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 ​

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:
    A.    Methods of Compliance
    B.    Hepatitis B Vaccine and Post Exposure Follow Up
    C.    Communication of Hazards to Employees
    D.    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.

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 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 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

                                         

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

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

 

If you suspect, witness, or become aware of suspected abuse of dependent adult or elderly, report immediately! You are one of those people – a “mandated reporter”

 

• 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 suspected abuse:

 

To report to Mains’l, call the administrative on-call phone at 530-723-2913 or contact your Program Manager

 

 

 

 

 

 

 

To report outside of Mains’l: For Adults: Adult Protective Services 1-800-664-9774 For Long Term Care Facilities: Ombudsman 1-800-846-4042

 

 

 

 

 

 

 

 

 

Suspected abuse must be reported.

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

                      

How people learn about responding to and reporting suspected abuse

 

1. All employees receive orientation training on their responsibilities as a mandated reporters, including video and in person training, review of this policy and procedure, statutes referenced in policy, the Personal Safety Plan 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.

 

1. All people receiving services and their conservators (when applicable) receive orientation to this policy and procedure, the Personal Safety Plan 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

 

1. 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 suspected abuse

 

Who is considered a dependent adult? In general, any person who needs assistance to adequately care for him or herself, and is therefore at a greater risk of abuse, is considered a dependent adult. Based on California laws, any person receiving services from Mains’l is considered a dependent adult.

 

Who is considered a mandated reporter? A person who has assumed full or intermittent responsibility for care of a dependent adult, whether or not paid for that responsibility.  Mandated reporters can include family, friends, hired employees, contracted service providers, and volunteers.

           

What is abuse? For dependent adults, abuse is defined as physical abuse, serious bodily injury, neglect, or financial abuse, abandonment and isolation. Definitions of each type of abuse are provided below in the definitions section.

 

Who is required to report suspected abuse? 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:

 

• Care of vulnerable adults or minor children; including relatives and other paid and unpaid caregivers
• Healing arts

• If you SEE SOMETHING… SAY SOMETHING!

  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 abuse must be reported within 24 hours of finding out.  Definitions of abuse are listed in this document.

 

Who do I report to? For the suspected abuse of a dependent adult, report to the California Adult Protective Services (APS). You may complete the documentation on line with the (SOC 341). For suspected abuse in a licensed service it also needs to be reported to the licensing entity Community Care Licensing (CCL) 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 a reason to believe that an internal or external report of alleged or suspected abuse has been made, we also report and respond.

1. When an internal suspected abuse report is received, Mains’l administrative on-call personnel is responsible for deciding if the report should be forwarded to the Adult Protective Services (APS). 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. 

 

 

1. An internal review is completed within 30 calendar days and corrective action is taken, if necessary, to protect the health and safety of dependent people.  The review includes an evaluation of whether:

1. related policies and procedures were followed;
2. the policies and procedures were adequate;
3. there is a need for additional staff training;
4. the reported event is similar to past events with the person or the services involved; and
5. there is a need for Mains’l to take corrective action to protect the health and safety of people.

 

Internal reviews are completed by Anne Silcher, Director or a designated Senior Manager.  Mains’l documents completion of the internal review and will provide a copy to the commissioner immediately upon request.

 

1. 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 happens if I do not report suspected abuse? There are many things that can happen if you do not report including:

• the continuation of abuse to the person
• you being removed from your 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 abuse 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.

 

Suspected Abuse definitions for adults

 

Abuse: Abuse can be physical, emotional, verbal, or sexual. This includes but is not limited to:

1. Physical Abuse:

1. Physical assault
2. Sexual assault
3. Unreasonable physical restraint

1. See CA Statutes for complete definitions and additional information.

   Deprivation of food and water

2. Inappropriate use of physical or chemical restraint

1. Emotional Abuse:

a.   Verbal assaults, threats, and intimidation

b.   Subjection to fear, isolation or emotional stress

c.   Withholding emotional support

1. Confinement

 

Neglect: Occurs when an individual’s health and safety needs are not being met. This includes, but is not limited to:

1. Failure to supply an 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.  Absence or likelihood of absence of care or services, including but not limited to food, clothing, shelter, health care, or supervision necessary to maintain the physical and mental health of the individual which a reasonable person would deem essential to obtain or maintain the person’s health, safety, or comfort.

           

Financial exploitation/abuse: Occurs when a person misuses funds, assets, or property of a dependent adult. This includes but is not limited to:

1.   Failure to use the dependent adult’s financial resources to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the individual, and the failure results in or is likely to result in detriment to the  individual;

 

1. Willfully using, withholding, or disposing of funds or property of a dependent adult without legal

authority;

 

1. 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;

 

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

 

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 Adult Protective Services
• We also ask that you immediately contact the Mains’l administrative on-call personnel at 530-723-2913

                                                                              

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:
a.    Program
b.    Medical
c.    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:
a.    Within the categories above, arrange them in the order they appear in the plan file or medical file, according to the table of contents 
b.    Organize all pages chronologically and orient all pages within the pile the same direction
c.    Remove all staples
d.    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:
a.    Incident Reports        
b.    Contracts            
c.    Licensing documents        
d.    Policies and Procedures
2.    Prepare all documents for scanning as follows:
a.    Organize all pages chronologically and orient all pages within the pile the same direction
b.    Remove all staples
c.    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.
    

