibilities as an employee on his or her support team. 
3. Orientation to the Site
   • Orientation to the site is the process of getting to know the place the employee will be working by reviewing documentation and information and visiting the location(s) he or she will work at. After completing Orientation to the Site the employee should have a good understanding of the setting or settings he or she will be working at. 
4. Orientation to Job Responsibilities
   • Orientation to job responsibilities involves getting to know the supervisor and learning what to do and how to do it by reviewing in detail the job description, policies, procedures, and other information related to the person’s role. After completing Orientation to Job Responsibilities the employee should have a good understanding of how to succeed as a Mains'l team member and have a good foundation of understanding what resources guide their work. 
   • Included in orientation to job responsibilities are a variety of online, person to person, and classroom trainings that provide knowledge and skill building opportunities and communicate job expectations for the employee. Online, person to person and classroom trainings are assigned to each employee based on their specific job. 
5. Job Specific Competency Test (for services)
   • A job specific competency test provides the employee the opportunity to recall information, and demonstrate the skills and abilities needed to perform the job. This allows the employee and supervisor to know what information the employee has remembered from their orientation so far, and to clarify where further follow up information, training or practice is needed. 
6. On the Job Training
   • On the Job Training occurs when the employee takes all of the information he or she has learned so far and begins to apply it on the job. This is the time when the employee and supervisor can decide if this is the right job for this person. While there will always be opportunities to learn more, after completing On the Job Training the employee should have demonstrated competence to do the job with minimal or no supervision. 

Ongoing Training and Development
There are two (2) parts to Mains’l ongoing training and development

1. Annual and as needed trainings 
   • There are a variety of in-person, online, and classroom trainings that are required for some or all employees based on the needs of the person or people they support, their position within the agency and the specific program or programs they work in. Annual trainings are the employee’s opportunity to refresh and enhance knowledge and skills and the agency’s opportunity to ensure a competent workforce.
2. Ongoing Employee Development
   • In addition to training, each employee may collaborate with their supervisor to create an individualized plan as it relates to their work/career development. The process is ongoing with the expected result that each employee of Mains’l will have clear goals and objectives that are personally meaningful and contribute to the mission and vision of Mains’l. 

The supervisor may assign to another trained and competent person parts of training and employee development with pre-approval from their supervisor. Trainers document the training topics, and the dates and times they train an employee. The employee and trainer(s) sign off after training is completed. 

Alternative Sources of Training
Employees who choose to attend training offered outside of the agency should check with their supervisor to clarify if the training will count towards their Mains’l trainings and if time or training costs will or will not be paid by Mains’l. Trainings from sources other than Mains’l may count toward the orientation or annual training requirements if:

1. The training occurred within the same 12 month period as the current annual training time period.
2. The documentation includes the topic/instructor/date.    
   • Prefer it also includes the hours.
3. The employee provides Mains’l acceptable documentation of the training and staff person's competency in the required area. The documentation is reviewed by the HR Generalist to determine if it meets our standards. 

Due to the considerations of our nurse’s licenses, we do not accept Medication Administration from other agencies. 

Supervisors may schedule and complete trainings with employees over the phone to fulfill annual training requirements. Phone training must be approved by the supervisor. Phone trainings are documented on the Training Log and submitted to Human Resources for data entry. Supervisor approved trainings completed over the phone may be entered on a timesheet.

Team Meetings
Team meetings are defined as in-person or over the phone correspondence with one or more employees and their supervisor or a trainer approved by the supervisor. 

Employees are expected to meet with and correspond with their supervisor as requested. Supervisors communicate team meeting expectations during Orientation to Specific Job Responsibilities and will inform employees of additional meeting and training requirements as they occur to ensure employees are properly trained and competent to perform their jobs.

Mains’l expects that employees working in houses that are licensed as Community Residential Settings and office staff attend a monthly in-person team meeting. All other employees are expected to meet with and correspond with their supervisor as requested. Supervisors communicate team meeting expectations during Orientation to Specific Job Responsibilities and will inform employees of additional meeting requirements as they occur to ensure employees are properly trained and competent to perform their jobs. 

Employees communicate with their supervisor if they are unable to attend a team meeting. Unapproved absence from a team meeting or frequently missing meetings is a performance issue that supervisors are expected to address with employees. 

How much training is needed?

Minnesota Employees:

1. For employees who work in licensed services, each employee completes orientation sufficient to create staff competency for direct support within 60 days of hire. This combines supervised on-the-job training with review of and instruction on multiple topics that are described in the employee’s orientation training plan
    

   Service Type	Years of Experience	Orientation Training Hours Required	Annual Training Hours Required
   Basic Licensed Services – Respite, Personal Support, Homemaker	0-4 years	10 Hours	12 Hours
   	5 or more years	10 Hours	6 Hours
   Intensive Licensed Services or all other Licensed Services	0-4 years	30 Hours	24 Hours
   	5 or more years	30 Hours	12 Hours

    

2. Administrative employee traiing is determined by position and the supervisor

California Employees:

1. Employees who work in licensed services must complete thirty (30) hours of orientation training within ninety (90) days of hire.
2. Employees who work in un-licensed services must complete thirty (30) hours of orientation training within ninety (90) days of hire.Service Type    Years of Experience    Orientation Training Hours Required    Annual Training Hours Required
3. Additionally there is a list of topics for licensed services staff to learn about and demonstrate competency in. 
    

   Service Type	Years of Experience	Orientation Training Hours Required	Annual Training Hours Required
   Licensed Day Program Services	Any	8 Hours	8 Hours
   Licensed Level 4-In Home	Less than 12 months	32 Hours	20 Hours
   	Greater than 12 months	20 Hours	20 Hours

    

4. Administrative employee training is determined by position and the supervisor. 

There may be variations on the required hours and topics of training based on the employee's experience and/or person being supported. 

How is training recorded?

Mains’l maintains a training record for each employee. Proof of attendance for in-person, over the phone, or trainings offered outside of Mains’l is submitted by the trainer to the human resources or support services department immediately following the training (within 2 business days), and then it is entered in our Human Resource Information System. Online training is automatically recorded in the Human Resource Information System.

Documentation of training completion, competency tests, and a record of the amount of time credited towards training are recorded in the Human Resource Information System. The employee, human resources, support services, and the supervisor are able to view where the employee is at with completion of training.

On a monthly basis, training reports are provided to all supervisors who in turn notify employees of training requirements and/or hours not yet completed. It is the responsibility of the employee to assure that these trainings and hour requirements are fulfilled. Participation in trainings must be documented and turned in on a timely basis to ensure accurate training records.

The Key to Your Success is You!

We are committed to being guided by our mission, vision and values, as well as the rules and regulations that set standards for our work. Successful completion of training requirements and ongoing participation in employee development is a collective responsibility of the Mains’l Team, with you as the centerpiece. We succeed in large part because of the training and development we undertake and subsequent skills and abilities we demonstrate and expand on.

 

Honoring the Mains’l standard of excellence

1. If you are struggling with understanding, ask questions or ask for help.
2. You will be asked to show competency and will be tested on your knowledge.
3. If you continue to struggle with understanding or demonstrating knowledge through skills, we will help by creating a plan that may include retraining, practice and active coaching.
4. Trainings are expected to be completed by the assigned dates. If you are struggling, please ask for help in a timely manner so that trainings are still completed within the needed time frames.
5. Mains’l believes that all employees have the ability to successfully meet training requirements. However, in the event that training requirements are not completed as assigned within the required time frames, it may result in written performance feedback that could include removal from work until the employee successfully completes training.
6. Mains’l is committed to excellence in who we are, what we do, and how we do it. If there are concerns regarding training completion, skill demonstration, or the wellbeing of the individuals we serve, it could lead to an employee no longer working for Mains’l.
7. It is the goal of Mains’l to coach and mentor employees to successfully meet training requirements.

Rev. 10-08-2019

Mains’l has appointed the HR Director to manage the Equal Employment Opportunity program in collaboration with the Human Resources Departments in each state. Their responsibilities will include monitoring all Equal Employment Opportunity activities and reporting the effectiveness of this Affirmative Action Program as required by Federal, State and Local agencies. 

At least annually, internal audit reports will be prepared. Data collected for these reports include applicant flow, new hires, promotions, transfers, and separations (voluntary and involuntary) by job group. Figures for each personnel process show a breakdown by sex, minority classification, and disability status. Reports are shared within the appropriate levels of management, and any problem areas are addressed as promptly as possible. The Chief Executive Officer of Mains’l. receives and reviews reports on the progress of the program. 

If any employee or applicant for employment believes he/she has been discriminated against, they should contact Director of Human Resources, 7000 78th Avenue North, Brooklyn Park, Minnesota 55445 or call 763-416-9136.
 

All requests for employment information, by outside agencies or current or former employees are forwarded to and answered by the human resources department. 

All requests from outside agencies must be in writing and must include a signed release from the employee. Any information provided to an outside agency must also be in writing.

The requested information cannot be transmitted by Mains’l to an outside agency.

Mains’l releases information according to the following guidelines. These guidelines are in accordance with MN Statute: (H.F. No 3092 sec. 4 [604A.33]):

Upon written request from an outside agency, Mains’l may disclose, in writing, the following information about a current or former employee. This information cannot be provided without the written authorization of the current or former employee:

1. Dates of employment;
2. Compensation and wage history; and
3. Position.

Mains’l has a 72 hour turn-around time for all verifications of employment. 

Employees have the right to review the content of their employee file, upon written request to Human Resources, once every 6 months, and once a year after separation of employment. Mains’l has a 7 day turn-around time for personnel file requests (see Employee File and Employee Request for Records Policy and Procedure).
 

Benefits and Protections
Mains’l provides eligible employees up to 12 weeks of unpaid family and medical leave annually in accordance with the Family and Medical Leave Act (FMLA).  FMLA may be taken for any of the following purposes:

1. For incapacity due to pregnancy, prenatal medical care or child birth;
2. To care for the employee’s child after birth, or placement for adoption or foster care;
3. To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition; or
4. For a serious health condition that makes the employee unable to perform the employee’s job;
5. Military Family Leave for certain qualifying circumstances.  26 weeks of leave may be granted to care for a covered service member during a single 12-month period.

Eligibility

1. Employees are eligible for FMLA leave if they have:        
   • worked for Mains’l for at least one year, and;
   • Worked at least 1,250 hours over the previous 12 months.
2. If an employee does not meet the eligibility requirements and has a medical condition that requires them to be off of work for more than three days, please call Human Resources.
3. An eligible employee is entitled to take up to 12 weeks of leave in a 12-month period.  An employee’s 12 month leave period is a “rolling” 12 month period measured backward from the date an employee uses any FMLA leave.  Each time an employee takes FMLA leave, the remaining leave entitlement is any balance of the 12 weeks which has not been used during the immediately preceding 12 months

Employee Responsibilities

1. Mains’l requests that employees provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. Employees submit the Request for Leave of Absence Form to their supervisor as soon as possible. When a 30 day notice is not possible, it is expected that the employee provide notice as soon as possible. 
2. Employees need to provide sufficient information for Mains’l to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave.  Employees need to inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified.  Employees also may be required to provide a certification and periodic certification supporting the need for leave or may be required to provide a fitness-for-duty certification prior to returning to work.
3. Mains’l may delay or deny leave if employee fails to provide certification in a timely manner. If employee fails to provide certification, any leave taken will not be protected under FMLA.  
4. If an employee fails to return to work on the agreed upon return date, Mains’l will assume that the employee has resigned.

