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Dear Team Member,

Thank you for your role as an employee at Center For Family Services. As part of the Center For Family Services team, you have the opportunity to impact the lives of people in need. Whether you are brand new to Center For Family Services or whether you are a long-time team member, you are an important part of the team.

The work you do is challenging, exciting, and important. Center For Family Services is a constantly evolving organization dedicated to meeting the communities changing needs. Your role as an advocate for the mission and vision helps to build awareness and recognition for Center For Family Services as a high quality workplace and a high quality service provider. 

The Guidelines for Daily Operations manual is a set of standards designed to help you in your daily work activities. All staff are asked to review and follow the policies and guidelines outlined in this manual. The policies and guidelines in this manual are designed to maximize our effectiveness and to ensure the highest possible quality services. All staff are asked to adhere to the highest professional ethical standards at all times. All staff are asked to treat fellow employees with respect and open communication. 

New and updated procedures and guidelines are added on an ongoing basis, and staff are encouraged to frequently revisit the Guidelines for Daily Operations manual. If you have specific questions about the manual please contact your supervisor or your Associate Vice President/Vice President. 

Thank you for all that you do in service to others. It is because of you that Center For Family Services is able to build stronger, safer, and happier individuals and communities. I wish you all the best in your role at Center For Family Services. 

Yours Truly,

Richard Stagliano 
President/CEO

Center For Family Services Overview

Center For Family Services is a leading nonprofit social services agency. The vision of Center For Family Services is for all people to lead capable, responsible, fulfilled lives in strong families and healthy communities. The mission is to support and empower individuals, families, and communities to achieve a better life through vision, hope, and strengthCenter For Family Services offers a full range of specialized services to address the needs of the population at every stage of life:

Community Connections - mentoring programs, volunteer efforts, neighborhood-based resource centers, ongoing partnerships with local neighborhoods, and internship experiences.

Counseling & Behavioral Health -  clinical and counseling services designed to build self-sufficient families, encourage strong parent/child relationships, increase conflict resolution skills, provide crisis-intervention, and connect individuals to resources.

Early Childhood Education - high-quality early childhood education and supporting students to increase attendance rates and achieve long-term positive outcomes.

Family Support & Prevention - programming designed to teach critical parenting skills, increase problem solving abilities, and decrease high-risk behaviors through evidence based programs that strengthen families and create safe environments for children.

Safe & Supportive Housing -  safe home environments for children and youth who are homeless, abused, abandoned, or neglected; women who are victims of domestic violence; and young mothers who are homeless.

Addiction & Recovery -  recovery support groups and specialized treatment programs for adolescents, adults, mothers, and the deaf and hard of hearing community, as well as a peer-driven, community-based center for sustaining recovery;

Victim & Trauma Response -  24/7 crisis intervention, counseling, and support to survivors of sexual and domestic violence, safe housing for survivors of domestic violence, and trauma response across the community.

Workforce Development -  job readiness, job seeking and job keeping training opportunities.

Center For Family Services provides a comprehensive continuum of care and high-quality, innovative services to meet the community’s changing needs. Through a wide range of specialized services, Center For Family Services reaches thousands of children and families each year to prevent child abuse or neglect, to provide intervention services when necessary, and to break the cycle of challenges that often cause serious family problems. With in-home, after-school, school-based, and community programs, Center For Family Services provides the tools to keep children safe and help families become self-sufficient.

For a complete list of Center For Family Services programs, click here

With an operating budget of over $80 million, Center For Family Services employs more than 1600 staff in office locations across the state of New Jersey.

Center For Family Services is accredited by the Council on Accreditation of Services, meeting national standards for quality of services.

Program Service Areas

Center For Family Services offers a wide range of specialized services. Each program is unique, and all services share a common goal; to provide a life altering service that will help those being served to become happy, healthy, and self-sufficient.

The continuum of care at Center For Family Services and the ability to help community members who are facing several challenges receive services under one roof. Each one of our programs falls into one of Center For Family Services designated program service areas:

  • Community Connections
  • Counseling & Behavioral Health
  • Early Childhood Education
  • Family Support & Prevention
  • Safe & Supportive Housing
  • Addiction & Recovery
  • Workforce Development 
  • Victim & Trauma Response

Goals and Values

Core values are those principals and qualities literally at the heart, or central to the mission of Center For Family Services. These values form the basis for behaviors and attitudes that support and sustain the mission. Please become familiar with and incorporate these goals and values into your work and interaction with both the families and individuals you serve and other staff members.

  1. To respect the dignity and worth of each individual by providing professional services with compassion and humility.
  2. To provide direct services to individuals and families through therapy, education, counseling, safe housing, support, and advocacy.
  3. To ensure ethical and moral conduct at all times and in all relationships.
  4. To honor diversity and to provide services with sensitivity to differences in race, culture, gender, language, age, religion, disability, and sexual orientation.
  5. To ensure access to services through overcoming barriers, vigorous outreach and service delivery to homes, schools, and the community.
  6. To take a leadership role with other community members in planning and advocating to improve social conditions on a local, state, and national level.
  7. To hold ourselves professionally accountable for our effectiveness by measuring the outcomes and impact of our services.
  8. To create a work environment that honors our staff as our most valuable resource.
  9. To establish Center For Family Services as a continually learning, adaptive, and innovative organization that expands services to meet changing community needs.
  10. To maintain quality and excellence in all Center For Family Services activities.

Core Performance Metrics and Values

Center For Family Services’ Core Performance Metrics and Values apply to all of Center For Family Services. Employees are observed and evaluated throughout the course of each year in the execution of their respective position and the Core Performance Metrics and Values.

For more information on Annual Performance and Evaluations, please visit the Human Resources section of this manual.

  1. Agency Channels/Policy: An individual’s ability to demonstrate that they utilize proper agency channels and chain of command. Ability to follow agency established policies and procedures as expected and required. Adherence to well established protocols, procedures, and related timelines concerning the execution of critical processes i.e.: completion of timesheets, submission of payroll, adherence to timelines for time off requests, and utilization of benefit time, etc.
  2. Intercultural Competency: An individual’s knowledge about cultural sensitivities and acceptance of others cultural differences both personally and professionally. An individual’s ability to understand how cultural differences interplay both on a personal and professional level. An individual’s ability to utilize and translate their cultural competence into effective relationships, service programming, and agency intercultural development processes and efforts.
  3. Organization/Time Management: An individual’s ability to organize, document, and prioritize work efficiently and productively in order to meet schedules and deadlines common to their position. An individual’s ability to create efficiencies for themselves and others.
  4. Responsibility/Accountability: An individual’s ability to demonstrate ownership for their work and reliability to complete expectations of their job descriptions. The ability to rise to the occasion or above general expectations when needed or called upon to do so. An individual’s ability to demonstrate a responsiveness to agency business concerns rapidly.
  5. Dependability/Follow Through: An individual’s ability to follow their prescribed work schedule and demonstrate that they can complete assigned tasks as given or outlined in their job description. A staff person’s ability to demonstrate attention to detail and not leave a process or product incomplete.
  6. Initiative: An individual’s ability and willingness to continuously identify areas that can be strengthened. An individual’s ability and readiness to take action to problem solve and/or initiate innovative solutions that translate into increased productivity for themselves and others.
  7. Customer Services: An individual’s ability to demonstrate effective customer service principals in all tasks and interactions. An individual’s ability to maintain a positive demeanor and utilize effective communication skills when interacting with and assisting all levels of customers in order to provide outstanding customer services to build successful relationships.
  8. Professionalism (Courtesy, Diplomacy, Empathy, and Communication): An individual’s ability to demonstrate a professional demeanor in whatever position or role they serve within the organization. An individual’s ability to maintain effective working relationships internally and externally. An individual’s ability to represent themselves in a fashion that is mindful and diligent to always present the agency and themselves in a positive light. An individual’s ability to communicate information and ideas effectively through verbal and written means.
  9. Judgment/Ethical Practices: An individual’s ability to use principles of sound judgment in their decision making taking into account policies and best practices. An individual’s ability to maintain appropriate boundaries and behaviors in the execution of their duties and interactions. An individual’s ability to demonstrate ethical decisions in keeping with Center For Family Services’ Code of Ethics and any other industry standards, regulations, or compliances.
  10. Supervision/Professional Development: An individual’s commitment to continuous learning and developing through all activities, professional relationships, and interactions. Demonstrates proper use of supervision, seeking guidance as needed to best execute their job responsibilities, is open to constructive feedback as provided and willing to further develop as may be needed or instructed.
  11. Team Work/Collaboration: An individual’s ability to demonstrate that they are a team player. Their ability to lead and/or follow as may be necessary in order to work with others for the greater good of the process. The ability to collaborate and generate collective energy for moving agency initiatives and objectives forward. To participate effectively as their individual skillset or expertise allows.
  12. Technology/Systems: An individual’s ability to effectively use technological tools and platforms in order to complete their work functions efficiently. Ability to utilize technology for effective documentation, data management of agency service provision, and outcomes.
  13. Agency Mission/Referral: An individual’s understanding of the organization’s Core Mission and Values. An individual’s ability to demonstrate a family-centered approach in all of their work. A demonstrated understanding of the services provided by the agency and the ability to make referral linkages as appropriate both internally and externally to the agency.
  14. Safety Best Practices: An individual’s ability to demonstrate a commitment to personal and collective safety of themselves and others across the organization. A person’s ability to identify and report safety issues, problem solve, and monitor activities to effectively reduce risk to the organization.

Roles & Responsibilities

The foundation of Center For Family Services’ is built on our goals, values, and commitment to achieving our mission and vision. On the following pages you will be guided through employee expectations such as the importance of interagency program referrals, and agency communication standards.

All employees are expected to become knowledgeable and will be held accountable to learn and follow these policies and procedures.

Foundation Principals

Center For Family Services exists to help improve the lives of children and families by providing a quality continuum of care to help people through all stages of life. It is essential for all employees to have a basic understanding of the execution of agency policy, implementation of program activity, the care of clients, and the direction of personnel.

This understanding forms the core standards and values that underpins all other standards adopted by Center For Family Services. In dealings with the community, clients, donors, vendors, contractors, volunteers, and staff, management must positively reflect this basic value.

It is our mission to support and empower individuals, families, and communities to achieve a better life through vision, hope, and strength. It is critical for all employees to keep the vision and spirit of this mission before them as they work to support and care for the children and families in our community.

Agency Manuals, Policies and Procedures

All staff should maximize agency resources. Center For Family Services has adopted the following manuals and materials to guide organizational behavior and practices as well as to disseminate important agency information.

All employees must become familiar with these manuals and materials:

  1. General Agency Standards, Policies and Procedures
    An in-depth, comprehensive document that serves as the basis for Center For Family Services policies, procedures, and guidelines. The manual is in accordance with Council of Accreditation standards.
  2. Guidelines for Daily Operations Manual
    Designed to help supervisors navigate the agency’s policies and procedures so they can be successful employees and managers.
  3. Program Guide
    An eight panel fold out brochure containing a complete listing of all Center For Family Services programs and resources.
  4. centerffs.org
    Center For Family Services’ website. A great resource when needing to make a referral or to learn about programs, events, and volunteer opportunities.
  5. Staff Portal https://www.centerffs.org/portal/employee-portal
    Link to Center For Family Services Employee portal where staff can download administrative forms, access Work Orders for IT and Maintenance, read about upcoming events or deadlines, and get information about agency committees.
  6. Specific Program Manual
    Please refer to your specific program manual for requirements regarding screening, intake, assessment, service planning and monitoring, and termination of services.
  7. Agency Portal Stay in the loop on important internal communications like program announcements, trainings, events, and more. You can view the Agency Portal each day when you log onto your computer and open your web browser. 

Implementation of Programs

Center For Family Services continues to expand its services to address the changing needs of the community. As employees, you must continually change and grow in order to effectively and efficiently help the children and families you serve. Our mission and vision is the guide we will use to determine the relevance and appropriateness of new program areas.

A continued commitment of our mission and vision requires a solid program and fiscal plan and full and complete evaluations that measure productivity and program impacts. Leadership assesses community needs, develops program plans, and creates operational objectives and methodologies using:

  • The practice, wisdom and experience of staff;
  • Information from the children and families we serve, community leaders, research data; and
  • Full detailed knowledge of organizational structure and purpose, professional standards, contract expectations, legal requirements and regulations, and organizational and community relationships.

Committed relationships, clear objectives, modeling of organizational values, and good stewardship of resources help the community understand the purpose of Center For Family Services and thereby give its support to our activities. Those characteristics also make it possible for agency employees and volunteers to understand and embrace their own personal role in contributing to Center For Family Services effectiveness, growth, and improvement.

In recognition of this philosophy, leadership will:

  • Maximize the potential of our array of services to the benefit of our clients and constituencies through greater internal and external integrated service delivery.
  • Operate with a long-range vision of its social goals. That vision will find expression in the agency’s strategic plan. All annual program plans will be constructed with both the agency mission and the long range plan in mind.
  • Conduct formal program evaluations annually. Such evaluations will be used to provide an accounting of resources given to us for good stewardship, guide future program planning, and support decisions about the allocation of discretionary revenue.
  • Set annual program goals and targets using a team effort. It is incumbent upon management to maintain close, positive contacts with direct service and support staff and the community. Management will also generate appropriate reports from those contacts in order to craft objectives which reflect the reality of human needs and service delivery requirements.
  • Create and maintain an effective client-responsive work environment conducive to mission-directed, team-based, high-quality service delivery.

Program Referrals

In order to truly maximize the potential of our array of services and provide children and families with a full continuum of care it is necessary for all employees to have a full understanding of all Center For Family Services programs and initiatives. By possessing knowledge about all agency programs, employees can appropriately refer clients to other Center For Family Services programs, providing a continuum of care often necessary for many of the children and families we serve.

Staff are encouraged to stay up to date on all Center For Family Services programs by utilizing agency resources such as centerffs.org and the Program Guide.

Correspondence & Documentation Policy

Documentation

Written documentation and correspondence are integral to the operation of and services provided at Center For Family Services.  The way we communicate and correspond with the individuals we serve, our community partners, and each other is vital to the mission and vision of the organization.

The following policies and procedures provide a foundation for the expectations regarding written communication, verbal correspondence and documentation at Center For Family Services. All written documentation and correspondence is written with the understanding that the writing can be viewed at any time. All written correspondence, verbal communication, and documentation is to be polite, professional, accurate, and neat. Staff are to be clear about what forms of writing they are required to and privileged to write.

This is not a comprehensive document. Please refer to Center For Family Services’ Code of Ethics, Goals and Values, Program/Department Policy Manual, and other policies and guidelines for additional expectations on communication and written documentation.
 

Correspondence Policy

Purpose
Correspondence is essential for Center For Family Services.  Correspondence is an opportunity to positively reflect the mission and vision of the organization. Correspondence becomes an essential part of the agency’s brand.  Brand recognition and communication begins with our logo and letterhead.

Emails

Email is the primary means of communication at Center For Family Services. All staff must regularly check emails and respond to them accordingly. All staff are required to use a standard Center For Family Services signature line in their emails. The standard signature may be found by visiting the staff section of centerffs.org.

Staff are expected to check their email regularly.  Staff are expected to respond to communication within an appropriate time frame.  

Outgoing Correspondence

All outgoing correspondence must be on agency letterhead or sent from an agency email address. Both forms of communication include the sender’s contact information.  All staff are required to use the appropriately branded materials, such as letterhead, as a primary means of communication with donors, funders, employees, and community partners. 

Center For Family Services letterhead is only be used for letters, any other usage is strictly prohibited.
The following outgoing correspondence may only be sent only under the direction of Center For Family Services’ CEO, President, or Chiefs:

  • Grant applications and contracts
  • Letters to public officials
  • Any correspondence with Center For Family Services insurance companies
  • Any correspondence regarding client incidents
  • Leases, agreements of sale, or documents which ask for a signature from an agency authorized representative or owner

The following outgoing correspondence may only be sent under the direction of the agency’s Leadership Council:

  • Letters to funding sources
  • Letters to client’s terminating services
  • Any correspondence regarding client incidents
  • Letters, or memos, to staff regarding requests for leave, discipline, or termination issues 
    • This correspondence must be approved by Human Resources and Program Leadership.

Press and Media Correspondence

Contact with the press and media is handled by the Public Relations Department. Staff are not to contact members of the press/media. As per the Communications, Fundraising, and Development Manual, staff cannot solicit community members and local businesses for donations or sponsorships without first contacting the Public Relations Department. (Refer to Media Protocol) 
 

Correspondence to Clients

  1. Center For Family Services must have the client’s permission to send information to them through mail or email.
  2. The program supervisor must approve correspondence to clients and their families. (note requirements above regarding need for executive approval.)
  3. Professional correspondence is to be clear and factual without any judgments.
  4. Correspondence concerning a client’s termination of services is to be kind and respectful, and when possible leaving an opportunity for the client to reapply for services in the future or to access another CFS program.

Correspondence Concerning a Client

Center For Family Services only releases information when necessary and in the best interest of the client. Center For Family Services must have a signed release form by the client or their legal guardian to send correspondence about the services they receive through CFS. Request from the courts, attorneys etc. must be reviewed to be certain that the release of client information is actually required. Center For Family Services follows the law. Questions concerning release forms are submitted to the Chief Administrative Officer.  See Confidentiality and Privacy Protections.

  1. All written correspondence regarding a client is released on a “need to know” basis. For example, if a referring agent needs to know if a client is attending sessions, this is much different from knowing what the client is sharing during the sessions. Staff must be sure of the details of the release form.
  2. Written correspondence will only include specific information requested and allowed for.
     

Client Rights & Protections

Every day, Center For Family Services’ staff work hard to empower, heal, and support children and families so they can live self-sufficient, happy lives. The rights and protections of the individuals receiving services from Center For Family Services are of greatest importance and were established with the expectation that their observance will contribute to more effective care and greater satisfaction for not only the recipient of care but the staff involved and the agency as a whole.

The following procedures outline the rights and responsibilities of individuals receiving care from Center For Family Services. Also highlighted are employee ethical practices that pertain to client/staff interactions that have been created to protect both parties.

As always, Center For Family Services staff should always set forth with ethical practice in mind. Please refer to the agency’s Code of Ethics and the National Associate of Social Workers Code of Ethics (found by visiting socialworkers.org) for more details.

Rights & Responsibilities

All individuals in the care of Center For Family Services shall have the following rights inclusive of any age, race, ethnicity, national origin, color, gender identity/expression, sexual orientation, religion, culture, ability/disability, personal values or belief systems.

Those receiving services have the right to:

  • Receive professional care needed to regain or maintain their maximum potential.
  • Expect clinical staff who provide service to be friendly, considerate, respectful, qualified through education and experience, and perform services for which they are responsible with the highest quality.
  • Expect full recognition of individuality, including privacy in treatment and care, with confidentiality kept in regards to all communication and records.
  • Complete information, to extent known, regarding diagnosis of treatment.
  • Be fully informed of the scope of services available at the agency, emergency resources, and related fees for services rendered.
  • Be a participant in decisions regarding the intensity and scope of treatment. If the patient is a minor, or unable to participate in those decisions, the patient’s rights shall be exercised by the patient’s legal guardian.
  • Refuse treatment to the extent permitted by law and be informed of the consequences of such a refusal. The client accepts responsibility for their actions should they refuse treatment or not follow the treatment plan agreed on.
  • Approve, or refuse, the release of records to any individual outside Center For Family Services, except as required by law or third-party payment contract.
  • Be informed of research/educational projects affecting their care or treatment, and can refuse participation in such research, without compromise to usual care.
  • Express and/or file grievances/complaints and suggestions at any time, without interference or retaliation.
  • Change primary service provider if other qualified service providers are available.
  • Be fully informed, and involved, before any transfer to any other service provider or organization.
  • Express those spiritual beliefs and cultural practices that do not harm others or interfere with the agency.
  • Be free from unnecessary or excessive medication (see N.J.A.C. 10:37-6.54).
  • To not be subjected to non-standard treatment or procedures or research, psycho-surgery, sterilization, electro-convulsion therapy, or provider demonstration programs, without written informed consent, after consultation with counsel, or interested party of the client’s choice.
    • If the client has been adjudicated incompetent, authorization for such procedures may be obtained only pursuant to the requirements of N.J.S.A. 30L4-24.2(d)2.
  • Treatment in the least restrictive setting, free from physical restraints and isolation, provided, however, that a client in inpatient care may be restrained or isolated in an emergency pursuant to the provisions of N.J.S.A. 30:4-24.2d(3).
  • To be free from corporal punishment.
  • To privacy and dignity.
  • To the least restrictive conditions necessary to achieve the goals of treatment/services.

Those receiving services are responsible for:

  • Being considerate of other clients and personnel and for assisting in the control of noise, smoking, eating, and other distractions.
  • Respecting the property of others and the facility.
  • Reporting whether he or she clearly understands the treatment plan, and what is expected of them.
  • Keeping appointments and, when unable to do so for any reason, notifying the facility 24 hours in advance.
  • Recognizing that the given appointment time is dedicated to the client, and arriving on time for that appointment.
  • Providing the clinician with the most accurate and complete information regarding present concerns, past history, hospitalizations, medications, changes, or any other health or circumstance matters.
  • Observing the rules of the agency during their treatment and, if instructions or agreed plan is not followed, forfeits the right to care at the agency is response for the outcome.
  • Promptly fulfilling their financial obligations to the agency.
  • Reporting any change in insurance, financial ability, and status.

Grievance Procedure

If a client feels they have a grievance, attempts should be made to resolve the concern with the provider. If this does not resolve the issue, the client may ask to see the Program Director. In consultation with Leadership, the Program Director will respond to the complaint within ten days. The decision is made in writing with copies going to the client.

Note: If any programs have a specific contract, funder or licensing that requires a shorter time frame, then the more stringent requirement must be met and included in the program's policy manual.

If the client prefers to share this grievance anonymously, they are able to report their concern via a confidential 3rd party hotline.  This service can be reached by

If there is still no resolution, the client may appeal directly to program leadership, Chief Administrative Officer and/or the CEO of the Agency, who is responsible to address the complaint within fifteen working days. If the decision does not meet the needs of the client, the client may then request in writing a conference with the Executive Committee of the Board, who will arrange a conference within thirty working days. While these hearings are informal, the client may bring a person of their choice with them to assist in presenting the concern. At a grievance conference, the client, witnesses, and staff shall have equal opportunity to:

  • Present and establish relevant facts
  • Discuss, question or refute material
  • Examine relevant records available

The Executive Committee’s decision is made in writing, and copies go to the client, CEO, and on file with the Committee. The agency will maintain confidentiality in all client grievance procedures and information.

At any point, the client may contact an outside agency to respond to concerns or provide praise for services. A list of resources are as follows:

State and Local Support Resources

Atlantic County

Kathleen Quish
Mental Health Administrator
Atlantic County Mental Health Board
101 South Shore Road
Northfield, NJ 08225 
609-645-7700 Ext. 4519

Mental Health Advocate of the Prosecutor’s Office
Atlantic County   609-909-7800

Bergen County

Shelby Klein
Mental Health Administrator
Department of Health Services
One Bergen County Plaza, 4th Fl
Hackensack, NJ 07601
201-634-2745

 Mental Health Advocate of the Prosecutor's Office
Bergen County 201-646-2057

Burlington County

Shirla Simpson
Mental Health Administrator
Division of Behavioral Health
795 Woodlane Rd
Mount Holly, NJ 08060
609-265-5383

Mental Health Advocate of Prosecutor's office
Burlington County 609-265-5035

Camden County

John Pellicane, MBA
Mental Health Administrator
Dept. of Health & Human Services
DiPiero Center, 512 Lakeland Rd, Suite 30, Blackwood, NJ 08012
856-374-6320

Mental Health Advocate of the Prosecutor’s Office
Camden County   856-225-8400

Cape May County

Patricia Devaney
Mental Health Administrator Dept. of Human Services
4 Moore Rd. DN907
Cape May Court House, NJ 08210
609-465-1055

Mental Health Advocate of the Prosecutor's office
Cape May County 609- 465- 1135

Cumberland County

Melissa Niles
Human Services & Mental Health
Administrator Dept of Human Services 70 W. Broad St
Bridgton, NJ 08302
856-459-3080

Mental Health Advocate of Prosecutor's office
Cumberland County 856-451-3177

Essex County

Joseph Scarpelli D.C.
Mental Health Administrator Essex Co. Mental Health Board
201 Grove Ave
Cedar Grove, NJ 07009
973-571-2821/2822

Mental Health Advocate of Prosecutor's Office
Essex County 973-621-4700

Gloucester County

Rebecca Dilisciandro
Mental Health Administrator
115 Budd Boulevard
West Deptford, NJ 08096
856-483-6889

Mental Health Advocate of the Prosecutor’s Office
Gloucester County   856-384-5500

Hudson County

Kayla Hanley
Mental Health Administrator of Dept of Human Services
830 Bergen Ave, 2B
Jersey City, NJ  07306
201-369-5280 ext.4254

Mental Health Advocate of Prosecution's Office
Hudson County 201-795-6400

Hunterdon County

Susan Nekola
Mental Health Administrator of the Dept of Human Services
8 Gaunt Place, PO Box 2900
Flemington, NJ 08822
908-788-1253

Mental Health Advocate of Prosecution’s Office
Hunterdon County 908-788-1129

Mercer County

Michele Madiou
Mental Health Administrator of the Division of Human Services
640 South Broad Street
Trenton, NJ 08650
609-989-6574/ 6305

Mental Health Advocate of the Prosecutor's Office
Mercer County 609-989-6428

Middlesex County

Elisabeth Marchese
Mental Health Administrator Middlesex Co.
Division of Addiction & Mental Health Planning Office of Human Services
JFK Square, 5th floor
New Brunswick, NJ 08901
732-745-3300

Mental Health Advocate of the Prosecutor's Office
Middlesex County 732-745-3394

Monmouth County

Lynn Seaward
Mental Health Administrator Division of Mental Health
3000 Kozloski Road
Freehold, NJ 07728
732-431-6451

Mental Health Advocate of the Prosecutor’s Office
Monmouth County 732-431-7160

Morris County

Amy Archer
Mental Health Administrator Department of Human Services
P.O. Box 900
Morristown, NJ  07960-0900
Phone: (973) 285-6852

Mental Health Advocate of the Prosecutor’s Office
Morris County (973) 285-6200

Ocean County

Tracy Maksel, PhD
Mental Health Administrator of Dept. of Human Services
1027 Hopper Ave, Building 2
Toms River, NJ 08754
732-506-5374

Mental Health Advocate of the Prosecutor’s Office
Ocean County 732-929-2027

Passaic County

Chi Shu (Bart) Chou, Director
Division of Mental Health
401 Grand Street, Suite 506
Paterson, NJ  07505
Phone: (973) 881-2834

Mental Health Advocate of the Prosecutor’s Office
Passaic County (973) 881-4444

Salem County

Shannon Reese
Mental Health Administrator Salem County Dept. Health & Human Services
110 5th St. Suite 500
Salem, NJ 08079
856-935-7510 ext.  8468

Mental Health Advocate of the Prosecutor's Office
Salem County 856-935-2212

Somerset County

Megan Isbitsk
Mental Health Administrator to Dept. of Human Services
27 Warren St, 3rd Floor
Somerville, NJ 08876
908-704-6302/ 6300

Mental Health Advocate of the Prosecutor’s Office
Somerset County 908-575-3359

Sussex County

Cindy Armstrong
Mental Health Administrator
Sussex County Administrative Center, 1 Spring Street
Newton, NJ  07860
Phone: (973) 940-5200, ext. 1371

Mental Health Advocate of the Prosecutor’s Office
Sussex County (973) 383-1570

Union County

Marilucy Lopes
Mental Health Administrator Dept. of Human Services
Division of Individual & Family Support Services
10 Elizabeth Plaza
Elizabeth, NJ 07207
908-527-4846

Mental Health Advocate of the Prosecutor’s Office
Union County 908-527-4596

Warren County

Laura Ritcher
Mental Administrator Dept. of Human Services
1 Shotwell Dr. Belvidere, NJ 07823
908-475-6275

Mental Health Advocate of the Prosecutor’s Office
Warren County 908-475-6284

NJ State Wide

Valerie L. Mielke, Assistant Commissioner, DMHAS
5 Commerce Way, P.O. Box 362
Trenton, NJ 08625
1-800-382-6717

Disability Rights New Jersey
Gwen Orlowski
1-800-922-7233 and 609-292-9742

Division of Mental Health Advocacy
877-285-2844

NJ Division of Consumer Affairs
973-504-6200

NJ Division of Mental Health Services
800-382-6717

The Mental Health Association in Southwestern New Jersey  
856-522-0639

NJ Division of Addiction Services
609-292-5760

Division of Child Protection and Permanency
1-877-NJ ABUSE (652-2873)
1-800-835-5510 (TTY/TDD)

Division of Children and Families
Office of Advocacy
1-877-543-7864

NJ Department of the Public Advocate
609-826-5057

Office of the Ombudsman for the Institutionalized Elderly
1-877-582-6995

Revised 12/2022

 

Privacy Practices

Center For Family Services is committed to protecting the personal information of those we serve. While in our care, we create a record of the treatment provided to ensure the quality, continuity, and effectiveness of our services. In keeping with our caring culture, we strive to maintain a balance between privacy protection, providing quality treatment, and ensuring health and safety. Our Notice of Privacy Practices details how we may use and disclose our clients protected health information to carry out treatment, payment, healthcare operations, ensure health and safety, and for other purposes that are permitted or required by law.