<p><strong>Suspending Services</strong></p>

<p><strong>Reasons for temporary suspension of services:&nbsp;</strong></p>

<ol>
<li>A person may suspend services with Mains’l at any time. Some reasons a person might choose to suspend services are:</li>
</ol>

<ul class="rteindent1">
<li>Scheduling conflicts or lack of staffing.</li>
<li>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).</li>
<li>Temporary situations that change the person’s service needs such as a medical condition (less than 3 months).&nbsp;</li>
<li>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).</li>
</ul>

<p class="rteindent1">2. Mains’l may also choose to suspend services. Temporary service suspension by Mains’l is limited to the following situations:</p>

<ul>
<li>The person's conduct poses an imminent risk of physical harm to self or others and either:
<ul>
<li>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</li>
<li>less restrictive measures would not resolve the issues leading to the suspension.</li>
</ul>
</li>
<li>The person has medical issues that exceed our ability to meet the person's needs.</li>
<li>Mains’l has not been paid for services.&nbsp;
<ul>
<li>This includes non-payment of waiver obligations, spenddowns, private pay, GRH, Medicaid and any other funding sources.&nbsp;</li>
<li>Medicaid or other funding being inactive or person is no longer eligible for services.&nbsp;</li>
</ul>
</li>
</ul>

<p><strong>Actions taken before services are suspended:</strong> 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.&nbsp;</p>

<ol>
<li>Action taken by Mains’l must include, at a minimum:</li>
</ol>

<ul class="rteindent1">
<li>Consultation with the person's support team or expanded support team to identify and resolve issues leading to the notice being issued; and</li>
<li>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.</li>
<li>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.</li>
<li>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.</li>
<li>Prior to suspension due to non-payment, the person is sent written notification from Mains’l detailing the money owed and payment expectations.&nbsp;</li>
</ul>

<p>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.</p>

<p><strong>Actions taken when suspending services:&nbsp;</strong></p>

<ol>
<li>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. &nbsp;</li>
<li>If the temporary service suspension is from supported living services or community residential services:a.&nbsp;&nbsp; &nbsp;</li>
</ol>

<ul class="rteindent1">
<li>In Minnesota, the senior manager must notify the DHS Commissioner in writing. DHS notification will be provided by fax at 651-431-7406.&nbsp;</li>
<li>In California, the senior manager must notify the Case Management Supervisor in writingThe Notice of Temporary Service Suspension is given on the first day of the service suspension</li>
</ul>

<p class="rteindent1">3. The Notice of Temporary Service Suspension is from supported living services or community residential services:</p>

<p>&nbsp; &nbsp; &nbsp; 4. The written notice of service suspension must include the following elements:&nbsp;</p>

<ul>
<li>The reason for the action;</li>
<li>A summary of actions taken to minimize or eliminate the need for temporary service suspension; and&nbsp;
<ul>
<li>Why these measures failed to prevent the suspension.<br />
5. During the temporary suspension period the manager must:</li>
</ul>
</li>
<li>In Minnesota, the senior manager must notify the DHS Commissioner in writing. DHS notification will be provided by fax at 651-431-7406.&nbsp;</li>
<li>In California, the senior manager must notify the Case Management Supervisor in writing.&nbsp;</li>
</ul>

<p class="rteindent1"><br />
a.&nbsp;&nbsp; &nbsp;The reason for the action;<br />
b.&nbsp;&nbsp; &nbsp;A summary of actions taken to minimize or eliminate the need for temporary service suspension; and&nbsp;<br />
c.&nbsp;&nbsp; &nbsp;Why these measures failed to prevent the suspension.</p>

<p>5.&nbsp;&nbsp; &nbsp;<br />
a.&nbsp;&nbsp; &nbsp;Provide information requested by the person or case manager;<br />
b.&nbsp;&nbsp; &nbsp;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<br />
c.&nbsp;&nbsp; &nbsp;Maintain information about the service suspension, including the written notice of temporary service suspension in the person’s record.</p>

<p>d.&nbsp;&nbsp; &nbsp;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:</p>

<p>1.&nbsp;&nbsp; &nbsp;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.&nbsp;</p>

<p>2.&nbsp;&nbsp; &nbsp;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.</p>

<p>Ending Services</p>

<p>a.&nbsp;&nbsp; &nbsp;Reasons for ending services:&nbsp;</p>

<p>1.&nbsp;&nbsp; &nbsp;A person may end services with Mains’l at any time. Some reasons a person might choose to end services are:<br />
o&nbsp;&nbsp; &nbsp;The services are no longer in the best interest of the person receiving services.<br />
o&nbsp;&nbsp; &nbsp;The person wishes to change to a different provider and/or is not interested in receiving supports by Mains’l.&nbsp;<br />
o&nbsp;&nbsp; &nbsp;Person receiving services no longer qualifies for the service or is no longer eligible under program rules.<br />
o&nbsp;&nbsp; &nbsp;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.&nbsp;<br />
o&nbsp;&nbsp; &nbsp;The person moving to a location where services cannot be or do not need to be provided.<br />
o&nbsp;&nbsp; &nbsp;Person has successfully achieved their goals and no longer requires the support of Mains’l.&nbsp;</p>

<p>2.&nbsp;&nbsp; &nbsp;Mains’l may also choose to end services. Termination of service by Mains’l is limited to the following situations:<br />
o&nbsp;&nbsp; &nbsp;The termination is necessary for the person's welfare and the person's needs cannot be met by Mains’l.<br />
o&nbsp;&nbsp; &nbsp;The safety of the person or other people is endangered and positive support strategies were attempted and have not achieved and effectively maintained safety for the person or others.<br />
o&nbsp;&nbsp; &nbsp;The health of the person or others would otherwise be endangered.<br />
o&nbsp;&nbsp; &nbsp;Mains’l has not been paid for services.<br />
o&nbsp;&nbsp; &nbsp;Mains’l no longer offers the service.<br />
o&nbsp;&nbsp; &nbsp;The person has been terminated by the lead agency from waiver eligibility.<br />
o&nbsp;&nbsp; &nbsp;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.)</p>

<p>b.&nbsp;&nbsp; &nbsp;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.</p>

<p>&nbsp;&nbsp; &nbsp;Actions taken will include, at a minimum:<br />
o&nbsp;&nbsp; &nbsp;Consultation with the person’s support team to identify and resolve issues leading to the notice being issued; and<br />
o&nbsp;&nbsp; &nbsp;A request to the case manager for intervention services, including &nbsp;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.<br />
a.&nbsp;&nbsp; &nbsp;A request for intervention services will not be made for service termination notices issued because the program has not been paid for services.<br />
o&nbsp;&nbsp; &nbsp;An individual agreement will be developed with the person, if it is believed that their commitment to receiving services from Mains’l is absent.&nbsp;</p>