Mains’l Responsibilities

1. Mains’l will inform employees requesting leave whether they are eligible under FMLA and the amount of leave counted against the employee’s leave entitlement.  If they are, the notice will specify any additional information required as well as the employees’ rights and responsibilities.  If they are not eligible, Mains’l will provide a reason for the ineligibility.  
2. Supervisors are responsible for contacting human resources as soon as possible if an employee:
   • requests leave;
   • requests a change in their leave status;
   • requests to return to work.
3. Human Resources is responsible for approving/denying FMLA, sending required notices and following up with employees and supervisors and interpreting this policy.

Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities.  

Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with a least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition.  

Military Family Leave Entitlements
Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies.  Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangement, attending certain counseling sessions, and attending post-deployment reintegration briefings.

FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service member during a single 12-month period.  A covered service member is: (1) a current member of the Armed Forces, including a member for the National Guard or Reserves, who is undergoing medical treatment, recuperation or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness*, or (2) a veteran who was discharged or released under conditions other than dishonorable at any time during the five-year period prior to the first date the eligible employee takes FMLA leave to care for the covered veteran, and who is undergoing medical treatment, recuperation, or therapy for a serious injury or illness*.

The FMLA definitions of “serious injury or illness” for current service members and veterans are distinct from the FMLA definition of “serious health condition”.

Use of Leave
FMLA Leave can be taken in one block, intermittently or on a reduced leave schedule based on the employee’s healthcare provider’s statement or other certification.  Employees are required to make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt operations.  

Use of Paid Time Off and/or Sick Leave and other approved leaves
An employee who is taking FMLA may use sick leave, accrued PTO, Mains’l paid parental leave, unpaid leave or a combination of all as the employees chooses. See Paid Time Off Policy for additional information.  Any period of leave during which an employee received workers’ compensation benefits will be counted toward the employee’s entitlement to family and medical leave, provided the leave is due to the employee’s serious health condition as defined in this policy.  Any period of parental leave or other leave under state law will count toward the employee’s FMLA entitlement.
 

Eligibility
Employees hired to work an average of thirty (30) hours per week or more are eligible for insurance benefits including medical, dental, vision, short-term disability, accident insurance, basic life, and voluntary life. Salaried employees meeting this status also are eligible for long-term disability insurance.

Enrollment is explained in the graphic below:

1. Medical Coverage

• Any employee who is not regularly scheduled a minimum of 30 hours or more a week, may be eligible for medical coverage only if they average 30+ hours a week during a twelve month measurement period as required by the Affordable Care Act. A variable hour employee is an employee who is not regularly scheduled to work 30 hours or more per week. If the variable hour employee works a minimum of 30 hours during a twelve month measurement period, insurance will be offered effective the first of the month after a full month’s administrative period and the insurance, if chosen would be effective for a minimum of a twelve month stability period. This is explained in the graphic below:

• Limitations: Employees in participant directed services that are classified as joint employees are eligible for medical insurance benefits only if eligibility requirements are met. Employees in this group have set hours and are not treated as variable hour employees unless indicated by their Manager.

Enrollment
The eligible employee receives information on the insurance plans after attaining eligibility. Enrollment elections must be made through Colonial Life during the enrollment period listed in the information packet. Failure to enroll through Colonial Life during the enrollment period results in the employee voluntarily declining coverage. 

Once the initial enrollment period has passed, the employee is not eligible to reapply for coverage until the designated annual open enrollment. Open enrollment for all benefits is in November/December with effective coverage January 1st, or for variable hour workers, after meeting the hour requirement after a measurement period. If you are newly hired during the year or have a status change that makes you eligible enrollment will be the first of the month following 60 days of employment with your qualifying status. During open enrollment, any eligible employee can apply for coverage, or add dependents to their coverage.

Dependents may be added or dropped from your insurance policy at the time of marriage, birth or adoption. Other qualifying events may allow an employee or dependents to enter the plan.

Enrollment in the Mains’l paid life insurance and long term disability plan is mandatory for all eligible employees. All employees will be enrolled. There is not an open enrollment for the Mains’l paid life and disability insurance.

Cost of Coverage
The exact amount of the employee contribution for the insurance is provided to employees with the enrollment information. The employee contribution for coverage is deducted from payroll. Employees acknowledge payroll deductions verbally and with an electronic signature through Colonial Life during enrollment.

The cost for the medical insurance depends on the coverage elected. For employee only, the cost is based on the age band of the employee. If electing spousal coverage, the cost for the spouse is based on the age of the spouse. Also, if electing coverage for children, the cost is based on number of children enrolled in the coverage. 

The cost for the dental insurance depends on the coverage elected – employee only or family.

The cost for the vision insurance depends on the coverage elected – employee only, employee plus spouse, employee plus child (ren) or family.

The cost for voluntary short term disability insurance depends on the coverage elected and is age based. Coverage can be elected for legal dependents. 

The cost for voluntary accident insurance depends on the coverage elected – employee, employee plus spouse, one parent family, or two parent families. 
            
The cost for voluntary life insurance depends on the coverage elected and is age based. Coverage can be elected for legal dependents. 

The cost for the mandatory life insurance and long term disability insurance (employee coverage is available) is paid by Mains’l

Please note that in order to enroll any spouse or children where coverages are available, the employee themselves must be enrolled in the coverage.

Ineligibility and Termination of Coverage
The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) and state law gives employees and their qualified beneficiaries the opportunity to continue health, dental, vision and life insurance coverage under the Mains’l sponsored plan when a “qualifying event” would normally result in the loss of eligibility. Typical qualifying events include resignation, separation of employment, or death of an employee; a reduction in an employee’s hours or a leave of absence; an employee’s divorce or legal separation; and a dependent child no longer meeting eligibility requirements.

If the employee is still employed, but is no longer eligible due to reduction of hours, the following will occur: 

1. Employees that are regularly scheduled 30+ hours a week who voluntarily reduce to part-time status (<30 hours a week), benefits will continue until the last day of the month of the status change.
2. Employees that are regularly scheduled 30+ hours a week that involuntarily have their schedule reduced due to changes in business needs will be given thirty days to find a position in the agency that allows them to keep their status. If a position isn’t found after thirty days, benefits will continue until the last day of the month after the thirty day mark.
3. Variable hour part-time employees that met the 30 hours a week average through a measurement period will be sent a notice prior to termination that they will have one month to obtain regularly scheduled hours for at least 30+ hours a week if they would like to maintain medical insurance. Failure to find additional hours in the time frame will result in loss of coverage on the last day of the month following the notice.

If coverage is cancelled, the employee will be offered continuation of insurance through COBRA. Under COBRA, the employee or beneficiary pays the full cost of coverage at Mains’l group rates plus an administration fee. Mains’l provides each eligible employee with a written notice describing rights granted under COBRA and state law when the employee becomes eligible for COBRA continuation coverage. Contact the human resources department for additional information.
 

For employees to return to work from a known communicable disease, workers compensation injury, or a medical leave of absence, the employee provides a medical clearance directly to their supervisor who will submit to Human Resources. Once provided, the employee is able to return back to work. 

For absences from work for three days or more due to illness, employees whom are requested will provide a medical clearance directly to their supervisor who will submit to human resources. Human Resources will maintain a record in the medical portion of the personnel file.    

California only: Mains’l Human Resources department will provide employees with the employee health screening report and this is completed with a TB test by the employee prior to beginning employment. Mains’l reserves the right to designate the health care provider and incurs the expense.
 

Personal Time Off

Eligibility:

All full time employees, after one (1) year of full time employment, are eligible for Personal Time Off (PTO).

On the employee’s first anniversary of full time employment, and on every subsequent anniversary date, the employee receives PTO according to the schedule in the Paid Time Off – Full time Hourly Employees policy.

Use: 

PTO is used in four (4) hour increments or for a regular scheduled shift, if less than four (4) hours.  (For example, a typical morning shift is two (2) hours - PTO can be used). PTO cannot be used if an employee wants to come in two (2) hours late for a regularly scheduled 8-hour shift, unless it has been arranged in advanced.  Exceptions to this guideline may be pre-approved by the supervisor.  

PTO requests for less than three (3) days needs to be given, verbally or in writing, to the immediate supervisor with as much notice as possible. Employees are asked to help find their own coverage.

PTO requests for three (3) days or more need to be given, verbally or in writing, to the immediate supervisor two (2) weeks in advance.   Employees are asked to help find their own coverage.

PTO requests for two (2) weeks need to be given, verbally or in writing, to the immediate supervisor four (4) weeks in advance of the first PTO day. Employees are asked to help find their own coverage.

Advances on PTO are not permitted. Requests to increase pay by cashing out PTO is not permitted.

Managers have the right to approve or deny vacations requests, if policy is not followed or it is not conducive to the program at that time.

Limits: 

Employees need to use their PTO within their individual full time year of service. The PTO balance is not carried over from one service year to another.  (For example, if an employee’s start date is June 1^st, all accrued PTO must be used within the pay period of June 1^st of each subsequent year).  If the PTO is not used by the end of the service year, the employee loses it.

Employees should be aware of their PTO balance as they approach their anniversary date.  The PTO balance is stated on the bi-weekly payroll advice.  Employees can also check your PTO balance on Solana under the “My Time Off” tab. Mains’l Services does not notify an employee of their approaching anniversary date and the possible loss of PTO.

If overtime is worked during a week in which PTO has been used, the employee will not be paid for overtime until the actual hours worked exceeds forty (40) hours. Also, replacement employees cannot incur overtime by working replacement shifts, unless approved by the supervisor.

When staffing schedules dictate, the immediate supervisor after consulting with human resources, may cancel or postpone previously approved PTO requests.  When this is necessary, as much notice as possible is given.

Termination: 

An employee cannot use PTO as part of the notice given before resigning

PTO is not paid to the employee at the time of resignation or termination

Comment:

PTO accounts are maintained by the payroll department. The PTO balance is recorded on the payroll advice or payroll check stub. 

Interpretation:

The Human Resource Department is responsible for interpreting the PTO policy and procedure. 

Sick  Leave

Eligibility:      

All full time hourly employees are eligible for sick leave and receive it at the beginning of full time employment and on every subsequent employment anniversary date. 

Before using sick leave, employees need to successfully complete three (3) months of employment.

The amount of sick leave credited to the employee remains the same throughout the length of employment (six (6) days per year).

Use:    

Sick leave may be used for illness, injury, or medical/dental appointments of employees or their spouse, children, parents, sibling, mother-in-law, father-in-law, grandchild, grandparent, or stepparent.                             

Sick leave may be used for an employee or relative (as listed above) to provide or receive assistance because of sexual assault, domestic abuse, stalking, or harassment.

We ask that unexpected sickness or injury is telephoned to the supervisor at least four (4) hours prior to the scheduled shift. If sick leave is anticipated the employee is asked to help find replacements for their sick time.  Replacement employees must not incur overtime by working the replacement shift, unless approved by the supervisor.

Limits:    

If overtime is worked during a week in which sick leave has been used, the employee will not be paid                      overtime until the actual hours worked exceeds forty (40).

Sick leave is not earned on overtime hours. 

 An employee cannot use sick leave as part of the notice given before resigning.

A doctor’s statement may be required to verify absence. A doctor’s statement may be requested upon return to work if the sick leave is (3) days or more.

If absence exceeds three (3) consecutive days, Family and Medical Leave policy may apply and continuing absences are counted toward the FMLA leave.

Limit on sick leave balances is twenty (20) days.

If an employee changes status from FT to PTWB or PT and has accrued Sick Leave, they will be eligible to use that sick leave until their next Anniversary date. Whatever sick leave is not used by that time will be lost and their Sick leave balance will be set back to zero (0) days.