When a new client enrolls in services at Center For Family Services they must read and sign our Notice of Privacy Practices. This notice describes how medical information about the client may be used and disclosed and how the client can get access to their information.

A copy of the Notice of Privacy Policy should be given to the client, the signed original must be kept in the client file. Upon request, we will provide the client with any revised Notice of Privacy Practices. A copy of our Notice of Privacy Practices is available on our website www.centerffs.org. Copies are also available from your program or the Agency’s Privacy Officer.

The Notice of Privacy Practice also describes client rights to access and control of their protected health information. Protected Health Information is information about the client, including demographic information such as gender, ethnicity, date of birth, diagnosis and telephone number that may identify them and that relates to their past, present or future physical or mental health, condition and related healthcare services.

Center For Family Services is required to abide by the terms of our Notice of Privacy Practices. We may change the terms of our notice at any time. A new notice will be effective for all protected healthcare or service information that we maintain at that time.

Case Records

Purpose

Center For Family Services follows the law and protects confidential client information. Center For Family Services realizes that individuals and families trust their personal information with us. Clients and their families have a right to have their information safeguarded. 

Policy

Center For Family Services maintains a case record for each person, family, or group served and the record contains information necessary to provide appropriate services, protect the Center, and comply with legal requirements.

Note: In the event a program cannot maintain a traditional case record per funder requirements, staff are to refer to the program policy and procedure manual for specific documentation requirements.  

Confidentiality

Confidentiality is our number one priority. It is expected that employees take the appropriate steps to keep client and agency documentation, communication, and correspondence confidential.

Case records are confidential and access to case records is limited to:

  1. the person served, or as appropriate, their parent or legal guardian;
  2. personnel authorized to see specific information on a “need-to-know” basis; and
  3. others outside the organization whose access to the information contained in case records is permitted by law.

Case Record Documentation

Case records are to be in good condition, allowing for someone else to service the client in the event that a new staff person needs to assist the client. (Refer to the Electronic Health Record Policy)

  • All written documentation is to be professional, timely, and accurately reflect the services provided.
  • All files must include signed Client Rights & Responsibilities and HIPAA forms.
  • Release of information forms must be fully completed and include date, signatures and to whom the information can be released. Release of information forms must have an expiration date and must be renewed at a minimum annually.
  • File forms are to be filled out completely.

  • Progress notes must be dated and signed.
  • Proper grammar and complete sentences are used.

  • Employees must print and sign their proper name and title on all documentation.  
  • Supervisors are to review and sign off on files, or have a system in place for file review, on a regular basis, not less than every three months.
  • Supplemental paper records, when mandated by funder requirement, are to be kept in a secure locked location and may not be removed from these locations without the expressed permission of the supervisor.  See EHR and Record Retention Policy.

Documentation

A case record is maintained for each person or family served that complies with all legal requirements and contains, at a minimum (refer to program manual for any differences from the following):

  1. Demographic and contact information;
  2. the reason for requesting or being referred for services;
  3. up to date assessments;
  4. the service plan, including mutually developed goals and objectives;
  5. copies of all signed consent forms;
  6. a description of the services provided either directly or by referral;
  7. routine documentation of ongoing services;
  8. documentation of routine supervisory review;
  9. discharge or aftercare plan;
  10. recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and
  11. discharge entered within 30 days of termination of service. 

When necessary, the information contained in the case record is supplemented by the following:

  1. orders for and results of psychological, medical, toxicological, diagnostic, or other evaluations
  2. documentation of all prescribed and over-the-counter medications including copies of all written orders for medications, when applicable;
  3. special treatment procedures, allergies, or adverse treatment responses; and
  4. court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal directives related to the service being provided.
  5. information about services provided by other organizations or service providers; and
  6. other information essential for delivering the service.

Only authorized personnel make entries into case records, and all entries are:

  1. specific, factual, relevant, and legible;
  2. kept up to date from intake through case closing;
  3. completed, signed, and dated by the person who provided the service; and
  4. signed and dated by supervisors, where appropriate.

Note: Programs, or funding sources, may require more frequent activity documentation, including documentation for each contact, or each day of service.  Staff are expected to follow the more stringent policy.   

Access to Case Records

Center For Family Services staff are expected to be very careful and respectful with any written information concerning clients. Persons served have the right to request to review the information in their file.

Policy

Persons served or their designated legal representatives have access to their case records, consistent with legal requirements and the organization’s professional judgment as to the best interest of the persons served. 

(Board approved policy 4/27/05)

Access to confidential case records is limited to:

  1. the service recipient or, as appropriate, a parent or legal guardian; 
  2. personnel authorized to access specific information on a “need-to-know” basis;
  3. former service recipients;
  4. individuals requesting records of deceased service recipients; and
  5. auditors, contractors, and licensing or accrediting personnel consistent with the organization’s confidentiality policy. (See Confidentiality and Release of Information Policy for additional information)

Client Review of their Own Records

Persons served have the right to review their case records, unless prohibited by law or determined to be harmful to the persons served, and such reviews are consistent with all applicable legal requirements, conducted in the presence of professional personnel on the Center’s premises; and carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record. 

Clients, including minors age 14 and up, have the right to inspect their own record or appropriate sections of the record on agency premises, in the presence of their worker.  The request to review a record is made, in writing, to program leadership.  All requested corrections by the client will be in writing and are treated as addenda to existing records and signed by the client. 

Limits to Client Review of Own Record

If the Center determines that allowing a person or family to review their case record would be harmful, and applicable law neither prohibits nor requires direct case record access by persons served, then:

  1. Senior management reviews, approves in writing, and enters into the case record the reasons for such refusal; and
  2. the Center has procedures that permit a qualified professional to review the records on behalf of the persons served, provided that the professional signs a written statement that the information determined to be harmful will be withheld.

Client Statements Inserted in Case Records

Persons served have the right to insert a statement into their case records, and if personnel insert a statement in response, such statements are inserted with the knowledge of the person served, and they are given the opportunity to review and comment on such a response.

Supervisory Case Record Review

Supervisors are to review and sign off on files, or have a system in place for file review, on a regular basis, not less than every three months.  File reviews include both case supervision, as well as an administrative review of the case record.  Case record reviews are documented and maintained separately from the client case record. 

Supervisors are to review case records to ensure compliance with the Center For Family Services’ documentation and case record policies, and any licensing, funder or regulatory requirements.  Supervisors are to log into the electronic health record regularly.  Case record reviews must include a review of electronic health records, and supplemental paper records, where applicable. Reviews include, but are not limited to, demographics, intake procedures, consents, ongoing services, service planning (where applicable), and case closing documentation.  

Supervisors include and document feedback from case record reviews into staff supervision.  All supervisory documentation is stored separately in a supervision file.  
 

Electronic Health Record

Policy

Center For Family Services utilizes an electronic health records (EHR) system for the purposes of conducting business in support of behavioral health and community based consumer care.   All electronic records are the property of Center For Family Services. Center For Family Services reserves the right at any time to limit, restrict or deny access to its EHR system to the extent provided by law.

This policy provides guidance for maintaining a quality health record in accordance with standard electronic record keeping and to meet federal, state and local guidelines. The use of the EHR system will be standardized and utilized in all Center For Family Services programs.

Scope
This policy applies to all staff, including but not limited to, employees, subcontractors, providers and interns.
 

Procedures and Responsibilities

  1. Confidentiality
    All data contained in Center For Family Services’ EHR regarding consumers must be treated confidentially as mandated by federal and state laws and regulations including but not limited to HIPAA and 42 C.F.R. Part 2. Violation of the agency’s Confidentiality Policy is subject to progressive discipline.
     
  2. Rights and Privileges
    Only those Center For Family Services employees who need access to the consumer’s EHR will be given a user name and password.  Each newly hired staff will be provided with a unique username and set up password to the EHR utilized by their program.  The employee will be required to create their own unique password upon their first log in attempt.   The goal is to prevent unauthorized persons from accessing data and to monitor staff’s use of the EHR.  Continuous system monitoring is done by the System Administrator and Data Specialists.  Privileges allotted to staff will be specific to their program and only allow them to see needed information to perform the functions of their job.  These specific privilege groups will be customized by system administrators.  Violations and/or unauthorized use of the EHR will result in progressive discipline, or immediate termination, depending on the severity of the incident.
     
  3. Creation of an Electronic Health Record
    All consumers must be entered into the EHR system upon first contact with the agency.  When a consumer has been enrolled, an EHR chart is created.  All information within the EHR is to be documented accurately and completely.  

    Note: For programs that do not maintain a traditional case record per funder requirements, refer to the program policy and procedure manual for specific documentation requirements.  

    The following demographic information must be completed on each consumer entered into the system, with individual programs entering additional information as needed:
        a.  First name, Last name (Preferred Name is available for all clients) 
        b.  Date of Birth  
        c.  Current living situation, Address, county and telephone number(s)
        d.  Race, ethnicity, preferred language 
        e.  Gender identity, sexual orientation, marital status
        f.   Education, employment status, veteran status 
        g.  Household Demographic information, including, but not limited to household size, household composition and household income 

    Clarification: All fields must be answered. Protocols are in place for proper documentation for programs that may have anonymous clients, etc.  EHR fields have an option for unreported or data not collected.  

    Note: Depending upon the nature of the service, it may not always be in the client’s interest to obtain all the information at the first interaction; however, all fields must be completed within 30 days of the creation of the client’s intake into the EHR.
     
  4. Content and Authentication of Electronic Health Records
    The Center For Family Services’ staff assigned to input the consumer into the EHR is responsible for reviewing and approving all consumer information initially entered into the EHR. The staff assigned to the consumer are responsible for continued oversight and documentation within the consumer’s record.  Staff are responsible for meeting all agency and program criteria for EHR content.  

    The following information must be included in all client records:
        a.  The consumer’s progress
        b.  Services provided by staff 
        c.  Referrals made. 

    The following information must be included in Clinical programs:
        a.  The consumer’s progress, including response to treatment, change in diagnosis, and patient’s non-compliance. 
        b.  Past and present diagnosis must be accessible to the treating and/or consulting physician. 
        c.  Relevant risk factors. 

    For each visit the following are the standards for medical records documentation: 
        a.  Billing codes, including CPT and ICD codes reported on health insurance claim forms or billing statements are supported by the documentation in the EHR.  The program staff, support staff, supervisor and billing department will all be working to ensure the accuracy of the EHR for the processing of the billing submittal.
     
  5. Plan of Care for Clinical Programs (including discharge plan, if appropriate) should include:
    1. Treatments and medications (prescriptions and samples) specify amount, frequency, number of refills, and dosage;
    2. Referrals will be placed in the EHR upon receipt;
    3. Specific instructions for follow up.
    4. Any written consents for treatment or surgery, requested from the patient/family by the physician.
    5. Clinicians must assure the accuracy and medical necessity of the level of Evaluation and Management CPT Code recommended by the EHR before submitting the charges.
    6. Any amendment, supplementation, change, or correction in an EHR shall be noted by indicating the time and date of the amendment, supplementation, change, or correction and clearly indicating that there has been an amendment, supplementation, change, or correction.
    7. Consumer records received from another physician or health care provider involved in the care or treatment of the patient will be maintained as part of the consumer’s EHR. This includes all pertinent diagnostic medical test reports received from providers outside of Center For Family Services. The provider shall review and initial the medical report. The medical report should then be summarized into the EHR, scanned and entered into the EHR’s file cabinet.
    8. Verbal orders shall be documented in the EHR on the date of service or by the next business day.
       
  6. Prescriptions
    NOTE: This section only applies to programs that issue prescriptions.
    1. Prescribing is available through the EHR system and is utilized when possible.
    2. Center For Family Services requires that any prescriptions which are manually printed contain the original signature of the Provider and/or designee on the prescription. This includes prescriptions that are printed and faxed. Only prescriptions which are automatically generated and sent from the EHR are exempt.
       
  7. Timely Completion of Electronic Health Records
    The goal of the completion of an EHR is to ensure relevant data is inputted timely, with regards to funder requirements, billing, chart review and chart standards.  The Center For Family Services’ staff will complete consumer progress notes, or appropriate data information entry, within 72 hours of the service.  If any program has contract, licensing or funder requires that have a shorter time frame, then the program staff must follow the more stringent requirement. 
     
  8. Documents to be scanned into the Electronic Health Record
    Documents that need to be scanned into the EHR system are scanned and uploaded to the EHR file cabinet.  All documents to be scanned will be maintained confidentially in accordance with the record retention guidelines.  The original document must be properly destroyed or filed in accordance with the agency/program guidelines.  Documents should be named in accordance with the program guidelines.  
     
  9. Supplemental Paper Records
    All consumers are to be documented in an EHR.  If funder requirement mandates a supplemental paper chart for case record information, programs must ensure accuracy and consistency between the two file types.  The EHR must include documentation of the existence of a supplemental, paper-based portions of the records.  These records must be stored in accordance with the Record Retention Guidelines.  Center For Family Services prohibits the storage of consumer records outside of the EHR and supplemental paper-based file. 

    Note: For programs whose funder mandates a supplemental paper record, refer to the program policy and procedure manual for specific documentation requirements.
     

Maintenance of Electronic Health Records

  1. Consumer who have an established Electronic Health Record
    Center For Family Services’ staff are responsible for ensuring all demographic information is complete and updated for all consumers, upon every visit.

    When applicable, prior to a scheduled appointment, the designated staff will be responsible for insurance verification and consumer demographic review for consumers with an established EHR record.
     
  2. Late Entries, Amendments, and Corrections to the Electronic Health Records
    When a document is signed with staff’s electronic signature, it is ‘locked’ within the system, and can only be unsigned by a system administrator.  Staff are encouraged to discuss the need for a service document to be unsigned with their direct supervisor, who will then request this permission via a work order to the appropriate system administrator, if needed.  Documents that are signed and/or scanned into the system will only be unsigned and/or removed with appropriate supervisor permissions, and after the need for such a request has been validated.
     
  3. Correcting data in “Locked Encounters”
    System Administrator will assist supervisor in making requested corrections.  Staff member will upload the correct document or make appropriate changes, edits or additions to the unsigned document and sign using electronic signature.

    Any amendment, supplementation, change, or correction in an EHR is to be noted by indicating the time and date of the amendment, supplementation, change, or correction and clearly indicating that there has been an amendment, supplementation, change, or correction. 

    Incorrect data, which must be removed from the current record, must reflect documented approval by the supervisor (i.e. wrong consumer EHR). 
     
  4. Correcting Scanned Documents
    In the event a previously scanned document was scanned into the wrong patient’s EHR, contact the system administrator via a work order ticket, using the consumer ID, reason for requested removal and approval from the supervisor. Document will be removed once appropriate approvals/reasons have been validated.
     
  5. Retention of Electronic Health Records
    The retention of EHRs will follow the guidelines set forth by the Center For Family Services’ record retention and destruction policy.
     
  6. Shared Records
    The EHR will allow for program linkages for continuity of care, as well as to coordinate services between programs.

Revised: 3/2022

Record Retention Guidelines

Purpose

Center For Family Services follows the law and protects confidential consumer information. We realize that individuals and families trust their personal information with us. Consumers and their families have a right to have their information maintained, safeguarded and disposed of in a manner that protects their privacy and confidentiality and is in accordance with the law. 

Scope

This procedure applies to all staff, volunteers and members of Center For Family Services who come into contact with consumer records.

Procedures

​A. Record Storage

All Case Records are to be stored in locked metal files cabinets within a Center For Family Services’ building, as designated for each program. Records taken out of file cabinets for update, supervision or review, must be returned to the file cabinets by the end of the day. The Program Supervisor must have access to record at all times. Case Records are not to be removed from their designated location, except under very restricted circumstances as approved by the Vice President.

Case records will not be kept in staff cars or taken home. Progress notes written outside the agency buildings, must be added to records within 24 hours.

Security of Information

All Center For Family Services information is safely and securely maintained. Center For Family Services has control mechanisms to ensure that records can be located at any time. Center For Family Services has procedures to protect service and organizational records, whether in electronic or paper form, from destruction by fire, water, loss, or other damage, and from unauthorized access, which include:

  1. daily backup of all electronic records;
  2. electronic back up maintained off-premises; and
  3. storage of paper records in locked, fire resistant cabinets in secured areas.

B. Record Retention

Center For Family Services maintains all consumer records for at least ten (10) years following the termination of services in accordance with COA requirements, unless otherwise mandated by law.

a)      Records where youth and adolescents are the primary consumer must be retained for ten (10) years after they reach their 18th birthday.

b)      Drug Treatment Record Retention

NJSA 26:8-5 et seq. Retention of records – Client records must be maintained for a minimum of 10 years in accordance with N.J.S.A. 26:8-5 et seq. and disposed of in the manner prescribed.

Records for outpatient substance abuse treatment consumers must be retained for a minimum of ten (10) years in accordance with NJSA Title 26:8-5 following the consumer’s most recent discharge or until the age of 23, whichever is longer.  In addition, a discharge/continuum of care summary sheet shall be retained for twenty (20) years following the most recent discharge of a consumer.  The discharge summary sheet shall contain the consumer's name, address, date(s) of admission and discharge and a summary of the treatment and medication rendered during the consumer's stay.

c)       Youth Residential Living

Records for youth and adolescents under Youth Residential Living must be retained for ten (10) years after they reach their 18th birthday in accordance with NJSA Title 26:8-5 Institutional Records.

d)      Medicaid/DHS/DMHS

10:37-6.77 Retention of records

  • Records of adults must be retained five years after the last date of service. Records of children must be retained for five (5) years after they reach their 18th birthday.
  • Records may be destroyed by burning or shredding. The destruction must be complete; no readable material or client identification may remain.
  • A list of the destroyed records must be kept on file for an additional five years. This list should include the client’s name, case number and date of destruction. It should be signed by the staff person who supervised the records destruction.

If any programs have specific contracts that require consumer records be kept longer than ten (10) years, then the records should be retained to the more stringent requirement.   

C. Record Disposal

  1. All records must be destroyed by shredding.  The destruction must be complete; no readable material or consumer identification may remain.  
  2. A list of the destroyed records must be kept on file an additional five (5) years unless contractually required for a longer term then the program should follow the more stringent requirement.  This list must include the consumer’s name, date of birth, and date of destruction.   Each entry should be signed off on by the staff person who supervised the record destruction. 

 

Prohibited Practices

The health and well-being of those we serve must be a priority for the employees’ of Center For Family Services. We strive to provide a safe and secure environment that fosters healing and growth. Center For Family Services prohibits the following practices in all of its facilities and programs:

  • Any type of threat of physical hitting or the use of corporal punishment
  • Use of aversive stimuli
  • Interventions that involve withholding nutrition, or hydration, sleep, mail, clothing appropriate to the season, or verbal communication, or that inflict physical or psychological pain
  • Use of demeaning, shaming, or degrading language or activities, verbal abuse, ridicule, humiliation, or other forms of degradation
  • Unnecessarily punitive restrictions, including cancellation of visits as a disciplinary action
  • Unwarranted use of invasive procedures or activities as a disciplinary action
  • Forced physical exercise or forcing a youth to take an uncomfortable position, to eliminate behaviors
  • Assignments of overly strenuous physical work or punitive work assignments
  • Punishment by peers
  • Group punishment or discipline for individual behavior
  • Mechanical or chemical restraint
  • Locked seclusion
  • Exclusion from any essential program or treatment service, such as educational or clinical treatment
  • Refusal of entry to the home or program
  • Restraints shall not be used as a means of coercion, as discipline, for retaliation, or for staff convenience

For very young children:

  • Ignoring the child
  • Labeling the child as “bad”
  • Isolation
  • Punitive overuse of time outs

The above prohibited practices include parents residing in Center For Family Services’ shelters, such as the Services Empowering Rights of Victims (SERV) Safe Houses or Mother Child, foster parents and volunteer mentors.

Board Revised April 26, 2017

Expulsion of Adult Shelter Residents

Adult shelter residents may be expelled for serious violations including but not limited to violence or threats of violence, possession and or use of alcohol or drugs and related paraphernalia, any circumstance that compromises the safety of the resident community, and in the domestic violence SERV Safe House, for disclosing the location of the shelter residence.

Program Directors, in consultation with Leadership may use their discretion in circumstances of multiple, repeated violations of program policies, procedures or expectations, that may warrant a client’s expulsion from the shelter.

Prohibition of Weapons

Center For Family Services prohibits the possession of weapons on its facilities premises or on the job, except by law enforcement personnel.

Mandatory Reporting

Purpose

Center For Family Services prioritizes our clients’ safety and care.  In the event that there is a concern about the abuse, neglect, or exploitation of a minor or vulnerable adult, the organization is mandated to report those concerns to the proper authorities.  Under the law, any person having reasonable cause to believe that a child has been subjected to abuse, neglect, and/or exploitation shall report this information to the Division of Child Protection and Permanency (DCP&P). Health care professionals, law enforcement officers, firefighters, paramedics, or emergency medical technicians are required by law to report suspicion of abuse of a vulnerable adult to Adult Protective Services.

Definition

Vulnerable Adult – Per Adult Protective Services, a vulnerable adult is a person age 18 years or older, and residing in the community, and due to physical or mental illness, disability or deficiency, lacks sufficient understanding or capacity to make, communicate, or carry out decisions concerning their own well-being and is the subject of abuse, neglect or exploitation.

Procedure

  1. Any staff person who has reasonable cause to believe that a minor, or vulnerable adult, is currently a victim of abuse, neglect, and/or exploitation will immediately report the allegation to the appropriate hotline.
  2. Any staff person who has reasonable cause to believe that a minor, or vulnerable adult, is currently a victim of abuse, neglect, and/or exploitation will immediately report this information to their supervisor. If their supervisor is not available, the staff person should report this information to their Program Director, and so forth up the leadership structure, if they are not available. 
  3. After completion of the initial call to report the allegation to the abuse hotline, the staff person will also complete an internal incident report that will be forwarded to their supervisor and Senior Leadership for review.
  4. The staff person is also responsible to document the concern for abuse and actions taken in the consumer’s electronic health record.
  5. The Program Manager, or appropriate supervisor up the leadership structure, will complete a state incident report within 24 hours and provide follow up reports as indicated by the designated state agency.

Revised April 6, 2023

Duty to Warn

Counselors have the ethical and legal obligations to prevent their clients from physically harming themselves or others. If you believe a client is dangerous, you must use reasonable and conscientious effort in taking decisive actions to both protect and warn the potential victim of your client’s violence.

The Legal Basis

The Tarasoff ruling, expanded further by the Hedlund case and other decisions, details the counselor’s duty to protect and warn. “The protective privilege ends where the public peril begins.” If you break the privilege of confidentiality in an effort to protect life, you generally will not be held liable for this breach under a doctrine of “qualified privilege” (i.e. if you can prove that there was a necessity to breach confidentiality). A recent review of suits against counselors for warning others indicates that, even though warning potential victims opens the counselor to allegations of breach of confidentiality, they should still do so to avoid liability for subsequent violence.

When adopted Tarasoff, the courts have usually followed these three basic principles in assessing liability:

  1. Foreseeability of harm (i.e. verbal threat to an identifiable victim)
  2. Identifiability of a victim
  3. Feasibility of counselor intervention

Courts have never held a counselor liable when a professionally proper response was made. You will not be held responsible for a negative outcome if you have carefully and diligently performed proper evaluation, planning, and implementation of your client’s treatments.

When do you have a “Duty to Warn”?

Counselors have a duty to warn – and should reveal the threat of violence – whenever there is reasonable cause to believe a client is dangerous to a person or to a property. “Reasonable cause” is determined by these two core characteristics:

  1. The threat must be towards a specific and definable target.
  2. The threat has to be believable. It should be explicit, not vague. Motives count, as does the client’s personal history or threats or violence behavior.

Speak with your supervisor about becoming educated in evaluating dangerousness and violence. A counselor is not liable for simple errors made in good faith and with reasonable professional judgment.

Steps to take when you decide to “warn”

Many factors are involved in what attorneys refer to as “discharging your Tarasoff duties.” While you are mandated to take “reasonable” and “necessary” steps to protect the potential victim, each situation is unique and your course of action will be guided to a great degree by the specific circumstances. Discuss this with your supervisor or the most immediately available supervisor or experienced clinician. Good sense suggests that you implement as many of the following options as are reasonable, appropriate, and in observance of New Jersey laws:

  1. Warn the intended victim. Warnings to intended victims should be as discreet as possible in an effort to protect the client’s confidentiality, however, the warning my include statements made by the client which you believe are necessary to reveal in order to effectively convey the serious intent of the threat to the victim (Menendez v. Superior Court).
  2. Notify the local law enforcement agency. With approval from your supervisor and your programs COO, contact the police in the precinct nearest the client and get the name and badge number of the person taking the report. You may want to discuss with your supervisor about sending a follow up (certified) letter to the police and intended victim stating your concerns; always remember that disclosure should be discreet and limited to the prevention of threatened violence. ]
  3. Contact relatives or others who can apprise the potential victim of danger. Discuss this with your supervisor before taking this action.
  4. Document all your observations and efforts.

Research Safeguards

The Continuous Quality Improvement Practices Committee reviews any requests to conduct research or follow up studies involving clients. Any client involvement in follow-up studies or research of any kind is strictly voluntary, and participation will not affect continued or future service. In any research endeavor, the signed informed consent of the client will be required. In any proposed human subject research, the research project must comply with all applicable laws and regulations governing research with human subjects.

If research is also connected with a university, the research design must have been approved by their Human Subjects Research Committee. All proposed research projects must be reviewed and approved by Center For Family Services Executive Team and Board of Trustees.

Quality Improvement

Continuous Quality Improvement Process

The purpose of the Continuous Quality Improvement Process (CQIP) is to advance efficient, effective service delivery and the achievement of agency goals and to ensure that every person touched by the agency – customers, consumers, staff and the community - receives Center For Family Services’ best at all times.

The overall responsibility for coordination of the Continuous Quality Improvement Process is the responsibility of the Vice President of Administration, who sits on the CQIP Committee, compiles the annual report to the Board, appraises the Executive Team of any needed action, and reviews internal policies, including the CQIP policies, and external standards for best practices and compliance.

The CQIP Committee includes the Executive Team, representatives from all service areas, including a significant number of Program Directors, Coordinators and Supervisors, as well as direct services staff, students and volunteers. See Current Structure and Membership list following policies.

The Continuous Quality Improvement Process at Center For Family Services is a coordinated system of multiple components, at many levels, and across all programs.

Case Level

At the case level of service to each individual and family, CQIP begins with a unique and individualized service plan, determined by the client in conjunction with the counselor. This service plan is signed by both parties, and is continually reviewed to determine level of achievement towards the stated goals. Modifications and adjustments are made, either at predetermined intervals, or as needed to assure effective and efficient progress towards goals.

Service plan achievement is monitored by client and counselor, by supervisor, by psychiatrist if appropriate, by external monitors if appropriate, and by the CQIP Review Committee. The CQIP provides a mechanism for reporting of findings and for corrective action if necessary.

Program Level

At the program level, there are written goals, outcome objectives, and expected levels of service. These Outcomes and Levels of Service are written in the Program Manual. If the program is funded by specific contracts, the Outcomes and Levels are also contained in the program contract.

