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SURVEYWINTER 2024PREPGUIDECARF PROGRAMS BEING SURVEYED:Outpatient Treatment - Integrated - SUD/MH - AdultsOutpatient Treatment - Integrated -SUD/MH - Children & AdolescentsBehavioral Health - Crisis Program - Crisis Contact Center - Integrated SUD/Mental Health - AdultBehavioral Health - Intensive Outpatient Treatment - Substance Use Disorders/Addictions - AdultsBehavioral Health - Integrated Behavioral Health/Primary Care - Comprehensive Employment & Community Services - Service CoordinationBehavioral HealthBehavioral Health & Integrated Primary Care (replaced our Health Home) Care - AdultsDevelopmental Disabilities

How do you make the vision areality?VisionTo create an atmosphere wherepeople in our community areinspired to reach their fullestpotential with access toservices and a culture devotedto promoting optimal healthand wellness.MissionHelping people, changing livesthrough education, prevention,intervention treatment in aneffort to enhance quality of life.How do you fit with the missionof SCLHSA? How does your jobhelp our mission?Core ValuesRespectShowing regard for people'sabilities and worth; valuingtheir feelings and their views,even if you don't necessarilyagree with them.EmpoweringProviding individuals theresources and support necessaryto have power and control overtheir own lives.IntegrityEncompassing honesty, keepingone's word, and consistentlyadhering to principles ofprofessionalism, even when it isnot easy to do so.CollaborationCommitting to the possibility ofproducing an outcome greaterthan one entity alone couldachieve.QualityAchieving improved health,responsiveness and efficiencyby doing the right thing, at theright time, for the right personto obtain the best possibleresults.South Central Louisiana Human Services Authority

SCLHSA STRATEGIC GOALSShort Term (1-3 Years)Goal 1: improve service outcomes by collaboratingwith stakeholders to expand integratedservice programs in the community andwithin SCLHSA’s Behavioral Health Centers.Goal 2: Increase staff accountability and fiscalintegrity of the agency.Goal 3: Provide the infrastructure, information and systems to helpemployees successfully complete their jobs.Long Term (3-5 Years)Goal 1:Develop Crisis Continuum to provide pre-screening assessments,resource linkage, act as gatekeepers for inpatient hospitalization andmanage access to crisis diversionary services.Goal 2: Establishment of an Assisted Outpatient Treatment (AOT) CourtProgram in one or more of the seven parishes in the SCLHSAcatchment area.

AGENCY FUNDEMENTALSAgency History & Relationship to LDH:The Louisiana State Legislature established the South Central Louisiana HumanServices Authority (SCLHSA) in 2006 to provide administration, management andoperation of mental health, addictive disorders, and developmental disabilities servicesto the residents of Assumption, Lafourche, St. Charles, St. James, St. John the Baptist,St. Mary, and Terrebonne parishes.District oversight of these services was previously provided through the LouisianaDepartment of Health (LDH). Currently, SCLHSA contracts with LDH to provide coreand targeted behavioral health and disability services with monitoring conducted byinterdisciplinary LDH programmatic teams.Board of Governance:Governance of SCLHSA is conducted by a nine (9) member Board of Directors. TheBoard includes two residents from the parishes of Lafourche and Terrebonne and oneresident from the parishes of Assumption, St. Charles, St. James, St. John the Baptistand St. Mary. Each board member is appointed by the governing authority of eachparish and must possess experience in the areas of mental health, addictive disorders,or developmental disabilities and represent parents, consumers, advocacy groups, orservices as a professional in one of the areas. All members serve without compensation.Assumption - Ray NicholasLafourche - Bryan Zeringue, Board Chairperson & Nicole BourgeoisSt. Charles - Barbara FuselierSt. James - Rachel Becnel, RN, BSNSt. John the Baptist - Lynne Ralph Farlough, Board Vice ChairpersonSt. Mary -Terrebonne - Becky Hohensee & Travion SmithCurrent Board Members: (click to learn more about our board members.)

SCREENING, OREINTATION &ASSESSMENTWorkflowClient calls or comes in for screening.Screening is completed and client is given an appointment, unless client is in crisis or needs immediate attention. Clients needing immediate attentionare seen the same day.Client comes in for assessment appointment and meets with administrativecoordinator staff to complete consents, releases, demographics andfinancial info. (Orientation)Counselor meets with clients and completes the BHA to determine eligibilityand level of care needs.If meets criteria and will be receiving counseling, client completes apersonal safety plan and treatment plan is scheduled for services.If does not meet criteria:Client is informed verbally and /or in writing of the reason why andis given resources that will better meet their needs.Discussion with client, reasons for ineligibility and communityresources provided are documented in the progress notes.Report to referral source is sent, if applicable.1.2.3.4.a.b.i.ii.iii.TerminologyIntake - the orientation and signing of papers.Assessment - The Behavioral Health Assessment done by theCounselor or the Psychiatric Evaluation done by the Prescriber.Only licensed Clinicians, MDs and NPs give Diagnoses.