Termination:

Sick leave is not paid upon termination.

Comment:

The payroll department maintains the sick leave accounts.  The sick leave balance is recorded on the payroll advice or payroll check stub.  

Interpretation:

The human resource department is responsible for interpreting the sick leave policy and procedure.

 

Bereavement Leave

Eligibility:

All full time hourly employees are eligible for Bereavement leave. 

Use:    

Up to three (3) days can be used in the event of the death, loss of pregnancy, funeral or estate settlement of an immediate family member. The number of hours per day of funeral leave is based on the regular scheduled hours the employee would normally work on that day.

Bereavement Leave may be used for employees who experience miscarriage, ectopic pregnancy, or stillbirth as well.

Immediate family members include spouse, parents, children (including unborn children), siblings, grandparents, step-children, parents-in-law, sister-in-law, brother-in-law, daughter-in-law, and son-in-law.

If the Funeral Leave is needed, employees notify the supervisor, verbally or in writing, with as much notice as soon as possible.

Limit:

No Limit

Termination:

Bereavement leave benefits do not accrue and no payment is made for unused funeral leave benefits upon termination.

Interpretation:

The human resources department is responsible for interpreting the Bereavement Leave policy and procedure.

 

Jury Leave

Eligibility:

All full time hourly employees are eligible for paid time off while serving on a jury.

Use:

Up to a maximum of two (2) weeks of pay to supplement jury pay. 

The employee is asked to help find replacements for their jury leave.  Replacement employees should not incur overtime by working the replacement shift.

If Jury Leave is needed, employees notify the supervisor, verbally or in writing, with as much notice as soon as possible. Documentation of Jury Duty from the County, District or Federal court is also submitted to the employee’s supervisor, who partners with human resources to coordinate jury pay.

Limits:    

Paid jury leave from Mains’l Services supplements the Jury Duty Pay from the court.  The money received from the court system is deducted from the paid jury leave that Mains’l Services pays the employee.   If the court reimbursement exceeds the compensation lost through not working, supplement pay is not made.

The employee and the supervisor determine the extent of the employee‘s job responsibilities while on jury duty.

Termination:    

Jury leave benefits do not accrue and no payment is made for unused jury leave benefits upon termination.

Interpretation:

The human resource department is responsible for interpreting the jury leave policy and procedure.  

Parental Leave

Eligibility:    

All full time hourly employees, who have been employed for a minimum of one consecutive year prior to the leave request, and have been full time during that year, are eligible for paid time off following the birth or adoption of a child.

Use:

Parental leave is available following the birth or adoption of a child. The employee completes the “Mains’l Parental Leave” with approximate dates of the leave, and submits to the immediate supervisor. 

Limits:  

Paid leave is equivalent to the regular schedule of the employee.  For example, if an employee works 37 hours per week, the employee is eligible for 4 weeks at 37 hours of paid parental leave or 148 total hours.  Mains’l will not exceed 160 hours of paid parental leave.

The leave must be taken within the first six (6) months of the birth or adoption. 

The cost of medical, life, and dental benefits must be assumed by the employee effective on the first of the month following four (4) weeks of leave.  For employees who are eligible for Family and Medical Leave benefits, other arrangements may apply.  (See policy Family and Medical Leave).

Termination:

Parental leave benefits do not accrue and no payment is made for unused parental leave benefits upon termination.

Comment:

If the employee requests a leave in excess of four (4) weeks, the Family and Medical Leave policy or the Unpaid Leave of Absence policy is followed.

Interpretation:

The human resource department is responsible for interpreting the parental leave policy and procedure.
 

Personal Time Off

Eligibility:     

Salaried employees are eligible for Personal Time Off (PTO) and receive it at the beginning of full time employment and on every subsequent employment anniversary date according to the schedule as stated in the Paid Time Off – Salaried Employees policy.

Before using PTO, employees must successfully complete three (3) months of employment.

Before using PTO, employees must satisfactorily complete the orientation training requirements as determined by the immediate supervisor.

Use:     

PTO requests for less than three (3) days needs to be given verbally or in writing to the supervisor with as much notice as possible. A contact person is designated in the employee’s absence. 

PTO requests for three (3) days or more needs to be given verbally or in writing to the immediate supervisor two (2) weeks in advance.  The employee will discuss and make arrangements for any pending meetings, appointments, and other commitments that are planned during their absence.  A contact person is designated in the employee’s absence.

PTO requests for two (2) weeks or more needs to be given verbally or in writing to the immediate supervisor four (4) weeks in advance of the first PTO day. The employee will discuss and make arrangements for any pending meetings, appointments, and other commitments that are planned during their absence.  A contact person is designated in the employee’s absence.

Advances on PTO are not permitted.

PTO must be used for all time off and cannot be used to supplement income over full time status.  

Limits:     

Employees need to use their PTO within their individual year of full time service.  The PTO balance is not carried over from one service year to another.  (For example, if an employee’s start date is June 1st, all PTO must be used by May 31st of each subsequent year).  If the PTO is not used by the end of the service year, the employee loses it.

Employees should be aware of their PTO balance as they approach their anniversary date.  The PTO balance is stated on the bi-weekly payroll advice. Employees can access their PTO balance on Solana under the “My Time Off" tab.  Mains’l Services does not notify an employee of their approaching anniversary date and the possible loss of PTO

Termination:    

An employee cannot use PTO as part of the notice given before resigning.

PTO is not paid to the employee at the time of resignation or termination.

Comment:    

PTO accounts are maintained by the payroll department. The PTO balance is recorded on the payroll advice or payroll check stub.  

Interpretation:

The Human Resource Department is responsible for interpreting the PTO policy and procedure.  

 

Sick Leave

Eligibility:

All salaried employees are eligible for sick leave and receive it at the beginning of employment and on every subsequent employment anniversary date.

Before using sick leave, employees need to successfully complete three (3) months of employment.

Before using sick leave, employees need to satisfactorily complete the orientation training requirements as determined by the immediate supervisor.

The amount of sick leave credited to the employee remains the same throughout the length of employment (six (6) days per year).

Use:

Sick leave may be used for illness, injury, or medical/dental appointments of employees or their spouse, children, parents, sibling, mother-in-law, father-in-law, grandchild, grandparent, or stepparent.                             

Sick leave may be used for an employee or relative (as listed above) to provide or receive assistance because of sexual assault, domestic abuse, stalking, or harassment.

Sick leave which can be anticipated should be requested with as much notice as possible.

We ask that unexpected sickness or injury is telephoned to the supervisor at least four (4) hours prior to the scheduled shift.

Limits: 

An employee cannot use sick leave as part of the notice given before resigning.

A doctor’s statement may be required to verify absence. A doctor’s statement may be requested upon return to work if the sick leave is (3) days or more.

Limit on sick leave accrual is twenty (20) days.

If absence exceeds three (3) consecutive days, and is considered a “serious health condition,” the Family and Medical Leave policy applies and continuing absences are counted toward the FMLA leave.

If an employee changes status from FT to PTWB or PT and has accrued Sick Leave, they will be eligible to use that sick leave until their next Anniversary date. Whatever sick leave is not used by that time will be lost and their Sick leave balance will be set back to zero (0) days. 

Termination:

Sick leave is not paid upon termination.

Comment:

The payroll department maintains the sick leave accounts.  The sick leave balance is recorded on the payroll advice or payroll check stub.  

Interpretation:

The human resource department is responsible for interpreting the sick leave policy and procedure.

 

Bereavement Leave:

Eligibility:    

All salaried employees are eligible for Bereavement Leave. 

Use:

Up to three (3) days can be used in the event of the death, funeral or estate settlement of an immediate family member.

Bereavement Leave may be used for employees who experience miscarriage, ectopic pregnancy, or stillbirth as well.

Immediate family members include spouse, parents, children (including unborn children), siblings, grandparents, step-children, parents-in-law, sister-in-law, brother-in-law, daughter-in-law, and son-in-law.

If the Funeral Leave is needed, employees notify the supervisor, verbally or in writing, with as much notice as soon as possible.

Limit:    

No Limit

Termination:    

Funeral leave benefits do not accrue and no payment is made for unused funeral leave benefits upon termination. 

Interpretation:    

The human resource department is responsible for interpreting the Funeral Leave policy and procedure.

 

Jury Leave

Eligibility:    

All salaried employees are eligible for paid time off while serving on a jury. 

Use:    

Up to a maximum of two (2) weeks of pay to supplement jury pay.

The employee is asked to help find replacements for their jury leave.  Replacement employees should not incur overtime by working the replacement shift.

If Jury Leave is needed, employees notify the supervisor, verbally or in writing, with as much notice as soon as possible. Documentation of Jury Duty from the County, District or Federal court is also submitted to the employee’s supervisor, who partners with human resources to coordinate jury pay.

Limits:    

Paid jury leave from Mains’l Services supplements the Jury Duty Pay from the court.  The money received from the court system is deducted from the paid jury leave that Mains’l Services pays the employee.   If the court reimbursement exceeds the compensation lost through not working, supplement pay is not made.

The employee and the supervisor determine the extent of the employee‘s job responsibilities while on jury duty.

Termination:

Jury leave benefits do not accrue and no payment is made for unused jury leave benefits upon termination.

Interpretation:

The human resource department is responsible for interpreting the jury leave policy and procedure.  

 

Parental Leave

Eligibility:    

All salaried employees, who have been employed a minimum of one consecutive year prior to the leave request, and have been full time during that year, are eligible for paid time off following the birth or adoption of a child.

Use:   

Parental leave is available following the birth or adoption of a child. The employee completes the “Mains’l Parental Leave” with approximate dates of the leave, and submits to the immediate supervisor.  

Record Parental Leave hours on the Salaried Employee Time Sheet, noting date and total hours taken. Write the hours in the “Parental” column.  The time sheet must be approved by the supervisor who then submits it to payroll.

Parental leave is paid on the basis of an eight (8) hour day/forty (40) hour week.

Limits:    

Four (4) weeks, or 160 hours, is the maximum of paid leave.

The leave must be taken within the first six (6) months of the birth or adoption.  

The cost of medical, life, and dental benefits must be assumed by the employee effective on the first of the month following four (4) weeks of leave.  For employees who are eligible for Family and Medical Leave benefits, other arrangements may apply.  (see policy Family and Medical Leave.)    

Termination:   

Parental leave benefits do not accrue and no payment is made for unused parental leave benefits upon termination.

Comment: 

If the employee requests a leave in excess of four (4) weeks, the Family and Medical Leave or the Unpaid Leave of Absence policy must be followed.

Interpretation:    

The human resource department is responsible for interpreting the Parental Leave policy and procedure.

 

*For information on paid holidays, see Holiday Schedule Policy and Procedure
 

The Fair Labor Standards Act (FLSA) is a law that requires employers to classify jobs as either exempt or nonexempt. Nonexempt employees are covered by FLSA rules and regulations, and exempt employees are not covered by FLSA rules and regulations.

• Nonexempt Mains’l employees are paid for each hour worked based on hours reported on a timesheet
• Exempt Mains’l employees are paid a salary

Exempt or non-exempt status is determined by Human Resources and communicated to each employee on the Offer of Employment Letter.