Program Outcomes achievement may be determined by a process of aggregating individual service plan case objectives. Specialized contracted programs may have other specific ways to measure and report program outcome achievement.

Planning to Achieve Outcomes

The Program Methods are designed to ensure that outcomes are achieved. Program Methods are described in the Program Manual, and in the program proposal for contracted programs. These Methods are reviewed and / or revised annually, or at time of re-contracting, to assure effective and efficient use of resources to achieve appropriate outcomes. In the record review process, individual cases are reviewed to determine that service activity is appropriate to meet program goals. If overall, there is a lack of program effectiveness, methods will be reviewed for modification to improve program effectiveness and achievement of outcomes. The CQIP Committee will monitor this process and report findings to the Executive Team and Board.

Agency-wide Outcomes

In an effort to be able to report on the aggregate effectiveness of Center For Family Services, the Outcomes Initiative Project identified eight outcomes, of which every Center For Family Services program identifies at least two or more of the outcomes as among the outcomes of the program. These Outcomes are as follows:

  1. Improving the Physical Family Unit: This can include preventing out-of-home placement of a family member, family reunification, stabilizing current placement, preventing homelessness.
  2. Preventing Abuse and Neglect
  3. Completing Individual Service Plan Goals
  4. Preventing Recidivism in the Justice System
  5. Client reports benefit from service received
  6. Client increased Psycho-Educational Knowledge
  7. Increased Mental Health / Substance Abuse Reduction
  8. Sustained Sobriety

Programs routinely aggregate these outcomes from individual client cases and aggregate data on a program level. With AWARDS electronic records, Center For Family Services will be able to aggregate data on an agency-wide level.

Levels of Service achievement is determined by measuring achieved levels of service against predetermined Level Of Service expectations, which in many programs is determined by contract.

Program level Outcome achievement is monitored by program supervisors, coordinators, and directors, by external program monitors if appropriate, and by the CQIP Review Committee. The CQIP provides a mechanism for reporting of findings and for corrective action if necessary. Summary results are periodically tabulated and distributed to Program Coordinators, Directors, the Executive Team and the Board of Trustees.

Organizational Level

At the level of the organization, there are several processes to ensure Continuous Quality Improvement.

A. The Continuous Quality Improvement Committee meets monthly to review Case Level and Program Level findings from CQIP record reviews, and program monitoring reports. The Committee makes recommendations for corrective action if necessary to assure best practices. Summary results are periodically tabulated and distributed to Program Coordinators, Directors, the Executive Team and the Board of Trustees. Minutes are taken at Committee meetings.

B. Client Satisfaction Surveys may be sent to clients as cases are closed and at agency-wide point in time intervals, to receive client feedback on the effectiveness of services and learn from the client if there are ways to improve the service experience. Results of surveys are periodically tabulated and distributed to Program Coordinators, Directors, the Executive Team and the Board of Trustees.

C. Incident Reports are completed whenever there is an incident or accident. Incidents are submitted into the Clarity Healthcare SafetyZone portal per the Incident Reporting Policy. Incident Reports are reviewed by the immediate supervisor for corrective action if possible at that level. The program management,  up to and including the senior leadership, are notified of the incident report for review. All incident reports are reviewed by CQIP Committee to review, to determine if appropriate policies are in place to prevent future incidents or accidents. Depending on findings, corrective actions are recommended, which may include policy implementation or modification. Summary results are periodically distributed to Program Coordinators, Directors, the Executive Team and the Board of Trustees.
Special Indicators are included as incident reports.

D. Client Grievances Client Complaints and Grievances must be reported on Incident Report forms whenever received by staff within 24 hours of the complaint. These reports will be reviewed by the immediate supervisor for corrective action if possible at that level. Complaint / Grievance Reports should be forwarded to Program Coordinator, Director, and Vice-President for review. All reports are then forwarded to the Continuous Quality Improvement Committee for review, to determine if appropriate policies are in place to prevent future complaints / grievances. Summary results will be periodically distributed to Program Coordinators, Directors, the Executive Team and the Board of Trustees.

Client confidentiality must be maintained throughout this process.

The outcomes of any formal client complaint or grievance will be kept in writing, and clients will be notified of any decision within a reasonable time frame.

All serious problematic and unresolved issues will be reviewed by the Board for careful oversight of the issue of potential liability and possible need for correction. Client confidentiality must be maintained throughout this process.
See Generic Policies: Client Complaints in GASPP for more information and compliance with NJAC 10:37-4.6 “Client Complaint / Agency Ombudsman Procedures”.

E. Risk Management – Loss Control – Center For Family Services maintains a program of Risk Management and Loss Control as proactive measures to minimize and prevent incidents, accidents, and other negative actions that could reduce or prevent optimum service outcomes. The program includes attention to the physical environment, appropriate procedures, and appropriate orientation, supervision and training of staff, volunteers and interns.
Universal Precautions and Infection Control – The Senior Vice President of Operations maintains the Infection Control Policies and ensures program and facility compliance. See full document in Center For Family Services General Agency Standards, Policies and Procedures Manual, Chapter 6: Risk Prevention and Management.
The Senior Vice President of Operations maintains a schedule of proactive measures, and a log of this activity. Summary report is presented periodically to the CQIP Committee and the Executive Team.

F. Policy Modifications The CQIP Committee reviews and / or implements policy and practice modifications which impact the full organization. Written policies are disseminated through supervisory channels and at various staff meetings.
The Committee will review any use of treatment modalities which risk or limit freedom of choice, or problems with the administration or prescription of medications, including confidentiality and release of information.

G. Annual Report to the Board of Trustees A comprehensive Continuous Quality Improvement Report is presented annually to the Board of Trustees, including Summary and significant elements from the above components.

H. Evaluation of Operational Plan On an annual basis the Executive Team reports to the Board of Trustees an evaluation of its previous operational plan, and makes recommendations for the coming year.

The Operational Plan is derived from the Long Range – Strategic Plan.

On an annual basis, each program is reviewed to assess efficient allocation and utilization of human and financial resources towards achieving organizational goals, its effectiveness, and the relationship of service delivery costs to the benefits derived by clients. This process may be conducted in part by an external contract monitor for funders. This process typically takes place within a contract or funding renewal process, when the agency determines that it is interested in continuing the service activity for the coming year, and the funder determines that it is interested in funding the service for the coming year. These are independent but related decisions based on assessed need, effectiveness, cost efficiency, and other concerns.

Review of Case Records

The CQIP Committee implements the internal Review of Records. The purpose of the review is to determine that records reflect best practices of service delivery are in compliance with various accreditation and licensing standards. The purpose is to provide assurance that the organization’s resources are being used with effectiveness and efficiency in meeting organizational goals, as reflected in each program’s goals and objectives.

All programs participate in a process of peer monitoring and independent case review. This review supplements routine case supervision and consultation. All records are reviewed by staff who are not in positions of conflict of interest, specifically, are not employed in the program being reviewed. Records are also reviewed by program supervisors and by external reviewers.

A review form is completed for each reviewed case. One copy is forwarded to the supervisor. The supervisor follows up on any corrective action needed in that case. A second copy is retained by the CQIP Chair in a locked file. A summary of significant findings for the program is prepared by the reviewer. The summary is forwarded to the Program Director. This summary report contains no identifying information on clients or clinicians.

In programs with a history of good compliance to record keeping standards, supervisors may also submit evidence of quarterly record reviews as an alternate to external CQIP review. Record reviews of contract monitors external to Center For Family Services can also be used as evidence of quarterly record review. Reports of these alternative reviews will be forwarded to CQIP.

Thresholds

Programs or individual clinicians with patterns of substandard practice will be re-reviewed monthly until practice meets standards. A threshold of 10% non-compliance in the sample shall trigger corrective action and re-review.

CQIP Committee reviews summaries to determine if policy modification or training is needed to correct problems and improve quality.

Sampling

Cases are selected for review using methods of random selection. Number of cases reviewed should follow COA Guidelines.

Frequency

Cases are reviewed quarterly, unless otherwise directed.

Special Indicators

100% of cases with special indicators will be reviewed. Special indicators include: suicide threats or attempts, violent behavior with potential for risk to self and others, adverse medication reactions, client complaints, client incidents and client accidents. A summary report of special indicators will be included in the annual report. Special indicators are included as incident reports.

Reporting to Senior Management

Summary findings on a program level are reported to the Executive Team on a quarterly basis, and included in the Annual CQIP Report to the Board of Trustees.

Review Checklist

Generic or program specific checklist may be used for record reviews. Checklist includes questions about appropriateness, effectiveness and if service should continue. The checklist also includes mandatory documentation including intake information, service plan signed by client, progress notes, and closing statements (if closed). Records are reviewed for quality of assessment, service planning, service provision, outcomes, and aftercare, as well as required documentation.

Program evaluations may aggregate data on outcomes in relation to expectations. Deviations from expectations are examined for problems, causes and solutions.

Reporting to Senior Management

Summary findings on a program level are reported to the Executive Team on a quarterly basis, and included in the Annual CQIP Report to the Board of Trustees. This report is also made available to staff and other interested parties.

Shared Findings

Client – The client is a partner with the counselor in assessing the level of achievement of objects.

Funders – Funding organizations typically request and receive program evaluations. Summary findings may be included in the Annual CQIP Report, or other documents.

Any other findings of professional interest may be disseminated through publications, workshops, on the Center For Family Services website, etc.

Purchase of Services

In the event that services are purchased through subcontracts from other organizations, Center For Family Services will monitor and evaluate those services through processes comparable to those above.

Longitudinal Studies

Longitudinal studies are conducted in Family Preservation Services, on 3, 6, 12 and 18 month periods to determine if results are sustained over time.

Multi-Systemic Therapy MST also conducts longitudinal evaluations.

External Review Processes

External record reviews are conducted in accordance with the contracted specifics of individual contracts, and may be included in quarterly review.

Research Safeguards

The CQIP Committee reviews any requests to conduct research or follow-up studies involving clients. Any client involvement in follow-up studies or research of any kind is strictly voluntary, and participation will not affect continued or future service. In any research endeavor, the signed informed consent of the client will be required. In any proposed human subject research, the research project must comply with all applicable laws and regulations governing research with human subjects. If research is also connected with a university, the research design must have been approved by their Human Subjects Research Committee. All proposed research projects must be reviewed and approved by the Executive Team and the Board of Trustees.

CQIP Committee Membership

All service areas and programs are represented in the CQI Process.

Stakeholders

Service Recipients

Service recipients are encouraged to participate in various ways to the overall CQI Process. On an individual case level, the periodic review and updating of individual service plans contributes to determining service effectiveness individually and can be aggregated to determine program service effectiveness. Service recipients are asked to complete client satisfaction surveys. In some programs, service recipients may serve on advisory councils. The Center For Family Services website is available to service recipients as members of the general public.

Center For Family Services Board of Trustees

Center For Family Services’ Board Members direct the overall expectation of continuous quality improvement through strategic planning and the work of various Board committees. The Board is advised of progress periodically at appropriate Board meetings and formally each year with the Annual CQIP Report to the Board.

Staff: Employees, Contractors, Interns, Work-Study and Volunteers

Staff participate as members of various committees at Center For Family Services which contribute to CQIP, including Residential QI, Behavioral Health QI, Head Start QI, Wellness, Ethics, Cultural Competency, and other committees. Employees are encouraged to participate in employment satisfaction surveys, and provide other constructive ideas. CQIP information is disseminated through the general website, the staff section of the website, email and various other communications.

Funders

Funders participate in annual reviews of contracts through face-to-face monitoring events, and through the re-contracting process, which is sometimes competitive. Many programs have on-going case reviews with contractors where discussion of individual cases may bring about constructive modification of services and process for the program as a whole.

Citizen Advisory Groups

From time to time, Center For Family Services is involved with various citizen advisory groups in the community, especially the Cooper-Lanning Neighborhood Association. Center For Family Services joins with its neighbors to work on community development concerns, especially in Camden City. This can inform programming and resource direction.

Safety & Risk Prevention

Safety & Risk Prevention

The safety of our employees and the individuals we serve at Center For Family Services is our priority.

The following protocols, policies, and guidelines have been implemented to facilitate not only a safe work environment but a safe place for the individuals we serve to receive the care needed to become whole again.

Within these pages you will become educated on our Operations Department and how they’re available to assist your program with needs such as facility maintenance, inspections, and emergencies. You will also learn about safety policies in regards to universal infection control and emergency/evacuation procedures.

Lastly, you will read about our vehicle guidelines and policies and how they relate to you as an employee and to those we serve.

Also included in this section of the manual are tips on how to stay safe in the workplace.

Universal Building Protocols

The appearance and maintenance of our properties is an important part of Center For Family Services’ brand. We strive to present a welcoming and safe place for not only the individuals we serve but for our employees, volunteers, student interns and donors.

The following guidelines and practices are applicable to all Center For Family Services properties. They are intended to assist staff in maintaining a safe, clean, and professionally appealing environment.

If you have additional questions after reviewing these protocols, please contact the Senior Vice President of Operations or the Facilities Director.

Work Orders

As facility issues arise staff are required to reach out to Center For Family Services’ Operations Department for assistance by submitting a work order through the agency’s employee section of the website. By submitting a work order for each specific issue, Operations will be able to monitor and track all work across the entire agency.

When submitting work orders, please be aware of the following:

  • When submitting work orders it is important to provide as much information as possible and be sure to include accurate contact information.
  • Work orders are reviewed daily and are prioritized based on the severity of the issue, materials needed, maintenance schedules, and budgetary considerations.
  • Some work orders may not be approved due to compliance with building and safety codes and/or may be deferred or delayed due to lack of resources, materials or budgetary constraints.
  • Work orders deemed Imminent Life Safety issues by code or regulatory compliance will be immediately addressed.
  • Follow up review of completed work orders will be conducted by the Facilities Director to ensure the work was completed correctly.

Fire/Life Safety Inspection Reports

The Fire/Life Safety Inspection Reports identify a host of facility issues that are the joint responsibility of both Center For Family Services’ Operations Department and the program staff occupying and operating from a building. Fire/Life Safety Inspection Reports are to be conducted monthly by the designated Operations staff person assigned to each specific property.

Completed Fire/Life Safety Inspection Reports are to be used to proactively identify life safety concerns and prompt needed work orders as well as serve as the most current record of the safety status of a given facility.

The original report will be submitted monthly to the Facilities Director and will be saved within Operations SharePoint record retention system. Center For Family Services Maintenance staff are to review and discuss these report with the Director of Operations to assess and plan appropriately the correction of issues identified.

Emergencies:

All Emergency/Life Safety issues should immediately be brought to the attention of the Senior Vice President of Operations or the Facilities Director. Examples of emergencies include broken pipes, power outages, flooding, ceiling collapses, etc.

External Property/Grounds:

First impressions are important. The first impression an employee, donor, or volunteer gets upon visiting a Center For Family Services site is critical to their relationship with the organization. At the start of each business day, the outside of each property should be visually inspected by program staff to ensure there are no visible trip or fall hazards that would inhibit safe access by our clients, staff, or other patrons.

Properties should be inspected relevant to changing weather conditions or other factors that may affect its continued safe operation. Any issues should be reported immediately to the Operations Department.

Lastly, windows, doors, storage sheds, parking, external security lighting and trash areas should be visually monitored to ensure they are secure and have not been tampered with or vandalized and that debris and litter is not accumulating.

Lobby/Reception Areas:

Lobby and common areas are critical in that they provide the community their first impression of Center For Family Services. Significant attention should be made to keeping them clean, orderly, and attractive. Trash should be emptied daily and carpets vacuumed and/or tile floors polished regularly. Use of plants, pictures and other decorative items should be appropriate, compliant with COA standards, correctly mounted and interculturally competent.

The use of throw rugs, candles etc. are strictly prohibited by COA / Licensure regulations.

ID Badges:

All full and part-time employees, AmeriCorps members, and student interns will be issued a Center For Family Services ID badge and lanyard within the first few days of beginning their position. For security purposes it is imperative that ID badges be worn at all times while on Center For Family Services grounds so that you can be identified as an employee of the agency.

ID badges are valid for one year and will be replaced annually by the Human Resources Department.

Volunteers are never issued a Center For Family Services ID badge. Instead, volunteers should be given a temporary volunteer badge upon entering their volunteer site. This badge should worn during their volunteer hours and returned to the front desk at the end of their volunteering shift. Volunteers are not permitted to take the badge with them.

Visitors to Center For Family Services should be given a temporary visitor badge after signing in at the front desk of the site they are visiting. This badge should be worn during their visit and returned to the front desk where they signed in.

Reception/Client Sign In:

In addition to receptionists ensuring volunteers and visitors receive an ID badge upon check in, receptionist and staff must ensure that all visitors, vendors, guests, or volunteers also sign in. After signing in, visitors or guests are to be escorted by a Center For Family Services staff member to their destination and are not to roam freely throughout agency buildings. It is the responsibility of Program Directors and Associate Vice Presidents to ensure this process is followed.

Those receiving services are not required to sign in for confidentiality purposes but should be accompanied by a Center For Family Services staff person so that their presence within a building is known. Individuals receiving services should never be left unaccompanied in a Center For Family Services building.

Universal Postings:

Every building must have the following documents posted in a conspicuous area within the entrance/reception area. Attention should be paid to ensure that they remain current and are properly laminated, framed, and mounted. A single location should be identified for them and remain stationary. These documents should be posted separately from any other informative postings.

  1. Center For Family Services’ Mission, Vision, and Goals Statement
  2. Grievance Procedures
  3. Client Rights Statements
  4. Program/Facility License
  5. Municipal Certificate of Occupancy
  6. Municipal Fire Inspection Certificate/or Mercantile License
  7. Office Hours/Access Numbers
  8. Center For Family Services Fire Equipment Inspection Log
  9. Procedures for Emergency Evacuation
  10. Universal Precautions Protocol
  11. Notice of Reporting Authorities “NJDOHSS”
  12. Poison Control number posted

Staff Space(s):

Housekeeping services are provided weekly to maintain common areas including lobby’s, foyers, hallways, bathrooms and kitchen areas. Staff are responsible to maintain their own individual work spaces and offices.

Different properties have different needs and have slight variations as to their internal supports for housekeeping needs, practices, and schedules. It is important that all new staff are informed about office culture and norms regarding trash removal, recycling practices, etc. by the site’s office manager or program director.

Storage Spaces:

Storage areas are identified and maintained at each location for the storage of paper products and cleaning, office, and maintenance supplies. Many of our locations also have basement storage. Please be mindful that items in basement storage should never be stored under stairways. Stored items are never to be placed in front of electric or fire panels, heaters and water heaters; always ensuring a 4 foot radius of clearance to these systems.

The tracking and monitoring of stored items should be conducted by support staff at each location.

In-kind Donations:

We value the support of our partners in the community and rely on in-kind and monetary* donations to assist us in helping the children and families we serve. It’s important that in-kind donations are vetted through the Operations’ Logistics and Public Relations Departments before being accepted. These departments will consider the type and quality of the donation, the immediacy of the need, and the program’s ability to distribute the donation to their clients quickly without having to store it. Due to limited space and limited resources we are unable to accept used or gently items of any kind. This includes used furniture, appliances, clothing, coats, blankets, mattresses, toys, stuffed animals, or books. Only new items are accepted and distributed. 

If it is determined that the organization will accept the donation, the Operations’ Logistics and Public Relations Department will work together with the program to make appropriate arrangements to pick up the items.

Please be mindful that the Operations’ Logistics Department and Public Relations Department is not available regularly to pick up donations. They will only make pickups on a case by case basis once it is determined that the donation is acceptable. It is imperative that all potential donations be communicated to both the Operations and Public Relations Departments before being accepted. Be aware that donation pickups made by the Operations’ Logistics Department or Public Relations Department can only then be delivered to a Center For Family Services’ location and cannot be delivered to the home of an individual receiving services.

If your program is the recipient of donations, a staff member(s) should be designated to oversee the distribution of those items and follow the appropriate guidelines regarding Receipt of Goods outlined in the Public Relations section of this manual.

Script for conversations with community members interested in donating their used items: 
Thank you for thinking of Center For Family Services for your donations!  We have certain types of gifts we are able to accept, but due to limited space and limited resources, we are unable to accept used items of any kind. This includes used books, clothing, coats, mattresses and furniture. Our mission at Center For Family Services is to provide counseling, safe housing, and supportive services to help people to heal and follow a path to their own best future.  We do not have the facilities to store, sort and distribute used items.  We recommend donating your used items to Goodwill or Habitat Restore. Please contact us at 856.651.7553 x40110 or 40129 for information about the ways you can help to support our work.

*If you receive a monetary donation, the cash or check should be turned into the Public Relations Department immediately along with the donor’s name and contact information. If you are communicating with someone who is interested in making a monetary donation, please connect them with Jen Hammill, Associate Vice President of Public Relations and Development, at 856.651.7553 x40129. 

Safeguarding of Personal Property:

Center For Family Services staff must be mindful that if their personal belongings are not properly stored they become susceptible to theft. Staff should make every effort to leave items of personal or monetary value at home. Although responsible to provide a safe and secure work environment, Center For Family Services is not responsible for misplaced or stolen items or for investigating or responding in such an event. This includes individual’s motor vehicle which should be properly locked and without articles of importance or value left visible to others.

Safeguarding Agency Property:

Staff are responsible to protect agency property, equipment, and vehicles that they have been entrusted with from damage and/or theft. These items include: vehicles, office furniture, supplies, computers, cell phones, software, and other forms of technology. Attention to the proper use, routine maintenance/repair, and return of such articles in proper condition should be taken into consideration by all staff.

Problems, misplacement, or theft should be reported immediately to your supervisor and the administration team responsible for the purchase, replacement, and insurance claims for each item by completing an Incident Report.

Safeguarding Case Records

All Case Records are to be stored in locked metal files cabinets within a Center For Family Services’ building, as designated for each program. Records taken out of file cabinets for update, supervision or review, must be returned to the file cabinets by the end of the day. The Program Supervisor must have access to record at all times. Case Records are not to be removed from their designated location, except under very restricted circumstances as approved by the Vice President.

Case records will not be kept in staff cars or taken home. Progress notes written outside the agency buildings, must be added to records within 24 hours.

Security of Information

All Center For Family Services information is safely and securely maintained.

Center For Family Services has control mechanisms to ensure that records can be located at any time.

Center For Family Services has procedures to protect service and organizational records, whether in electronic or paper form, from destruction by fire, water, loss, or other damage, and from unauthorized access, which include:

  1. daily backup of all electronic records;
  2. electronic back up maintained off-premises; and
  3. storage of paper records in locked, fire resistant cabinets in secured areas.

Center For Family Services maintains Case Records for at least seven (7) years after termination of service, unless otherwise mandated by law or COA requirements for specific services. Records of children must be retained for five (5) years after they reach their 18th birthday. Drug Treatment client records must be maintained for a minimum of 10 years.

Drug Treatment Record Retention

NJSA 26:8-5 et seq. Retention of records – Client records must be maintained for a minimum of 10 years in accordance with N.J.S.A. 26:8-5 et seq. and disposed of in the manner prescribed.

Medicaid / DHS/DMHS

10:37-6.77 Retention of records

  1. Records of adults must be retained five years after the last date of service. Records of children must be retained for five (5) years after they reach their 18th birthday.
  2. Records may be destroyed by burning or shredding. The destruction must be complete; no readable material or client identification may remain.
  3. A list of the destroyed records must be kept on file for an additional five years. This list should include the client’s mane, case number and date of destruction. It should be signed by the staff person who supervised the records destruction.

Destruction of Case Records

All case record material must be shredded prior to being discarded.

Overall Building Safety

All employees of a Center For Family Services owned or operated building are to be knowledgeable of their sites security system, codes, passwords, and be capable of arming and disarming their system correctly. Program Directors are responsible for educating and ensuring their staff are trained during their initial orientation.

Center For Family Services’ work/office sites should have regular standard operating hours visible and posted. Staff should adhere their work activities to when the building is open. Any diversion from the standard work hours must be pre-authorized by a supervisor. Any supervisor whom provides such an approval is directly responsible for their staff person’s safety.

As a general rule, no staff person should ever be working alone by themselves in a Center For Family Services facility. Bringing non-staff guests or family into an agency facility afterhours prohibited.

Any security incident that poses real and imminent threat of harm to building occupants should be immediately directed to local authorities for immediate assistance and response by calling 911.

Appliances:

Appliance refers to any item that requires an electrical connection or a power source for operation, including permanent fixtures and temporary devices, other than general electronics such as personal computers (PC’s), monitors, printers, and related technology items.

Appliances must always meet Underwriters Laboratories (UL) safety certification. Appliance installation must comply with the 46 Code of Federal Regulations (CFR), 111.77-3, Appliances and Appliance Circuits. Appliances must be suitably installed for the locations and service intended.

Evaluation of requests for agency or program furnished shared appliances (refrigerators, microwaves, toaster ovens and shared coffee services for designated refreshment areas) will be based on the assessed necessity and the capacities of any particular building for supporting a request. Evaluation of requests for shared appliances will be situation specific. It is recognized that various facility types will have varying requirements. (For example, the requirements of a 24/7 residence or workplace may differ from the requirements of an office site.) Exceptions to standards will be reviewed on a case-by-case basis.

All agency-furnished and employee-furnished appliances are subject to review and approval by Center For Family Services Operations Department.

Requests for agency-furnished appliances should be made to the Center For Family Services Operations Department through the Work Order Request web portal. The Facilities and Operations Department will use the principles of employee health and safety, and energy efficiency to determine if appliances meet the criteria. As appropriate safety considerations will take precedence over any perceived need or desire for an appliance request. No one is to purchase, and/or install any appliance at their locations until such approval to do so has been granted by Center For Family Services Facilities and Operations Department.

Managers must assume responsibility for any appliance that has been approved and installed for use in the workplace. Small personal appliances must not pose potential disruptions to the workplace, such as interference with fire alarm and sprinkler systems, lighting or building power, noise pollution, and/or possible odors generated from them due to lack of proper maintenance or cleaning, etc.

The following appliances are not approved for installation in a Center For Family Services workplace: personal coffee pots, electric coolers, grills, griddles, hot plates, small refrigerators, toaster ovens, microwaves, pole lights, fish tanks, and water fountains. These items may cause safety or health hazards, significant noise pollution, or potential water damage. Cumulative use of these items may cause overload on certain building electrical systems and trigger outages. Any consideration of one of these appliances requires specific detailed justification and approval by the Facilities and Operations Department. Any exception based on medical reasons for placement of unauthorized appliances must meet the standard evaluation process for ADA reasonable accommodation through Human Resources in cooperation with Facilities and Operations Department specifically in respect to personal heating devices.

The acquisition process for agency-furnished appliances for all Center For Family Services work sites are as follows:

  1.  
    1. Manager reviews and evaluates the request for an appliance based on business need, cost, and budget. and prepares a brief justification.
    2. Manager completes a work order request attaching the justification, and submits the request to Facilities and Operations for review and approval
    3. Facilities Staff will determine the physical site capability to accommodate any request specific to fire, electrical, safety, and building requirements and codes,
    4. Facilities Operations, in consultation with the SR VP Operations, determines appropriateness for acquisition and installation of any appliance. If a request is denied, Facilities Operations will provide the rationale and alternatives that are available.

Incidents/Accidents:  

Incident Reporting 

Policy

All incidents are to be reported immediately via the Clarity Healthcare Safety Zone portal. Immediately means as close to the incident as safely possible for those involved, but no later than within 24 hours of the incident.  If a shorter reporting period is required by the funder, licensing, and/or program regulations, then the more stringent requirement must be followed.   

Protocols

Submission

Any incident or accident that involves a Center For Family Services’ staff, intern, student, volunteer, person(s) served, client, property or the agency must be reported with immediacy by submitting a detailed incident report via the Clarity Healthcare Safety Zone portal.  Wherever possible, the incident report should be written by the staff who were involved or have firsthand knowledge of the incident.

Incidents include, but are not limited to, deaths, suicide attempt, injuries, abuse/assault, property damage, criminal activity and/or newsworthy occurrences.  For a more comprehensive list, see Incident Report Appendix A.

Notification

In the event of an incident, staff are to follow their program’s guidelines for immediate notification to their supervisor and/or chain of command.  This usually occurs via direct communication such as a phone call.  Supervisors are responsible for notifying appropriate members of the chain of command regarding serious incidents. 
**Submission of the incident report into the Clarity system does not constitute notification**

Supervisory Review

Once submitted, supervisors/reviewers in the notification chain will automatically receive an email from [email protected] informing them that an incident report was submitted to review.  The reviewer can access the form by clicking the link in the email or logging into the Clarity HealthCare SafetyZone site.