<p>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.</p>

<p><br />
c.&nbsp;&nbsp; &nbsp;Actions taken when terminating services:&nbsp;</p>

<p>1.&nbsp;&nbsp; &nbsp;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.&nbsp;<br />
a.&nbsp;&nbsp; &nbsp;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.<br />
b.&nbsp;&nbsp; &nbsp;For all other services, the notice must be provided at least 30 days before the proposed effective date of service termination.<br />
c.&nbsp;&nbsp; &nbsp;&nbsp;&nbsp; &nbsp;If the service termination is from supported living services or community residential services:<br />
o&nbsp;&nbsp; &nbsp;In Minnesota, the senior manager must notify the DHS Commissioner in writing. DHS notification will be provided by fax at 651-431-7406.<br />
o&nbsp;&nbsp; &nbsp;In California, the senior manager must notify the Case Management Supervisor in writing within 60 days.&nbsp;</p>

<p>2.&nbsp;&nbsp; &nbsp;This notice may be given in conjunction with a notice of temporary service suspension.</p>

<p>3.&nbsp;&nbsp; &nbsp;The written notice of a proposed service termination must include all of the following elements:<br />
a.&nbsp;&nbsp; &nbsp;The reason for the action;<br />
b.&nbsp;&nbsp; &nbsp;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);<br />
c.&nbsp;&nbsp; &nbsp;&nbsp;&nbsp; &nbsp;The person's right to appeal the termination of services under Minnesota Statutes, section 256.045, subdivision 3, paragraph (a); and&nbsp;<br />
d.&nbsp;&nbsp; &nbsp;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).</p>

<p>4.&nbsp;&nbsp; &nbsp;During the service termination notice period, the manager must:<br />
a.&nbsp;&nbsp; &nbsp;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;<br />
b.&nbsp;&nbsp; &nbsp;Provide information requested by the person or case manager;<br />
c.&nbsp;&nbsp; &nbsp; &nbsp; Complete a Starting Service/Change Form and Employee Status Change or Termination forms as applicable and distribute within the agency as the forms direct.<br />
d.&nbsp;&nbsp; &nbsp;Assure that information about the service termination, including the written termination notice, is maintained in the person’s plan file.&nbsp;<br />
e.&nbsp;&nbsp; &nbsp;Organize the person’s personal information according to the Record Retention Procedure, and scan the records for electronic storage<br />
&nbsp;</p>

Upon receiving a request, the Company will engage in a timely, good faith, and interactive process with you to
determine effective reasonable accommodations.

If you no longer need an accommodation, you must notify the Company that the accommodation is no longer
needed. If circumstances change and you need a new accommodation, you must request one.

Certification

When requesting a reasonable accommodation, you will be asked to submit a signed, written statement that certifies that the accommodation is for an authorized purpose. You may also be asked to provide documentation that demonstrates your status as a victim of domestic violence, sexual assault, or stalking, such as:

• A police report showing that you were the victim of domestic violence, sexual assault, or stalking.
• A court order protecting you from the perpetrator or other evidence from the court or prosecuting attorney that you appeared in court.
• Documentation from a medical professional, domestic violence or sexual assault victim advocate, health care provider, or counselor showing that your absence was due to treatment for injuries from domestic violence or sexual assault.

Unpaid Leave

The Company will also provide victims of domestic violence, sexual assault, or stalking with unpaid leave to obtain or attempt to obtain any relief, including, but not limited to, a temporary restraining order, restraining order, or other injunctive relief, to help ensure the health, safety, or welfare of you or your child. You may use available vacation, personal leave, accrued paid sick leave, or compensatory time off for your leave unless you are covered by a collective-bargaining agreement that states otherwise.

Notice

You must provide reasonable advance notice of your intention to take leave for the above reasons unless advanced notice is not feasible. If an unscheduled absence occurs, you must provide the following documentation within a reasonable amount of time after your absence:

• A police report indicating that the you were a victim of domestic violence, sexual assault, or stalking;
• A court order protecting or separating you from the perpetrator of an act of domestic violence, sexual assault, or stalking, or other evidence from the court or prosecuting attorney stating that you have appeared in court; or
• Documentation from a licensed medical professional, domestic violence counselor, sexual assault counselor, licensed health care provider, or counselor stating that you were undergoing treatment for physical or mental injuries or abuse resulting from victimization of an act of domestic violence, sexual assault, or stalking.

Confidentiality

The Company will maintain the confidentiality of anyone requesting time off or requesting an accommodation under this policy, except as required by federal or state law or as necessary to protect your safety in the workplace.

Retaliation

The Company will not retaliate against a victim of domestic violence, sexual assault, or stalking for requesting or obtaining leave or a reasonable accommodation in accordance with this policy.

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:

• Scheduled Work Time: Any time an employee is scheduled to work, including scheduled attendance at orientation, required meetings, and training sessions.
• Approved Absence: When an employee notifies their supervisor, according to designated timelines, 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.
• 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.
• Tardy: Any late arrival for a scheduled work time without the pre-approval of the supervisor.
• Occurrence: Any single instance of an unapproved absence or tardy.
• 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:

• A situation recognized by the organization as unavoidable (i.e. car accident on the way to work verified by an accident or police report.)
• The Occurrence is caused by a serious illness, where the illness is documented by a physician within one week of the absence.
• 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.