The following information applies to both exempt and nonexempt employees:

• Pay Periods: Each pay period is made up of two (2) weeks for a total of fourteen (14) days. Each week starts on Sunday at 12:01 a.m. and ends the following Saturday at 11:59 p.m. Pay periods are listed on the payroll calendar that is given to each employee during orientation and can be accessed on the portal at any time.
• Paydays: Employees are paid every other Friday by an electronic direct deposit to a bank, credit union, or pay card of your choice. If a regularly scheduled payday falls on a holiday that the Federal Reserve (bank) is closed, employees receive their pay before the regularly scheduled payday as coordinated by the payroll department. Advances of payroll are not made for any reason. Mains’l is not responsible for any delays in mail service or electronic deposits in your bank account. Errors in electronic deposits resulting in funds not being deposited will be re-issued after verification has been received from the bank that the funds have been returned to Mains’l. Pay dates are listed on the payroll calendar that is given to each employee during orientation and can be accessed on the portal at any time.
• MN Wage Disclosure Protection Law: Under the Minnesota Wage Disclosure Protection law, you have the right to tell any person the amount of your own wages. Your employer cannot retaliate against you for disclosing your own wages. Your remedies under the wage disclosure protection law are to bring a civil action against your employer and/or file a complaint with the Minnesota Department of Labor and Industry at 651-284-5070 or 800-342-5354.
• Review your pay advice: A few days before pay day, a document called a pay advice is mailed or e-mailed to each employee who reported work time for that pay period. You indicate to Mains’l how you want to receive your pay advice on the Payroll Direct Deposit Authorization Form. Each payroll advice includes year to date earnings, amounts withheld for taxes, garnishments, and other deductions or reimbursements. To ensure that you are paid properly and that no improper deductions are made. Please review your pay advice each time you receive. 
• Ask if you have a question or concern about your pay or a payroll deduction: Mains’l makes every effort to ensure that our employees are paid correctly. Occasionally mistakes happen. When mistakes occur Mains’l will promptly make any corrections necessary to provide you with the pay you were entitled. Please review your pay stub when you receive it to make sure it is correct. If you believe a mistake has occurred or if you have any questions, please use the following procedure.

1. If you have questions about your pay (over or under payment) or any deduction from your pay, immediately contact your supervisor/manager. If your supervisor is unavailable, you may contact the Payroll Department or the Human Resources Department at 763-494-4553 or 1-800-441-6525. State, Federal, Social Security and Medicare taxes are deducted automatically per State and Federal regulations. No other deductions are made unless required or allowed by law or prior authorization.
2. Mains’l will assess your report by reviewing appropriate time and payroll records.
   • If you have been paid incorrectly, or if Mains’l determines that a deduction was improperly made, Mains’l will reimburse you as promptly as possible; which will be no later than one pay period from the time you report the suspected problem.
   • If you have been overpaid,  the employee returns all funds to Mains’l immediately upon discovery of the error. Mains’l will then reissue to you the corrected amount. ​

• Understand and prevent timesheet fraud: It is a violation of policy and state and federal laws for any person to:
  • Falsify or lie on a timesheet
  • Alter another employee’s timesheet
  • Instruct an employee to incorrectly or falsely report hours worked or alter another employee’s timesheet.

If anyone instructs you to falsify or lie on a timesheet or to instruct someone else to falsify or lie on a timesheet you must report the situation immediately to Human Resources at 763-494-4553/800-441-6525.

Certain edits may be made to an employee’s timesheet by Mains’l that does not constitute a violation of this policy or state and federal laws. Allowable edits are limited to:

1. Correcting the Department or  Number of the person receiving services when it is certain you have the wrong number.
2. Correcting the pay code when it is certain you have the wrong pay code.
3. Human Resources Generalist entering timesheet information on behalf of an employee when it is certain that the Generalist has accurate data to create the timesheet. The data must be provided by the employee or the manager to the Generalist. This may only occur in very rare circumstances where the employee is unable to enter the data on their own. 

Any person who is suspected of committing timesheet fraud will be reported to the Office of the Inspector General. Mains’l will not continue to employ or do business with an individual who has committed timesheet fraud. 

• Keep your information up to date: It is your responsibility to inform the payroll department as soon as possible of any changes to:

1. Bank account information: Submit a revised direct deposit/payroll authorization form.
2. Your address: Submit an Employee Information Change Form.
3. Your e-mail that pay advices are sent to: Submit a revised direct deposit/payroll authorization form and an Employee Information Change Form.
4. The amount of withholdings you want to claim: Submit a revised W-4 Form.

Notification of changes to your direct deposit information must be submitted to the payroll department on a Payroll Direct Deposit Authorization Form no later than one week before payday. If an employee fails to submit a change one week before payroll, payroll deposits will be made to the account on file, if no account is on file a Visa Rapid! PayCard will be issued. 

• Holidays: Due to the variety of work environments and services that Mains’l provides, we have holiday pay practices that are different based on the type of work being performed.
  • Twenty four (24) hour per day direct support services provided by Mains’l often require employees to work on national and religious holidays. The agency provides an incentive to facilitate the scheduling of holidays in 24 hour direct support services when staffing is required. 
  • Non-exempt employees working in 24 hour support services, where Mains’l is required to provide staffing, are eligible to receive the benefit of time and one half pay. To receive this benefit the employee must enter the time worked under the Holiday pay code only when they work on the following holidays:

New Year's Day- January 1	Independence Day- July 4th
Martin Luther King Jr. Day- Third Monday of January	Labor Day- First Monday in September
President's Day/Washington's Birthday- Third Monday of February	Thanksgiving Day- Fourth Thursday of November
Easter- Date Changes	Christmas Eve- December 24 from 12pm-12am
Memorial Day- Last Monday in May	Christmas Day- December 25
Juneteenth National Independence Day- June 19	New Year's Eve- December 31 from 6pm-12am

Whenever there are two premium pay rates for hours worked (i.e. overtime and holiday) only one premium pay rate is paid. 

• Non-24 hour per day direct support services provided by Mains’l usually do not require employees to work on national and religious holidays and the reimbursement rates to pay for these services do not include funds to pay time and a half to employees. Employees working in non- 24 hour hourly services who work on a holiday as define above will receive their regular pay rate and should NOT submit their time as Holiday pay. If an employee in a non-24 hourly service is required to work, they may be eligible to receive time and a half pay and should discuss this with their supervisor and HR before the holiday. Use the pay code that is assigned to the service being provided.
• Office and management staff, including exempt (salaried) and non-exempt are usually not expected to work on holidays and are not eligible for time and one half pay. When the office is closed including the holidays listed above, full time 35-40 hour per week nonexempt and exempt office and management staff will receive pay at their regular pay rate for the number of hours they would have been scheduled to work if the office was open. Part time office and management staff can take the day off, or work hours on different day that the office is open. If you observe different religious holiday’s than those provided by Mains’l, please contact your supervisor to discuss swapping your preferred religious holiday with one identified in this policy. The agreement to swap holidays should be documented and provided to HR for the employees file. 
• Logging case notes: When the person receiving services has unit-based or hour-based services, each employee working with that individual both, nonexempt (hourly) and exempt (salary), is responsible for completing a notes entry to record the amount of time spent on approved activities. These notes entries are completed for all direct care (billable) hours to provide legal documentation of the services being provided. The notes entry field is located:

1. In the timesheet system: When you choose a department number that requires a notes entry it will appear on your screen. You can record your work activities online when you enter your hours worked.

Without an electronic notes entry, the hours cannot be billed. Employees who are required to complete notes entry should do so each day they work and must submit no later than due date and time listed on the payroll calendar. The supervisor is required to review note entries before approving the hours to be paid for that employee. 

 

NONEXEMPT  EMPLOYEES (PAID OVERTIME FOR WORKING OVER 40 HOURS PER WEEK)  

The following information applies to nonexempt employees only:

• Recording your work: It is your responsibility to submit an accurate and complete record of each time you work. We offer  two ways to do so.
  • Online at www.mainsl.com  or directly at dataplus.solanapro.com
  • Mobile phone app at www.mainsl.com/mobi

Both options for recording your work time create an official record called a timesheet. A permanent record of your timesheets is stored in the timesheet and reimbursement system..

Mains’l employees enter time as it is worked. When it is not possible to enter your time at the start and end of each shift, it is your responsibly to enter your time soon as possible and no later than the due date and time listed on the payroll calendar.

It is the goal of Mains’l to train employees to successfully submit time records as part of their documentation responsibilities and to ensure employees are paid accurately. We expect that after proper training, all employees will enter their time as it is worked and ensure the data that is entered is accurate and fully complete before the due date and time.

In the event that time records are not completed within the established time frames or within the expectations required for billing and pay purposes, Mains’l expects that the supervisor and employee form and follow a plan to correct the performance issue. If you are struggling with time entry, ask questions or ask for help immediately. 

 

Many of the services that Mains’l provides are billed in 15-minute units. So, our timesheet system requires time to be entered in 15 minute units. Start and end times must be rounded to the nearest fifteen (15) minutes using the 7 minute rule. The 7 minute rule states 0-7 minutes is rounded down to 0 and 8-14 minutes is rounded up to 15 minutes.

Mains’l expects that employees arrive to work and leave work on time. Arriving early or leaving late to intentionally increase the time you are paid for is unethical.                                                                               

• Reviewing and approving timesheets: You are responsible for making sure the information you enter on your timesheet is accurate and entered on time. A user guide, online training, and on the job training are provided to teach you how enter timesheets. A payroll calendar is provided for each employee to ensure you know important dates.

The payroll calendar provides:

• Dates included in each pay period
• Dates and time your timesheet must be accurately completed by to ensure you are paid on time.
• Pay dates

Your supervisor is responsible for reviewing and approving your timesheet before it is sent to payroll. You will be paid on time if your timesheet is entered accurately and on time and it is approved by your supervisor.

• Fixing timesheet errors: We understand that mistakes can happen. However, it is critical that if there is an error on your timesheet, it gets fixed right away. Your timesheet is used to pay you and may also be used to bill for the services you provided. If your timesheet is submitted with errors, it can cause billing and payroll errors.

You may not be paid on time if one of the following errors is made:

• You do not provide the required information to create your timesheet.
• The information you provide is not complete, or is not accurate.
• You do not enter your time worked by the timesheet due date and time.

If you make an error, it is your responsibility to correct any information that is not accurate. Once your timesheet is entered accurately and approved, it will be processed on the next timesheet due date and paid with the next pay date.

If your supervisor makes an error, it is your supervisor’s responsibility to work with the payroll department to issue your pay on the correct pay date. If there is a system error, Mains’l will work to correct the error as soon as possible.

• Unapproved work time: Non-exempt (hourly) employees are expected to only perform work as instructed by their manager/supervisor. It is your responsibility to ensure you work within the timeframe of your shift and/or assigned hours per week. You should not work any time that is not scheduled or requested of you unless you are given permission by your manager/supervisor before doing the work. Unapproved work is a performance issue that supervisors are expected to address with employees.  ​

Unapproved work time includes:

• Starting work before your scheduled time, 
• Stopping work ater your scheduled time, 
• Overtime that is not pre-approved by your manager/supervisor, 
• Working more than your allotted or assigned hours, 
• Doing work that is not based on the service needs of the person receiving services,
• Working when you have been instructed not to
• Off the clock: Non-exempt employees are not allowed to do “off-the-clock” work. “Off-the-clock” work means work you perform but fail to report on your timesheet. If you do work, you need to enter it on your timesheet. Please be sure to communicate with your supervisor if you are performing work that is not normally scheduled for you, will lead to overtime or will exceed your typical hours worked. Working unapproved hours is a performance issue.