Supervisors are to complete their initial review of the Incident Report in the Clarity Healthcare Safety Zone portal immediately upon receipt, but no later than 24 hours using the Clarity System.  When possible, incidents are resolved at the level closest to the incident. Complete follow up or corrective action as necessary.  Once reviewed, complete the follow up questions required for the incident report.  Submit the report to leadership within 72 hours of initial review.  Upon completion of the review, check Review Completed, in the Communication Center and change the status to Review Completed to notify the leadership team that the program has finished their review. 

In the event that additional follow up is active and/or required, the status is to be changed to Under Review, and at a minimum, weekly updates must be made to indicate the program’s ongoing actions in follow up to the incident. 

Notes

  • Once a supervisor is informed that IAIU is involved in an incident, they are responsible for notifying the Associate Vice President and the Quality Improvement Director immediately. 
  • Supervisors are responsible for ensuring debriefing occurs for consumers and staff following a critical incident.  A critical incident includes (but is not limited to the following categories):
    • Physical Restraint, Property damage Over $500, Medication Error requiring medical treatment, Suicide Attempt, Physical Assault that led to injury, All A+ and A level category incidents as defined by the DCF Unusual Incident Reporting and Management System.
  • Supervisors are responsible for ensuring staff are trained on the importance and rationale for reporting incidents.
  • Supervisors are responsible for providing constructive, helpful, and supportive feedback to staff after reviewing incident reports.  This includes ensuring all elements of the incident report have been thoroughly completed.

Leadership Review

Leadership will review all incidents, as well as to evaluate the appropriateness of intervention and determine if additional factors will affect ongoing delivery of services.  For example, review if the appropriate policies and procedures in place to prevent future incidents or accidents.

Closing an Incident Report

Incident reports are to be closed within 14 days.  Leadership must change the status of the incident report to Closed once all follow up and review is completed. 

  • If an incident report is unable to be closed within 14 days, then a follow-up report must be completed and documented no less than every 30 days by leadership or their designee. 

Timeline

  • Incident Occurs
  • With immediacy (within max. 24 Hours): Submit IR
  • Within 24 hours of submission: Supervisor completes initial review
  • Within 72 hours: Supervisor completes review/follow-up
  • Within 14 days: Leadership review and close incident report

Storage

Copies of incident reports are not to be placed in the individual’s electronic health record or client file. 

Confidentiality

All incident report records, reports or other information, whether written or verbal, which directly or indirectly identifies a former or current client receiving services by the Agency must be kept confidential. Staff who fail to maintain confidentiality of such records in accordance with this policy and state law may be subject to disciplinary action, up to and including termination, or civil liability by parties claiming that their confidentiality rights have been violated.

Staff Incidents

Submission

Any incident or accident that involves a Center For Family Services’ staff, intern, student, property or the agency must be reported with immediacy by submitting a detailed incident report via the Clarity Healthcare Safety Zone portal.  The involved employee submits the incident report via the Clarity portal. 

Follow Up

The review process will proceed as outlined above for all incident reports.

For a staff injury/accident, forward the necessary information and reports to the human resources department for distribution to the appropriate insurance provider.

If a vehicle incident/accident occurs, forward the report and necessary information to the appropriate insurance provider. 

In the event of a situation or physical condition that is identified as a potential risk, immediate repairs and/or improvements are to be made to rectify the situation, remove and/or improve the potentially hazardous condition. 

External Reporting – Unusual Incident Reports

  • For unusual incidents involving programs licensed by the Division of Mental Health Addiction Services (DMHAS), an internal investigation with a full report completed by the appropriate supervisor staff will be completed within 24 hours of incident. In these instances, the internal "Incident Reporting Form" will be completed.  This report will include a description of the event, and evaluation of the adherence to agency policies, DMHAS standards and the individual staff involved, conclusions and recommended actions.  DMHAS Reportable incidents shall be reported to the DMHAS Program Analyst and/or Regional Quality Assurance Specialist by telephone no later than one working day following incident and an incident number will be acquired.  The initial “Community Unusual Incident Initial Report Form” shall be submitted via fax to DMHAS Incident Coordinator (609) 943-4272, (609) 341-2316 and to the Regional QAS (609) 567-4468 no later than 5 working days following the date of the incident or allegation.  A copy of the report will also be sent to the Contract Administrators as well.  No later than 45 days following the incident, an internal review of the incident and follow up report is be forwarded to the Division of Mental Health Addiction Services.
  • For unusual incidents involving programs licensed by the Department of Children and Families, the “Unusual Incident Report” is be submitted to the UIR Coordinator on the same day for incident levels A & A+, the following day for B level incidents to https://dcfebpr.dcf.state.nj.us.  Follow up report is due 30 days following the incident date and at 45-day intervals until incident is closed.  
  • When appropriate, Unusual Incident Reports (UIR) are referred to Bureau of Standards and Inspection, and the Regional Coordinator by a member of the Executive Leadership.
  • A copy of the UIR is be uploaded as an attachment into the Clarity portal. 

Monitoring

Incident reports are aggregated and reviewed at a minimum of quarterly for trend analysis and recommendations for improvements by the Quality Improvement Committee.

Procedures

How to Write an Incident Report

  • Include all essential information, such as the identity of the person involved and the exact time and location of the incident.
  • Record in detail the events leading up to the incident, during the incident, and afterwards.  All attempts to de-escalate an incident are to be clearly detailed.  Include specifics as relevant, such as statements made by the person(s) involved, actions taken, staff response, interventions provided, etc. Use behaviorally specific language.
  • Write the incident report objectively, avoiding opinions, judgements, or assumptions.  If you have additional concerns or opinions, discuss them with your direct supervisor.
  • Describe what you heard and saw, and actions that you witnessed being taken.  If documenting something that was reported to you, clearly state specifically who informed you and the specific statements that were made, including the timeline of events.
  • If more than one individual is involved in an incident, complete a separate incident report for each client involved. The incident report for each person is to have the identified youth name listed for “Who was involved”.  All mentions of other clients in the report are to be noted by using another identifier, such as the client’s EHR # or initials. 

 Revised: January 2021

Clarity Healthcare Safety Zone Guidelines

Accessing Clarity Healthcare Safety Zone

To access Clarity Healthcare Safety Zone Incident Reporting system, you can click the icon on your desktop or copy and paste this web address in your browser:

https://events.healthcaresafetyzone.com/EventsModuleWeb/default.aspx?cs=4b904de1-babb-4e55-91ba-04263d800ba0

The web address is also available on the staff section of the Center for Family Services website on the Clarity page.  https://www.centerffs.org/staff/clarity

Quick Tips for using the Clarity Healthcare SafetyZone site

  • Submitters do not need a log in for this site. 
  • Top Right of the form indicates the form you are using and incident number assigned. 
  • Blue Reset button will clear the answers you have selected in the form and starts over
  • Blue Cancel button will bring you back to the Clarity Healthcare SafetyZone home page

When using the form, submitters have 60 minutes to complete submission.  5 minutes prior to the time being up a will pop up, reporting that all information will be lost if not completed or saved.

If a submitter is idle for 20 minutes (no keyboard or mouse movement) the system will close the application and the incident will need to be re-submitted.

  • * Note Required Questions.  The incident cannot save without answering the question.  When the incident is complete and Save is selected a note will pop up promoting the user to answer any required questions that were missed.
  • Red Save button will save the incident report
  • Incident Type and Location are the drivers of notifications in the system.  It is important to pick the correct program and type of incident to route the incident to the correct supervisors.

Detailed Instructions for completing the form

This provides the basic instructions for the Incident Reporting Form.  The Employee Incident Report Form is very similar in structure.

Access the Clarity Healthcare SafetyZone website:  https://events.healthcaresafetyzone.com/EventsModuleWeb/default.aspx?cs=4b904de1-babb-4e55-91ba-04263d800ba0

Click “Submit Event” and select the appropriate form incident reporting form or employee incident report form. 

  • Select the Date/Time of the incident
  • Which Program/department is reporting the incident?  This identifies the program that is reporting the incident.  If the program has multiple sites, you will be prompted to select the sub program for the identified youth.
  • Location Type identifies the physical location the incident occurred.  If the incident occurred at the program location, select “Yes”. If the incident did not happen at the program location you must select where the incident occurred:
    • CFS Satellite Location – These are locations not owned by Center For Family Services but we have programs that use the space.
    • Community – This location would be an incident that happens in the community, such as if an incident at public place such as a courthouse, police station, school, community venue, etc.
      • When this option is selected, the writer will be prompted to enter the address where the incident occurred.
    • Individual/Family Home – Select this if the incident happened at the home of the individual or family and not in the program location.
    • When this option is selected, the writer will be prompted to enter the address where the incident occurred.
    • When this option is chosen, the writer will be prompted to select the Center For Family Services location from the pre-populated drop down.
    • When this option is selected, the writer will be prompted to enter the address where the incident occurred.
    • Other CFS Location – This location would be selected if an incident occurred at a Center For Family Services location that is same as the program the client is involved. For example, if a youth in our residential program was at the outpatient counseling building and an incident occurred. 
    • Other – This option would be selected if an incident occurred that does not fit into the other categories
  • The specific program location describes where the incident occurred such as the kitchen, hallway or driveway.
  • Type of Incident identifies the type of incident that occurred.  This section is broken down to several categories with sub categories in each area.  An incident can fall into more than one category.  The writer should choose the main event type and then can add up to 3 additional event types, if indicated.  Listing of event types and definitions for each category can be found in Appendix A and Appendix B.
  • Who was involved identifies the person the Incident Report is being written about.  The writer will select the category the person falls into.  A client would be identified as a “Person Served”. The writer will then be prompted to enter the First Name and Last Name of the identified person.
  • Were additional parties involved identifies if anyone else was involved in the incident.  If more than one client is involved in an incident, complete a separate incident report for each person involved. The incident report for each person should have the identified youth name listed for “Who was involved”.  All mentions of other clients in the report should be noted by using another identifier such as the client’s EHR # or initials. 
  • The writer will be prompted to enter the Gender Identity, Race/Ethnicity, and EHR number (if known) for the individual identified.
  • The writer will select the type of injury sustained from the options listed
  • The writer will select the affected area of the injury
  • Did The Condition result in?  This will identify if the person identified received medical care and the type of care received.
  • Was this person injured identifies if the person involved in the incident was injured.  If Yes is selected then the writer will be prompted to answer the following questions:
  • If yes was selected, the writer will be prompted to answer the following questions:
    • Date and Time hold started and ended
    • Type of Hold identifies the Safe and Positive Approaches approved technique used.
    • Justification for Hold identifies the reason for the hold.
    • Was another Hold involved identifies if more than one hold was implemented.  If more than one hold was implemented, you will be prompted to answer questions about each hold.
    • Youth condition after hold ended – Describes the youth response to the hold.  The writer should select all that apply from the checklist.
  • Was medical attention required asks if following assessment for youth physical condition after hold if additional medical review was required.
  • If Yes, the writer will select from the check boxes the Type of medical attention required after hold.
  • Is this person involved with another program identifies if the person identified in the incident report is involved in any other Center For Family Services’ programs.
  • Did this Incident involve a Safety Technique or Personal Emergency Intervention Hold identifies if behavior management techniques were used.  This option should be selected for all guides, deflections, physical interventions or holds implemented.

**Reminder for All Restraints, A Debriefing Form and completion of the Restraint Log are still required. A copy of the Debriefing Form must be attached to this Incident Report. **

  • Who has been notified/contacted documents who was notified of the incident.   This section details the name(s) of who was contacted, the date and time contact was made, and the type of contact that was made.  **Submission of IR to the system does not constitute notification**
    • The writer will answer these questions for the following questions:
      • Was Supervisor contacted?
      • Was family/guardian notified?
      • Was 911 was called?
        • The writer will be prompted to note if Emergency Services Reported to the site. If Yes is selected, the type of emergency services that arrived must be selected as well as a brief summary of the actions/services provided by the emergency services provider.
      • Was DCP&P or the NJ Abuse Hotline notified?  If yes, the writer must record the name of the person notified and screener number.
      • Was the UIR Coordinator notified of A+ incidents?  If yes, the writer will be prompted to elect if the UIR falls under DCF or DHMAS.
      • Was anyone else notified identifies if anyone else not listed was notified of the incident such as a CMO worker, APN or emergency contact.
      • Was an Unusual Incident Report required identifies if a UIR was completed.  When the incident type is selected, it will note if a UIR is required for the incident. 
  • Events leading up to the Incident: Describes the behavior/actions and/or events immediately before the incident, and the staff’s responses to these actions.  Ex.  this could include any attempts to use self-regulation tools,  or de-escalation techniques.
  • Describe the Incident: Describes the incident in behavioral specific detail (actions that can be observed and measured).  This includes behaviors from the individual, staff actions, and injury or damage to property until the incident ended
  • Action Taken: Identifies what the user did following the incident.  The writer should check all that apply.
  • Results/Response or action Taken: Describes what occurred after the incident ended, including other individuals’ and staff’s reactions, and plans to provide follow-up.
  • Was this event witnessed by anyone not listed above? If yes, the writer will enter information for any witnesses not previously entered into the incident report.
  • Reporter Name identifies the writer of the report.
  • Reporter Title identifies the writer’s position.
  • Select Save will save the incident.  If any required questions were missed, it will prompt the user to complete the required questions.
  • Are there any attachments for this event? If yes is selected the writer can attach a document or video to the incident report.  Examples of types of documentation that can be attached are:
  • Correspondence
  • Legal Documentation
  • Search and seizure forms
  • Medical Paperwork or discharge instructions
  • Debriefing form
  • Police Report
  • The writer will then be notified that the event has been successfully saved.

Supervisor/Reviewer Responsibilities

Supervisors are provided a log in for the Clarity HealthCare SafetyZone website.  This log in allows the supervisors to review submitted incidents.  As a supervisor or reviewer, the log in credentials are the same as the network credentials (to sign onto an agency computer).  This is often firstname.lastname and does not include an email handle.  To access the submitted incident reports, the supervisor selects the My Review button from the left hand side of the web page.

  • Supervisors/Reviewers in the notification chain will automatically receive an email from [email protected] informing them that an incident report was submitted that they need to review.  The reviewer can access the form by clicking the link in the email or logging into the Clarity HealthCare SafetyZone site.
  • The Supervisor selects the form they are reviewing.  For Incident reports, select the Incident Reporting Form from the drop down and press select, and do the same for Employee Incident Report.
  • The My Review Grid is a tool to help reviewer manage the events they are responsible for.   Reviewers can sort the information by any field selected.  By selecting “Review Events Grid” will show the reviewed all events that have been submitted by staff and are still open.
  • To select an event the reviewer should click on the event number, which will bring the reviewer to the Live Event. The live event tab shows the reviewers all of the questions and answers from the original report.  If a reviewer has the authority to do so, they will have an “Edit” button on the far right, which will allow reviewers to edit any questions that need to be edited. The Change Logs keeps track of any and all changes.
  • The Follow Up Tab is the communication center and where the incident follow up is tracked.
    • At the top of the page, the communication center will note all reviewers that were automatically notified of the incident and the date that they reviewed the incident.
    • Reviewers have the ability to add other staff who have Clarity HealthCare SafetyZone accounts but may have not been automatically notified of an incident.  Example of this may be therapists, case managers, or nursing staff who need to be made aware of the incident and will have a role in follow up.
      • To add additional reviewers, they should be selected from the drop down list and an optional note can be sent with the notification. 
    • View/Assign tasks allows the reviewer to send other reviewers a note of what is needed in order for the incident to be completed.
    • The Assistant Program Director/Program Director will answer the following questions:
    • Were all appropriate Actions Taken?
    • Were additional Notifications Required
    • Was a UIR submitted (All submitted UIR’s must be added via attachment)
    • Did IAIU respond to the incident?
    • Follow Up Actions Taken
    • Is additional follow up needed?
    • Managers Comments
    • What can be done to prevent chances of a similar incident occurring?
    • Submitted – the incident was submitted by the writer
    • Under Review – the incident has been reviewed but awaiting an additional follow up prior to complete review
    • Review Completed – the incident follow up has been completed by the Program Director/or designee.
    • Closed – This notes the incident follow up is complete and incident can be closed.  Incident closure can only be completed by a  member of the leadership council (AVP, Regional Director, etc.) or their designee.
    • Status notes the status of all submitted incident reports
  • Change Log tracks any changes that are made to the original incident report.
  • Original Event tab shows the initial report submitted by the writer.   The original tab will not change regardless of edits, follow up and investigation.
  • Attachment allows the reviewer to review and add supporting documentation for an incident.

Supervisor Reminders

  1. Supervisors are responsible for notifying appropriate members of the chain of command regarding serious incidents.
  2. Once a supervisor is informed that IAIU is involved in an incident, they are responsible for notifying senior leadership and the Quality Improvement Director immediately. 
  3. Supervisors are responsible for ensuring debriefing occurs as outlined following a critical incident.  A critical incident includes (but is not limited to the following categories):
    • Physical Restraint
    • Property damage Over $500.00
    • Medication Error requiring medical treatment.
    • Suicide Attempt
    • Physical Assault that led to injury
    • All A+ and A level category incidents as defined by the DCF Unusual Incident Reporting and Management System.
  4. Supervisors are responsible for ensuring staff are trained on the importance and rationale for reporting incidents.
  5. Supervisors are responsible for providing constructive, helpful, and supportive feedback to staff after reviewing incident reports.  This includes ensuring all elements of the incident report have been thoroughly completed.
  6. Supervisors are responsible for providing an update on all open incidents every 30 days until each incident is closed. This update is completed within Clarity.

Snow Emergency/Disaster Closure Protocols:

Center For Family Services is strongly committed to ensuring that all essential services (24 hour programming) remain operational at all times and that all non-essential agency services operate as regularly scheduled unless extreme conditions or other emergency events prevent the agency from operating safely.

Essential 24/7 services are not affected by agency closure protocols and are directed to review and initiate as necessary their sheltering-in and/or sheltering-out protocols.

Delayed Openings/Closings for Non-Essential Operations

Unless otherwise directed, non-essential agency staff are to report to work as scheduled and cannot independently choose not to report. Only if the safety of Center For Family Services’ staff, clients, and the general public cannot be fully assured will the agency divert from its normally scheduled business.

In the event of closure or delayed openings it is the responsibility of each Center For Family Services program to develop protocols to communicate such changes to their client. Program staff should not rely on front desk staff or any other staff to make such communications to clients.

Delayed Openings/Closing Protocols for Non-Essential Operations:

In the event of a snow and/or other emergency situation whereby the non-essential operations of the agency need to be closed or delayed prior to the start of a normal business day, the following protocol is set in place to communicate such information to staff agency wide.

During a potential weather emergency a decision regarding a delayed opening or agency closing will be made by the Center For Family Services’ Senior Vice President of Administration and the Vice President of Head Start. Communication of any delay or closure will be sent out through an agency wide email, posted on the agency website homepage and added to the administrative headquarters recorded voice message.

Head Start will additionally communicate via internal Global Connect text alert system and Radio School Closure notification via KYW 1060 AM. Center For Family Services’ Head Start school closing number is 614, which is the number for Camden City Public Schools. If Camden City schools are closed, Center For Family Services’ Head Start is also closed.

All program staff, volunteers, and student interns should, therefore, check their email or the homepage of the agency website by 6:30am for such emergency posting.

Early Closings

Should the agency need to make a decision to close business early or shut down services at individual sites during normal business operating hours, such decisions will be made by the Senior Vice President of Operations and communicated directly to Program Directors or Supervisors. All attempts will be made to ensure that decisions are made as quickly as possible in an effort to provide suitable time to notify scheduled clients of agency closure and support staff and client in finding a safe commute home.

Program Events:

In the case a program needs to hold an event for clients, donors or others at their site or another Center For Family Services site the program director should contact both the Operations and Public Relations Departments. In some cases the Operations and Public Relations Departments will assist with event planning and coordination, safety measures, logistics, etc.

Before any event is held on Center For Family Services’ property, the director and staff of the program hosting the event should be familiar with and follow the Event Safety Checklist:

  • Event title
  • Purpose of the event
  • Event location/date
  • Indoor/Outdoor
  • EMS/First Aid
  • ADA Compliance
  • Occupancy Compliance
  • Emergency protocols
  • Signage
  • Sanitation
  • Restrooms
  • Crowd Management
  • Security
  • Permits/licenses
  • Insurance coverage
  • Food preparation
  • Waste collection
  • Information technology
  • Utilities/power
  • Special equipment
  • Tents/seating
  • Staging/fencing
  • Traffic control/parking
  • Drinking water
  • Setup/breakdown
  • Communication chain
  • Weather monitoring
  • Vendors
  • Street closures
  • Entertainment
  • Grills/tanks
  • Combustible materials
  • Marketing
  • Noise
  • Time restrictions

Building Protocol Best Practices

  • If you see a problem (a safety hazard, a broken appliance, etc.) report it to your supervisor and submit an Operations Work Order. If you see a stranger in the building ask for identification or report it to a supervisor.
  • Be mindful of the shared spaces throughout your building. Dirty dishes aren’t to be left in the sink, food is not to be left in the refrigerator, meeting spaces should be cleaned of trash and food when you’re down using the space, and bathrooms should kept clean and orderly.
  • Be mindful of your own personal work space. Food should not be consumed or stored at your desk and should not be discarded in your trash.
  • Be aware of all facility safety and security measures and get to know your building and its systems. Learn your buildings security code, find out where the main electric and fire panels are located and learn the proper routes and procedures for evacuations.
  • Basements and storage areas/units should be kept neat and clean.
  • For your safety, the use of small appliances such as space heaters, coffee pots, etc. for personal use is strictly prohibited. Please see Appliance Policy on page (add link for electronic version)
  • Decorative fixtures such as pictures and wall hangings should be properly mounted on bulletin boards or in frames. The use of tape and push pins is prohibited. Fixtures should be of a professional nature.
  • Before purchasing large office equipment, office furniture, technology equipment, etc. please consult your supervisor for clearance.
  • Technology equipment is never to be discarded. Always contact the IT Department for the removal of old or broken computers, laptops, printers, etc.

Emergency Response Protocols

The goal of Center For Family Emergency Response Protocols is to provide staff, volunteers, student interns, and our clients with guidelines and directions in the event of a possible or unforeseen disaster. This plan would initiate immediately upon first acknowledgment of such event and remain in effect until normal operating practices can be effectively restored.

Center For Family Services’ Emergency Response is a sub-committee of and is also monitored by the Risk Prevention Safety Committee led by the Senior Vice President of Administration and Operations.

The Emergency Response Protocol has been adopted by the Emergency Management Guide for Business and Industry. This model is specifically configured to facilitate all operational and communication objectives led through a multi-tiered Emergency Response platform comprised of three groups: Executive Team, Emergency Management Group, and the Incident Commander Group.

The Executive Team under the leadership of the CEO, executes all decisions of a global nature concerning Center For Family Services in instances of an emergency nature and communicates them to all federal, state, and local authorities as required by various governing and funding regulations.

Emergency instances include: fire, medical emergency, natural disaster, utility related emergency, terror or biological threat, intrusion or assault, or any other life threatening situation.

In the event of a terror threat or disaster it is imperative that the following chain of authority and communication channels be adhered to:

The Executive Team is comprised of key staff including the CEO, COO and Senior Vice Presidents. Members of the Executive Team, under the leadership of the CEO, interact as necessary with all relevant federal, state, and local authorities relative to any incident that may impact the agency. Such authorities include but are not limited to FEMA, State and County Department(s) of Health, Fire, and Police, National Guard, etc. Additionally, the Executive Team or designated personnel will communicate to funding and licensing entities as specific to the program and service affected by any emergency, threat, or disaster.

Responsibilities of the Executive Team:

  • Coordinate with all appropriate local, state, and federal governmental authorities;
  • Communicate with and guide Emergency Management Group in the execution of emergency protocols and their interactions with emergency first responders;
  • Assessment and response to any incident involving harm or violence and/or threat of harm or violence;
  • Consultation with health professionals and other experts concerning measured and appropriate responses to handling various emergency situations;
  • Communicating relevant information concerned such incidents to funding sources, agency governing body, agency personnel, service clientele/guardian(s), and the media.

In the event that there is an emergency or natural disaster the Executive Team will inform and activate the internal Emergency Management Group. The Emergency Management Group is comprised of key personnel within Center For Family Services including the Risk Prevention Safety Committee, Management Information Services, Finance, and Public Relations/Development. The Emergency Management Team will communicate and execute emergency management protocols and response efforts.

Responsibilities of the Emergency Management Group:

  • Implement Center For Family Services’ global health and safety procedures;
  • Ensure that all sites and vehicles have proper emergency protocols, first aid supplies, and poison control information;
  • Train Center For Family Services’ staff in assessing risk, safety, and handling of emergencies;
  • Communicate with onsite personnel to ascertain real time conditions and needs during an emergency incident or natural disaster;
  • Coordinate needed resources and response measures during and after an incident;
  • Facilitate the sheltering in or out of programs and services and establishment of remote or ancillary worksites in response to an emergency;
  • Maintenance and protection of agency information and employee/volunteer records;
  • Real time communication to Executive Team of emergency needs and responses;
  • Coordination of Crisis Response Debriefing Team services;
  • Initiation of disaster recovery, site security, and restoration of activities.

The Emergency Management Group acts as the agencies Internal First Responder, communicating with key staff located at all agency sites. The Emergency Management Group acts as an intermediary between the Executive Team and the Incident Commander Group offering cohesiveness to internal communication and response.

The Emergency Management Group is comprised of Associate Vice Presidents and key personnel from departments that support the global operations of Center For Family Services and chaired by the Senior Vice President of Operations. This group has the ability to initiate measures for immediate relief of circumstances arising from an emergency.

The Emergency Management Group works directly with Incident Commander Group at each location to gain information concerning onsite conditions and needs and to initiate coordinated responses to identified needs. The Emergency Management Group also reports directly to the Executive Team keeping them apprised of all current and ongoing updates concerning the nature of the emergency as it is being responded to.

Each Center For Family Services site has Director level staff designated as Incident Commanders that communicate internally to the Emergency Management Group, execute site specific emergency assessment and evacuation protocols, and direct all necessary activities relative to proper disaster response. Such activities include coordination of evacuation, lockdown protocols, sheltering-in protocols, and accounting for staff, clients, volunteers and residents.

Each Incident Commander is equipped with the knowledge of the property they are responsible for, contacts for local first responder groups and access to staff and client lists for accounting of occupants. Incident Commanders utilize the Emergency Management Group as a resource to expedite immediate response to assessed needs.

Responsibilities of the Incident Commander Group:

  • Summon first responder authorities to scene of emergency;
  • Facilitate onsite emergency activities and/or evacuation protocols once an emergency has been identified;
  • Assist with any special populations i.e.: DHH, Mobility Impaired;
  • Account for all person(s) onsite at the time of the incident;
  • Contact and report the incident to the Emergency Management Group for concurrent and ongoing assistance;
  • Initiate directives of Emergency Management Group;
  • Provide regular status updates until emergency is resolved.

Center For Family Services will provide a single point of entry for obtaining all necessary agency wide information and/or direction through the voice messaging system by calling 856.964.1990 and on the agency website centerffs.org.

Upon execution of immediate emergency response measures by the Emergency Management Group and the Incident Commander Group, the Emergency Management Group will engage the Crisis Response Debriefing Services to coordinate systematic post occurrence internal debriefing of all staff, volunteers, student interns, and clients involved or affected by an emergency or traumatic event. Crisis Response Debriefing Services will determine what level, duration, and methods of response are necessary and will make formal recommendations to the Emergency Management Group as how to proceed most effectively. Crisis Response Debriefing Services upon clearance from the Emergency Management Group will coordinate with the Incident Commander Group to schedule and facilitate all necessary services that support the effective debriefing and healing process.

The Executive Team will communicate formally with all federal, state, and local authorities as well as the media concerning any emergency, natural disaster, or threat.

Evacuation Procedures

No person(s) shall fail to leave a building if an alarm is sounded or when directed to evaluate for either a known or perceived emergency.