SUICIDE PREVENTIONThe Crisis Assist Link Line (CALL Line) will provide immediateassistance afterhours to anyone of any age who is experiencing apersonal, emotional or mental health crisis. Callers will alwaysspeak with a master’s prepared or licensed clinician. CALL Linecounselors are trained in telephone lethality assessment todetermine the level of individual risk and the appropriate level ofservices.The CALL Line service provides crisis counseling, suicideprevention, support, information and referral for immediateassistance to prevent emergencies and decrease recidivism.Suicide Risk AssessmentStaff completed supervised training to perform.Clients are assessed for Suicide Risk every visit.If the client presents a risk for suicide a safety plan isreviewed/updated/completed.

Person/Family Centered PlanningRecoveryAllows the staff to support the individuals to achieve life goals and toimprove their quality of life.Encourages the consumer to live as independently as they wish.The goals and objectives are written in the person’s own words todescribe his or her strength’s, needs, abilities and preferences.A process for planning and supporting individuals receiving services that islead by the individual/family member’s active participation by directing theprocess and being the final decision maker (s).An Individual’s definition of their recovery is very unique and personaland it is defined using a person’s own words.The goal is to guide clients in understanding their potential to healthemselves.The process in which people are able to live, work and fully participate intheir communities.PERSON CENTERED PHILOSOPHYFamily SupportFamily involvement is encouraged when appropriate and beneficial to theclient.If family support is not involved, the reason why is always documented.Family education sessions occur at least quarterly.Intensive Outpatient Treatment Programonly at TBHC9 hours/week for up to 6 weeks. We provide transportation withreferral.

TREATMENTPersonal Safety PlanEach client gets a Personal Safety Plan at assessment and it is reviewedif/when the client is in crisis.When do you do a personal safety plan with a client?Person Centered PlanIndividualized to client.Client driven and client focused; in their words.Completed with the client.Based on client strengths, needs, abilities and preferencesWe want to all use the same terminology, so try not to call it a treatmentplan.Always encourage family involvement in plan.The surveyors will ask the clients if they received a copy of their plans andwhat are their goals, objectives and interventions. Clients may not knowword for word but should be able to provide some idea since it is their plan. identified in the assessment. Use these resources in the interventions.Discharge PlanningBegins at admission and is based on the client’sgoals and expectations of treatment.

INTEGRATED PRIMARY CAREIn-house Primary CareCare Coordination such as transportation and external provider referral and follow-upMedication Management ReviewsAnnual Disease Focus i.e. HTN, DM, Dep (reflected in Performance Indicators)Nutritional Services ConsultMedication for Opioid Use (MOU)Services specific to Integrated Primary Care include:SCLHSA uses an Integrated Treatment Team Staffing approach.Integrated Primary CareSCLHSA offers integrated primary health care services to active clients in our system thathave been stabilized on behavioral health medication. The integration of primary care andbehavioral health care provides another step in the continuum to recovery and resiliency.

Patient PortalEmail addresses are requested of patients at screening.Information about the portal is given to patients at orientation.Appointment reminders are sent to patients multiple times before their appointment.Conduct TelevisitsSend a refill requestObtain lab resultsAccess their Personal Health Record (PR)Receive appointment remindersView their visit summaryReceive and create messages to the clinicClients can use the portal to:Online ResourcesSCLHSA Website - SCLHSA.orgA great resource for a full description of our services, patient portal access, appointmentrequests, customer service access, pertinent health information, clinic locations andcontact information and employee onboarding.Community Resource GuideA directory, housed on SCLHSA.org, of various agencies and hotlines available inthe SCLHSA catchment area. Topics include but are not limited to BehavioralHealth, Government Assistance, Halfway Houses, Legal Aid, Transportation andFood Banks.Social MediaFollow SCLHSA of social media. (Click the icon for links)STAYING CONNECTED

DEVELOPMENTAL DISABILITIESFlexible Family Funds (FFF) - These funds are provided through Louisiana’sCommunity & Family Support System and are designed to offset theextraordinary costs associated with raising a child with a severe disability athome.Individual and Family Support (IFS) - provides assistance not available fromany other resource. These services include respite care, personal assistanceservices, specialized clothing dental and medical services, equipment andsupplies, communication services, crisis intervention, specialized utility costs,specialized nutrition and family education.Intermediate Care Facilities for People with Developmental Disabilities(ICF/DD) - The ICF/DD provides a protected residential setting, ongoingevaluation, planning, 24 hour supervision, coordination and integration ofhealth and habilitative services that are individualize per participant needs.Preadmission Screening and Residential Review (PSRR) - Determines whethera person with disabilities requires a level of service provided by a nursingfacility and if specialized services are needed.Waiver Services - Provides Medicaid funding availability for services in thehome and community. Types include:Children’s Choice WaiverNew Opportunities WaiverSupports WaiverResidential Options WaiverDevelopmental Disabilities office serves as the Single Point of Entry intodevelopmental disabilities services system and oversees public and privateresidential services and other services for people with developmental disabilities.The Entry Unit services determines eligibility by assessing individual needs andservices as orientation to services available such as:

STAFF INVOLVEMENTHow are staff involved in:SafetyStrategic PlanningSurveysAll personnel receive safety training within the first 30 days of employment.Safety Meetings are conducted at least quarterly in each clinic.Hazard logs are posted for employees to identify potential or actual risks.All staff members participate in disaster/emergency drills.All personnel completed questionnaires and had input on developing themission and vision of the organization.The Clinic Managers shared the strategic plan with the staff members oncecompleted.Satisfaction surveys are distributed quarterly. Results are posted forstaff to review and discussed at monthly staff meetings. Shout outsgiven!Employee satisfaction results are reviewed annually and addressed byadministration when appropriate.Satisfaction SurveysAccessibilty SurveyCultural Competency, Diversity & Inclusion SurveyMeetingsClinic meetingsSupervisory/Staff meetingsAll Staff meetingsEmailsNewsletter

STAFF INVOLVEMENTOutcomesData is analyzed quarterly on services provided.Staff members facilitate performance indicators by collecting data on depressionsymptoms and client improvement.Performance Indicators are reviewed at the Quality Committee meetings by theadministrative staff and shared with the board. They are discussed at monthly staffmeetings. Input from staff members is encouraged.CLIENT INVOLVEMENTSurvey sent after each visit.Results compiled quarterly & reviewed at committee meeting.Results posted in each facility lobby.Satisfaction SurveyC’est BonState survey that comes out annually or as announced to talk with clients about theirexperience.Results posted in the lobby.We Love FeedbackWe post our complaints and grievance policy and request comments and feedback inour lobby.The More You Know...We provide clients with all the information on client rights, advance directives, self-help and supports, our services and additional resources in our lobby.Regional Advisory Committee (RAC)The Behavioral Health Regional Advisory Committee is a stakeholder group made up ofpeers, parents of children with serious emotional or behavioral disturbances, family andcommunity agency members who actively participate in helping to identify, plan anddevelop the needs, initiatives and services for our local community.

PlanCheckDoAcTPERFORMANCE IMPROVEMENTPurposeProcess ModelAllows for a systematic, coordinated and continuous approach to improvingperformance.Focuses upon processes and mechanisms that address these items.Involves multiple programs and disciplines.Focus ActivitiesPerformance ImprovementSafetyQuality AssuranceSatisfactionUtilization ManagementData Drives Our DecisionsPERFORMANCE INDICATORSEach program has a set of indicators which measures:AccessEfficiencyEffectivenessSatisfactionBehavioral Health Integrated CareDevelopmental DisabilitiesCALL LineIntensive Outpatient Program

Risk ManagementWe reduce risk by identifying areas of high exposure and severity. We implementprocesses to reduce that risk.Safety Meetings, Drills & InspectionsDone quarterly to help prepare us for fires, bombs, natural disasters, utility failures,medical emergencies and threatening situations.Nonviolent Physical Crisis InterventionEmphasizes care, welfare, safety and security for all. Only therapeutic holds taught in CPIcan be used to assist persons who are acting out. We intervene early to de-escalate andprevent crisis situations.Critical IncidentsReported immediately to the Safety Officer. Debriefing following an event is held to clarifyevents and to educate about normal responses and coping mechanisms.SAFETY/RISK NEED TO KNOWEach clinic has a Safety Officer who is responsible forimplementing the health and safety plans for SCLHSASafety Training is done on Relias and by lesson plans from your safetyofficer.SCLHSA vehicles are equipped with first aid kits and fire extinguishersto aid during emergencies.There is no tobacco use or vaping allowed in/on SCLHSA property.RACErescuealarmcontainextinguishPASSpullaimsqueezesweep

INFECTION CONTROLWe use PPE and wash hands to maintain a safe, hygienic andsanitary environment.We offer TB, HIV and HCV screenings to help reduce risk topatients and our community.Telemedicine Cleaning: The microphone and Polycom System iswiped down with a Clorox or Lysol wipe once per week andimmediately after a symptomatic patient’s session.INFORMATION TECHNOLOGYSCLHSA ensures that its IT security guidelines followindustry best practices for electronic and physicaldata access. These best practices are applied withrespect to computer equipment, electroniccommunications, data access and voicecommunications to reduce the risks of datacorruption, viruses, ransomware, unauthorized dataaccess and other malicious attacks.IT maintains a list of user requests for all hardware and software.Passwords are encrypted, never shared, and must meet complexity standards.Passwords expire every 90 days.IT equipment is organized to minimize tripping hazards while creating aproductive user environment. Where possible, IT equipment is positioned toensure privacy of data.Privacy screens are used in all areas where outside parties could access.