The following are not considered “off-the-clock work” and should not be entered on your timesheet:

• Completing work related documentation, such as entering your timesheets, completing timesheet summaries, or mileage logs outside of your scheduled shift. Entry of time and related documentation should be completed at the end of each shift.
• Being in the presence of the person you work with or at the work site after your work shift ends if you are no longer responsible for work duties.
• Time spent with an individual you work with outside of work activities. For example, if you are a family member or close friend of the person you work with, it is expected that you will spend time with the person outside of work time.

• Overtime: Mains’l employees keep track of all hours they work and ensure they do not accidently go into overtime. If an employee is asked to or expected to work any hours over 40 per work week, they must first contact their supervisor to explain how many hours they have worked and receive approval before working any time over 40 in the workweek. Working unapproved overtime is a performance issue that supervisors are expected to address with employees.

Non-exempt employees are paid overtime at the rate of one and one-half times their regular rate of pay for hours worked over 40 hours per work week. Overtime pay is based on actual hours worked. PTO, Sick, or any leave of absence is not considered hours worked. Overtime is not paid more than once for the same hours worked. Overtime is calculated to the nearest fifteen (15) minutes.

• Travel Time: Time spent driving during normal work hours is considered paid work time. When the time spent driving is with a person receiving services, the time is direct work time and should be entered under the pay code assigned for the type of service being provided. Time spent driving to and from work is considered commute time and is not paid time. Additionally, employees cannot enter Travel Time for trips made during the work day that are not required by Mains’l. This includes travel for personal meals, personal errands, and the commute to and from work.           

When Mains’l requires an employee to travel to more than one work site within the work day, the employee is paid at their primary pay rate for the amount of time required to travel to the next work site. Time spent driving from one work site to another that is not with a person receiving services, should be entered into the timesheet system as Travel Time. The supervisor is responsible for informing the employee which department number to use when entering travel time. In general travel time is assigned to the department for which the employee is traveling on behalf of (department you are driving to the next location for) or the department that the employee primarily works in.

• Day Light Savings: Twice a year during daylight savings time hourly employees working overnights will either gain an hour worked (fall backwards) or lose a hour worked (spring forward). Payroll will make the adjustment for the employee automatically.

EXEMPT EMPLOYEES (SALARIED AND NOT PAID OVERTIME)                                                          

The following information applies to exempt (salaried) employees only:

1. Salary basis of compensation: Exempt employees receive a salary to compensate for all hours worked for Mains’l. The salary is a predetermined amount that is not subject to deductions for variations in the quality of the work you perform.
2. Recording your time: Although exempt employees are not paid by the hour, all exempt employees are required to account for their time. This is important for a variety of reasons, but it is not for the purpose of paying an exempt employee other than on a salary basis. Exempt employees are required to document time worked if their time is used for billing purposes or as requested by their supervisor.      
3. Workdays: The regular business workday for salaried employees varies based on position. A supervisor/manager may specify expectations. Mains’l generally expects that an exempt employee will work forty or more hours in each workweek. Exempt employees are required to meet attendance standards.
4. On call time: Exempt employees who are assigned on-call duty or administrative cell phone duty do not receive additional pay for that duty.
5. Pay for working direct care hours: Managers who are assigned direct care hours do not receive additional pay for that duty. Exempt employees who are not assigned direct care hours and work an overnight shift on an emergency basis will be paid the equivalent of minimum wage for hours worked. Exempt employees must receive pre-approval from their director and must enter the time in the Timesheet System for the stipend to be approved and paid.  
6. Deductions from your salary: A deduction from salary results in a lower gross pay amount on an employee’s paycheck. Deductions will only be made in good faith and in compliance with applicable law. No manager or other employee has the authority to order any deductions from an exempt employee’s salary without the approval of the CEO or Corporate Director of Human Resources. Federal and state law limits the deductions that can be made from the salary of an exempt employee. Mains’l intends to fully comply with these limitations.
   1. Allowable deductions from salary: The salary of an exempt employee may be reduced for any of the following reasons:
      • Full day absences for personal reasons. 
      • Full day absences for sickness or disability (which absence may otherwise be paid through any sick time benefits available to the salaried employee, if any). 
      • Full day suspensions for infractions of Mains’l policies and procedures.
      • Full day suspensions for violations of workplace safety rules of major significance.
      • To offset amounts received as payment for jury and witness fees or military pay.
      • The first or last week of employment in the event the employee works less than a full week.
      • Certain types of deductions such as the employee’s portion of health, dental or life insurance premiums; state, federal or local taxes, social security; or, voluntary contributions to a 401(k) retirement plan.
      •  
   2. Un-allowable deductions from salary: In a work week in which an exempt employee performs any work, the exempt employee's salary amount will not be reduced for any of the following reasons: 
      • Absence because the facility is closed on a scheduled work day.
      • Absences for jury duty, attendance as a witness, or military leave in any week in which you have performed any work.
      • Any other deductions prohibited by state or federal law.
7. Deductions from Paid Time Off (PTO) or Sick Time balances: A deduction from an employee’s PTO or sick time balance reduces the amount of an employee’s unused personal time off (“PTO”) or sick time off. It does not reduce the employee’s salary. Mains’l reduces an exempt employee’s PTO or Sick balance for full and half day absences. Exempt employees use the timesheet and reimbursement system to record deductions from the PTO or Sick Time account balances each payroll that time off is used by the established deadline. The information is then approved by your supervisor.

 

Mains’l employees use their personal phones during employee breaks or at any time in emergency situations.

If a situation arises that requires an employee to make a call that carries an additional charge, the employee may be required to reimburse the agency for the amount of the call plus applicable taxes.  

It is requested that the employee identify that they need to make a call that may carry additional charges and the employee is asked to notify the agency to make arrangements for payment.

Rev. 10/08/2019, HR Policy Team
 

Any suspicions of fraud, abuse, and waste should be directly reported to our Public Funds Compliance Officer, the Vice President of Administration. 
The Public Funds Compliance Officer conducts an internal investigation. In the event that our Public Funds Compliance Officer, the  Vice President of Administration is suspected or alleged to be involved in fraud, the Corporate Director of Human Resources completes the investigation. The investigation will include at least the following:
1.    Whether fraud, abuse, or waste occurred;
2.    Whether written policies and procedures were adequate;
3.    Whether written policies and procedures were followed;
4.    Whether there is a need for additional staff training;
5.    Whether there is a need for external reporting.

If it is determined after a thorough investigation that any employee has committed fraud, their employment will end immediately. 

If it is determined that a vendor, person who uses services, or other business partner has committed fraud, Mains’l reserves the right to end the relationship. 

While Mains’l prefers that reports of suspected fraud and abuse are made internally, you have the right to report suspicions of Medicaid abuse or fraud to a state agency. 
In Minnesota:     Department of Human Services Provider Fraud: 800-657-3750 Recipient Fraud: 800-627-9977
http://mn.gov/dhs/general-public/licensing/report-fraud/index.jsp
In California:     Department of Health Care Services/Health Care Programs at 800-822-6222 or 
http://www.dhcs.ca.gov/individuals/pages/stopmedi-calfraud.aspx
Office of the Attorney General 800-722-0432 or http://www.ag.ca.gov/bmfea/medical.htm

Mains’l will not discharge, discipline, threaten, or discriminate against, or penalize an employee, who in good faith reports or participates in an investigation of fraud, abuse, or waste internally or externally. However, failure to report suspicions of fraud, abuse, and waste will result in disciplinary action, up to and including separation.
 

The goal of this procedure is to provide guidance which establishes steps around a timely process where Mains’l will collaborate with employees and/or applicants to explore reasonable accommodations. 

To request a reasonable accommodation, submit in writing a request to your supervisor. All requests must have the following information (applicants to seek a request from HR):

1. Who is making the request for accommodation (must be employee and/or applicant) 
2. What specific reasonable accommodation is needed
3. Why reasonable accommodation is needed
4. Clarify how the accommodation will assist the employee or applicant to complete essential job duties
5. Expected amount of time the accommodation is needed. For example, 3 months or permanently
6. Documentation from a medical provider if applicable

For employees, the supervisor is to review the request and send the request to Human Resources for approval or denial. As HR receives requests from applicants, HR will partner with interviewing supervisors to share the request. Human Resources will guide the supervisor on next steps and expectations.

Human Resources review the request and determine:

1. If more information is needed
2. If the request is reasonable 
3. Next steps and expectations for the supervisor

Once all information is received and within a reasonable time frame, a determination of approval, denial or alternative accommodation is sent to the employee or applicant within 10 working days. 

Mains’l will check in periodically with the employee to ensure that the accommodation is effective. If the accommodation is not effective, Mains’l will reengage in an interactive process.
 

Rev. 3/13/2019, HR Policy Team
 

1. All use of personal vehicles or personal funds for business purposes must have prior approval of the immediate supervisor. Every approved work-related vehicle trip can be documented in the “My log” area of Sandata’s timesheet and reimbursement system. Every expense is logged in our online tracking system.

   • Each time an employee uses their vehicle for work related purposes, they can enter this information in to Sandata. They will need to include the dates of travel, destination, and total trip miles. The total miles are multiplied by the reimbursement rate and the resulting number is the amount of reimbursement.

   • Each time an employee uses their own funds for purchases; they will need to submit an image of their receipt and submit the information into Sandata. 

   • The supervisor will then review these entries and approve the entries for reimbursement.  

2. The due date for all expenses and mileage is consistent with the due date of entries for time worked of Mains’l’s payroll calendar. The calendar is sent to all employees at the beginning of the year, and given to new employees at orientation. The calendar is also in Sandata Crews Quarter’s document center in the payroll information folder.

3. The deadline for reimbursement of expenses, including reimbursement for mileage, is one (1) month after the due date. If submissions are not put into Sandata by that time, they may not be paid at any time.  

We ask employees to submit a written notice of resignation to the immediate supervisor which includes the date that notice is given, the last day of work, the reasons for the resignation and the employee’s signature (The Mains’l form, “Letter of Resignation” may be used.)  If there is a forwarding address, that information should also be provided at this time. 

Employees are encouraged to provide a thirty (30) day written notice in advance of resigning from their position with Mains’l. The thirty (30) day notice is essential to facilitating a smooth transition out of the company as well as to hire a new employee to the position.  

The employee is responsible for returning all Mains’l property (keys, phone, etc.) to the supervisor prior to their last day of employment.  The final paycheck is mailed/direct deposited to the resigned employee at the time of the next scheduled payroll.  When an employee resigns from Mains'l, PTO is not paid and the PTO account is reset to zero.  

An in person exit survey may be scheduled with the employee’s supervisor and/or a human resources representative.  Otherwise an electronic exit survey may be administered. 

Employees Separated for Performance/Misconduct
When an employee is separated from Mains’l for performance/misconduct, the employee is furnished with a letter stating the reason(s) for separation as requested by the employee. The request is made in writing by the employee within 15 working days of separation. The employer has 10 working days from receipt of the request to provide a letter.  If negligent or criminal behavior or abuse or neglect are the grounds for separation, possible criminal charges may be filed against the employee.

It is the employee’s responsibility to make arrangements to return all Mains’l property (keys, phone, etc.) to the supervisor at the main office within 24 hours.  The final paycheck is mailed/direct deposited at the time of the next scheduled payroll unless otherwise requested by the employee. When an employee is separated from Mains’l for performance/misconduct, PTO is not paid and the PTO account is reset to zero.

Employees That Are Separated From Mains’l for Reorganization or Economic Necessity
When a separation occurs due to reorganization or economic necessity, employees who are interested in resuming employment with Mains'l should submit a written statement of interest.   Employees are rehired according to the skill needs of the agency. 