Steps for evacuation (fire, flood, bomb, terroristic threat):

  1. Upon the sounding of an alarm or the direction of supervisory staff, all persons must evacuate the building swiftly and without exception.
  2. If a fire is observed and an alarm has not sounded, persons should use a pull station located near an entrance or exit to sound the alarm and notify authorities.
  3. All persons should follow the evacuation guides posted in the building to identify the shortest and safest means of exiting the building safely.
  4. All persons should convene to a designated point that is predetermined at each facility location.
  5. The Program Director/Incident Commander or other designated staff member must inspect all floors to ensure areas are fully evacuated and attempt to identify and confine the fire if possible before evacuating the property themselves.
  6. Once at the designated point, the Director/Incident Commander or other designated staff member must ensure that all persons are accounted for.
  7. Upon the arrival of the responding authorities the Director/Incident Commander or designated staff member will inform the authorities of the current status of the property and direct them accordingly.
  8. If the alarm was a false signal or misperceived emergency, the Director/Incident Commander or designated staff member shall only allow the re-entrance to the building by residents upon the full clearance of the responding authorities.
  9. Paramedics should be summoned for any injuries resulting from an incident and addressed by professionals, not by staff.
  10. Any incident or occurrence needs to be reported immediately to the Emergency Management Group and directly reported to an Associate Vice President. Incident Reports must be completed within 24 hours.

Guidelines for conducting fire/disaster drills:

  1. All staff must be knowledgeable and practiced in program fire/disaster protocols.
  2. All staff and residents must be informed of emergency evacuation protocols upon hire or admission to a program. Staff and residents should be routinely trained during their employment or service stay.
  3. All staff and residents must participate in the execution of fire/disaster drills on a monthly basis.
  4. Fire/disaster drills must be documented and logged on the Emergency Drill Observers Comment form. To download a copy of this form, click here http://www.centerffs.org/staff/forms-guidelines-0

Fire Prevention Guidelines:

  1. Make sure all exits and exit access paths are clean and unobstructed.
  2. Make sure all exit signs are illuminated and Emergency Lighting is functioning.
  3. Make sure Emergency Lighting is tested monthly and logged on the Fire/Life Safety Review Checklist.
  4. Make sure all fire extinguishers are charged, tagged, and have been inspected within the last month.
  5. If your building has a fire sprinkler system make sure it has been inspected within the last 12 months by a State of New Jersey registered contractor. A current copy of your inspection report should be posted on the fire panel.
  6. If your building has a fire alarm system make sure it has been inspected within the last 12 months by a State of New Jersey registered Alarm Company.
  7. If you have a cooking operation that requires a suppression system make sure the system has been inspected within the last 6 months. The system is required to be inspected bi-annually by a State of New Jersey registered alarm contractor and a tag should be posted on the system.
  8. Refrain from using extension cords as a substitute for permanent wiring or outlets. The use of extension cords is strictly prohibited. Use fused plug strips, UL Tested for computers, etc. Do not plug one strip into another strip and be sure to replace surge protectors every 36 months.
  9. Do not store combustibles within 36” of heaters or water heaters under any circumstances.
  10. Do not store anything within 2’ of a ceiling or 18” below a sprinkler head.
  11. Clearance of no less than 36” diameter shall be provided between electrical service equipment and storage in the area.
  12. Do not allow trash or litter to accumulate.
  13. Keep all fire lanes clear of vehicles.
  14. Make sure Fire Department Connections (FDC) is marked and access is free of obstructions.
  15. The use of candles, space heaters, and small appliances for personal use is strictly prohibited.
  16. Fire Drills should be conducted at all sites specific to funding guidelines.
  17. Evacuation routes should be posted in all areas.
  18. Staff training should be conducted upon hire and annually on fire/disaster planning.

Fire/Disaster Drill Procedure:

As Full Audible System Drills are not always conducive to general business, mock drills are permissible to be conducted at Center For Family Services’ sites. However, an audible test must be conducted at least annually at all sites and can be done at the time a vendor completes their annual system inspection.

If a program decides to conduct a Full System Audible Drill the fire/security system vendor should be contacted first and the system placed on a test mode for no more than thirty minutes to conduct the drill. Once the drill is completed the system should be restored to an active monitoring mode immediately.

  1. The director or designated staff person should verbally initiate the drill by announcing it throughout the building or by using a secondary audible device such as an air horn. *In a Full Audible System Drill use a pull station to activate the systems alarm signal.
  2. Designated staff persons should respond to various locations/floors within the building to supervise the proper evaluation of all occupants.
  3. All employees and clients are to convene at a safe, designated point and be fully accounted for.
  4. The Director or designated staff person will silence the alarm once all persons have vacated the premises properly.
  5. All employees and clients should be directed back into the building only following a communication by the Director to do so. A brief summary of the evacuation will be made to residents correcting any problems encountered.
  6. Full written document of the drill must be made on the Emergency Drill Observers Comment form.
  7. In a Full Audible System Drill documentation would take place following restoring the system to an activated monitoring status with the vendor.

Onsite Terrorism Protocol for Incident Commanders:

  1. As with any notification of emergency occurrence by telephone staff should follow telephone bomb threat procedures as outlined in the program manual for collecting as much information as possible concerning the threat communicated and the person communicating the threat. All information should be carefully documented in writing.
  2. Incident Commanders should immediately determine if the threat is an internal (building related) threat or external (community related) threat to assess whether evacuation protocol or sheltering-in protocols should be initiated immediately.
  3. In case of an internal threat, standard emergency evacuation procedures should be followed and local authorities notified of the specific event or threat.
  4. In case of an external threat, sheltering-in protocols should be initiated immediately.

Unlike most emergency lockdown procedures for extreme weather conditions such as a hurricane or tornado where persons are generally instructed to get low within a building, chemical/biological threats recommend moving to an elevated and enclosed area.

Sheltering-in Procedures:

  1. Shut and seal all external doors and windows.
  2. Turn off all HVAC air handlers.
  3. Incident Commanders should instruct staff to gather all emergency equipment including flashlights, radio, cell phones/chargers, medical kits and food to be taken immediately to the identified safe room.
  4. Staff and clients should be immediately informed concerning the potential threat and encourage them to remain calm while proceeding to the designated safe room. All staff and clients should be accounted for once within the safe room.
  5. Once emergency measures have effectively been set into action by the Incident Commanders, the Incident Commanders should attempt to contact the Emergency Management Group for additional information and ongoing updates concerning the occurrence.
  6. Incident Commanders should communicate and encourage all persons on-site regarding the importance of sheltering-in but should in no way restrain a person from leaving the site against their will.
  7. Food should be inventoried in relation to the number of persons sheltered within the safe room. The Incident Commanders should determine how much food can best be rationed to sustain a 24-48 hour period.
  8. Radios should be tuned into KYW 1060 AM for regional alerts.

Universal Infection Control Guidelines

General Agency Procedures:

  1. CFS staff, volunteers, students and consultants are to avoid exposure to direct contact with any bodily fluid without proper protection and without following specific precautions. All blood and other bodily fluids of staff, clients, or visitors are to be considered conceivably infectious at all times and dealt with as such. This is called UNIVERSAL PRECAUTIONS which is the standard practice followed by CFS staff. In all cases where an incident occurs involving exposure to a potentially infectious contaminant, an incident report must be completed and submitted within 24 hours.
  2. CFS staff, volunteers, students and consultants are to in all cases use infection preventative materials and procedures such as disposable latex gloves for the handling, cleanup or removal of bodily fluids and/or materials contaminated by bodily fluids. The use of alcohol wipes to clean and disinfect hands and surfaces exposed to potentially infectious elements is highly recommended. CFS will provide infectious preventative materials as is appropriate to the program needs or requirements.
  3. CFS staff, volunteers, students and consultants are required to immediately report any condition of personal illness to their supervisor. The supervisor shall determine or seek medical clearance as indicated to verify a person’s suitability for services, specific to role and function and individual job requirements.
  4. CFS staff, volunteers, students and consultants are to immediately report to a supervisor any client identified as having been exposed to or been diagnosed as having contracted any form of communicable disease or illness. The supervisor shall then determine or seek medical clearance for any client who may pose a health risk to other agency clientele or other personnel.
  5. CFS staff, volunteers, students and consultants may decline to work with a client or enter a client’s residence where a known communicable disease exists or is reasonably suspected, without concern that such a decision may adversely affect their employment status with the agency. 
  6. CFS supervisors who determine that a particular situation poses threat beyond what the organization can reasonably counter or protect against may choose to deny services upon informing the VP of their division and obtaining approval to deny services. In such instances, an appropriate referral for services capable of assisting with critical needs shall be provided to the inquiring client in all cases.

Proper Hand Washing Procedure

Center For Family Services’ staff, volunteers, student interns, and consultants are to always observe proper hand washing procedures relative to their job function and potential for exposure to infectious elements. For example, any staff providing home visitations should wash their hands properly both upon entering a residence and upon leaving at the close of a service, or regularly wash throughout the day if providing onsite direct services.

  • Remove all jewelry (wedding rings are permitted to be left on)
  • Turn water on at lukewarm temperature
  • Use a gentle anti-bacterial soap
  • Wash for 15-30 seconds
  • Wash all surfaces and under each fingernail
  • Rinse hands thoroughly without touching any objects
  • Dry well with clean, dry paper towels

 

  1. Center For Family Services’ staff are to avoid deliberately placing their hands into body fluids or exposed blood. Seamless latex gloves are to be worn in all instanced whereby contact with such fluids may take place (i.e. urinalysis testing).
  2. All surfaces contaminated by body fluids or products should first have the protein or secretions properly removed. Contaminated surfaces are to be properly sanitized using 1 part to 10 part solution of household bleach and H2O mixed the same day. Spray bottles used must be clearly marked with contents.
  3. All products, tissue, or waste that are to be discarded must first be placed in a sealed plastic container, bag, or coffee can. Then sanitized with a disinfectant and securely placed in the trash.
  4. Center For Family Services’ staff that may be required to clean toilet areas are required to use heavy-duty gloves and be properly dressed eliminating exposed skin to surfaces. Cleaning utensils, which are not disposable items, should be properly and regularly washed and stored.
  5. All cloths, cleaning utensils, linens or other related equipment used for cleaning lavatory areas may not be used in the kitchen or other areas of residence or work sites maintaining kitchenettes.
  6. Center For Family Services’ staff having any form of skin rash or open sores are to report such conditions as per the Infection Control Policy to their supervisor for proper clearance prior to work.
  7. Center For Family Services’ staff are to observe and report all instances regarding a potential infectious incident through proper reporting procedures for all clients, staff, volunteer, student intern, or visitor within 24 hours of occurrence or identification.

Sharps Safety Procedures

The purpose of the Sharps Safety Procedures is to ensure the health and safety of all staff, volunteers and members of Center For Family Services who may encounter hypodermic needles, syringes, lancets and other "sharps" within the course of doing business. Safe disposal also minimizes both sharing of syringes and accidental needlestick injuries.

This procedure applies to all staff, volunteers and members of Center For Family Services who come into contact with sharps or potentially hazardous medical waste.  Programs that conduct community or volunteer activities that have the potential for coming into contact with sharps or potentially hazardous medical waste should also ensure best practice safety policies and trainings are in place prior to the event and monitored regularly.  Records of these trainings should be maintained. 

What are Sharps?  Sharps include needles and syringes, razor blades, scalpels, broken glass, pipettes, and other used items that could cause a puncture, cut, or abrasion. Sharps can be a kind of medical waste, or bio-hazardous waste. Medical waste also includes; bandages, materials and equipment that may have come into contact with blood or body fluids and pose a personal hazard when handled.

A sharps injury or needlestick is a wound caused by sharps that accidentally puncture, cut, or abrade the skin.

Procedures

Safety Precautions

Universal precautions are an important method to prevent blood exposures to skin and mucous membranes and should be adhered to at all times.  Barrier precautions and safety practices are the first line of defense (CDC, Guide to Infection Prevention in Outpatient Settings).  Although personal protective equipment (e.g., gloves) provide a barrier to shield skin and mucous membranes from contact with blood and other potentially infectious body fluids, most protective equipment is easily penetrated by needles.  

In the event of known sharps materials, all precautions should be taken, including the use of personal protective equipment.  If a situation has a potential for sharps contamination, all precautions should be taken.  This can include cleaning areas that have potential for containing sharps, such as an apartment, medical closet or community areas. 

Appropriate personal protective equipment must be provided for employees, volunteers, members and clients.  Personal protective equipment may include gloves (up to and including heavy duty rubber gloves), masks, face shields, eye protection, and/or other appropriate devices, dependent upon the activity being conducted. Gloves are to be worn when handling chemicals and/or body fluids.  Wear boots or shoe covers, and/or an apron, if hazardous substances are likely to splash. Train staff in the correct use of personal protective equipment, tongs, and handling materials.  (See Personal Protective Equipment)

Never handle sharps with bare or gloved hands. Put on two pairs of gloves.  Set container on the ground next to the sharp and use a mechanical aid to place sharp into the container. Mechanical aids, such as tongs, forceps, or dustpan and brush are to be used to clean up and discard broken glass (OSHA, 2011). Give verbal announcements when moving sharps. Avoiding hand-to-hand passage of sharp instruments to prevent additional injuries. Watch out for your feet as well.  (CDC, Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program, 2008, p. 19) Never carry an open sharps container with you that contains medical waste. Fill it up, package it properly, and then dispose of it.

Personal protective equipment needs to be removed carefully to avoid further contamination.  Once the sharps pickup is completed and the container disposed of, remove one pair of the latex gloves. With the other pair of gloves still on your hands, clean and disinfect the tongs any fluid splashes on shoes or elsewhere with the alcohol or bleach solution. Contaminated clothing should be removed and laundered on the “Sanitize” cycle of your washing machine or thrown away.  Put the equipment away and remove one last pair of gloves. Wipe off hands with alcohol. As soon as possible, wash hands with soap and warm running water.

Avoid touching eyes, nose or mouth with dirty hands. Do not eat, drink, or smoke until hands can be washed with soap and running water.

Disposal

Sharps should never be disposed of in the regular trash. Safe disposal prevents these items from ending up on streets, in parks, in schoolyards, in municipal wastewater treatment plants, in the solid waste stream or in with recyclables; as well as removing them from the community for the safety of all residents. Used sharps containers may be taken to a collection facility such as an area pharmacy, hospital, or clinic that provides this service.  For disposal options closest to the program/site, refer to New Jersey Department of Health, Consumer, Environmental and Occupational Health Service, www.nj.gov/health/phss.

Containers

All sharps must be disposed of within sealed, puncture-resistant, leak-proof containers that assure the safety of the client and/or anyone else who may come into contact with the container.  Programs and/or sites that have routine needs for sharps on site must have an approved sharps disposal container.  This includes residential sites that have clients who may need sharps disposal sites for medical needs.  These sharps containers must be prominently marked with either the word "sharps", the universal warning sign, or the word "bio-hazard".  Do not re-cap needles for disposal (CDC, Preventing Needlesticks). Place the needle into the sharps container after final use. This should be completed with as few persons as possible to avoid unnecessary exposure. 

In the event of an emergency, when an approved sharps container is not available, a puncture resistant bleach or detergent container with a screw on top can be used. They would need to be labeled with a permanent marker “Do Not Recycle – Contains Sharps” (Safe Syringe Disposal, New Jersey Department of Health)

Never fill sharps containers more than ¾ full.  Use a size and shape container that will allow the sharp to freely and completely enter the container.  Ensure that the program or site has sharp disposal containers that are an adequate size for the task at hand. 

Placement

Sharps containers should be secured in a manner such that only employees or other appropriately trained persons, such as regulated medical waste disposal staff, have access to used sharps containers and can be monitored and secured at all times.

Safety

Under no circumstances, should an individual reach into any type of sharps container (CDC, Preventing Needlesticks).  Safe disposal also minimizes accidental needlestick injuries.  Each program should assess potential circumstances that may lead to needlestick injury.        

Incident Follow-Up

Avoid skin contact with needles or fluids containing blood. If contact does occur, wipe off skin and clean with alcohol.  Wash the surface immediately with soap and running water.  If a needlestick or puncture wound does occur, keep calm and assume it is contaminated.  Encourage bleeding for a minute or two by squeezing the wound to push out any germs. If you prick your finger, hold the impacted hand below your waist to encourage the blood to run down your arm and squeeze some blood out- similar to how diabetics test their blood sugar.  Do NOT suck on the wound or place the affected area in your mouth. If safe to do so, save the needle in a safe container for testing at the hospital.  Contact a physician within one hour regarding disease exposure risks and appropriate post-exposure vaccines.

The National Institute for Occupational Safety and Health (NIOSH) recommends that if a needlestick injury occurs, the following steps are taken:

  • Wash needlestick and cuts with soap and water.
  • Flush splashes to the nose, mouth, or skin with water.
  • Irrigate eyes with clean water, saline, or sterile irrigates.
  • Report the incident to your supervisor.
  • Seek medical treatment immediately.

Reporting

It is the responsibility of the staff working when an incident occurs, or is reported, to document that incident.  A needlestick incident needs to be documented on Incident Report form and the Employee Injury Reporting Form.  The administrator on call should be contacted immediately as the incident involves the safety of staff and/or the consumer.  The report must be turned in to the Program Director for review and signature.  Incident Reports should be completed per the Incident Reporting Policy for follow up and review.  The report will be reviewed by the Quality Improvement Committee.

Employees are required to complete an Employee Injury Reporting Form and fax it to Human Resources at 856-964-3702 as soon as possible following an employee injury.  You must also forward the form to your Supervisor and/or Associate Vice President. All staff injuries must be reported immediately to the Supervisor on duty.  In the event of a work related injury, CFS employees are covered under the agency’s Workers' Compensation Insurance for injuries that occur in the course of employment.

Personal Protective Equipment

Appropriate personal protective equipment (PPE) must be provided for employees, volunteers, members and clients.  The type and need for personal protective equipment will vary dependent upon the risks involved with the work being conducted.  Personal protective equipment, commonly referred to as “PPE”, is equipment worn to minimize exposure to a variety of hazards (Personal Protective Equipment, OSHA, 2004). 

The Personal Protective Equipment Pamphlet released by OSHA in 2004, states:  “OSHA requires that many categories of PPE meet or be equivalent to standards developed by the American National Standards Institute (ANSI). Employers should inform employees who provide their own PPE to ensure that any employee-owned PPE used in the workplace conforms to the employer’s criteria”.  ANSI standards fall into three categories: Eye and Face Protection, Head Protection and Foot Protection.   “For hand protection, there is no ANSI standard for gloves but OSHA recommends that selection be based upon the tasks to be performed and the performance and construction characteristics of the glove material.”

Hand Protection

  • Latex Gloves (up to and including heavy duty rubber gloves)
    • Hypoallergenic gloves, glove liners and powderless gloves are possible alternatives for employees who are allergic to latex gloves (OSHA, 2004).
    • Easy availability for purchase at retail stores, office supply stores and pharmacies.   
    • Environmental services personnel often wear reusable heavy duty gloves made of latex or nitrile to work with caustic disinfectants when cleaning environmental surfaces (CDC, 2004)

Eye/Face/Body Protection

  • Safety Spectacles or Goggles
  • Apron
    • Can be purchased online, medical clothing stores or large big box store

Foot Protection

  • Leggings protect the lower legs and feet.  Programs may want to implement dress codes that include pants in the event of community clean up events. 
  • Soled Shoes – Flip flops, bare feet and open sandals are not safe for community cleanup activities. 
  • Boots/Steel Toe Boots – if needed
    • Toe guards fit over the toes of regular shoes to protect the toes from impact and compression hazards. They may be made of steel, aluminum or plastic (OSHA, 2004).  These are available online or through local hardware stores. 

Mechanical/Assistive Devices for PPE

  • Tongs, forceps, or dustpan and brush
  • Trash Pickers are available from local hardware stores and big box stores, while rubber tongs or barbeque tongs are available in big box stores as well. 

Methicillin-resistant Staphylococcus aureus/Vancomycin-resistant Enterococcus Response Guidelines

Upon receiving any report about potential Methicillin-resistant Staphylococcus Aureus (MRSA) threat (whether from a client or staff person) whom has traveled our premises or come in contact with others while having an active infection either known or unknown to them, an incident must be completed and the Program Director notified immediately.

  1. Once notified, the Program Director should investigate the report directly with involved parties to document and ascertain the specifics and timelines regarding possible exposure and or transmission to others, and areas potentially affected.
  2. Specific information to the type and location of MRSA infection (skin, wound, respiratory, eye, etc.) should be gathered and documented as it will direct the level and type of response necessary by Center For Family Services personnel or vendors.
  3. The Program Director should immediately contact and inform their Associate Vice President, Senior Vice President of Administration or Senior Vice President of Operations to discuss and determine appropriate response at all levels.
  4. Funding sources or any entity where we are legally required to give notice of such an event should be informed immediately by the appropriate Program Director or Associate Vice President.
  5. If a case is found to be Respiratory MRSA all individuals having come in contact with the infected party must be informed directly and in writing and directed to seek medical screening with their primary care physician to identify transmitted infection or gain medical clearance before returning to regular activities or programming.
  6. In cases where the MRSA incident was a skin site or wound infection, determination as to the timelines for exposure and potential for direct skin to skin or skin to surface transmission will be evaluated and a specific disclosure to potentially affected individual enacted accordingly.
  7. All reported cases of MRSA will prompt a systematic disinfecting of all areas and spaces where the host party would have occupied or have been believed to have traveled within a building with appropriate products for cleaning MRSA/VRE.
  8. Depending on the type and potential of the transmission of MRSA/VRE, decisions regarding the immediate closure or limited quarantine of an area, building, and/or residents will be made and communicated accordingly.

Driver & Vehicle Safety

At Center For Family Services, the safety and well-being of the children and families we serve, as well as our staff, is our number one priority. Safety on the road is no exception.

This section of the manual will help you navigate the guidelines and protocols around transportation and driver safety at Center For Family Services. On the following pages you will read about our driver policies and guidelines, and emergency/safety protocols and tips designed to keep you and your clients safe.

If you have additional questions about transportation and driver safety, please contact the Human Resources Department, Operations Department, or Fleet Manager.

Driver Eligibility 

Center For Family Services has a system of evaluating a candidate’s or employee’s motor vehicle record to determine whether they are an Acceptable or Unacceptable driver.  The evaluation includes five-year history of vehicle-related incidents, accidents, citations, etc.  Center For Family Services utilizes the state Motor Vehicle Report to determine scoring for the evaluation.

The MVR check is a standard component of the Agency’s Onboarding process.  While not all positions require a driver’s license, potential employees who do possess a driver’s license must pass the Motor Vehicle Report.  The results must be in good standing. 

Each and every position at Center For Family Services will specify the necessity for driving for that position, classifying whether driving is an essential component of the position. 

Any exceptions to the Driver Standards and Classifications must be authorized by the appropriate Executive and Vice President. 

Agency candidates are required to sign a Motor Vehicle Report release form. The Motor Vehicle Report release form allows Center For Family Services to rerun the Motor Vehicle Report as needed without obtaining a new one. It can take from 24 hours to several weeks to receive the report’s results. Offers of employment cannot be made unless evaluated as acceptable by Human Resources.

All staff are required to pass the motor vehicle clearance for the state in which they reside. Staff with essential driving positions are required to maintain their license in good standing with 6 or less motor vehicle points on their Motor Vehicle Records. 

Any employee who has an unacceptable rating will have their agency driving privileges revoked.

The Human Resources Department is responsible for the administration of this system, including Motor Vehicle Reports, their evaluation of them, and notifying Program Directors of their results.

If the Motor Vehicle Report may result in an adverse employment decision, Human Resources will notify the candidate or employee and send the results with a summary of rights under the Fair Credit Reporting Act. If the Motor Vehicle Report evaluation does result in an adverse employee decision, Human Resources will send a second notice to the candidate or employee notifying them.

Center For Family Services reserves the right to reevaluate an employee’s Motor Vehicle Report at any time. 

All staff drivers are responsible for providing Human Resources with a copy of their current driver’s license.  Any vehicle used for any company purpose must have current registration, insurance card, valid inspections sticker, and must be driven by someone with a valid driver’s license.

Monitor Window:

In general, a Motor Vehicle Report reviews the last 5 years of the driver abstract. The Motor Vehicle Commission has criteria for when points come off of an individual’s license. In the event that staff chooses to take a defensive driver’s course to remove points from their license, this is sole responsibility of the staff.  The staff is responsible for the cost and scheduling.  Staff are required to communicate any updates with the Human Resources Department. 

Violation(s):

Violations, incidents, citations or convictions are any traffic citation a driver receives. This may include, but it not limited to the following:

  • DWI or DUI;

  • Hit and run; 

  • Failure to report an accident; 

  • Homicide, manslaughter, or assault arising out of the operation of a motor vehicle; 

  • Driving while license is suspended or revoked; 

  • Reckless driving; 

  • Possession of an opened container of alcohol beverage; 

  • Participation of any illegal speed contest or drag racing; 

  • Any attempt to elude an officer of the law; 

  • Using a motor vehicle for a commission of a felony; 

  • Operating a motor vehicle without the owner’s authority (grand theft); 

  • Permitting an unlicensed person to drive.

  • Violation of motor vehicle equipment, load or size requirements;

  • Improper display or failure to display license plates;

  • Failure to sign or produce registration card;

  • Failure to sign or produce insurance card;

  • Failure to have in possession a valid driver’s license;

  • Failure to use seat belts;

  • Unsafe operation of a motor vehicle;

  • Use of a cell phone while operating a motor vehicle;

  • Driver’s license suspensions, for any reason;

  • Fleet GPS Report that shows driving outside acceptable measures; 

  • Driver Safety Report deemed valid by Center For Family Services;

  • Parking tickets for Center For Family Services vehicle 

  • Toll violations for Center For Family Services vehicle 

  • Failure to return Center For Family Services vehicle to designated agency location at the end of a work assignment;

  • Failure to maintain Center For Family Services vehicle in safe and clean condition; and

  • Any other violation of agency driver policies 

Driver’s License Change of Status Requirements:

All tickets, citations, violations, accidents, and suspensions are to be reported by the employee to an employee’s supervisor and the Human Resources Department within 72 hours.

Not reporting any changes to your driving record or not reporting any incidents to a Center For Family Services vehicle may result in disciplinary action up to and including termination.

Essential Driver Standards

Staff with essential driving positions are required to maintain their license in good standing with 6 or less motor vehicle points on their Motor Vehicle Records. 

Any employee who has an unacceptable rating will have their agency driving privileges revoked.

If a staff’s position has an essential driving component, the staff must be removed from that job, and will be ineligible to transfer to any other Center For Family Services’ position which requires driving. They may apply for any non-driving positions that are open but will not be given preferential consideration over other candidates. If there are no available alternative positions, staff will be terminated from employment at Center For Family Services.

The Human Resources Department may reevaluate employee Motor Vehicle Report as deemed necessary for the following reasons:

  • An incident, accident, violation, or citation

  • Prior transfer, promotion, or adding a position

  • Upon learning of a failure to appropriately report any incident, accident, violation, or citation

  • Reports of violations of agency’s Driver Safety including but not limited to Fleet GPS records 

All staff with an essential driving component are responsible for providing Human Resources with a copy of their current driver’s license and if they utilize a personal vehicle as part of their essential driving, a copy of their current registration and insurance for that vehicle must be provided.

Staff are required to complete an Online Defensive Driver Training upon hire and attend a Center For Family Services’ Driver Policy Training. Staff are subject to following all agency Client Transport Guidelines and Protocols.

Definitions:

Acceptable Driver: A staff member with an essential driving component for their position must have a score of 0-6. All other staff are required to pass the Motor Vehicle Clearance Report. 

Unacceptable Driver:  A staff member whose position is categorized as having an essential driving component with a score of 7 or more, or due to any of the following reasons:

  • Anyone with an international or foreign driver’s license; 

  • Anyone licensed less than three years regardless of age;

  • Anyone with a graduated or provisional license;

  • Anyone with a suspended or expired license;

  • Anyone who is not licensed to drive in the state in which they reside. New Jersey and Pennsylvania laws require drivers to be re-licensed within 60 days of their move to either state.

Staff Driver Policy

  • Drivers operating a vehicle for Center For Family Services must possess a valid, properly classed driver’s license (as applicable).

  • Seatbelts must be worn at all times.  Drivers are responsible for ensuring that all passengers likewise comply with the state’s seatbelt law.