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:

• Arrive on time and to be prepared for their scheduled work time;
• Using respectful and courteous language (abusive language is not acceptable behavior and doesn’t align with who we are as an organization);
• 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;
• Decisions and actions are aligned with Mains’l’s mission, vision, and core values;
• 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;
• Complying with safety standards--use of transfer belts, back braces, proper assistive lifting devices, seat belts, wheelchair belts;
• Maintaining work place cleanliness and orderliness;
• Implementing Person Centered Practices;
• Using work time efficiently and effectively so as to promote the best interests of the people served;
• 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):

• Failing to follow any of the above mentioned positive and role modeling behaviors;
• Theft, destruction, inappropriate removal, or misuse of Mains’l or person’s property;
• Failing to report unethical, suspicious, or illegal conduct by other employees; 
• Insubordination or other disrespectful conduct;
• Possession of dangerous or unauthorized materials, such as explosives, firearms, or other weapons in the workplace. Physical assaults or threats to others;
• Borrowing money or purchasing personal items from a person receiving services, selling merchandise or personal services to a person receiving services;
• Working or being at work under the influence of alcohol or illegal drugs;
• 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;
• Sleeping on the job during any time, except for those employees who work within an asleep overnight position;
• Sexual or other unlawful or unwelcome harassment;
• Conduct that is offensive, or discriminatory;
• Violation of Mains’l policies or procedures;
• Falsification or misrepresentation of information in applying for a position;
• Failure or inability to complete all required training that is part of a job assignment;
• Unsatisfactory performance or behavior;
• Excessive absenteeism or any absence without notice;
• Failure to obtain or maintain a current license or certificate required by Mains’l or by law;
• 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:

• 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;
• 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;
• Accepting employment or compensation or engaging in any business or professional activity that might require disclosure of confidential information or business secrets;
• 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; 
• 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;
• Accepting employment or compensation or engaging in any business or professional activity that is in direct or indirect competition;
• 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;
• Any other arrangements or circumstances, including family or personal relationships, which may dissuade the employee from acting in the best interest of the company.

Reimbursable Employee Property

• Clothing, eye glasses, and wrist watches;
• Employee vehicles;
• 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.
2. The supervisor analyzes the report, recommends necessary action, signs the report, and forwards it to the HR designee who will investigate the incident and damage and make a determination.
3. The 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.
4. The “Employee Property Damage Report” is maintained by the HR designee.

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.
• The use, sale, manufacture, distribution, or possession of illegal drugs 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.
• 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 supervisor, supervisor’s supervisor or human resources, contact the on call administrative personnel. 
  • The supervisor and/or the on call administrative personnel notify the director of human resources 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

1. 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. This protects both the supervisor and the employee.

2. 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:                       

• 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.
• 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) or director of human resources to explain the test result. 
• 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 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.
• 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.
• 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.

• 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.
     

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 their 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:

• Accredited colleges or universities;
• State or public school systems, adult education systems;
• Vocational or trade schools;
• 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. 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.

Fair Labor Standards Act Job Classification

Refers to the standard by which an employee is paid and their eligibility for overtime. The two (2) 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. 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 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:
   1. 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)
   2. 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)
   3. Employees who work in our Participant Directed Services program are eligible for group medical only
2. Ineligible:
   1. 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.

              

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.

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:                                                                                    

• Why are you leaving?
• What could we have done differently?
• Would you refer someone you know to work at Mains’l?
• 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.

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

• Employment application;
• Letter confirming employment and work location;
• Employee evaluations and performance records;
• Any licenses, professional affiliations, or certificates;
• Documentation of changes in employment status;
• Documentation of changes in wage or salary status;
• Written communication between Mains’l and the employee;
• Employee training records and documents;
• W-4 forms;
• References;
• Orientation Checklists and Log;
• Copy of automobile insurance coverage, if applicable;
• 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:

• I-9 Employment Verification;
• Benefit information;
• Medical information including documentation relating to the Americans with Disabilities Act;
• 401K Information;
• 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:

• Managers;
• Senior Managers;
• Directors;
• Executive Team members;
• Human Resources staff;
• Finance staff.

Access to the files 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 of their own employment information, Mains’l requires a signed release; when the employee requests information via telephone or email, the requested information may:

• Be mailed directly to the employee’s home address,
• Picked up by the employee in the main office, or
• 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 talk 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:
   • The scheduled hours of the new position plus those of the current position must not exceed forty (40) per week;
   • The employee completes an Internal Application and forwards to Human Resources;
   • Human Resources will connect with the supervisor of the new program and shares with them the employee’s interest in the position;
   • The employee provides full disclosure of his/her current schedule;
   • 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).
   • The employee lets the current supervisor know that they have applied internally for another opening or more hours.
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:
   • 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, people receiving services.
   • The employee completes an Internal Application and forwards to Human Resources.
   • Human Resources will connect with the supervisor of the new program and share that there is a current employee interested in the opening.
   • 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.)
   • 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 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:

• Job duties at Mains’l
• Applicable licensing and contract requirements
• Requirements of the program the employee is working in
• Mains’l policies and procedures
• 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 their 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
   
   1. First day orientation is the employee’s welcome to Mains’l. New employee paperwork is reviewed with human resources or other designee and completed by the employee. Expectations for how and when to complete the rest of orientation are provided.
2. Orientation to the Individual (for direct support services)
   
   1. 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
   
   1. 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
   
   1. 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.
   2. 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)
   
   1. 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
   
   1. 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
   
   1. 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
   
   1. 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, 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.          
   
   1. 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?

• Employees who work in licensed services must complete thirty (30) hours of orientation training within ninety (90) days of hire.
• Employees who work in un-licensed services must complete thirty (30) hours of orientation training within ninety (90) days of hire.
• Additionally there is a list of topics for licensed services staff to learn about and demonstrate competency in.
• Administrative employee training is determined by position and the supervisor.

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

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.

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.

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

 

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) and California Family Rights Act (CFRA). FMLA/CFRA 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.

Following the approved leave, Mains’l returns the employee to the same or equivalent position with equivalent benefits, pay and conditions of employment.

During FMLA/CFRA leave, Mains’l will maintain the employee’s insurance benefits on the same terms as if the employee had continued to work. The employee portion of the insurance premiums must continue to be paid by the employee, or reimbursed by the employee upon their return to work. We request that employees who are currently enrolled in any benefits through Mains’l partner with Human Resources to formulate a plan for the employee’s portion of insurance premiums to be covered while out or when they return from leave.