When an employee has been separated by Mains'l for reorganization or economic necessity, PTO is paid. The employee is responsible for returning all Mains’l property (keys, phone, etc.) to the supervisor prior to their last day of employment.  

Inactive Employees
The personnel files of inactive employees who have not worked for three (3) months are separated; PTO is not paid and the PTO account is reset to zero.  If an employee is rehired more than six (6) months after their last day of work, they are considered a new employee and all orientation training requirements need to be fulfilled.
 

Employees report to Mains’l the following as soon as they occur:

1. Any auto accident that involves a person receiving services
2. Any auto accident that involves an employee during their work time
3. Any auto accident, damage to, or maintenance need involving an agency owned vehicle.
4. Loss of ability to drive, including a suspended or revoked license, no car insurance, lack of an operable vehicle.
5. Issues or concerns about supplies or equipment that is used to transport a person who receives our services
6. Any tickets or tows while working. Please note that parking tickets or tows from towing zones for employees that occur while driving on the job are not paid by Mains’l. They are the responsibility of the employee. 

Employees who drive for work purposes:

1. Maintain the vehicle in safe working order with an adequate supply of fuel.  (1/4 tank minimum in winter).
2. Wear seatbelts at all time when driving for work and ensure any passengers in the vehicle are also wearing seatbelts.
3. Use defensive driving techniques.  
4. Demonstrate safe driving habits.
5. Not be on medications that impair your ability to drive.
6. Willing and able to evacuate the person or people they are driving if necessary.
7. Check first aid kits to be sure full stocked in agency vehicles.
8. Use hands free driving. This includes:
   
   1. Don’t use cellular phones while driving. (Minnesota and California state law).
   2. Don’t text while driving (Minnesota and California state law).

Assistive techniques:

When people need assistance the following techniques are used:

1. Provide physical support when necessary.
2. Assist with the use of any ramp or step stools.
3. Properly secure all supplies and equipment (i.e. wheelchairs) before driving
4. Assist with seatbelts, as needed, so they are correctly fastened.
5. Follow seat belt and child passenger restraint system laws.

Driver eligibility guidelines:

To ensure safe transportation, employees who drive for work purposes:

1. Have a valid driver’s license from the state in which they live without any current revocation or suspension
2. Report to the HR Generalist any status changes or written violations, including speeding, that occur following the initial driving record check.  Failure to report any changes may result in disciplinary action up to and including separation.  Mains'l also reserves the right to check any staff driver’s driving record at any time to assure continued driver eligibility.
3. Having valid insurance coverage is important when driving for Mains’l. To ensure coverage in case of an accident, any employee who is eligible to drive either a company vehicle or their own vehicle for work purposes will be asked to provide a copy of their personal auto insurance. Employees will be assigned a task through Sandata to send in their most current auto insurance card and expiration date as it occurs. Mains’l also reserves the right to check any staff driver’s insurance validation at any time to assure continued driver eligibility. If an employee does not have their own personal insurance they may still be able to drive for Mains’l using a company vehicle.

If circumstances occur where employees are not able to furnish personal auto coverage. the employee will need an exemption on file and should contact their manager and HR for more information.

A state department of motor vehicle report is processed for each potential driver. Mains’l may check employee driving records at any time to verify driver suitability.  Mains'l follows the recommendations of our commercial general liability insurance company on driving histories as to the eligibility of the employee to drive the vehicle.

Driver’s licenses are not required for working at Mains'l, however not having one limits employment options for those employees.  This can even result in separation of employment if no acceptable position exists where driving is not required.

Mains’l uses a ten (10) point aggregate system. Points are assigned for each driving infraction in one’s history. Employees with driving records of ten (10) points or more within the look-back period are considered to be an ineligible driver for employment purposes. The look-back period is three years for all violations.

 

10 Point System

Driving Without License	10 Points
Driving While License is Suspended/Revoked/Withdrawn	10 Points
Driving Under the Influence or while Impaired	10 Points
Reckless/Careless Driving	10 Points
Any Speeding Violation	4 Points
Child Restraint/Wheelchair Restraint Violation	5 Points
Driving Without Insurance	5 Points
Any Moving Violation (excluding speed)	2 Point
Texting While Driving	4 Point
Cell Phone Use While Driving	4 Point
Seatbelt Violation	2 Point

Use of an employee owned vehicle for work

At work sites where no agency owned vehicles or modes of transportation, such as buses, are not available or appropriate, use of employee vehicles to transport a person receiving services is permitted.

 

1. Requirements: The following are requirements when an employee uses their own vehicle to transport a person we support.

• Keep the vehicle well maintained and in good working order.
• Report immediately any mechanical concerns to the manager.
• Use only vehicles registered in the employee’s name or that of an immediate family member. 
• Never use a borrowed vehicle to transport a person we support.
• Report to the manager if you purchase a different vehicle.
• Report to the manager that day if you arrived to work in a borrowed vehicle. 

2. If damage occurs to an employee owned vehicle: When there is damage to an employee’s vehicle, the following guidelines apply:

• The employee writes and submits an incident report to the manager.
• If the person receiving services caused the damage Mains’l will cover the cost of repair.
• There is no coverage for the physical damage to an employee-owned vehicle under the Mains’l Business Auto policy. This applies whether an employee was alone in the vehicle or was transporting a client. Every employee is responsible for the damage to their personally owned vehicle and should make sure that they carry comprehensive and collision coverage if they want the physical damage to their vehicle repaired. If the other driver is at-fault for the accident it is possible that the employee’s personal auto insurance may subrogate against the responsibly insurance and recover the deductible.
• When an employee is driving their own vehicle for work, Mains’l Business Auto insurance is secondary over the employee’s personal auto insurance for liability when the employee is at-fault for an accident. This means that the employee will need to first make a claim under their own personal insurance policy and if their personal limits are exhausted, then Mains’l policy would be triggered.

Use of an agency owned vehicle:

1. When agency vehicles are provided: Mains'l provides agency owned vehicles for selected work sites.  Agency owned vehicles are used for the transportation of the people we support, and are not for the personal use of the employee. Use of Agency Owned Vehicles, without pre-approval from a manager, will result in immediate separation. Drivers are responsible for the security of agency vehicles assigned to them.
2. Age requirements: All drivers of agency vehicles should be 21 years of age or older.  Drivers under 21 years of age may operate low seating capacity (8 or less) vehicles if they have no MVR infractions. This includes both minor and major infractions. If a driver under the age of 21 has any MVR infractions, they will be disqualified from driving until they are able to meet the driving requirements. Agency vehicles typically include passenger automobiles, mini vans and full size vans.  Drivers of 15 passenger vans must be 25 years of age or older.
3. Safe Driving Training: All Driver’s of Mains’l will partake in safe driving training through Mains’l. This training is assigned at the beginning of employment and is taken annually. Employees who work at a CRS home will be assigned a similar training that is combined with home maintenance topics.
4. GPS Trackers: It is a requirement of the agency’s insurance carrier that all agency owned vehicles have a GPS tracker. These transponders have been supplied by our insurance company and are installed in all agency vehicles. The GPS monitoring system will collect data during all hours of operation. Information from GPS system will not be used or disclosed for purposes other than those for which it was collected, except with the consent of the individual or as required by law.
   
   1. Use of Retention of Data: The company reserves the right to report information gained from the GPS system to comply with requirements from our insurance company or law enforcement. Information may also be viewed in cases of emergency for the protection of all vehicle passengers. At no time will persons other than those designated by Mains’l have access to the data collected during surveillance.
   2. Enforcement: Employees who fail to follow this policy or who use GPS data inappropriately will be subject to disciplinary sanctions, up to and including termination.
   3. GPS Surveillance Consent Form: All employees will be required to sign the “GPS Surveillance Policy & Consent Form” before operating a Mains’l owned vehicle.

While using an agency vehicle:

1. Record beginning and ending odometer reading on the mileage log.
2. Shut off the engine, remove the keys and lock the doors if leaving the vehicle unattended
3. Have agency vehicles which transport wheelchairs and have lifts or ramps inspected by Minnesota State Patrol each year when the inspection dates and locations are announced.
4. Apply the state patrol inspection sticker to the windshield.  

 

Manager responsibilities:

1. Keep agency owned vehicles in good condition, performing necessary inspections, service and documentation. 
2. Managers make sure agency vehicles contain the following:
   
   1. Emergency phone numbers including site, manager, senior manager, and a towing company.
   2. First aid kit and first aid handbook
   3. Proof of insurance card
   4. Vehicle registration card
   5. Current license tabs
   6. Written vehicle accident protocol
3. All agency vehicles which transport wheelchairs and ramps or lifts will have properly working securement belts and web cutters.
4. If either the insurance card or the license tabs are expired, the manager contacts the Customer Specialist at the main office and the missing document will be replaced as soon as possible.

Vehicle accidents (Accident Protocol): 

If an employee has an accident while working:

1. The employee remains at the scene of the accident and calls 911 to report the accident. The employee does not leave the scene of the accident until the police officer has either dismissed the parties involved or, in cases where the police will not respond, the employee and the other driver, if that is the case, have exchanged names, addresses (use Mains’l office for agency owned vehicles), telephone numbers (use work number for agency owned vehicles), license plate numbers, and insurance company contact information.
2. In cases where the police respond, the employee asks the police officer for a business card and a case number.
3. The employee immediately reports the accident to the supervisor, who reports the accident to the Senior Manager. 
4. All accidents with agency owned vehicles are reported to the agency’s commercial, general liability insurance company by the Senior Manager working together with Administration.
5. The employee completes the required paperwork which may include an employee incident/accident report.
6. Mains'l conducts an investigation, which may result in the employee being disqualified from driving any agency vehicle.

Training on agency vehicles:

1. Training will occur for all people who are unfamiliar with wheelchair transports, who work at sites where a person uses a wheelchair, in the use of securement belts to properly secure passengers in wheel chairs. 
2. The manager, once trained, trains all new staff in the use of restraint belts and reports the training completion list of employees to human resources.
3. The manager confirms that all team members are familiar with, and follow, the procedures as outlined in this document

Agency owned vehicle maintenance:

In California:

1. For routine maintenance please check with the manager. The location for maintenance may vary depending on dealership coverage.
2. All agency vehicles are repaired at Affordable Automotive 2106 Park Avenue Chico, CA 95928 530-892-1774.

In Minnesota:

1. All agency vehicles are serviced at Noble Mobil, 9500 Noble Parkway, Brooklyn Park, MN; 763-315-2886; Cornerstone Chevrolet, Intersection of I-94 and State Highway 25, Monticello, MN; or other designated and approved sites.  
2. Services include preventative maintenance (oil changes, tire rotations, transmission flushes, etc.), inspections, and repairs.  Any exceptions to this procedure are approved by the maintenance technician.
3. In the event of roadside breakdown, employees may contact the maintenance technician or call Nobile Mobile at 763-315-2886.  If after hours, Noble Mobil may direct you to call City Wide Towing at 763-424-4900. If directed to call City Wide Towing report this information immediately to the manager.  After hours towing, car start, flat fixing services are through City Wide Towing who will perform the service and submit an invoice for payment to the vice president of administration.
   
   1. Managers arrange all necessary vehicle repairs and services (including scheduled oil changes, tire replacement, mechanical repairs, etc.), on a timely basis. 
   2. If the manager needs assistance in assessing or scheduling repairs, they may contact the Mains’l maintenance technician. 
   3. All invoices, including all receipts, are submitted to the maintenance technician for coding and recording, who will forward to the accounts payable manager for payment.  If advised of repairs that are in excess of $250.00, while having routine maintenance completed, the manager contacts the Mains’l maintenance technician.  The maintenance technician advises whether to proceed with the repair or offer other direction.