All data is backed up daily plus replicated to the cloud to reduce the risk of dataloss.All IT Disaster Recovery Policy provides work processes for preventing data loss,preparing for a serious weather event and responding to a disruption of services.SCLHSA maintains an IT Help Desk system to facilitate user requests for services,to report issues and to quickly communicate incident status with the requestor.All outages are documented by the site manager and reviewed by the IT Directorso risks can be reduced and mitigated.A security risk assessment of the SCLHSA IT environment is performed annuallyby an outside agency.WORKFORCE MANAGEMENTJob descriptions are reviewed at orientation and annually with supervisors.Skill/Competencies are developed and continuously reviewed with staff,supervisors and Human Resources.Performance Evaluation System (PES) & Physician/APRN/PsychologistAssessment monitors job performance.Supervisors monitor performance on an ongoing basis and discuss issues withstaff.All policies and procedures can be viewed on the Internal DatabaseManagement System.Complaints and concerns are handled according to the chain of command.Trainings are taken annually through Relias and LEO (for CPTP courses). Sometrainings are conducted in person. Productivity is monitored.Employee onboarding/orientation is in We recognize employees for their years Staff input is always welcome and person and involve various agency departments. of service annually. encouraged through surveys, meetings and phone/email communication with all levels of management.SCLHSA BoardExecutive Mgmt. StaffClinic ManagersSupervisorsStaffExecutive DirectorOrganizational StructureOrganizational Structure

TIDBITSMedical RecordsAll Behavioral Health records are electronic through eCW.All paper records must be kept secure. No records may be kept in offices overnight.Records are stored for a minimum of six years since the last service date.The records room is supervised by the assigned medical records custodian or lockedat all times.Medical records are double-locked (in locking file cabinets within a locked room).Protected health information is safeguarded according to HIPAA and CFR 42regulations.Access to ServicesWe do not use the term “waiting list, list or wait” when referring to our services.Please say “Scheduled Appointments.” Clients are always welcome to walk-in forimmediate issues.How long does it take to see a prescriber?Acceptable Answer: “The appointments are scheduled within 4 weeks.”Unacceptable Answer: “There is a 4 week wait.”ComplianceCorporate Compliance is an organized response to all applicable laws, rules,regulation and ethical standards.Examples of non-compliance; fraud or abuse of fiscal, business, medical practices orclinical documentation.Reports may be made to the SCLHSA Compliance Officer:Charlotte Richard @ 985-857-3751Anonymous reports can be mailed to: Compliance Officer158 Regal RowHouma, LA 70360

TIDBITSFiscal ServicesTravelPurchasing (Requisitions)Staff submit requisitions to Supervisor who reviewsthen approves/deniesSupervisor submits approved requisition to Fiscal forreview and approval before Executive Director signs offAll requisitions must be submitted before purchasetravelStructures have been in established within clinics/sites for:Billing for ServicesBilling for our services is at the core of what we do. Eachclinic has an assigned Billing Liaison ready to:Consult with providers to improve coding accuracy.Serve as a resource for staff and clients.Mitigate issues and submit claims timely.We review financial responsibilities with clients at orientation and client signs thisagreement.We bill third party and/or client for services.Progress Notes and Client Bills are audited for accuracy. In-depth training is provided at orientation and on-going as pertinent to provider concerns.For accurate billing of services remember to:Chart concurrently.Lock notes timely.Document according to template guidelines.Code to the highest level of specificity and medical necessity.Billing (Invoicing to Insurance and Patients for services rendered)Petty Cash/Bank Accounts (Reconciliations)Contract Monitoring: Professional (MDs and Nurses) and Social Services(Prevention and Residential Programs)

SURVEY DOS AND DON’TSBe courteous to survey team members.Dress appropriately. (Review Dress Code in Internal Database ManagementSystem)Only answer what has been asked. If the surveyor wants more informationhe/she will ask.This is not the time to air dirty laundry. If you have an issue with a process orperson, handle it through the chain of command.Take the survey suggestions positively. They are peers and comments shouldnot be responded to defensively.It is okay to say “I don’t know, but this is where I can find out.” (Policies &Procedures/Ask your Supervisor or Manger).All personal cell phones are to be turned off during the survey.There are NO waiting lists for services!Clients may leave even if they are PEC’d. We get officers involved and/or call thelocal law enforcement agency.Clients and their families are included in all aspects of care and treatment - it isPERSON CENTERED!We assess Suicide Risk every visit!#HELPINGPEOPLECHANGINGLIVES