The obligation of Mains’l to maintain insurance benefits during FMLA/CFRA leave stop if/when:

• the employment relationship would have ended if the employee had not taken FMLA/CFRA (position eliminated due to a lay off);
• the employee informs Mains’l of his/her intent not to return from leave;
• the employee fails to return from leave.

Eligibility

 Employees are eligible for FMLA/CFRA 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.

*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.

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/CFRA leave. Each time an employee takes FMLA/CFRA 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

Mains’l expects employees provide 30 days advance notice of the need to take FMLA/CFRA leave when the need is foreseeable. Employees submit the Request for Leave of Absence Form to their supervisor as soon as possible. When 30 days notice is not possible, it is expected that the employee provide notice as soon as practicable and comply with Mains’l normal call-in procedures.

Employees need to provide sufficient information for Mains’l to determine if the leave may qualify for FMLA/CFRA 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.

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.

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

Mains’l will inform employees requesting leave whether they are eligible under FMLA/CFRA 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.

 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.

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

Use of Leave

FMLA/CFRA 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/CFRA may use sick leave, accrued PTO, unpaid leave or a combination of all. 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/CFRA entitlement.

When taking a preventative cool-down rest period:

• You will be monitored and asked if you are experiencing any symptoms of heat illness.
• You will be encouraged to remain in the shade.
• You will not be requested back to work until any signs or symptoms of heat illness have abated, but in no event sooner than five minutes after accessing shade, excluding the time needed to access the shade.

The Company provides fresh, pure, and suitably cool drinking water at no charge. When the work environment is hot, you are encouraged to frequently drink small cups of water, with up to four cups (one quart or more) per hour recommended, to stay hydrated.

The Company has in place effective emergency response procedures if you show signs or report symptoms of heat illness while taking a preventative cool-down rest period.

You must immediately report to your Manager if you experience any symptoms or signs of heat illness or see signs of heat illness in co-workers so that the Company can respond with medical attention, as appropriate.

The Company will not discriminate or retaliate against employees who take preventative cool-down rest periods in accordance with this policy.

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:
   1. 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.
   2. 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 1^st, 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.

 

All employees will need to show proof of vaccination upon hire or qualify for an exemption. 

Vaccination Exemption procedure:

To be eligible for a Qualified Medical Reasons exemption, the worker must provide to their employer or employer-recipient:

1. A written statement on official letterhead,
2. Signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician,
3. Stating that the individual qualifies for the exemption (but the statement should not describe the underlying medical condition or disability),
4. Indicating the probable duration of the worker’s inability to receive the vaccine (or if the duration is unknown or permanent, so indicate).

To be eligible for a Religious Exemption, the employee must have a sincerely held religious belief, practice, or observance which prevents them from receiving the vaccine and must provide to their employer or employer-recipient:

1. A written statement on official letterhead,
2. Signed by their faith’s priest, minister, chaplain, rabbi, or other official (including contact information),
3. Explaining the specific faith-based teachings that oppose immunizations.

All exemption requests will be reviewed by the COVID Response Team and stored in the employee file.

All employees with an exemption are required to test weekly, and report each weekly test result to Mains’l. The employee is responsible to upload test results into the confidential employee file by the due date. If a weekly test is missed due to absence or time off the employee will have 72 hours from the original test day to be tested.  If the employee fails to test within the timeline, they will be placed on unpaid leave pending negative test results.

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.    

Mains’l Human Resources will provide employees with the employee health screening report. 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 (PTO)

All full time employees are eligible for Personal Time Off (PTO) according to policy. Full time employees receive PTO according to the schedule in the Paid Time Off – Salaried and Hourly Employees policy.

1. How can I request to use PTO?
   
   1. Notify the supervisor, verbally or in writing, and submit an online request in the time tracking system.
   2. All PTO requests must be given two (2) weeks in advance.
   3. The employee is expected to find replacements for their personal time off.
   4. Replacement employees must not incur overtime by working the replacement shift.
   5. 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.
   6. Advances on PTO are not permitted
   7. PTO must be used for all time off that is not covered by another paid time off account.
2. What are the limitations?
   
   1. If overtime is worked during a week in which PTO has been used, the employee will not be paid time and one-half for overtime until the actual hours worked exceed forty (40) hours.
   2. The PTO balance is carried over from one service year to another up to 150% of the accrual rate.
3. What happens if I leave Mains’l?
   
   1. PTO is paid to the employee at the time of resignation or termination.
4. How is PTO administered?
   
   1. PTO balances are recorded on the online platform or payroll check stub.

Bereavement Leave

1. How can I request to use bereavement leave?
   
   1. If the bereavement leave is anticipated, notify the supervisor, verbally or in writing, and submit an online request in the time tracking system with as much notice as possible.
2. In what situations can I use bereavement leave?
   
   1. All full time employees are eligible for bereavement leave.
   2. Up to three (3) days can be used in the event of the death, funeral or estate settlement of an immediate family member.
   3. Immediate family member includes spouse, parents, children (including unborn children), siblings, grandparents, grandchildren, step-children, parents-in-law, sister-in-law, brother-in-law, daughter-in-law, and son-in-law and common law domestic partners as defined by law.
3. What happens if I leave Mains’l?
   
   1. Bereavement leave benefits do not accrue and no payment is made for unused bereavement leave benefits upon termination.

Jury Leave

1. How can I request to use Jury leave?
   
   1. Notice of Jury Duty from the Country, District or Federal court must be submitted accompanied by an online request in the time tracking system with as much notice as possible.
2. In what situations can I use Jury leave?
   
   1. All full time employees are eligible for paid time off while serving on a jury.
   2. Employees are eligible to receive up to a maximum of two (2) weeks of pay to supplement jury pay.
3. What are the limitations?
   
   1. The employee and the supervisor determine the extent of the employee’s job responsibilities while on jury duty.
4. What happens if I leave Mains’l?
   