  • Staff driving Center For Family Services owned or leased vehicles are subject to public observation and comment of their driving practices. Staff are subject to any progressive disciplinary actions warranted by the agency in correlation with motorist’s observation report.

  • Any tickets or traffic violations and fees incurred while driving an agency vehicle are the sole responsibility of the staff driver; repetitive infractions may prevent your continued use of company vehicles. Staff must always operate vehicles in accordance with state MVC statues and should always drive within the posted speed limits.

  • Drivers are to never operate a company owned/leased vehicle or a personal vehicle on behalf of Center For Family Services while under the influence of drugs or alcohol or any substance that could negatively impact their ability to safely operate a vehicle.

  • Personal vehicles operated for Center For Family Services business must satisfy compulsory liability insurance requirements

Use and Care of Fleet Vehicle

  • All company owned/leased vehicles must have current registration, insurance card, valid inspections sticker, and must be driven by someone with a valid driver’s license.

  • Center For Family Services owned, leased or rented vehicles are to be operated only on official business, and only by CFS Staff. Use of such vehicles for personal use is strictly prohibited. Agency vehicles are never to be driven home except by directive of an Associate Vice President, or higher position, approval.

  • Agency vehicles are to be parked overnight in a well-lit location designated by each program and theft protection devices should be properly used if such equipment is provided for your vehicle.

  • Vehicles are to be kept neat, clean, and presentable at all times. Vehicles should be taken to a car wash quarterly, or as needed, to maintain them in their best condition.

  • Driver shall perform daily pre-trip inspections of agency vehicles prior to use.

  • Only individuals on official Center For Family Services business are permitted to operate, or ride in, a Center For Family Services owned, leased or rented vehicles or personal vehicles being operated on Center For Family Services business.

  • All Center For Family Services’ vehicles are non-smoking. Staff that transport clients in privately owned vehicles are not to smoke while transporting clients.

  • Center For Family Services’ vehicles are serviced under a fleet maintenance agreement. Program Directors and their staff are to ensure that vehicles are kept mechanically safe at all times and that routine self-inspections are conducted regularly to identify potential or existing problems that need correction. Programs may take their vehicles in for service at any time for any need and should be routinely taken in every 3-4 months for standard oil changes and fluid checks.

Fleet GPS

Policy

Agency vehicles are equipped with a Global Positioning System. The Fleet GPS Program is mandatory for all Center For Family Services’ vehicles. 

Purpose

Center For Family Services is committed to the safety of the staff, and those we serve. To reduce risk of injury to employees, clients, and the traveling public, all agency vehicles will meet operational and monitoring requirements.  The Fleet GPS program is mandatory for every Center For Family Services’ vehicle.  The Operations Department assists with the maintenance of all agency vehicles and verification of Fleet GPS reports.  The Fleet GPS program is designed to improve utilization efficiencies, while also helping to minimize loss resulting from property damage claims. 

Scope

This policy applies to all agency vehicles and all employees operating vehicles, whether leased, owned or rented by the Center For Family Services.

Vehicle Operation Monitoring (Azuga GPS)

Agency vehicles are equipped with a Global Positioning System (GPS) known as Azuga, which monitors vehicle operations including, but not limited to, speed, location, idle times and routes. Monitoring such usage permits Center For Family Services to identify means by which to increase driver safety, improve utilization efficiencies, reduce fuel costs, and identify potential vehicle misuse. 

The Fleet Manager, Program Supervisors or their designee(s), are required to review GPS data to determine whether employees are operating vehicles safely within reasonable proximity of assigned work locations, efficient travel routes are being utilized, work activities are being planned efficiently, and reported activities correspond with designated work hours and assigned duties. Operation of a particular vehicle may be assessed at any time for business reasons. 

The GPS data reports that require review will include the following:

  • Fleet Utilization

  • Posted Speed Report

  • Odd Hours Report 

  • Idle Summary

  • Performance Report

The Azuga platform allows for data to be reviewed specific to a predetermined group of vehicles, most commonly this will be by program.  Reports will be scheduled for automated distribution on a monthly basis to designated supervisors and staff.  Additional reports may be generated as requested.  The GPS platform is designed to manage the operation and condition of agency vehicles. In the event of a reported driving violation, GPS data in conjunction with programmatic vehicle driving logs will be reviewed.

When GPS monitoring reveals that an employee may have engaged in conduct that violated this policy or acceptable business practices, supervisors shall evaluate all relevant information, including input from the employee. In determining whether corrective action is warranted, consideration shall be given to the nature, severity and frequency of the violation(s).  Disciplinary action shall be the recommended course of action for the following: 

  • Reporting work hours on time statements that are inconsistent with GPS data;
  • Reporting work activities on work logs/reports that are inconsistent with GPS data;

  • Excessive idling which results in excess fuel usage;

  • Excessive Speeding;

  • Identified hard braking incidents;

  • Use of a Center For Family Services vehicle beyond authorized work hours;

  • Use of a Center For Family Services vehicle for personal reasons;

  • Use of a Center For Family Services vehicle beyond the geographical limits reasonably required to perform assigned job duties.

NOTE: Center For Family Services maintains a “zero tolerance” policy for GPS tampering.  Any identified attempt to remove, disable or otherwise tamper with a GPS device installed on a Center For Family Services vehicle may be subject to disciplinary action, up to and including termination. Employee misconduct relating to the GPS Devices may be subject to disciplinary action, up to and including termination. 

Since the primary purpose of this policy is to enhance employee and public safety, any failure to comply with the requirements of this policy will be viewed as a serious safety violation. Any employee failing to comply with this policy may be subject to disciplinary action, up to and including termination. 

Questions concerning this policy should be addressed to the Human Resources Department, Operations Department or Fleet Manager.

Violations of Driver Safety Policy 

Any credible negative Fleet GPS report will be recognized as a driving incident. In the event that CFS receives a credible report regarding a vehicle incident this will also be recognized as a driving incident. Center For Family Services believes that a dangerous driving practice of an employed driver constitutes a violation of the agency’s driver safety policies. 

Every reported incident is handled individually and is investigated based on information provided by the Fleet GPS program, agency sources and external resources. All disciplinary actions imposed are determined on a case by case basis, and subject to the interpretation of information, staff member feedback, and the judgment of Center For Family Services’ Fleet Manager, Operations Department and Human Resources Department.

If there is concern for questionable driving, an automatic rescreening of the Center For Family Services’ Motor Vehicle Report for the purpose of reviewing the status of your current driving record may be conducted.

All violations of the driver safety program will be investigated, and will include a direct meeting with the staff driver cited and their immediate supervisor to complete and sign any necessary documentation.

Progressive Discipline

Any employee failing to comply with the vehicle and safety policies may be subject to disciplinary action, up to and including termination.

Questions regarding the appropriate disciplinary response should be raised to the Chief of Human Resources.

Vehicle Safety Policy for Transportation Services

The purpose of the Vehicle Safety Policy for Transportation Services is to ensure the safety of Center For Family Services’ staff and the passengers who are transported by them for company, or program, purposes. It is the responsibility of Center For Family Services’ drivers to operate any vehicle, personal or company owned, in a manner that is safe and defensive in order to prevent and avoid potential accidents, personal injury, and property damage.

Center For Family Services endorses all applicable state motor vehicle regulations relating to driver responsibility and expects drivers to abide by them dependent upon the state in which they may be traveling and/or transporting. Additionally, Center For Family Services’ drivers are to be safe and courteous on the roadways and abide by all internal company policies which pertain to the appropriate use of vehicles in the execution of agency business and services.

Routine Transport Guidelines

  • Staff are to follow and abide by all Client Transport Guidelines set forth by Center For Family Services.

  • Staff operating any vehicle for the purpose of conducting agency business in transporting clients and/or other staff, are to abide by all state MVC regulations and uniform company policies.

  • Individuals who are not Center For Family Services’ clients or staff are not to be transported in agency vehicles.

  • In order to ensure client confidentiality, only those directly involved in the care of the client is authorized to travel in the vehicle with them. Under no circumstances are other non-care related individuals or staff authorized to be in the vehicle while transporting clients whether it is a company owned or personal vehicle.

  • Staff must always conduct a routine walk around of the vehicle to be driven to inspect for any possible new or unreported damage and/or potential safety concerns prior to loading the vehicle with occupants or cargo.

  • Staff must conduct internal vehicle safety checks ensuring that mirrors, seats, seatbelts, and steering wheels are functional and properly adjusted for use, and ensure that all safety features, including emergency kits and proper vehicle documentation, are in place.

  • Drivers and passengers must wear seat belts at all times. Approved child safety restraints must be used in transporting all children and infants.

  • Staff must verbally direct all occupants to use safety restraints, and conduct a visual check, to ensure that all occupants are properly restrained prior to starting the ignition of the vehicle and while in transport, if necessary.

  • Cell phones are not to be used while operating Center For Family Services’ owned or leased vehicle or while transporting any client, staff member, student intern, or volunteer. This applies to staff utilizing personal vehicles to transport clients. Calls may be placed or received if the vehicle is safely off the roadway and in a parked and stationary position.

  • Drivers of multi-passenger vans must be trained and knowledgeable on the particulars of driving such a vehicle.

  • Staff driving minivans or extended multi-passenger vans must load occupants from front to rear, equally distributing passengers and ensuring they are sitting forward of the rear axle of the van. Passengers may be seated in the rear seating areas only if the vehicle is at maximum load/occupancy.

  • Staff/passenger ratios must abide by both required funding and proper service delivery ratios. Never should a single staff person be transporting more than six persons by themselves. In order to protect and ensure confidentiality of services is maintained, only persons associated directly with a client’s care and for the purpose of providing such care are to be transported with a client(s).

  • If any occupant presents themselves to be an obstacle to the safe and effective transport of themselves or other occupants in the vehicle, then policies concerning dealing with difficult passengers should be abided by.

  • If an occupant becomes ill, or sick, while in transport, the sick passenger policy should be abided by. 

  • Drivers of multi-passenger vans should be mindful of rollover risks and practice strict reduction and accident prevention measures. 

  • Staff should always utilize travel lanes and routes that offer the least potential hazard and ensure a proper cushion of safety around the vehicle in relation to other vehicles or stationary objects. Proper following distance should always be adhered to and be extended with graduated increases in distance between other vehicles during inclement weather.

  • When backing up and/or parking in tight conditions, drivers should utilize the assistance of a staff spotter and should verbally review signals or gestures to be used prior to attempting such maneuvers.

  • Transport vehicles are never to be left unattended with passengers in them whether running or shut off. Occupants must be directly supervised at all times.

  • No smoking is permitted by either staff or clients in company vehicles at any time. Staff that use their own vehicles to transport clients should refrain from smoking while in the presence of clients.

  • Voices/conversations are to remain at an acceptable conversation level so not to distract the driver. No foul or abusive language or gestures are permitted nor are they acceptable to be directed externally toward other vehicles, drivers, or pedestrians.

  • All clients being transported by Center For Family Services must have been provided with and signed a Client Transportation Consent Form prior to being scheduled or accepted by a program for involvement in any activity requiring transport.

Best Practices

  • Make sure you visually inspect the entire vehicle before driving. Pay close attention to the tires, mirrors, headlights, and turn signals.

  • If you spot a problem report it immediately to your supervisor or the next driver.

  • If you are in an accident in a company vehicle report it immediately.

  • Don’t forget to use your vehicle inspection sheets and vehicle logs.

  • Keep track of the vehicle’s registration and insurance documents.

  • Client safety is our top priority, make sure they are being supervised properly at all times while in an agency vehicle.

  • Don’t forget to utilize the preventative and routine maintenance services available for your agency vehicle.

  • When utilizing Pep Boys’ services remember to provide them with as much specific information as possible. The more information, the easier it will be for them to identify the problem.

  • Remember to take your Driver’s License with you whenever you are driving an agency vehicle.

Difficult Passenger Guidelines

  • If a passenger becomes disruptive while in transport, the vehicle is to be stopped safely on the side of the road or in a parking lot so the driver and/or support staff can effectively address the issue with the client while the vehicle is stationary.

  • If the disruptive client is involved in a verbal or physical altercation with another passenger(s), they are to be relocated in the vehicle to no longer be in close proximity to the other client(s).

  • If a client continues to be disruptive after being addressed by staff and repositions in the vehicle, the vehicle is to again be safely stopped and the police called for backup. In such an event, the program supervisor or director should be notified immediately following summoning the authorities and told of your stationary location and apprised of the situation.

  • If it is determined by the driver that the disruptive client’s behavior may warrant the emergency evacuation of the occupants of the vehicle, they are to make every effort to find a safe location off of the main roadway in which to safely unload all passengers.

  • The program director or supervisor may opt to respond to your location to pick up the disruptive client and return them to the program and/or instruct you to request the police transport the client back to their primary residency or detain them at the police department until a family member can retrieve them.

  • In the event that a client becomes increasingly agitated to the point of physical violence, all attempts for verbal, non-combative, de-escalation measures should be attempted to regain order and control. If the safety and well-being of the other occupants becomes seriously compromised by direct violence of the disruptive client, then the other occupants’ rights for safety supersede that of the disruptive client. Staff should protect the group by physically removing the disruptive client from the vehicle and/or safely evacuating the vehicle of the other passengers, whichever is more feasible. Physical restraint of the disruptive client is acceptable only until authorities can respond to the scene.

Sick/Hurt Passenger Guidelines

  • If a client or staff person becomes physically ill while in transport, staff should attempt to park the vehicle in a safe location to determine the severity of the condition. If it is motion sickness, staff may allow the client to exit the vehicle for fresh air as long as the client remains supervised.

  • If a client or staff person is determined to need immediate medical attention for an illness they are to be taken directly to the nearest emergency room. If you are unable to transport them to the emergency room, paramedics should be summoned to the scene for their immediate care. Center For Family Services’ staff may provide necessary comfort to the ill person but are prohibited to attempt to provide care.

  • In the event of a vehicle accident where passengers and/or staff has become injured, staff are to summon police/paramedics to the scene immediately and provide verbal and emotional comfort to those injured wherever possible. Center For Family Services’ staff are not be moved or attempt to provide medical care unless directed to assist by other medical professionals on the scene.

Emergency Evacuation Guidelines

In the event that the vehicle experiences a mechanical problem, fire, or is disabled in conditions whereby an evacuation of the vehicle is necessary to ensure the safety of passengers and staff, the vehicle should be evacuated as quickly and safely as possible. The following are simple procedures to deal with most circumstances where evacuation is required:

Do Not Panic

Remaining calm will allow you to control the situation and reduce the possibility of panic in others.

Conduct a Quick Check

Check your vehicle for fire. If fire is detected, either under the dash or the hood, evaluate the vehicle immediately. Know the difference between the smell of burning oil and burning plastic (which indicates the presence of fire) and the steam created from a broken radiator hose. Evacuate the vehicle only if impending danger exists.

Examples of when a vehicle should be evacuated:

  • If there is a potential for fire to occur or there is evidence of a ruptured fuel tank or leaking fuel line, an electrical fire, presence of smoke, hot tires that may catch fire, or a brake fire.

  • The vehicle is parked or disabled off the roadway but in a hazardous position or location.

  • The vehicle is disabled on a highway in a hazardous location due to mechanical failure or accident.

  • The vehicle is disabled on a highway location within a curved portion where visibility is restricted in either direction.

  • The vehicle is disabled on railroad tracks.

  • When the vehicle is close to the roadway and disabled during adverse weather such as fog, rain, snow, smoke, and dust, which reduced visibility.

  • When the vehicle is overturned.

Evacuate Quickly but Safely

Step 1 – Notify the proper authorities and program personnel of your emergency. Give your location (street and nearest cross street) and number of passengers on board and any special needs. In the event of a fire or severe danger, evacuate first and notify once passengers are safely evacuated.

Step 2 – Calmly inform your passengers of the emergency and the need and plan to evacuate.

Step 3 – Reassure your passengers.

Step 4 – Calmly give clear instructions as you evacuate the vehicle.

Step 5 – Thoroughly check the vehicle’s interior to be sure all passengers have escaped.

Step 6 – Move your passengers to a safe location away from the vehicle.

Step 7 – Once passengers are secured, protect the vehicle by using warning reflectors if available. Never risk personal injury to protect the vehicle.

Protect Your Passengers after Evacuation

Protect your passengers at all times and keep them as comfortable as possible. Always lead your passengers upwind from the vehicle in case of fire. Always protect yourself and Center For Family Services from fraudulent claims or excessive liability by following company policies regarding evacuation procedures and dealing with the media at the scene.

Accident Handling Guidelines

Any accident involving a company vehicle or personal vehicle being utilized at the time of the accident to transport a client, must be reported immediately to administration via phone call and followed by the submission of an Incident Report within 24 hours. The Incident Report contains all of the necessary information for the Accident Data Checklist. 

Any time an accident occurs, staff must contact the police to respond to the scene. A police report must be obtained and submitted as soon as it is available. Employees involved in a vehicle accident must be medically cleared. 

*All accidents on company time must be reported immediately to administration with a copy of the police report upon its availability.

If you are involved in an accident while operating a company vehicle or your own personal vehicle if you are utilizing it to transport clients on their behalf of the agency, you must follow the protocols outlined herein to protect yourself, your passengers, and the agency in responding effectively to the accident:

Important Reminders:

  • Keep calm

  • Contact police and your supervisor

  • Protect your passengers, yourself, and your vehicle

  • Complete and submit the required agency documentation once safe

Accident Handling Procedures

Step 1 – Check your location. Do not move your vehicle unless you are instructed to do so by law enforcement or when leaving the vehicle where it is would expose the passengers to greater danger such as in a busy traffic lane, on a blind curve, near the top of the hill, or because of weather.

Step 2 – Secure the vehicle by disengaging the transmission (place in park or neutral), setting the brakes, turning off the engine, and turning on the four-way hazard flashers.

Step 3 – Decide to evacuate or not to evacuate the vehicle. Evacuate if necessary.

Step 4 – Assess the condition of your passengers. Call 911 then contact your program director or supervisor.

Step 5 – Provide law enforcement or 911 with the following:

  • Exact location, cross street or direction of travel;

  • Type of emergency and exactly what has occurred;

  • The number of passengers in the vehicle, number of wheelchair passengers, and any injuries involved;

  • What type of help you will need for law enforcement and emergency personnel;

  • Whether or not you are blocking traffic and if the vehicle can be safely moved.

Step 6 – Respond to passenger needs and assist any injured passengers consistent with Center For Family Services policies.

Step 7 – Inform all passengers of the situation, what actions you have taken and how they will be affected.

Step 8 – Request that all passengers and witnesses complete courtesy cards including their names, phone numbers, and any other information they can provide. Collect these cards and turn them into your supervisor.

Step 9 – Cooperate with law enforcement officials and system management.

Step 10 – Do not assign blame, nor take any responsibility for the accident. Police and insurance companies will determine responsibility.

Step 11 – Do not talk to the media. Please refer to the Media Policy in the Public Relations section of this manual for proper procedures.

Step 12 – Get all necessary information from other drivers, law enforcement, and emergency personnel including the license plate numbers of other vehicle(s) and the make/model/and color of the vehicle(s).

Center For Family Services Vehicles

Routine Preventative Maintenance and Repair Guidelines

Center For Family Services maintains a corporate fleet account for the servicing and repair of company vehicles for routine and preventative maintenance issues not generally covered by vehicle warranties. 

Current Accounts:

  • Pep Boys Account Information:  
    Center For Family Services Fleet Account #80219952 

  • Roadside Service with Wex 
    1-866-329-3471

Program Directors are responsible for ensuring the routine and general maintenance of Center For Family Services’ vehicles designated specifically to their programs in order to keep them safe and operational at all times. Program Directors can direct their program drivers at any time and for any reason to take a vehicle for servicing.

Routine maintenance can be addressed without preauthorization for costs up to $250.00. Staff take the agency vehicles into an approved service center to address the problem as identified. If the cost of repairs is assessed to exceed $250.00, the corporate fleet account holder will contact Center For Family Services’ Associate Vice President of Operations or Fleet Manager directly to gain authorization for intended work.

Staff do not need to call the Operations Department at any time throughout the process, the fleet account holder has contact information for gaining authorization necessary to complete their service.

Dealership Warranties

If any Center For Family Services’ vehicle that is under a current warranty experiences a major repair issue, the dealership must be contacted to determine if it is a covered repair prior to work being done. If it is covered, then all work should be done at the rightful dealership.

If the major repair problem is identified during a routine maintenance check, the fleet account holder, or Fleet Manager, is able to check on the status of the warranty.

Inspection

It is the policy of Center For Family Services that all agency fleet vehicles are inspected annually to assess their current condition, operational safety, mileage, and documentation.

Wright Express (WEX) Gas Card Procedure

WEX Fleet cards are provided for all company owned or leased vehicles. These cards are utilized for paying for fuel at any gas station and for paying for repairs at any fleet account provider.  These cards are specific to the vehicle/program they are affiliated with and should not be transferred or lent to any other program.

All staff within any program who are essential drivers must be entered into the WEX system by way of program affiliation, staff name and personal PIN Code.  It is each Program Directors responsibility, or designee, to ensure that new employees are entered into the system prior to using a program vehicle. To obtain a new pin number, the Program Director emails the Fleet Manager to request a PIN Code. Please provide 24-48 advance notice to ensure they can be added in time for your need.   

When refueling a vehicle, the attendant will request two numbers from the driver. The odometer reading and their personal PIN Code. This is how their purchase is approved and tracked.  The same applies when repairs have been made from a fleet account provider. They will utilize the card in the same fashion, entering the same information, at time of payment.

 

Ethics & Code of Conduct

Ethics is about behavior. In the face of dilemma, it is about doing the right thing. Ethical managerial leaders and their people take the “right” and “good” path when they come to the ethical choice points.

Workplace ethics and behavior are a crucial part of employment. Being ethical is part of every single employee’s job at Center For Family Services. Ethics is a matter of using integrity-based decision-making procedures to guide one’s decisions and actions. In addition to integrity, key components of ethics in the workplace include behavior, accountability, teamwork, and commitment. Employees should conduct themselves in accordance with Center For Family Services Code of Ethics and the National Association of Social Workers Code of Ethics.

In the following section, Center For Family Services Code of Ethics will be outlined in addition to professional boundaries for employee/client interactions. Lastly, included are both the primary and secondary procedures for reporting serious ethical concerns.

 

CODE OF ETHICS

In addition to the standards outlined below, all Center For Family Services staff shall follow the ethical principles and standards of the National Association of Social Workers Code of Ethics found by visiting www.socialworkers.org and any related code of ethics applicable to a staff members professional affiliation.

  1. I will not discriminate against or refuse professional services to anyone on the basis of race, creed, age, gender, sexual orientation, religion, disability, or nationality;
  2. I will not use my professional relationships to further my own interests;
  3. I will evidence a genuine interest in all persons served, and do hereby dedicate myself to their best interest and to helping them help themselves;
  4. I will maintain confidentiality when working with, storing, or disposing of client and staff records;
  5. I will maintain a professional attitude which upholds confidentiality towards individuals served, colleagues, applicants, and the Agency;
  6. I will respect the rights and views of my colleagues, and treat them with fairness, courtesy, and good faith;
  7. I will extend respect and cooperation to my colleagues and those of all professions;
  8. I, upon termination, will maintain client and co-worker confidentiality, and I will hold as confidential any information I obtained concerning CFS;
  9. I will not exploit the trust of the public or my co-workers. I will make every effort to avoid relationships that could impair my professional judgment;
  10. I will not engage in or condone any form of harassment or discrimination;
  11. If I have the responsibility for employing and evaluating staff performance, I will do so in a responsible, fair, considerate, and equitable manner;
  12. I will abide by all agency policies;
  13. I have total commitment to provide the highest quality of service to those who seek my professional assistance;
  14. I will continually assess my personal strengths, limitations, biases, and effectiveness;
  15. I will strive to become and remain proficient in my professional skills and the performance of professional functions;
  16. I will act in accordance with standards of professional integrity;
  17. I will not act outside the bounds of my competencies and assigned role;
  18. I will seek assistance for any problem that impairs my performance.
  19. I will accurately represent my education, training, experience, and competencies as they relate to my assigned job.
  20. I understand that violation of this Code of Ethics may be grounds for disciplinary action, including termination of employment.
  21. I will disclose to my Division Vice President any circumstances that pose or may appear to pose a potential conflict of interest.
  22. I will not direct or steer referrals of CFS clients to any private practice engaging a CFS employee or consultant unless the President/CEO waives the prohibition. A signed waiver would be filed in the client file.
  23. I understand that once a client leaves the program, I am not permitted to continue a relationship with the client without authorization of a Vice President.
  24. I will not violate the intellectual property rights of CFS. CFS has exclusive ownership of work products such as grants, publications, curriculum, written documents, manuals, and any other materials generated in the normal course of business and service delivery at the Agency.

 

Professional Boundaries For Client/Staff Interaction

Boundaries and Guidelines

Purpose:

Center For Family Services is committed to maintaining the highest ethical practices.  As an overall guideline, Center For Family Services adheres to the National Association of Social Workers’ Code of Ethics.   All staff will receive and sign a copy of the agency's Code of Ethics and Confidentiality Agreement upon hire. These agreements must be adhered to along with the Center For Family Services’ Residential Services Boundaries and Guidelines.

Scope:

This procedure applies to all staff, interns and volunteers within Center For Family Services’ Safe and Supportive Residential Housing programs, in regards to their interactions with the youth/young adults while they reside in our programs and after their discharge/transition. 

Responsibilities:

Work Responsibilities:

  1. Staff are expected to demonstrate a positive attitude towards the shift/job, their coworkers, and the youth/young adults, each time they arrive to work.
  2. Staff are to dress professionally as per the Dress Code Policy. Staff are to be ready to be actively engaged with the youth, but also ready to present themselves professionally to parents/ legal guardians and representative from outside agencies.
  3. All concerns are to be professionally presented to the appropriate coworker or supervisor. Staff are not to complain about policies, procedures, memos, supervisors, coworkers, youth, etc. in front of, or in hearing distance of, youth or staff.  
  4. Staff must clock-in and clock-out when working their shift as per the program's Employee Schedule.
    1. Staff are not allowed to clock-in or clock-out on their phone.
    2. Staff are not permitted to leave the program site/premises during work hours without approval from the Supervisor.
  5. Staff are to be on-site at their assigned program during their assigned employment hours. Staff are not to visit with Center For Family Services’ employees (for personal or social reasons) at other program sites during work hours.  Staff are not permitted to be at the program outside of their scheduled work hours. 

Comply with the Code of Ethics

  1. When an incident of abuse and/or neglect occurs at a program, staff must immediately follow all reporting procedures including:
    1. Reporting to 1-877-NJ ABUSE hotline
    2. Report internally to program administration
    3. Complete the Center For Family Services’ Incident Report via Clarity Health Care Safety Zone and any external reporting requirements (UIR/SIR) in the required timeframes. 
  2. Center For Family Services does not tolerate discrimination of any kind, under any circumstances. Staff are never to make any discriminating comments about any youth, or coworkers, to, or within hearing distance of, any youth or other staff regarding age, race, ethnicity, national origin, color, gender identity/expression, sexual orientation, religion, culture, ability/disability, body type, personal values or belief system, etc. 
  3. Staff are not to share personal opinions or persuade a youth to staff’s beliefs regarding religion, abortion, adoption, pregnancy, political preferences, etc.

Maintain Professional Boundaries and Avoid Dual Relationships

Relationships are Kept Professional and Avoid Physical Contact

  1. Staff are to be professionally addressed by their preferred name.  Nicknames are not to be used. Staff are not to be addressed by familial names, such as aunty, uncle, tio, tia, etc.  
  2. Staff are prohibited from engaging in personal, and/or physical, relationships with youth (active youth in any of CFS’ programs, or youth who have been discharged from the program).
  3. Staff are prohibited from having physical contact with youth/young adults (i.e. hugging, playing with a youth's hair, caressing to comfort a youth).  
  4. Staff are not to be in the presence of youth while a youth is showering, dressing, using the bathroom, etc.
  5. Staff must not discuss staff’s personal life with youth. These discussions are not to take place directly with youth, or in hearing distance of youth.
  6. Staff are not allowed to have contact with a youth outside of the agency program. If contact occurs coincidentally, supervisor must be informed, and a notation must be made in the youth's file.
    1. Staff are prohibited from having a youth/young adult (current and post discharge) at their residence at any time.  This includes the outside grounds, driveway, street or in front of the residence.
  7. Staff are not allowed to visit with youth while not working their scheduled work hours at any program at any time.
  8. Staff are not to give gifts (including candy, food, etc.) or lend personal items to youth, unless approved by a supervisor.
  9. Staff are not allowed to give youth their own personal money to purchase items for the youth. Staff are not allowed to purchase items for youth (i.e. food, drinks, cigarettes, clothing) with their own personal money.