Managers and/or support coordinators are directed to periodically inspect the agency vehicle for dents and verify that the lights, wipers, signal and horn work all work.

Disability Parking Permits: 

1. Used only in agency vehicle for transporting physically disabled persons receiving services.
2. Disabled people must apply for their own individual permit in their name
3. Mains’l keeps a list of which permits go to which sites
4. Mains’l keeps copies of the certificate letters with each permit
5. Copies of each letter are sent to the respective manager to review with their staff
6. Permits must be displayed by hanging from the rearview mirror

Agency Vehicle Inspections: 

The Maintenance Committee inspects all agency vehicles and log books during regularly scheduled routine inspections.  Any corrective action will be documented and forwarded to the manager.

This policy and procedure is reviewed during orientation and on an annual basis by employees who provide transportation.

Revised by HR Policy Team 7/2022

The AWAIR Program is intended to:

1. Establish an executive policy statement (we’re committed to safety)
2. Develop strategies to reduce workplace accidents and injuries
3. Provide for the safety inspection of worksites
4. Establish enforcement strategies to insure compliance
5. Provide for a training program (blood borne pathogens)
6. Provide for the assessment and control of hazards

Strategies to reduce workplace accidents and injuries
Once each year; CRS sites will conduct an exercise to list together 3-4 workplace conditions or behaviors that can cause accidents and/or injuries. In turn the supervisor will elicit solutions from the participants to address these conditions or behaviors. The results will be sent to the vice president of administration for review and any follow up action necessary.

Inspections of Work Sites
Home Safety Inspection Checklists will be used by CRS site staff to identify potential conditions that might also cause accidents or injuries. These checklists are to be completed once every two months and sent to the vice president of administration for review and any follow up actions necessary.

Enforcement Strategies
Employees who fail to follow safety rules or requirements will be subject to employee discipline as described in HR policies.

Training:
The primary training for safety in the workplace is blood borne pathogens. Otherwise CRS sites will acquaint employees with local safekeeping practices.

Assessment and Control of Hazards
Mains’l prohibits use and storage of hazardous materials.

Safety Coordinator
The safety coordinator for Mains’l is the vice president of administration.

 

Mains’l encourages employees to report all claims of sexual and other harassment immediately to their supervisor. If the supervisor is unavailable or an employee believes it would be inappropriate to contact that person, they should immediately contact human resources or any other member of management. 

Mains’l Services does not retaliate or take any adverse action against any person who, in good faith, makes a claim of sexual harassment.

All allegations of sexual and other unlawful harassment are quickly and discreetly investigated. To the extent possible, employee’s confidentiality and that of any witnesses and the alleged harasser are protected against unnecessary disclosure. When the investigation is completed, the employee is informed of the outcome of the investigation. The investigation is comprised of the following steps:

1. Confidentiality – Mains’l protects the confidentiality of employee claims to the best of its ability. At the same time, HR conducts a prompt and effective investigation. Therefore, it may not be possible to keep all information gathered in the initial complaint, such as interviews and records, completely confidential. All information gathered remains confidential to the extent possible for a thorough investigation. Some information is revealed to the accused and potential witnesses, but that information is shared only on a “need to know” basis.
2. Interim Protection – Separation of the alleged victim from the accused may be necessary to guard against continued harassment or retaliation. A schedule change, transfer or leave of absence may be necessary. Mains’l works with the complainant to ensure that he or she feels safe during the duration of the investigation.
3. Selection of the Investigator – HR staff have special training in conducting sexual harassment complaint investigations and are responsible for conducting investigations of these types.
4. Creation of an Investigation Plan – A plan is constructed which includes an outline of the issue, the development of a witness list, sources for information and evidence, interview questions targeted to elicit crucial information and details, and a process for retention of documentation.
5. Development of Interview Questions – Questions are developed during the planning stage, although additional questions may be added throughout the investigation as more evidence and information are shared. 
6. Interviews – The investigator informs all parties involved of the need for an investigation and explain the investigation process. Questions may be asked to relevant parties orally, and in some cases in writing.
7. Decision – Once the investigation is complete, credibility is assessed and all information is evaluated. A final decision of any employment actions that are warranted are made at this time and all parties are informed of the decisions made.

Rev. 2/28/2019, HR Policy Team
 

In consideration of others, maintaining a smoke-free environment is a role we all play a part in as employees of Mains’l. Employees work with people receiving services in several venues: 

• in a person receiving services’ home (leased by Mains’l or owned/rented by the consumer);
• in the employee’s home;
• in the community (in public and private places);
• in vehicles while transporting a person receiving services (owned by Mains’l Services, Inc. or by the employee).
• Mains’l office(s).
• This procedure addresses each of these situations with directives for maintaining a smoke-free environment.

A Person Receiving Services’ Home (leased by Mains’l or owned/rented by a person receiving services)

1. There is no smoking or use of tobacco products in a person receiving services’ home by employees, at any time. 
2. Designated smoking areas are individualized to each house, but every smoking area for employee use are to be at least twenty-five (25) feet from the entrance.
3. All materials used for smoking, including cigarette butts and matches, are to be extinguished and disposed of in appropriate containers.
4. If a person receiving services chooses to smoke in his/her home, she/he will be encouraged to use the designated smoking area. However, there is no obligation to do so. Employees are required to smoke in designated areas so as not to contribute to the second hand smoke in a person receiving services’ home. 
5. If an employee wants to work in a smoke-free environment, and is currently working with a person receiving services who smokes, a transfer may be requested. 

Employee’s Home (for employees who provide respite services)

1. While a person receiving services is in the employee’s home, smoking shall be in designated smoking areas. These areas are to be outside the house.
2. Even though this is the employee’s home, while a person receiving services is staying with the employee, Mains’l ensures a safe and healthy living environment, which includes freedom from second hand smoke.
3. If the employee cannot abide by this expectation, a person receiving services cannot stay in the employee’s home.
4. A guardian or a person receiving services may waive this section of the procedure.

In the community (in public and private places):

1. There is no smoking or use of tobacco products, at any time, while the employee is with a person receiving services. 
2. Arrangements should be made if the outing is for an extended period of time, to allow the employee to have a smoking break, in a designated area, at least twenty-five (25) feet from a person receiving services. 

In vehicles while transporting people receiving services (owned by Mains’l or by the employee):

1. There is no smoking or use of tobacco products, at any time, while the employee is with a person receiving services in a vehicle.
2. There is no smoking or use of tobacco products, at any time, while the employee is in an agency vehicle, with or without the person receiving services.
3. If the employee smokes in their vehicle, prior to a person receiving services being in the vehicle, the window should be down and ventilation systems operating. The high concentration of smoke in a small, closed compartment substantially increases the concentration of strong irritants and cancer causing substances in the vehicle.
4. If a person receiving services has known allergies or respiratory conditions, employees who smoke in their vehicles should not transport a person receiving services. 

At Mains’l office(s):

1. There is no smoking or use of tobacco products, at any time, while the employee is with a person receiving services. 
2. Designated smoking areas are individualized to each location, but every smoking area for employee use are to be at least twenty-five (25) feet from the entrance.
3. All materials used for smoking, including cigarette butts and matches, are to be extinguished and disposed of in appropriate containers.

Once again, maintaining a smoke-free environment is the responsibility of all employees. Thank you for playing your role as an employee at Mains’l to support this. Also, employees are informed of this policy and procedure at the Human Resources Policy and Procedure training and can access it through the employee portal. Employees who do not meet these expectations may receive written performance feedback.                                            

Rev.4/24/19, HR Policy Team
 

1. Senior management is notified immediately of any serious incident - suspected, alleged, or actual – involving an employee.
2. If a preliminary review of the report verifies the incident as serious, the employee is suspended, without pay, pending an internal investigation. 
   • The designated HR representative notifies the employee, personally and in writing, of the suspension. 
   • The manager is informed to remove the employee from the schedule.
3. An internal review will be completed as soon as possible by an objective administrative employee.
   • A report will be completed by the administrative employee assigned to the internal review. 
   • The Vice President of Administration and the designated HR representative are responsible for the decision to reinstate employment with or without corrective action and with or without paid time during the suspension. Separation of employment may also be the result.
4. The employee is provided with a written notification of the results of the internal review as soon as possible after the internal review is completed. 
   • The rationale for the decision is provided to the employee. 
   • If the employee feels that the decision is unjustified, an appeal through the established grievance procedure may be initiated.
5. Management may vary from this procedure if circumstances demand
    

Eligibility

Full time and part time employees may request an unpaid leave of absence if they have complete at least six (6) months of employment.  If the leave is not covered under any other leave policy or regulations, a position with Mains’l is not guaranteed following an unpaid leave of absence.

Use  
The use of unpaid leave is requested by the employee and will be approved at the discretion of Mains’l.

Limits
Eligible employees may request up to three (3) calendar months of unpaid leave within a one year period.

How to Request       
Requests for unpaid leave or any extension of an unpaid leave should be submitted in writing to the
employee’s immediate supervisor 30 days prior, or as soon as possible to the beginning of the leave period or extension of the leave period. The request needs to include the start and end date of the leave.

The supervisor will partner with the designated HR representative to discuss if accommodation can be made without negatively impacting the organization.   

The employee is notified in writing of the decision. The signatures of the supervisor and the designated human resources representative indicates the final decision.   

If a request is not received or not approved and the employee takes the leave, the employee will be considered to have abandoned their employment with Mains’l. 
        
Insurance Benefits     
Employees may continue the coverage in effect before their leave of absence according to the provisions of the insurance contract as well as the Minnesota Insurance Omnibus Bill and the Federal COBRA legislation. Information concerning provisions, restrictions, and cost of insurance under COBRA is sent to the employee. 

If the employee returns to full time work following the leave of absence, they must re-enroll in the insurance plan and are subject to the waiting period.

Other Benefits   
Holiday pay (salaried employees) will not be paid during an unpaid leave of absence.
    
Return to work        
It is expected that an employee will contact the supervisor prior to the end of their approved leave of absence. If the position is not available, the employee will be referred to human resources to apply for other positions with in Mains’l.  If an employee does not contact the supervisor at the end of their approved leave of absence, the employee is separated from their employment. Upon returning to work it is important for an employee to complete any missed trainings that would have occurred for their position during their absence. 

Interpretation 
The human resource department is responsible for interpreting the Unpaid Leave of Absence policy and procedure.
    

Rev. 2/18/2020, HR Policy Team
 

Eligibility  
Part time employees, after three (3) months of employment, can request unpaid time off. The supervisor approves all unpaid time off requests.    

Use     
Unpaid time off requests for less than three (3) days need to be given, verbally or in writing, to the immediate supervisor with as much notice as possible. Employees are expected to help find their own replacements. If the need for unpaid time off is unexpected, at least four (4) hours’ notice is requested.

Unpaid time off requests for three (3) days or more need to be given, verbally or in writing, to the immediate supervisor two (2) weeks in advance. Employees are expected to help find their own replacements for their unpaid time off. 

Unpaid time off requests for two (2) weeks or more need to be given, verbally or in writing, to the immediate supervisor four (4) weeks in advance of the first unpaid time off day. Employees are expected to help find their own replacements for their unpaid time off. 
 
How to Request
Notify the supervisor, verbally or in writing to receive approval. Replacement employees should not incur overtime by working the replacement shift.

Interpretation
The Human Resource Department is responsible for interpreting the unpaid time off policy and procedure. 