   1. Jury leave benefits do not accrue and no payment is made for unused jury leave benefits upon termination.

Parental Leave

1. How can I request to use parental leave?
   
   1. The employee completes the “Parental Leave Request,” with approximate dates of the leave, and an online request in the time tracking system to the immediate supervisor.
   2. The hours of parental leave taken per pay period must correspond to the regular schedule of the employee. (For example, if an employee is scheduled to work 37 hours per week, that is the amount of parental leave paid per week.)
2. In what situations can I use parental leave?
   
   1. Parental leave is available following the birth or adoption of a child.
   2. 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.
3. What are the limitations?
   
   1. The paid leave is equivalent to the regular schedule of the employee. 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. 160 hours is the maximum available.
   2. The leave must be taken within the first six (6) months of the birth or adoption.
   3. 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)
   4. 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 must be followed.
   5. In cases where both parents are employed by the Company and are eligible for leave, the maximum amount of total leave for both parents is 12 weeks. The Company may, but is not required to, grant simultaneous leave to both parents.
4. What happens if I leave Mains’l?
   
   1. Parental leave benefits do not accrue and no payment is made for unused parental leave benefits upon termination.

Bone Marrow and Organ Donor Leave

1. How can I request to use Bone Marrow and Organ Donor leave?
   
   1. Notify the supervisor, verbally or in writing, and submit an online request in the time tracking system.
   2. You are required to provide as much advance notice as possible if you wish to take leave to donate an organ or bone marrow.
   3. Provide Human Resources with verification from a physician that the donation will take place and that there is a medical necessity for the donation.
2. In what situations can I use Bone Marrow and Organ Donor leave?
   
   1. All employees are eligible for Bone Marrow and Organ Donor leave.
   2. Employees may take up to 30 paid business days in any one-year period. When donating bone marrow, you may take up to five paid business days in any one-year period
3. What are the limitations?
   
   1. Before taking paid leave under this policy, you must first use two weeks of accrued sick or vacation time when donating an organ, or five days accrued sick or vacation time when donating bone marrow.
   2. Leave taken under this policy does not constitute a break in service for health insurance coverage, accrual of vacation or sick pay, or seniority; however, the leave may not run concurrently with federal Family and Medical Leave Act or California Family Rights Act leave.
4. What happens if I leave Mains’l?
   
   1. Bone Marrow and Organ Donor benefits do not accrue and no payment is made for unused leave benefits upon termination.

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 employees are paid for each hour worked based on hours reported on a timesheet.
• Exempt 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: Pay periods are bimonthly, averaging fifteen (15) days per period. 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 on the 10^th and 26^th of each month 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 on the business day 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 onboarding and can be accessed or requested at any time.

• Review your pay advice: A few days before pay day, a document called a pay advice is available to access online to each employee who reported work time for that pay period. 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 one.
• 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.
  • 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 CA Payroll Department at (530-251-3776) or the Human Resources Department at (530-899-1907 ext. 351). 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.
  • 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 soon as possible.
    • If you are overpaid, Mains’l will ask that you sign a written agreement allowing the deduction from your wages.
• 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 530-899-1907 ext. 351.

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. The supervisor entering timesheet information on behalf of an employee when it is certain that they have accurate data to create the timesheet. The data must be provided by the employee to the supervisor. 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:
  • Bank account information: Submit a revised direct deposit/payroll authorization form.
  • Your address: Submit an Employee Information Change Form.
  • Your e-mail that pay advices are sent to: Submit a revised direct deposit/payroll authorization form and an Employee Information Change Form.
  • 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 paper check will be issued.

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 employee’s file.

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- 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 19th	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. The reimbursement rates to pay for these services do not include funds to pay time and one half to employees. Employees working in non- 24 hour hourly services who work on a holiday as defined above will receive their regular pay rate and should NOT submit their time as Holiday pay. 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, 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 a different day that the office is open. Here is the listing for Holiday Office Closures:

New Year’s Day- January 1*	Labor Day- first Monday in September
Martin Luther King Jr. Day- third Monday of January	Thanksgiving Day- fourth Thursday of November
President’s Day- third Monday of February	The Day after Thanksgiving- fourth Friday of Novemeber
Memorial Day- last Monday in May	Christmas Eve- December 24*
Juneteenth National Independence Day- June 19th*	Christmas Day- December 25*
Independence Day- July 4th*

*The holiday will be observed on the nearest weekday if the holiday lands on a Saturday or Sunday. 

• Day Services provided by Mains’l usually do not require to work holidays. The reimbursement rates to pay for these services do not include funds to pay time and one half to employees. Staff who work on a holiday will receive their regular pay rate and should NOT submit their time as Holiday pays. Use the pay code that is assigned to the service being provided. In addition, day services will receive regular pay for the following holidays but will not be open:

New Year’s Day- January 1*	Thanksgiving Day- fourth Thursday of November
Martin Luther King Jr. Day- third Monday of January	The Day after Thanksgiving- fourth Friday of Novemeber
Juneteenth National Independence Day- June 19th*	Christmas Eve- December 24*
Labor Day- first Monday in September	Christmas Day- December 25*

*The holiday will be observed on the nearest weekday if the holiday lands on a Saturday or Sunday. 

• 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:
  • 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 a 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 notes entries before approving the hours to be paid for that employee.

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 dataplus.solanopro.com
  • Mobile phone app 

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.

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 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 will automatically enter the time in 15 minute units.                                                        

• 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. Your supervisor is responsible for reviewing and approving your timesheet before it is sent to payroll. 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
• 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.
  • If you make an error, it is your responsibility to communicate with your supervisor as soon as possible so any adjustments can be made. If your supervisor makes an error, it is your supervisor’s responsibility to work with the payroll department to correct the error. 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 after 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. Employees must first contact their supervisor to explain how many hours they have worked and receive approval before working overtime. Working unapproved overtime is a performance issue that supervisors are expected to address with employees.
  
  • Twenty four (24) hour per day direct support services receive overtime if they have worked any time over 40 hours in a workweek.
  • Non-24 hour per day direct support services and licensed facilities receive overtime if they have worked any time over 8 hours in a day or 40 hours in a work week.
  • Office and management staff receive overtime if they have worked any time over 8 hours in a day or 40 hours in a work week.