Communicate Only Through Approved Channels

  1. Staff, interns, and volunteers are only allowed to communicate with youth/young adults during their scheduled working hours. All communication must pertain to youths' treatment planning/ case management goals, or any program issues. 
    1. When staff are transporting youth, and need to communicate with families, they are to use the program/agency cell phone to communicate any transportation delays. 
  2. Staff are prohibited from sharing their personal phone numbers, or addresses, with youth/young adults and their family members. 
  3. Staff are not allowed to communicate with anyone receiving services from Center For Family Services via Facebook, Twitter, or any other online/social platform communication service.
  4. Staff are not allowed to have contact with youth after transition from program. If youth attempts to contact staff via social media, text, phone, email or any other form of communication, program administration must be notified immediately, and an incident report must be completed. 

Respect and Uphold Confidentiality in all Areas

  1. Confidentiality must be upheld. Staff are not to discuss youth outside of the agency, e.g. with family, friends, colleagues, etc. 
    1. Staff are not allowed to engage in conversations with former employees (i.e. staff who no longer work at their program and/or are no longer employed at Center For Family Services) about youth issues, program issues, and/or administrative issues.
  2. Staff are not to discuss other staff with coworkers, or youth receiving services from Center For Family Services.
    1. Staff are not to discuss youth's status/behaviors (unless appropriate) in front of any youth, or within hearing distance of youth or others.
  3. Staff are not allowed to bring family members, or friends, to any program sites, program activities, program events, and/or program meetings, unless approved by a member of the Executive Team. Family members include spouses, partners, siblings, cousins, boyfriends/ girlfriends, children (regardless of age), nieces, nephews, uncles, aunts, grandparents, and grandchildren (regardless of age).
  4. Staff must comply with documentation policies, and cannot remove files from the program (e.g. youth’s paperwork, youth's documentation, youth’s medications forms/logs, or other documents associated with a youth’s treatment planning process).

Photos/Video/Media

  1. Staff are not allowed to take photos, videos or screen shots of youth/young adults using their personal cell phones, or personal cameras, at any time. Staff, interns and volunteers:
    1. May not give any photos of themselves to youth/young adult(s).
    2. May not accept photos provided by the youth/young adult(s) (i.e. DCP&P Prom photos). All photos of youth/young adults must be placed in their file, unless in accordance with program policy and approved by a member of the Executive Team for the photos to be posted/displayed in the program.  All photos are the property of Center For Family Services.
  2. Staff are not allowed to distribute, publish, post, and/or submit any photos of youth to any publications, organizations, friends, or relatives, or through any online communication or social media services.

Utilize Positive Behavior Management Approaches

  1. Staff are expected to enforce all rules and not to demonstrate any favoritism toward youth. Staff are expected to adhere to the behavior management guidelines. 
  2. Staff must stay calm and collected at all times, even when a youth is verbally attacking or physically threatening staff. Staff are not to feed into the youth's negative behaviors.  Staff are never to instigate, intimidate or retaliate against the youth.  Examples include, but are not limited to, arguing with the youth, yelling at the youth, provoking the youth with threatening responses, using profanity, or displaying anger.
  3. Staff are not to invade the personal space of youth (e.g. getting in the youth’s face to redirect them, or grabbing something out of the youth's hand such as a phone, pen, paper, etc.). Staff are not to get into a power struggle with the youth.
  4. Staff are not to yell/scream at any youth, or make any threatening statements, e.g. "sit down or I'll help you sit down”.
  5. Staff are not allowed to call people names, use demeaning words or use profanity while working at any of Center For Family Services’ programs. Profanity includes, but is not limited to, “pissed off”, “hell”, “shut up”, etc.

Respect Agency Buildings and Property 

  1. Staff are to lead by example in maintaining the cleanliness and order of our facilities and vehicles.  Staff are to invest in the cleanliness of the environment and have pride in the physical appearance of the program.
  2. Staff are not allowed to bring domestic animals into the programs.
  3. Staff are not allowed to remove CFS property from the facility.
  4. Staff are not allowed to remove other employees’ personal items from the facility (e.g. paychecks, wallets, handbags, mail).
  5. Staff are not allowed to take any donations given to the agency/program for their own personal use. All donations are for the youth at the programs.
  6. Staff are not allowed to use the agency's computer for personal use.

Smoke Free Facilities

  1. All residential programs are Alcohol-free, Smoke-free and Drug-free. Staff are not allowed to bring alcohol and/or illegal drugs into the facility.
  2. Staff are not allowed to smoke cigarettes/e-cigarettes, vapes in any CFS properties. There is no smoking in the agency vehicles, with or without youth present. 
    1. Vapes are not allowed on premises.  Any vapes/related paraphernalia must be left at home, or locked in your vehicle, before coming on shift. 
  3. At no time is a youth permitted to smoke, whether on recreation, or on agency property.

Transportation Protocols 

  1. Staff cannot use the agency's vehicle for personal use, or non-work-related activities, for any reason at any time (e.g. to go to lunch, to do personal errands, to transport staff home or to any non-work-related activities). 
    1. Staff are responsible for providing their own means of transportation to and from work and for personal use. 
    2. Staff are not allowed to use the agency's vehicle to do work for another agency's program unless approved by your Supervisor.
    3. Staff are not permitted to drive the company's vehicle and/or be transported in the company's vehicles while not working their scheduled work hours at any CFS program at any time.
  2. Staff are not permitted to transport youth in their own personal vehicles unless approved by the Associate Vice President. 
  3. Staff are not permitted to allow youth/residents to drive the staff person’s personal vehicle, or agency vehicle, for any reason at any time. 
  4. Agency vehicles are not to be used to teach youth to drive.  All youth driving lessons must occur through a driving school. 
     

Violations of Boundaries and Guidelines Policy:

Any violation of these guidelines, or other violations of ethical behavior, needs to be reported to your Supervisor, Associate Vice President, and/or Quality Improvement. It is the duty of Center For Family Services, and all members of the Center For Family Services community, to uphold the standards set forth in the Boundaries and Guidelines and to report violations by following the reporting procedures outlined by Center For Family Services. All programs follow the Ethics policies found in the Center For Family Services’ Guidelines for Daily Operations manual located on the staff portal.
Any employee determined to be in violation of these policies is subject to disciplinary action, up to and including termination. Center For Family Services will support and/or may take appropriate legal action for serious ethical violations that endanger the organization and/or youth we serve.

Revised 2023.6.16

 

Dual/Multiple Relationships

Policy:

Center For Family Services recognizes the potential for a staff person to potentially be familiar with or acquainted with a prospective and/or current consumer of the agency.  This policy addresses the responsibility of both the consumer and the staff person to notify the agency if there is a dual/multiple relationship that exists between the staff and consumer(s).  Center For Family Services will ensure that professional ethics and boundaries are incorporated once it has been notified.

Procedures:

  1. Employees of Center For Family Services shall apply professional boundaries regarding dual or multiple relationships with all consumers.
  2. Employees are responsible for setting clear, appropriate, and culturally sensitive boundaries to protect the consumer themselves and the agency.  Employees should not befriend or otherwise interact with current or former clients on their personal social networking websites. This is a clear violation of ethical standards and is strictly prohibited.
  3. Employees shall immediately notify their program manager in writing of an existing dual or multiple relationships with any consumer upon time of hire, or if a dual or multiple relationship develops during employment. See "Employee Dual Relationship Disclosure and Plan Form". 
  4. Employees assigned to a consumer with whom a dual relationship exists, will be subject to review by the program manager or supervisor per policy.  Only by approval can a dual/multiple relationship exist in Center For Family Services’ service delivery.
  5. The consumer can make the agency aware of a dual/multiple relationship at any time during their visit(s) with the agency. The consumer can inform the program manager, the access case manager, or any provider of the agency.  The program manager will review all dual/multiple relationship concerns.  If the consumer is a minor (18 years old or less), the parent/guardian, or the consumer themselves, can inform Center For Family Services of the dual/multiple relationship and it will be reviewed by the program manager.
  6. Once the dual/multiple relationship is brought to the attention of the agency by the consumer, it will be written on the Employee Dual Relationship Disclosure and Plan form with notification of the intended plan given to the consumer.
  7. All "Employee Dual Relationship Disclosure and Plan" forms will be signed by the staff person and the program manager.
  8. After the dual/multiple relationship concern has been addressed by the program manager, if established as inappropriate, Center For Family Services will ensure the services provided to the consumer are not served by the staff person with the dual/multiple relationship.
  9. Non-adherence, on behalf of the staff person, of the dual/multiple relationship policy is a violation of the agency's code of conduct policy, specifically the agency’s ethics policy and would be grounds for progressive discipline.
  10. Any gross misconduct of the agency's dual/multiple relationship policy could be grounds for reporting the unethical behavior to the relevant professional licensing authority.

Finance

Financial Policies and Procedures

The document provides an overview of the fiscal policies and procedures for CENTER FOR FAMILY SERVICES, which shall be referred to as “CFS or “Agency” herein after. CENTER FOR FAMILY SERVICES is incorporated in the state of New Jersey and is exempt from Federal Income taxes under IRS Section 501 (c) (3) as a not for profit corporation. The mission of CENTER FOR FAMILY SERVICES is as follows:

“The Mission of Center For Family Services is to support and empower individuals, families, and communities to achieve a better life through vision, hope, and strength.”

This manual presents the CFS Financial policies, procedures, operations and accounting policies and procedures, for staff in the Finance Office as well as direct service and supervisory staff, and other administrative staff. This manual also documents some of the internal financial controls.

Governance

Board of Trustees, Finance Committee, Audit and Audit Committee

CFS receives funding from multiple sources. In the event that a funding source has requirements more stringent or in variance with CFS, CFS will adhere to the requirements of the funding source and CFS general best practices.

CFS is governed by a voluntary Board of Trustees comprised of community representatives. The Board is responsible for general oversight of CFS and its resources, including its financial resources. CFS Board of Trustees has a Finance Committee , including members with auditing, banking and other financial expertise, which meets on a regular basis to review periodic financial and budgetary reports, and give direction to the CEO and Director of Finance. The Board establishes various policies, including fiscal policies. The Board hires the President / CEO for the overall administration of agency business. The President / CEO presents fiscal policies to the Finance Committee for review, and recommendation to the Board for approval. Implementation of Board policies is the responsibility of the CEO and Director of Finance. The CEO involves the Director of Finance in the development of the fiscal policies to be recommended to the Board. Auditor recommendations are also addressed.

The CFS Board of Trustees Audit Committee oversees financial reporting, internal controls and the annual audit processes. One Finance Committee Member chairs the Audit Committee, but other members are not members of the Finance Committee. The Audit Committee selects the external auditor to perform a single audit. Single audit includes assessing the grantee agency’s written procurement procedures (including the approvals required, competition process, documentation records required, etc.), and may include reviewing a sample of actual purchases made during the audit year. Ensuring that all records have been documented will be necessary since auditors conduct audits in a different manner. The Audit committee reviews the annual audit and makes recommendations to the full Board

The Director of Finance works with other Program Directors and staff to ensure all staff follow CFS fiscal policies and procedures.

This Fiscal Manual outlines Board policies, administrative policies and procedures. The Board may modify Board policies. The CEO may modify administrative policies and procedures, or make exceptions, when deemed to be in the best interest of CFS.

Staffing

Job Descriptions Job descriptions outline the various duties and responsibilities for the position described. As much as is feasible, duties and responsibilities will be separated so that no one employee has sole control over cash receipts, disbursement, payroll, reconciliation of bank accounts or any other material duty performed by the fiscal department on a day to day basis. Job descriptions are maintained and revised periodically as needed.

Finance Department Overview

The Finance Department consists of several staff members that manage, process, and report financial information for CFS. These positions include the following:

  • Associate Vice President of Finance
  • Grants Director
  • Business Manager
  • Payroll Manager
  • Staff Accountant
  • Accounts Payable Supervisor
  • Accounts Payable Clerk (3)
  • Accounts Receivable Clerk
  • Accounting Clerk

Other officers and employees of CFS who have financial responsibilities are as follows:

  • Board Officers
  • Full Board of Trusties
  • President / CEO
  • Assistant to the President / CEO
  • Vice Presidents
  • Program Directors

Other staff may handle petty cash, submit program advances or check requests, or may collect client and program fees, or contributions to CFS.

Responsibilities The primary responsibilities of the fiscal department consist of:

  • General ledger maintenance
  • Cash management
  • Asset management
  • Cash receipts
  • Accounts payable
  • Payroll and benefits processing
  • Preparation of Fiscal reports
  • Financial statement processing
  • Bank reconciliation
  • Compliance with government reporting requirements
  • Handle annual audit process & other periodic audit
  • Preparation and Modification of agency and contract budgeting process

Ethical Behavior CFS has a Code of Ethics for staff and a Code of Ethics for the Board of Trustees. All staff receive orientation is ethical behavior and expectations of ethical conduct at CFS. Unethical actions, or the appearance of unethical actions, are unacceptable under any conditions. Any employee determined to be in violation of the Code of Ethics, or any CFS policy, is subject to discipline up to and including termination. Each staff is responsible for applying common sense in business decisions where specific rules do not provide all the answers. If a staff person has any doubt about the appropriate course of action, they must consult with their supervisor, program director, or Vice President for direction.

As a general guideline, in determining compliance with this standard in specific situations, staff should ask themselves the following questions.

  1. Is my action legal?
  2. Is my action ethical?
  3. Does my action comply with CFS policy?
  4. Am I sure my action does not appear inappropriate?
  5. Am I sure that I would not be embarrassed or compromised if my action became known within the Agency or publicly?
  6. Am I sure that my action meets my personal code of ethics and behavior?
  7. Would I feel comfortable defending my actions for media?
  8. Would a reasonable person make the same decision under similar circumstances?

Each staff person MUST be able to answer, “yes” to all these questions, and confer with their supervisor, before taking any action. All employees must carefully weigh all courses of actions suggested in ethical, as well as economic terms and base their final decisions on the guidelines provided by this policy. If an employee feels this policy is not clear in a certain area, the employee should seek clarification from their immediate supervisor.

Governing Regulations The CFS receives revenue from many different funding sources. Each grantor requires recipients of their funding to comply with the regulations they have adopted. These regulations are typically spelled out in the grant award or funding contract. Each program director or their designee is responsible for ensuring that items they approve , or the request for payment of goods and services to be paid for with funding from their programs, are necessary, reasonable and allowable according to the regulations for the funding source being charged.

Conflicts of Interest Employees have an obligation to conduct business within guidelines that prohibit actual or potential conflicts of interest. This policy establishes only the framework within which CFS conducts business. These guidelines provide general direction so that employees can seek further clarification on issues related to the subject of acceptable standards of operation. In the event that a potential conflict of interest arises, the employee should contact, discuss and get approval from their supervisor, VP, or the CEO, for more information and direction about conflicts of interest. An actual or potential conflict of interest occurs when an employee, Board member, contracted personnel or sub-governing body at the program level is in an opportunity to influence a decision that may result in a personal gain for that employee or for a relative as a result of CFS business dealings.

No “presumption of guilt” is created by the mere existence of a relationship with outside firms.

However, if an employee has any influence on transactions involving purchases, contracts, or leases, it is imperative that he or she disclose to the CEO of CFS as soon as possible the existence of any actual or potential conflict of interest so that safeguards can be established to protect all parties. Personal gain may result not only in cases where an employee or relative has a significant ownership in a firm with which the CFS does business, but also when an employee or relative receives any kickback, bribe substantial gift, or special consideration as a result of any transaction or business dealings involving CFS .

Examples of conflicts of interest include, but are not limited to, situations in which a director, officer, member of governing body or employee:

  1. Negotiates or approves a new contract, purchase, sale or lease on behalf of agency and has a direct or indirect interest in or receives personal benefit from, the entity or individual providing the goods or services;
  2. Employs or approves the employment of, or supervises a person who is an immediate family member of the director or employee;
  3. Sells products or provides services in competition with the organizations;
  4. Uses the Organization’s facilities, assets, employees or other resources for personal gain, except the use of agency equipment such as copiers, , fax machines, computer, printers and cell phones as long as the employee reimburses agency for any personal use as stated later in this policy;
  5. Receives a gift from the vendor, more than $25 in retail value if the director, officer or member of governing body or employee is responsible for initiating or approving purchases from that vendor.

Fraud Any knowledge or credible suspicion of any instances of fraud, theft, or the improper use of agency property or equipment should be reported immediately to the CEO, VP or Director of Finance. Instances of fraud include, but are limited to the following:

  1. Theft, embezzlement, or any other misappropriation of assets. This includes assets of or intended for the Agency, as well as those of our clients, subcontractors, vendors, contractors, suppliers and others with whom the Agency has a business relationship.
  2. Intentional misstatements in the Agency’s records, including intentional misstatements of accounting records or financial statements.
  3. Authorizing or receiving payment from goods not received or services not performed.
  4. Authorizing or receiving payment for hours not worked.
  5. Forgery or alteration of document, including but not limited to checks, time sheets, contracts, purchase orders or any other Agency document.

Any person having knowledge of any of these situations should immediately contact his/her Program Director, VP, or CEO. CFS also has a confidential email reporting (whistle-blower) system. The phone numbers of any of these persons can be supplied by the Assistant to the President and CEO by calling 856-964-1990.

Employee Theft Insurance Protection CFS carries employee theft insurance protection. All official forms pertaining to financial operations are to be typed, computer generated or completed in ink. All certifying signatures are to be signed in ink as well. The financial records of CFS including bank statements are located at the administrative headquarters at 584 Benson Street, Camden, NJ. To protect the sensitive data contained in these documents, CFS does not allow this information to be removed from this location.

General Accounting

General Ledger and Chart of Accounts:

The general ledger is the collection and recording of all asset, liability, and revenue & expense activities. The general ledger is an accounting module to accumulate all financial transactions. General ledger accounts are used to accumulate transactions and the impact of each of these transactions on each asset, liability, net assets, revenue and gain or loss account.

The chart of accounts is comprised of six types of accounts:

  1. Assets
  2. Liabilities
  3. Fund Balance/Net Assets
  4. Revenues
  5. Expenses
  6. Gains and Losses

Each program is given abbreviated names and specific umbrella codes in the chart of accounts to track the revenue or funding source and expense by program. Within the umbrella code, sub-codes are set up by the funding source and / or program service acronym to track revenue and expense by the contract. The revenue and expenses are categorized by the suitable group to track the performance against the budget and produce expenditure report as per contract specifications. The Finance Director or a designee monitors, controls and maintains the chart of accounts and general ledger on a daily basis. Any additions or deletions of accounts should be approved by the Finance Director, who ensures the chart of accounts is consistent with the structure needed for producing reports for the Agency and meets the needs of each program at the funding source level.

Fiscal Year CFS operates on a fiscal year from July 1st through June 30th. CFS maintains its books on an accrual basis. Changes to the agency’s fiscal year and / or accounting basis must be approved by the CFS Board of Trustees.

Journal Entries All general ledger entries must be supported by backup documents with explanations suitable for the recording journal entries. All journal entries must be approved by the Finance Director or a designee.

Petty Cash To meet day to day petty cash expenses, agency allows setting up petty cash account at the program level. The petty cash request is authorized by the VP in charge of the program and approved by the finance director. The range of the amount of the request for petty cash varies from program to program based on budget size, location and nature of service rendered by the program. Petty cash funds must be kept in a locked file cabinet or safe with only designated employees having access and being responsible for the funds. Random checks are made periodically to assure internal controls are kept and maintained on the petty cash funds.

The amount of petty cash fund is limited to $500. A petty cash fund is used to make small purchases of goods and services and for emergencies. The use of petty cash fund for the residential programs includes payment for special activities for clients. Receipts for all purchases must be kept and submitted to the fiscal office every calendar month in order to replenish the funds. The funds will be reimbursed in accordance with the accounts payable process. The accounts payable check will be made payable to the “employee” authorized to having access to the funds.

Cash Receipts (including checks and direct deposits) The handling and receiving of cash will be conducted in the manner described. The following section pertains to funds received in the fiscal Office. Funds received at the county level are to be handled as described in “Other Cash Receipts”. All checks received through mail are opened and recorded by the Accounts Receivable Clerk. The Accounts Receivable Clerk assigns program and account codes, and processes receipts through the financial system. All receipts are computer generated and sequentially number. A copy of the receipt is filed numerically in the Finance Department on a calendar month basis as a backup to the bank statement for reconciliation purposes. Cash and checks collected and received are processed for bank deposits each Monday, Wednesday, Friday, and last working day of month by the Accounts Receivable Clerk. Copies of all checks are made for documentation. Cash and checks are maintained in a safe located in the Finance Department until such time deposits are made. Before the cash or check receipt is recorded in the books, the grant director reviews and approves deposit. Once the deposit is made, the amount is verified against the computer generated receipt journal, and the bank deposit receipt is attached to all supporting documentation for that deposit. Accounts Receivable Clerk records in the agency books all federal and state contacts, as well as various funding sources that transmit funds through automatic electronic deposit to the Agency’s bank account. Remittance notices are delivered to the Accounts Receivable Clerk for entry into the accounting system as noted above.

Other Cash Receipts Client fees collected by the program are deposited by designated staff every other day of the week into the Agency’s designated bank accounts. Original bank deposit slip along with back up documents are mailed to the Finance Department through inter-office mail. The Accounts Receivable Clerk then records deposit and attach document to the deposit slip. Other funds received through donations, special events such as fund raisers, etc. are forwarded immediately to the Accounts Receivable Clerk for entry into the accounting system as noted above.

Credit Card Use Only the President /CEO, Vice Presidents and selected program directors are authorized for the use of agency credit cards for the benefit of agency and / or program in performing job duties where it is deemed necessary to use the credit card in conducting agency business. Each program director is responsible for proper purchasing procedures when using the cards. Use of credit card can only be for agency business, NO exceptions. The Finance Department receives monthly statements for each card. The credit card statement is forwarded to the users to attach supporting receipts and any required paperwork for all purchases. Currently, the agency credit cards include Bank Visa, Sam’s Club, Lowes, Staples.

Credit Card Policy and Procedures

Purpose:

Provide Management and approved supervisors with Credit Cards to facilitate purchases of goods/services needed for agency and/or program use.

Administrative Policy:

  • Card holders must attach to copy of statement for all purchases made. Receipts should be accompanied by the completed “Receipt Summary Form”. (See attached form)
  • Copy of credit card statement along with attached receipts for the previous month must be delivered to Finance office no later than the 7th of the next month (ex. October receipts of purchases are due no later than November 7th.) Note: If the 7th of the month falls on the weekend, the receipts are due after the weekend.
  • Card holder should refrain from making purchases for products or services outside of his or her respective program(s). If card holder is in charge of more than 1 program, and an expense charged on the card belongs to more than 1 program, the program name must be identified with amount. Otherwise, expenses will be charged to the program, by default, based on card holders / Supervisor’s primary program.
  • Purchases for CFS programs and HS program must be made on respective cards as identified with CFS logo for CFS program and NO logo for HS program respectively. Card holder who is issued CFS card only may purchase goods and services for HS program but must identify as purchase for HS program.
  • Card holders should refrain from making any Gift card, Bank card, or Store card purchases on grant funded program(s). Other than grant funded program(s), purchases and distributions of such cards must be accompanied with the Receipt of Goods and Services form signed by the purchaser and attached to the copy of statement as part of back-up to the receipt. A signature of the recipient(s) is expected when deemed appropriate.
  • When purchase is made for client use, a completed Receipt of Goods and Services form, signed by the client must be attached to copy of credit card statement. All items must be listed and authorized by appropriate authority. Include notes, if any, to draw finance department attention to assist in determining the allocation or nature of expenses at the grant level by the program.
  • Dining expenses must include the names and relationship to the agency, of all who dined and the purpose of the meeting.
  • Meetings & Conferences including Training expenses incurred out of state or more than 50 miles from the primary place of card holder work location must be listed on a form “Travel Itinerary Form” and attach to the copy of credit card statement. (See attached form).

Procedures:

  • Card holders will be given a copy of their respective credit card statement at the beginning of each month.
  • Card holders will attach receipts for each prior month transaction and return to the finance office by the 7th of the month.
  • Card holder will write an explanation directly on copy of the statement to include: specific program/grant to be charged; if subject to reimbursement; any 3rd party involvement; date and location; nature of expenses etc., to assist finance in categorizing the expenses by correct expense line item.
  • The Travel Itinerary form must be filled out completely when the first Meeting & Conferences or Training expense is incurred.
  • First expenses usually occur in the form of a check request for registration fee or making advances reservations, for transportation, including loading using a credit card.
  • The Brochure, invitation, or agenda must be attached to the Travel Itinerary form or sent via email.
  • Copies of Head Start credit card statements are included with the monthly Financial Statements and presented monthly to the Head Start Policy Council for review and approval, and for review and approval of the CFS Board of Trustees.

End of Credit Card Policy

Draw Down From Payment Management At month end, financial reports are prepared for each program operated by CFS. These reports determine the monthly and year to date expenditures. Once the monthly reimbursement is determined, invoices are prepared to draw down budgeted and / or authorized funds. For programs whose funding is requested from the US Federal Payment Management System (PMS), the appropriate finance personnel enter the reimbursement request in the PMS website to draw down funds based on expense report. Payment when received is appropriately recorded in the books.

Procurement/Purchase Orders The Agency has Procurement Procedures that must be adhered to by all employees. There are three specific thresholds to be considered for purchasing:

  1. Purchases under $5,000: No purchase order is required for purchase of goods and service for value under $5,000. However, the program director making the purchase request must contact VP in charge for approval and authorization to be in compliance with contract guidelines. An approved purchase request through the check request supported by the appropriate estimates and/or quotes must be submitted to the finance office for check processing and record keeping.
  2. Purchases of over $5,000 but less than $100,000: Before making purchases of goods and/or services worth over $5,000, informal bids are required depending upon funding source requirements. The program director or the authorized person in charge of bidding process will follow Agency and / or funder guidelines. Before making purchases, the authorized person must contact Finance Department to obtain approval for type of purchase approved by the contract budget and for amount allowed. (Refer to Procurement Regulations). Once all the procurement procedures are properly followed, reviewed and met, the authorized person will seek CEO or VP’s approval before delivering appropriate documentation to Accounts Payable Clerks for payment processing.
  3. Purchases over $100,000 and above: Formal sealed bids are required from individual and / or business contractors. Authorized person must contact person in charge of approving Purchases and finance office for approval of budgeted amount and fulfillment of contract guidelines, if any. (Refer to Procurement Regulations). Once all procedures are thoroughly followed, reviewed and met, the Purchasing/Property Manager will deliver appropriate documentation to the CEO for final authorization to make purchases as requested. Any additions or deletions to this list must be authorized by a Program Director and VP.

See attached Head Start Procurement Policies and procedure in Addendum 1.

Accounts Payable Check Process The Accounts Payable Supervisor or a designee will be responsible for all blank checks, which will be kept under lock and key. The Accounts Payable Clerks will be responsible for printing and releasing checks for all approved invoices. Accounts payable checks are printed and released each week. The turnaround time for processing a check request is usually 3 -5 business days unless there is a special emergency request. The Accounts Payable person reviews all payable requests to ensure approval; accuracy and make sure that all required supporting documents are attached. Accounts Payable person assigns program and expense account code(s). Accounts Payable person enters data in the books. The Accounts Payable Supervisor prints check payable register to review the accuracy of data entry. The payable register is reviewed by the finance director before selection of check payment. Selected invoices are processed for payment and checks are printed. A computer generated check is attached to authorized invoices and / or check request voucher for signature. Two (2) signatures of the authorized signors is obtained before checks are delivered or mailed to the vendors. Copy of check stub is attached to the original invoice and filed in alphabetical order for easy access.

Bank Reconciliation Bank statements are provided monthly from the financial institutions with whom CFS conducts business. The reconciliation of the operating and other accounts is performed by the Finance Director or designated person. Finance Director reviews the bank reconciliation monthly to determine if any checks are outstanding over 90 days. An effort will be made to contact the payee to see if the check has been received. Before any outstanding checks are voided, the bank will be contacted to see if it has been cashed. If not, a stop payment will be issued for that check, it will be voided, and a new one will be issued if needed.