Rev. 02/18/2020, HR Policy Team
 

When an employee encounters sudden circumstances that compromises or eliminates child care and is scheduled to work, it is Mains’l policy that children or visitors of the employee should not come to the service location for the following reasons:

1. Confidentiality of information about people receiving services;
2. Compromise of supervision of the person/people as defined in each person’s Services Questionnaire and Safety Plan);
3. Distractions in emergency procedures;
4. Distractions from providing quality services;
5. Potential for injury.

If all other options by the employee, including attempting to find replacement staff, have been exhausted, the following procedure shall be in effect:

1. The staff will call their supervisor as soon as possible and explain the circumstances and what they have done to try to make other arrangements,
2. The supervisor will ask the staff questions to ensure that all attempts to find other solutions have been exhausted, 
3. The supervisor will verify that there are no issues in the person’s/people’s plans or emergency procedures that might prevent an exception to the policy from being granted for a short term basis,
4. The supervisor should confer with the senior manager to reach a decision.  At a minimum supervisor(s) notify the senior manager if/when an employee would need to bring a visitor to the workplace. 
5. The supervisor will communicate that decision to the requesting staff.
6. The decision by the supervisor and senior manager is final.

If an exception is granted in advance by the supervisor and senior manager, it is expected that the child (ren) or visitors are not napping or sleeping at the work location as this might compromise any emergencies requiring evacuation.

Mains’l ensures a safe and secure home for the people we support and the workplace for employees. Notwithstanding the fact that employees may have a lawful permit to carry a firearm, employees are prohibited from using, possessing, or storing weapons whenever they are engaged in work for Mains’l. Weapons include firearms, ammunition, knives, explosives, or similar dangerous items. 

Employees work with people in several venues as well as at the central office:

1. In a person’s home (leased by Mains’l or owned/rented by a person we support);
2. In the employee’s home;
3. In the community (in public and private places);
4. In vehicles while transporting for work purposes (owned by Mains’l Services, Inc. or by the employee).

This procedure addresses each of these situations with directives for maintaining a safe and secure environment.

In a Person’s Home (leased by Mains’l or owned/rented by a person we support) 
Employees are prohibited from using, possessing, or storing weapons while in the person receiving services home. If an employee believes that a visitor has a weapon in the person receiving services home, the employee will give an oral warning that weapons are prohibited on the premises. If the visitor refuses to comply, he/she will be ordered to leave the premises. If the visitor remains, law enforcement officials will be called.

In the Employee’s Home: (for employees who provide respite services)
Employees are prohibited from using, possessing, or storing weapons in their home while a person receiving services is in their home. If the employee cannot abide by this expectation, the person receiving services must not stay in the employee’s home.

In the community (in public and private places)
Employees are prohibited from using or possessing weapons while with a person receiving services in the community. 

In vehicles while transporting for work purposes (vehicles owned by Mains’l or by the employee)
If the employee is using their vehicle, the employee is prohibited from carrying, on their person or in the vehicle, any type of weapon. If the employee is using a vehicle owned by Mains’l the employee is prohibited from carrying, on their person or in the vehicle, any type of weapon. 

At the Office
Employees are prohibited from using, possessing, or storing weapons at the office. If an employee believes that a visitor has a weapon at the office, the employee will give an oral warning that weapons are prohibited on the premises. If the visitor refuses to comply, he/she will be ordered to leave the premises. If the visitor remains, law enforcement officials will be called.

Once again, maintaining a safe and secure environment is the responsibility of all employees. Anyone who has information of any potential violation of this policy must immediately inform a supervisor or office personnel. Failure to do so will result in employee discipline up to and including separation of employment. Furthermore, an employee who violates the directives in this policy as to their personal use, possession or storage of weapons will be separated from employment immediately.

Employees are informed of this policy at orientation.

Rev. 8/07/2019, HR Policy Team
 

The following procedure will govern the reporting of workplace injuries and reporting of such to Mains’l’s workers’ compensation insurance company:

1. Any employee who sustains a workplace injury reports the injury on the same day of the injury to their immediate supervisor.
2. The immediate supervisor will fill out at the time of notice the MAINS’L SERVICES, INC. CLAIMS INFORMATION REPORT with as much information as possible and directly fax that form to Mandi Irkfetz at Workers Compensation Modifier Controllers, Inc. (WCMC) 651-501-1493. The MAINS’L SERVICES, INC. CLAIMS INFORMATION REPORT may also be scanned and e-mailed to Mandi Irkfetz at claims@wcmcinc.com.
3. The immediate supervisor will see the employee as quickly as possible and ask the employee to sign and date the PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION form where it says “Date” and “Signature of Patient/Guardian.”; the EMPLOYMENT AUTHORIZATION AND CONSENT form where it says “Dated this day…By…”; the AUTHORIZATION AND CONSENT TO RELEASE INSURANCE RECORDS AND INFORMATION form where is says, “Dated…By…”; and the AUTHORIZATION FOR FILE REVIEW OR RELEASE OF COPIES OF WORKERS’ COMPENSATION CLAIMS FILE where it says “Dated…By…”.
4. The immediate supervisor will fill in the current date, the injury date, and the employee’s full name on the top of the LIGHT DUTY AVAILABILITY form.
5. In California the injured employee will also be provided with a DWC-1 form. The immediate supervisor and/or human resources is required to date the DWC-1 form and provide copies to WCMC and to the employee within one working day of receipt of the form from the employee.
6. Lastly, the immediate supervisor will either directly fax or e-mail these forms to Mandi Irkfetz at the above phone number or e-mail address.
7. The Claim form and the release forms, with the exception of the California DWC-1 form, are accessible at the conclusion of this procedure. 
8. The immediate supervisor will direct any questions or concerns the injured employee may have to Mandi Irkfetz at 651-501-1490.
9. The immediate supervisor will inform the injured employee that light duty work will be available to meet basically any restrictions the doctor may feel appropriate and that the employee will be required to work light duty if any time is lost from work.
10. The immediate supervisor will direct the injured employee to immediately bring all medical papers to their supervisor who will copy and fax or scan those documents to Mandi Irkfetz directly.
11. The immediate supervisor will finally e-mail a copy of the MAINS’L SERVICES, INC. CLAIMS INFORMATION REPORT to their Human Resource Generalist A designated Human Resources Generalist will prepare and maintain the required OSHA 301 reports on each reported injury.

In Minnesota the injured employee may select their own medical provider for treatment. It is the employee’s decision whether to be treated for an injury.

In California the injured employee will have either designated at the time of employment a medical provider of their choosing or will be required to seek treatment from a provider listed in the State Medical Provider Network (MPN). The MPN is available at the main office through human resources.

If the employee uses work time to go to the doctor on the day of the injury, the employee will be paid through the end of the shift. If additional time is required, the employee can use accrued sick time or Paid Time off (PTO).
 
Employees are on notice that all comments, job refusals, refusals of employment, or statements that may have a bearing on a workers compensation claim will be reported to WCMC.

WCMC will issue weekly progress reports to Mains’l Services, Inc. on all claimants and claims activities which will be reviewed carefully for progress on recovery and compliance with medical requirements.
 

1.    Access to Health Services

a.    The manager assists with or coordinates health service appointments using a tracking system which is maintained at the site
b.    The manager is responsible for the supervision of or assists the person in scheduling, attending, and documenting health related appointments as designated in the support plan.
c.    The manager is responsible for training the employees on the appropriate referral form needed for the health care provider and that all orders are implemented.
d.    Each person has the choice of which health care providers they desire to use.
e.    Each person will participate in the planning of their health care whenever possible.

2.    Health care appointments

a.    To maintain an optimal general level of health for each individual person’s physical and/or mental health diagnosis
b.    To maximize functioning, prevent disability; and promote optimal development of each person
c.    Managers will work to maintain a health care appointment tracking system.  For each person.  The tracking will include:

i.    A list of specific health care providers
ii.    Referral forms
iii.    Medication History Log 
iv.    Appointment Summary
v.    A calendar system 
vi.    display recommended frequency of appointments
vii.    the date of the last appointment
viii.    the date of any future scheduled and/or needed follow up appointments
d.    A physical examination should occur annually to:
i.    Obtain preventative health care screenings
ii.    Review medication and treatment orders
iii.    Review the use of standing order/over the counter medications
iv.    Evaluation progress and outcomes of treatment goals
v.    Determine further treatment planning

e.    A dental examination is recommended at a minimum every 6 months (or according to the person’s insurance carrier) to provide for:

i.    Examination and diagnosis
ii.    Restoration
iii.    Cleaning
iv.    Preventative screenings as prescribed
v.    X-rays 
vi.    Maintenance of dental health

f.    All other necessary appointments will occur as needed

i.    Vision
ii.    Hearing
iii.    Podiatry
iv.    Neurology
v.    Psychiatry
vi.    Other

3.    Monitoring Health

a.    When employee believes a medical emergency may be life threatening, they will call 911, or they will call the mental health crisis intervention team when the person is experiencing a mental health crisis
b.    The person’s health conditions are monitored according to written instructions from a health care provider and are documented on the Health Needs Record form.

i.    The Health Needs Record is completed at intake, 45 day meeting, annually, and as needed if there is a change in the person’s health condition

c.    Employee documents any changes in the person’s health in the Health Care Progress Notes (HPNs) and report changes to the manager before leaving their shift
d.    The manager notifies the health care provider of the changes within 24 hours or sooner depending on the severity of the changes.
e.    The manager notifies the person, person’s legal representative, if any, and case manager within 24 hours of changes in the person’s physical and mental health if they affect the health service needs assigned in the coordinated service and support plan (Support Plan) or the support plan.
i.    The notification is documented on a Health Needs Change Notice form
f.    Consistent coordination and communication to all involved in the care of the person
g.    Mains’l Services will provide a team approach for Health Care Quality Assurance to identify improvement needs in health care documentation, health care training and related processes.
h.    A Mains’l Services Therapist/Behavioral Specialist and/or a Nurse will be involved with providing recommendations in physical or mental health care when the likelihood of a change in condition requires a skilled assessment to identify a need for possible modification, treatment or initiation of additional medical services

i.    Acute and chronic conditions
ii.    Diabetes and insulin injection process
iii.    Other injection needs
iv.    Feeding tubes
v.    Oxygen and breathing assessments
vi.    Other skilled needs as identified

4.    Medical Equipment

a.    Orders for the medical equipment are filed in the person’s medical file
b.    An employee is trained on the safe and correct operation of medical equipment used by the person to sustain life or to monitor a medical condition that could become life-threatening without proper use of the medical equipment; including but not limited to ventilators, feeding tubes, or endotracheal tubes.

i.    The training is provided by a licensed health care professional or a manufacturer’s representative, who does an observed skill assessment as part of the training to ensure that the employee person demonstrated the ability to safely and correctly operate the equipment according to the treatment orders and the manufacturer’s instructions.
ii.    Training is documented on the “Training in Use of Medical Equipment Used to Sustain Life” form and filed at the site

5.    Mobility and Transfers Equipment

a.    Employee is trained on the safe and correct operation of equipment used for mobility and transfers such as mechanical lifts, van lifts, power wheelchairs, chair elevator lifts, standard wheelchairs and transfer equipment for showering/bathing.

i.    The training is provided by the manager, support coordinator or designated employee who does an observed skill assessment, as part of the training to ensure employee demonstrate the ability to safely and correctly transfer a person using the equipment
ii.    Training is documented, by the manager, support coordinator or designated employee on the “Training in Use of Equipment for Mobility and Transfer” form and filed in the medical book.

b.    A written procedure for each piece of equipment is available for employee to reference