Non-exempt employees are paid overtime at the rate of one and one-half times their regular rate of pay. 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. 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.
• Split Shift: A split shift is any two distinct work periods separated by more than a one-hour meal period. If there is more than one hour between shifts in the same workday, the employee must receive one hour’s pay at no less than the minimum wage rate for the time between shifts. If the hourly pay rate exceeds minimum wage, that dollar amount offsets the split shift and no additional pay is required. This means that the hour of split shift is only paid when the employee’s total hours worked for the day, plus one hour, would not equal to at least minimum wage per hour. 
  • Time paid for a one hour split shift does not count towards the calculation of overtime because it was not worked. It is not considered a split shift if an employee works overnight and returns in the evening for another overnight. To qualify as a split shift, the start of each shift must occur within the same work day.
• 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.

The following information applies to exempt (salaried) employees only:

• 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.
• 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.               
• 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.
• On call time: Exempt employees who are assigned on-call duty or administrative cell phone duty do not receive additional pay for that duty.
• Pay for working direct care hours: Managers who are assigned direct care hours do not receive additional pay for that duty. 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.
• Deductions: Mains'l is required by law to make certain deductions from your pay each pay period. This includes income and unemployment taxes, Federal Insurance Contributions Act (FICA) contributions (Social Security and Medicare), and any other deductions required under law or by court order for wage garnishments. The amount of your tax deductions will depend on your earnings and the number of exemptions you list on your federal Form W-4 and applicable state withholding form. You may also authorize voluntary deductions from your paycheck, including contributions for insurance premiums, retirement plans, spending accounts, or other services. Your deductions will be reflected in your wage statement.
  • The Company will not make deductions to your pay that are prohibited by federal, state, or local law. If you have any questions about deductions from your pay, contact your Manager. You will be reimbursed in full for any isolated, inadvertent, or improper deductions, as defined by law. If an error is found, you will receive an immediate adjustment, which will be paid no later than your next regular payday.
• 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.
  • 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.
  • 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.
• 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.

INTERNAL CONTROLS:

1. The Human Resources Department is responsible for researching and staying current on all federal and state rules and regulations regarding fair pay, timekeeping, and payroll including Fair Labor Standards and the Department of Labor.
2. The Payroll Department is responsible for researching and staying current on all federal and state taxes and IRS rules and regulations related to fair pay, timekeeping, and payroll.
3. Each state and or service Director is responsible for researching and staying current on all program rules and regulations related to fair pay, timekeeping, and payroll.           

Performance Management is the general term describing a process by which Mains'l helps employees to successfully manage their positions. The specific process and tool used is determined by the position of the employee and the outcome desired.

Performance Evaluations

Performance evaluations are intended to assist employees with their career development while helping the Agency retain a competent work force. It is the policy of the Agency to provide employees with a formal review of their performance at various career milestones, as follows:

Type of Evaluations:

• Ninety (90) Day Evaluation: A written performance evaluation of an employee’s performance after 90 days following the date of hire. In the case of a job transfer or change in job classification, an evaluation will 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.
• Employee Feedback and Development Summary: A written evaluation conducted by both the supervisor and employee identifying what’s working/not working and goals. Managers are responsible for initiating and conducting these evaluations annually or bi-annually depending on job title or as needed.

Evaluations will be reviewed with the staff member in private with the opportunity for the staff member to comment. The staff member signs the form to acknowledge that an evaluation has been done and receives a copy of the evaluation. In the event the employee refuses to sign the evaluation, a witness (other than the supervisor) will sign the evaluation confirming that the employee has received a copy of the written evaluation and refused to sign it.

After the employee signs the performance evaluations, all completed forms will be forwarded to human resources.

 

Any employee planning to take pregnancy disability leave should advise the HR Generalist as early as possible. The individual should make an appointment with the HR Generalist to discuss the following conditions:

1. Employees who need to take pregnancy disability are required to inform Mains’l when a leave is expected to begin and how long it will likely last. If the need for a leave or transfer is foreseeable, employees are required to provide notification at least 30 days before the pregnancy disability leave or transfer is to begin. Employees are required to consult with the HR Generalist regarding the scheduling of any planned medical treatment or supervision in order to minimize disruption to the operations of the Company. Any such scheduling is subject to the approval of the employee’s health care provider;
2. If 30 days’ advance notice is not possible, notice is required to be given as soon as practical;
3. Upon the request of an employee and recommendation of the employee’s physician, the employee’s work assignment may be changed if necessary to protect the health and safety of the employee and her child;
4. Requests for transfers of job duties will be reasonably accommodated if the job and security rights of others are not breached;
5. Temporary transfers due to health considerations will be granted when possible. However, the transferred employee will receive the pay that accompanies the job, as is the case with any other temporary transfer due to temporary health reasons;
6. Pregnancy leave usually begins when ordered by the employee’s physician. The employee is required to provide Mains’l with a certification from a health care provider. The certification indicating disability should contain:
   
   1. The date on which the employee became disabled due to pregnancy;
   2. The probable duration of the period or periods of disability; and
   3. A statement that, due to the disability, the employee is unable to perform one or more of the essential functions of her position without undue risk to herself, the successful completion of her pregnancy, or to other persons.
7. Leave returns will be allowed only when the employee’s physician sends a release;
8. An employee will be required to use accrued sick time (if otherwise eligible to take the time) during a pregnancy disability leave. An employee is able to use accrued vacation or personal time (if otherwise eligible to take the time) during a pregnancy disability leave; and;
9. Duration of the leave will be determined by the advice of the employee’s physician, but employees disabled by pregnancy may take up to four months. Part-time employees are entitled to leave on a pro rata basis. The four months of leave includes any period of time for actual disability caused by the employee’s pregnancy, childbirth, or related medical condition. This includes leave for severe morning sickness and for prenatal care.

Leave does not need to be taken in one continuous period of time and may be taken intermittently, as needed. Leave may be taken in increments of four hours.

Under most circumstances, upon submission of a medical certification that an employee is able to return to work from a pregnancy disability leave, an employee will be reinstated to her same position held at the time the leave began or to an equivalent position, if available. An employee returning from a pregnancy disability leave has no greater right to reinstatement than if the employee had been continuously employed.

 

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.

 

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.
   1. Each time an employee uses their vehicle for work related purposes, they can enter this information in 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.
   2. 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.  
   3. 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.  

 

Employee Resigns from Mains’l

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.

If an employee quits without giving notice, Mains’l will provide the final paycheck within 72 hours. If the employee quits and gives at least 72 hours’ notice, the final paycheck is given to the employee at the end of their shift on their last day.

Employees Separated for Performance/Misconduct

California is an at-will state, meaning that an employee may be terminated with or without cause at any time and for any lawful reason, with or without advance notice. Separation usually follows an unresolved job performance correction or disciplinary period but it may be immediate following an investigation into employee misconduct or other serious offenses.  If negligent or criminal behavior or abuse or neglect are the grounds for separation, possible criminal charges may be filed against the employee.

The final paycheck is given to the employee at the time of their separation. 

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.

The final paycheck is given to the employee at the time of their separation.

Inactive Employees

Employees who have not worked for three (3) months are separated from employment at Mains’l. If an employee is re hired more than six (6) months after their last day of work, they are considered a new employee and all orientation requirements must 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.
   
   1. 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 a 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 Points
Texting While Driving	4 Points
Cell Phone Use While Driving	4 Points
Seatbelt Violation	2 Points

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.
   1. Keep the vehicle well maintained and in good working order.
   2. Report immediately any mechanical concerns to the manager.
   3. Use only vehicles registered in the employee’s name or that of an immediate family member. 
   4. Never use a borrowed vehicle to transport a person we support.
   5. Report to the manager if you purchase a different vehicle.
   6. 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:
   1. The employee writes and submits an incident report to the manager.
   2. If the person receiving services caused the damage Mains’l will cover the cost of repair.
   3. 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.
   4. 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.

 

The AWAIR Program is intended to:

• Establish an executive policy statement (we’re committed to safety)
• Develop strategies to reduce workplace accidents and injuries
• Provide for the safety inspection of worksites
• Establish enforcement strategies to insure compliance
• Provide for a training program (blood borne pathogens)
• 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.

How can I request to use Sick Leave?

Sick leave may be used for illness, injury and medical/dental appointments. It may also be used if you are a victim of domestic violence, sexual assault or stalking. Employees may use the time for themselves, or their spouse, children, parents, step-parents, in-laws, registered domestic partner, grandparents, grandchildren, siblings, and a designated person. A designated person is a person identified by the employee at the time the employee requests the leave and is limited to one person in a 12-month period.

1. How can I request to use Sick Leave?
   
   1. If sick leave is anticipated, notify the supervisor, verbally or in writing with as much notice as possible.
   2. If sick leave is anticipated the employee is expected to find replacements for their sick time. Replacement employees must not incur overtime by working the replacement shift unless pre-approved by their supervisor.
   3. Unexpected sickness or injury must be telephoned to the supervisor as soon as feasible, preferably at least four (4) hours prior to the scheduled shift, whenever possible.
2. What are the limitations?
   
   1. 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).
   2. A doctor’s note may be requested to verify the reason for absence or upon return to work if the sick leave exceeds three (3) days.
   3. If absence exceeds three (3) consecutive days, Family and Medical Leave policy may apply and continuing absences may be counted toward the FMLA leave.
   4. Unused sick time will roll over into the next calendar year to a maximum of 80 hours for part-time employees (CA only) and 160 hours for full-time employees. Sick leave is not paid out if not used.
3. What happens if I leave Mains’l?
   
   1. Sick leave is not paid upon separation.

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.        

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, with pay, pending an internal investigation.
3. The designated HR representative notifies the employee, personally and in writing, of the suspension.
4. The manager is informed to remove the employee from the schedule.
5. An internal review will be completed as soon as possible by an objective administrative employee.
   1. A report will be completed by the administrative employee assigned to the internal review.
   2. The Senior Manager and the designated HR representative are responsible for the decision to reinstate employment with or without corrective action. Separation of employment may also be the result.

Management may vary from this procedure if circumstances demand.

 

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.

If a request is not received and approved and the employee takes the leave, the absence is considered a No Call/No Show or Unapproved Absence and the guidelines as stated in the Attendance policy and procedure apply.

Insurance Benefits     

Employees may continue the coverage in effect before their leave of absence according to the provisions of the insurance contract and the Federal COBRA legislation. Information concerning provisions, restrictions, and cost of insurance under COBRA are 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 leave is at the discretion of Mains’l and not covered under any other leave policy or regulation, there is no guarantee that the employee will be returned to their position. If the position is not available, the employee will be referred to human resources to apply for other positions within 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.

1. How can I request Unpaid time off?
   1. Notify the supervisor, verbally or in writing, and submit an online request in the time tracking system.
   2.  All unpaid time requests must be given two (2) weeks in advance.
   3. The employee is expected to find replacements for their unpaid time off.
   4. Replacement employees must not incur overtime by working the replacement shift.
   5. When staffing schedules dictate, the immediate supervisor after consulting with Human Resources may cancel or postpone previously approved requests. When this is necessary, as much notice as possible is given.
2. What are the limitations?
   1. Unpaid time off cannot be used unless all other forms of paid time off have been exhausted.

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:

• Confidentiality of information about people receiving services;
• Compromise of supervision of the person/people as defined in each person’s Services Questionnaire and Safety Plan);
• Distractions in emergency procedures;
• Distractions from providing quality services;
• 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 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,
3. The manager will notify their senior manager if/when an employee would need to bring a visitor to the workplace.
4. The supervisor will communicate the decision to the requesting staff.
5. 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:

• In a person’s home (leased by Mains’l or owned/rented by a person we support);
• In the employee’s home;
• In the community (in public and private places);
• 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 Persons 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.

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 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 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 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 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 on all claimants and claims activities which will be reviewed carefully for progress on recovery and compliance with medical requirements.