Payroll

All actions involving payroll such as a change of pay, position, location, percentage allocation by program, or change in scheduled work hours must be reported on a Payroll Status Change Form (PSCF). The form must be approved by the Program Director and VP or CEO. The original change form is filed in the employee’s personnel file with Human Resource Department and a copy is forwarded to Finance for update of payroll records. The PSCF and other payroll information are due to Finance one (1) week before the payroll submission date.

The HR Employee Administrative / Benefit Clerk in HR Department is responsible for seeing that the employee completes all relevant tax forms such as the W-4, I-9, Insurance Forms, Employment Contact information, etc. Payroll is processed bi-weekly.

Time Sheets Timesheets must be submitted by each employee with original signature of employee and approval of director. In order to get paid, the employee is responsible for completing and signing their own time sheet and obtaining approval from their supervisor. The employee also reports leave information on their timesheet. The supervisor is responsible for ensuring timesheets are accurate and all leave has been reported correctly. The supervisor is also responsible for accuracy of time calculated. After July 1, 2013, timesheets will be generated through the on-line ADP website, by the employee, and electronically approved by supervisors.

The Payroll Clerk re-checks all timesheets for accuracy and makes any necessary changes to the timesheet in ink. Summarized time data is then entered in to 3rd party payroll processing company software for generating pay checks. After July 1, 2013, data will be entered as described above.

The paycheck are delivered to the program location for handout to employees on the pay day due date. Payroll register and reports are delivered to the agency for recording payroll data in agency book. All ledgers are filed in the appropriate binders by pay date. Payroll binders are maintained in the payroll manger office to maintain confidentiality. Timesheets are filed alphabetically and maintained in the finance department. After July 1, 2013, timesheets are available only electronically. To ensure legitimate payment to the newly hired employee, finance office must receive Payroll Status Change Form for newly hired employee from HR department.

For termination of employee, a Payroll Status Change Form must be signed and submitted by employee’s supervisor to include Program Director and VP approval.

Correction of Payroll Errors In a situation where employee is under paid, Finance will review the case and determine impact of financial stress on employee before manual check is processed. In a situation where employee is overpaid, the employee will be notified of the overpayment with request to pay back overpaid amount before the payroll is processed through 3rd party payroll processor which is Monday of week of the next pay check is due. If an employee fails to pay back the over-payment, the over payment will be deducted from the employee’s next pay check.

Leave Employee may earn vacation, sick and personal leave, as per Agency approved leave policy in effect, based on each employee’s scheduled work time (See CFS Personnel Handbook for detail.) Every time payroll check is processed, the 3rd party payroll processing company software automatically calculates leave time earned, leave used, and balance available for future use. This information is presented on the employee’s pay stub. Agency does not allow employee to “borrow” leave. An employee who wants to take more leave than accrued must get prior approval from the VP and / or CEO. Employee who falls short of accrued leave balance in one category is automatically adjusted in another leave category, if enough balance is available to offset the shortage. Any further shortage must be authorized by the VP and President and CEO of the agency. (Sick time can only be used is employee is sick.)

Overtime CFS complies with US Department of Labor regulations for the payment of overtime for non-exempt employees. CFS work week is the seven day period from 12:01 a.m. Saturday till 12:00 p.m. the following Friday. Overtime is only applicable if the total time for the entire week is greater than 40 hours of actual work during one (1) week. An employee who works overtime must be pre-approved by Program Director.

Double Time Agency offers double time when employee is requested by the program director to work on an agency approved holiday.

Payroll Taxes and Other Deductions A third party payroll processor is responsible for making payroll taxes for the Agency. The payroll taxes are paid by ACH payment from the payroll account. All other payroll related deductions are paid through the accounts payable process.

Direct Deposit Agency offers direct deposit of payroll checks. Employees willing to avail the offer must fill out direct deposit form and submit an original voided check for checking account and bank authorization form for savings or credit union account in including money market account for direct deposit.

Travel Reimbursement Employees are reimbursed for the use of a personal vehicle while on Agency business at a rate up to that is determined by management. The management reviews the rate from time to time as per contract and/or IRS guidelines to determine the rate. Employees are notified by memo or e-mail of any rate changes approved by the management. To be reimbursed, employees must submit the request on the approved travel reimbursement form. The form must be filled out every calendar month. The form must be pre-approved by the immediate program supervisor before it is submitted to the finance office for reimbursement. The form must be due in finance office by 10th of each month. The reimbursement check is processed once a month and is handed out along with the last paycheck due each month.

The employee is reimbursed for out-of-the-area, overnight, or out-of-state travel. The travel must be pre-approved by the Program Director, VP and/or the CEO before travel is arranged. Out-of-State travel is reimbursed based on the agency or contract guidelines. All travel expenses are reported on the Agency’s Travel Claim form. This form requires the signature of the employee as well as their supervisor. All approved travel claims will be processed for payment in accordance with the accounts payable process. Employees may request a travel advance for expenses related to approved overnight or out-of –state travel. The travel advance should be based on the employee’s reasonable travel plans. An “actual” travel claim must be completed and submitted to the finance office within a week returning from travel along with reporting of actual business related expenses and providing all required and relevant receipts. If money is owed back to the Agency, the employee must settle with cash deposit to the finance department of the Agency. If money is owed to the employee, they will be reimbursed in accordance with the accounts payable process.

Budgeting

Budgets are prepared for each contract/program operated by the Agency as well as for the entire agency. The contract budgets as well as agency budget are prepared by the finance director with the help of program director(s) and VP in charge of the program and the CEO. Other senior staff may also be designated to help prepare budgets. At times, some of the locally operated program small size budgets shall be prepared by the Program Director responsible for overseeing the operation of the programs. Any budgets relating to the administrative department or the Agency as a whole are prepared by the Finance Director. All contract and program budgets must be submitted to the CEO. Sometimes Board approval is also required. The Finance Director meets periodically with Program Directors to discuss their current budget, including budget modifications, year to date expenditures, obligated funds, cash flow, and any concerns in the spending patterns. It is the responsibility of the Program Directors to manage expenditures and help Finance Director in revision of budgets accordingly.

15% Administrative Cost Limitation The Head Start program is subject to a 15% administrative cost limitation. The components that make up the administrative cost total are the Head Start administrative costs plus indirect costs allocated to the Head Start Program. The total of these two figures cannot exceed 15% of the total Head Start funding including the Non-Federal Match. A spreadsheet documenting this calculation can be found as part of the backup information filed with the quarterly and final SF269 report for the Head Start program.

Cost Allocation Plan (See Addendum)

Indirect Cost Allocation CFS’ Indirect Cost Allocation Plan is very simply and straightforward. Administrative cost will be equitably distributed among direct agency activities (programs and services) by dividing the total administrative cost by the total direct program expenses. The indirect cost allocation rate thus determined will be charged against total expenses.

Indirect Cost Rate Proposal CFS submits an Indirect Cost Rate proposal to the US Department of Health and Human Services Division of Cost Allocation since it operates a direct federally funded Head Start Program. This proposal includes the proposed method of allocating the Agency’s general administrative costs to the Head Start Program. The proposal is amended based on the timeframe outlined in the rate agreement. The Agency’s direct program salaries and wages plus in-kind wages are used as a base in computing the indirect cost rate. The Agency is assigned a provisional indirect cost rate that is not finalized until after the audit is complete each year. The quarterly and Final SF269 reports that are sent to the Head Start regional office require us to disclose the approved provisional indirect cost rate and the total indirect cost allocated to the Head Start program.

Financial Reporting/Invoicing

Financial reports and invoices are prepared on a monthly basis. Once all financial activity for a month is balanced and posted to general ledger, each program general ledger, specified by program code, is printed and used to prepare monthly/year- to-date financial reports and invoices for each contract. Financial reports are also prepared for each of the locally operated programs. All required reports and invoices are prepared manually due to the “program specific” formats and timelines. Quarterly financial reports are also required by various contracts operating within the Agency. The State of New Jersey, Department of Human Services (DHS), Division of Child Protection & Permanency (DCP&P / formerly DYFS) serves as the Agency’s cognizant agency. The Finance Director is responsible for ensuring all financial reports and invoices are accurate and submitted on a timely basis. Copies of all reports, invoices, and related documentation will be kept on file in the finance department. Copies will also be given to the Program Directors and VPs on request. The Finance and Program Director are responsible for reviewing the financial reports periodically to ensure spending is consistent and the Agency is at no risk of deficit spending within the programs. Reports will be submitted to governing bodies for approval.

Accounting records are maintained and reported separately as required by funding source regulations.

Financial Planning and Investment Policy

Board Approved: March 27, 2002

Goals:

  1. To create a sound financial structure to meet the short and long term financial needs of CFS for stability and future growth.
  2. Increase financial reserves through discretionary dollars and fundraising and maximize interest on reserve funds, while minimizing risk.
  3. When feasible, invest in real estate to house program operations while building equity for the organization.
  4. Set aside depreciation funds on an annual basis into a reserve account for future capital needs.

Objectives:

  1. Create an unrestricted reserve fund to meet the operating cash flow needs by setting aside funds on a regular basis into money market (MM) fund or short-term CD account.

Research the current interest rate situation and compare with the historical interest payment trend over a year and invest into liquid MM a/c with reputed financial institution up to $100,000 per a/c to benefit the cost free SPIC insurance offered by them.

Accounts to be opened for:

  1. Operating Cash Reserve a/c (MM or CD),
  2. Assets (Depreciation) Reserve a/c, and
  3. Friends of the Family a/c for Donations
  4. With changing economy, mortgage interest rates and investments opportunities need to be monitored suitable to the needs of CFS by reducing financial expenses by utilizing the reserve fund either to buy new assets, pay off balloon amount (partial or in full) to build up equity in the properties owned by CFS.
  5. Consider increasing financial income by investing money beyond MM a/c for steady flow of income and investment growth into either short-term (1-5 years) or long-term (5-10 years) government bonds or preferred stock of high rated quality corporation in various sectors.
  6. Maintain Reserve Account (Board Restricted) in high yielding income account.

End of Investment Policy

Mortgages, Loans, and Line of Credit

Any loan, mortgage, refinance or amount borrowed from the line of credit obtained by the Agency must be approved by the Board of Trusties. The Agency does not make loans of any kind to its employees.

Equipment

Fax Machines/Copy Machines Included in the indirect cost when multiple programs are involved outside the central office a cost pool charge is allocated to each program.

Postage Meter Most of the Agency’s postage is handled through the use of a postage meter. A report is generated through the usage of the meter and is submitted to Finance at the end of each month for allocation of cost to the program(s).

Telephones Agency prohibits use of agency phone for personal long distance telephone calls. Any personal long distance calls should be billed to the employees’ personal phone card or their home phone. Employees at locations that have a long distance code assigned to them should enter this code when making long distance calls relating to Agency business. The Agency receives monthly billing that allows us to review detailed information about each call made from an Agency phone. Telephone bills are analyzed monthly in an effort to detect any inappropriate use. The identified employee is responsible to reimburse agency all the cost for personal usage.

Cell Phones With exception, Agency allows personal use of Agency cellular phones by some programs and / or individuals within the Agency. It is advised to check with the program director to determine the adherence to the policy of the agency at the program level. If personal use of agency cell phones creates additional charges, employees will be responsible to reimburse full cost of personal use of agency cell phone.

Miscellaneous

Leases All leases must be approved and signed by the CEO, VP, or designee. Originals of leases are kept in the contracts and lease file, which is to be maintained in the Purchasing Property Managers Office. Copies of lease agreements are forwarded to Finance for monthly payment until lease is fully executed or terminated.

Insurance CFS maintains commercial insurance including general and professional liability, property, auto, directors and officers, volunteer and student accident insurance. The general liability includes protection against employee theft. CFS has an umbrella policy which provides insurance limits above those on the standard commercial policy.

CFS maintains mandated workers compensation and unemployment compensation.

CFS provides medical, vision, dental insurance coverage on a cost sharing basis for full-time employees. CFS provides life and long-term disability insurance for employees. Employees may buy additional life insurance. Employees may participate in Flexible Spending Accounts for medical and child care expenses.

The cost and coverage is reviewed on a yearly basis. Increases in the premiums are compared to the increase in market rates to determine if it is in the best interest of the Agency to re-bid coverage.

In- Kind In-kind contributions are received from time to time. Contributions could be in the form of donated goods or services. The value of in-kind contributions is calculated and tracked variously depending on the program or department generating and receiving the goods and services. Examples of goods include items received for the Holiday Gift Drive and Operation Backpack. Services could include the value of the time contributed by volunteers or student interns.

Head Start: Head Start has specific requirements for generating and tracking in-kind contributions. The Program Director is responsible for generating the in-kind required for their program. The Finance Department currently receives in-kind reports monthly from the Head Start Program as accumulated. The Finance Department enters this information into the Agency’s tracking system and generates a report monthly submitted with the monthly budget report. See Appendix C for details. where is this?

Retirement Fund Accounts and Audit The CEO and designated VP are custodian of retirement fund accounts of the agency. The custodians rely on the advice of the Board approved authorized retirement fund and benefit broker(s) services. The Agency’s retirement plan 401(k) is managed by The Standard. 403(b) is managed by Mutual of America. 457b is managed by The Standard. Retirement fund accounts are audited annually by the board approved outside independent auditors.

Property Federal Regulation defines major equipment as all items purchased or donated with a unit cost of $75,000 or more. Major equipment for Agency purposes shall be defined as all items purchased or donated with a unit cost of $5,000 or more and having a useful life expectancy of one year or more. For items purchased with grant funds from the State of New Jersey, major equipment is defined as all items purchased or donated with a unit cost of $5,000 or more having a useful life expectancy of one year or more. Major equipment items should be included on the Agency equipment depreciation list prepared by the auditing firm each year.

Sensitive Minor Equipment Sensitive minor equipment shall be defined as items which although expended, as supplies may be highly personally desirable and may be easily removed from the premises. This includes items such as camera, portable tape recorders, DVD player/recorders, televisions, calculators, computer components and software, etc. Refer to the end of this section for a complete list of items considered to be sensitive minor equipment; these items are not listed in the asset accounts of the Agency since these items are expended.

Inventory Both major and sensitive equipment items are tagged with inventory identification numbers. Tags are permanent, not easily changed, defaced, nor removed. The inventory data base includes the following: (a) a description of the item; (b) manufacturer’s serial number or other ID number if applicable; (c) acquisition date and cost; (d) fund source with applicable funding program number (e) location within the Agency’s operation where the equipment is utilized; (f) the condition of the equipment at the time of the inventory; (g) disposition information if the property has been disposed of. The inventory database also includes the purchase order number and the vendor the item was purchased from.

A physical inventory of the equipment items is taken at least once every two to three years. The Purchasing Property Manager will supply each Program Director or their designee with an inventory printout to be used in checking off the inventory items for their program. The person conducting the inventory should sign and date the inventory printout in the appropriate place. It is the responsibility of each Program Director and the Purchasing Property Manager to see that their program’s inventory is completed bi-yearly.

Head Start Inventory: Head Start program director may order an outside agency to perform an inventory the years the agency does not conduct their scheduled equipment inventory. All documentation will be forwarded to the Head Start Director upon completion.

Theft or Loss of Inventory: A written incident report will be completed. Written notification is given to the appropriate Program Director and the Purchasing Property Manager for any equipment that is discovered to be lost or stolen during the inventory process, or at any time during the year. Any theft or vandalism of major equipment (that starts an insurance claim) requires the Agency to contact the Police Department in their area concerning the loss or damage. Depending upon the initial cost of the sensitive minor equipment the President/CEO or VP may or may not request a Police Department investigation. This investigation and any related paperwork must be forwarded to the President/CEO or VP. The President/CEO or VP shall also be immediately notified, preferably in writing of all cases of loss, damage or destruction of Agency property or equipment.

Disposition of Property Disposition of property that is no longer fit for use or no longer needed, will be subject to the disposition regulation of the funding source that initially paid for the equipment. No property can be disposed of without written approval from the Program Director to the VP or President/CEO.

Federal Funds: Equipment with a per unit fair market value of less than $5,000 and with no further useful value may be retained, sold or otherwise disposed of with approval of management and / or Federal Government. Equipment with a fair market value of more that $5,000 requires Federal approval for disposition.

State Funds: For major equipment items, items that initially cost $5,000 or more then the proper State Department shall be contacted regarding the specific disposition request. For items costing less than $5,000 then it would be up the Agency to handle the disposition of them.

Other Funds: Equipment purchased with any other funds may be disposed of as the Agency wishes or in accordance with any particular restrictions the funding source place upon the equipment.

Assignment of Inventory ID Number All requests for the purchase of major equipment and/or sensitive minor equipment shall be identified on the Purchase Requisition Request form by placing a check mark in the inventory column. Provided the request is approved, the inventory number will be assigned when the transaction is complete. The authorized person and or professional consultant will enter the Inventory ID number along with the other inventory control data in the inventory control log. The actual inventory sticker will then be given to the Program Director, their designee or the person who requested the item. The designee of the Program Director will have the responsibility for properly affixing the inventory sticker to the item and then notifying the authorized inventory in charge person that the inventory sticker has been placed on the item. Once an item is received, inventories add form must be completed and forwarded to the authorized inventory in charge person. The Purchasing Property Manager shall maintain the inventory database. An inventory report may be requested from the authorized inventory in charge person.

Sensitive Minor Equipment Listing Only sensitive minor equipment costing over $1,000 will be tracked on the inventory. Items costing less than $100 will not be tracked. For a complete list of items considered to be sensitive minor equipment, see the Fiscal Policies.

Records Retention Financial records, supporting documents, statistical record and all other records pertinent to an award shall be retained for a period of seven years from the end of the agency’s fiscal year. There may be exceptions including the following:

(1) If litigation, claim, financial management review, or audit is started before the expiration of the seven year period, the records shall be retained until all litigation, claims or audit findings involving the records have been resolved and final action taken.

(2) Records of real property and equipment acquired with Federal funds shall be retained for three years after final disposition.

Forms Most commonly used forms are available to staff on the Staff section of the CFS Website: www.centerffs.org. Staff should regularly check the website to ensure that they are using the most current version of any form.

Information Bid Form Instructions

Step #1 Obtain an Informal Bid Form for all purchases of $1,000 and up to $4, 999.99

· Item description and quantity to be bid: Should be a description of item(s) or service(s) that are included in this bid and the quantity needed.

· Vendors contacted: A minimum of three bids is required for purchases over $1,000 to $4,999.99. If a program does decide to purchase from state or federal contracts, program must include contract number. State and federal contracts still require a purchase order and proper documentation over $5,000. If the item is on state or federal contract but program does not want to purchase it, program may use the contract price as one of the three bids. In some cases, three bids are not possible. If program cannot get at least three competitive bids, program must have documentation that proves that program made an effort to obtain two-three competitive bids. Please double check all vendor records to make sure that all of the information is complete and correct. Bid will be awarded to the vendor with the lowest cost unless specific valid justifications are determined and properly documented to bid out a contract otherwise. Any award to other then the lower bidder must make an entry into the justification for bypassing bid procedures section and attach a letter explaining the circumstances.

· Justification for bypassing bid procedures: This should only be used in case of special circumstances.

The Department Director and VP must approve bypassing the procedures prior to the purchase only with approval of President/CEO. Requester must state in writing the circumstances and the necessity to purchase without properly bidding the item or selecting a vendor other than the lowest cost. Poor or inadequate planning does not justify bypassing the correct procedures. Program Director or VP may attach an additional sheet if necessary. After program Director or VP has completed the above information, give the bid form to your department director for approval. The director will place the vendor number of the bid recipient in the space provided, signed for approval to purchase and list the programs and amounts or percentages to be charged for that purchase.

Step #2: After the information is completed in the area that says “ABOVE INFORMATION MUST BE COMPLETED BEFORE PURCHASE IS MADE”, the bid form is then taken to the Finance Department. The Finance Department will review accuracy of cost of bid. The accurately priced bid form then will be forwarded to the accounts payable department for processing approved bid. A purchase order is prepared and issued with a copy to the program director to place an order with the vendor or supplier. The bid form will remain in the purchasing department to be filed and held until the items are delivered and the invoices received.

Step #3 When the item(s) are delivered and the invoice is received, the invoice is taken to the purchasing department. If only a packing list is received, it must go to the purchasing department also. The purchasing department will contact someone about the receipt of the item(s) and forward all paperwork to accounts payable. (The correct charges must be listed on the invoice.)

No purchase orders are to be issued until all procedures are followed and all approval signatures are obtained.

Head Start Procurement Policy and Procedures

  1. INTRODUCTION:
    The procurement framework discussed in this document details the process of purchasing the necessary goods and services that Center for Family Services (CFS) Head Start requires for its operations.

    CFS Head Start follows in accordance with the regulations outlined in 45 CFR 74.40 (Procurement Standards) and 45 CFR 92.36 (Procurement), in developing this framework. Where they exist, our procurement procedures follow the federal guidelines or general industry best practices. In the special case of construction projects, the grantee’s guidelines apply, taking account those regulations contained in the Davis-Bacon Act.
     
  2. PROCUREMENT POLICY:
    It is the policy of CFS Head Start to utilize its financial resources to procure goods and service that are deemed allowable and allocable in a manner that promotes economic efficiency.
     
  3. PROCUREMENT PROCEDURES:
    CFS Head Start’s procurement procedures prohibit the purchasing of unnecessary items with federal funds. Unnecessary items are defined as those goods and services that are not relevant to the work of the agency.

    The CFS Head Start Director, and/or the CEO, or his/her designee determines the needs for product and has ensured the costs for services and/or goods are not being duplicated, have been determined to be allowable, allocable and economical.

Procurement Code of Ethics CFS Head Start maintains a strict code of conduct governing the performance of all employees, agents and Board members engaged in the procurement process. According to this code, none of the parties identified above is allowed to be involved in the administration of a contract supported by Federal (or stated) funds if a conflict of interest, real or apparent, would be involved. Such a conflict arises when the employee, agent or board member or any member of his/her family, his/her partner, or an organization which employs, or is about to employ, any of the above, has a financial or other interest in the company (or related to any consultant) selected agency.

The code of conduct for procurement further stipulates that, under no circumstances will employees solicit or accept gratuities, favors or anything of monetary value from vendors, potential vendors or contractors, or parties to sub-agreements. To the extent permitted by State or local law or regulations, such standards or conduct will provide for penalties, sanctions, or other disciplinary actions for violations of such standards by the agency or by contractors or their agents.

Complaints will be regulated using the protest procurement procedure and their state and local authorities before seeking Federal agency. Reviews by the Federal Agency will be limited to:

  1. Violations of the Federal law or regulations; and
  2. Violations of CFS’s failure to review a complaint or protest.

All purchases over $5,000 require Head Start director and/or CEO approval. The following procedures apply for all goods, professional services and fees, including but not limited to: auditors, attorneys, architects, engineers, etc.

Small Purchase Procurement Procedure For those small items with a list price of less than $5,000 no formal competitive bidding process is required. The procedure adopted is the same for goods and consultant services having a value in this range. The procurement procedure is as follows:

a. Cost comparisons are made utilizing a variety of media, including the internet, telephone request for quotations, referrals from other agencies and vendors. CFS can’t make a purchase until multiple agencies are considered.

b. Cost analysis and records should be maintained for all purchases that are above the small purchase threshold. Records should include:

1. Identification of vendor chosen;

2. Basis for contractor selection: Prices and comparisons;

3. Justification for lack of competitor;

4. Basis for cost and price; provide narrative for selection made

Selection is based on price, quality of product/service, after sales support (where applicable), accessibility, track record of the vendor and whether the company is a small business, minority or women’s business enterprise.

Any contract in excess of $2,000 for construction, alteration, and/or repair of facilities must comply with the federal Davis-Bacon Act. See attachment

Documentation should include procedures to ensure settlement and satisfaction of all contractual disputes.

Large Purchase Procurement Procedure The CFS Head Start Director, and/or the CEO, or his/her designee determines the needs for product and has ensured the costs for services and/or goods are not being duplicated, have been determined to be allowable, allocable and economical.

For those goods or services with a price over $100,000 a formal competitive bidding process is required. The procurement process is as follows:

a. The CFS Head Start Director, and/or CEO, or his/her determines the needs of the product

b. The invitation of bids will be publicly advertised (e.g., newspaper, phone calls, internet)

c. Bids are accepted until a specified deadline and then bidding is closed.

d. Bids should clearly state services/requirements that are needed to be filled in order for the bidder to properly respond

e. Clear description of requirements, materials and/or services should be listed

Selection is based on price, quality of product/service, after sales support (where applicable), accessibility, track record of the vendor and whether the company is a small business, minority or women’s business enterprise.

Documented files and records should be maintained for all purchases that are above the small purchase threshold. Records should include:

Cost analysis and records should be maintained for all purchases that are above the small purchase threshold. Records should include:

a. Identification of vendor chosen

b. Basis for contractor selection: Prices and comparisons

c. Justification for lack of competitor

d. Basis for cost and price; provide narrative for selection made

CFS must determine the best candidate from which to purchase items. Documentation of each quote and the rationale for the selection must be maintained with procurement/contract files. Once this is complete a written notice will be written determining the approved bidder and reason for the selection. Documentation should include procedures to ensure settlement and satisfaction of all contractual disputes.

Annual Contracts: CFS HS will follow annual procurement process for those goods/services including but not limited to: food, bulk classroom items, office supplies, paper products, cleaning supplies. Once a vendor has been selected this vendor is used all year.

Records and Audits: CFS will contract with an external auditor to perform a single audit. Single audit includes assessing the grantee agency’s written procurement procedures (including the approvals required, competition process, documentation records required, etc.), and may include reviewing a sample of actual purchases made during the audit year. Ensuring that all records have been documented will be necessary since auditors conduct audits in a different manner.

Procedure for selecting an outside auditor: Define the specific expectations that are required of the CFS Audit, how will they be evaluated, timeline expectations etc. Free and open competition is required when selecting an auditing service.

Once proposal period has ended a selection must be made that is uniform and demonstrates that that the standards are being met and satisfied. Experience and qualifications of the organizations must be sufficient. Once proposals have been evaluated consider price.

Clear documentation must be maintained to show selection process and reasons for choice.

Construction and Major Renovations: CFS Head Start must present a written application to HHS official when plans for construction or major renovations are being completed.

CFS may not advertise for bids or award a contract for any part of construction or major renovation funded by grant funds until the grantee has submitted to the responsible HHS official.

A written certification by a licensed engineer or architect as to technical appropriateness of the proposed construction or renovation and the conformity of the project as shown in the final working drawings and specifications with Head Start programmatic requirements, and a written estimate of the costs of the project by a licensed architect or engineer.

The written plans must include:

a. Legal description of the site and its intended use of the location, services being provided, transportation being provided, other child care or early education collaboration, and all other programs/services;

b. Plans of the structure of the site: number of rooms, lot size, type of structure, playground and or parking lots

c. Written estimate on the proposed renovation/construction. Estimate must be prepared by an architect or engineer (selecting an architect see attachment)

d. Assurance that the new construction complies with local codes and regulations

e. Proposal for length of project, construction to occupancy

Selecting an Architect:

The architect and/or project manager plays a key role in documenting the reasons for awarding a contract to the lowest best bidder rather than the lowest bidder. The architect is important in the entire bidding process. In most cases, the architect and/or the project manager work with the agency's administration in the following:

a. Administrator Director or his/her designee determines the needs for the work

b. Architect will fulfill the requirements excepted of the contract, including, cost efficiency and time frame

c. Provides proper references and is certified and insured.

Davis Bacon Act

SUBJECT: The Davis-Bacon Act and Head Start Programs

A new provision in Section 644(g)(3) of the Head Start Act signed into law by the President on May 18, 1994 requires that all contracts entered into by any Head Start program, on or after October 1, 1994, which are in excess of $2,000 and are for the construction, renovation or repair of buildings used by Head Start programs, are subject to the requirements of the Davis-Bacon Act.

The Davis-Bacon Act requires that any contractor hired to construct, renovate or repair a Head Start facility (if the contract exceeds $2,000) must pay the laborers and mechanics engaged in the construction, renovation or repair prevailing rate wages. These prevailing rate wages are determined by the Department of Labor for each county in the country and are updated, as necessary. The Davis-Bacon Act also includes provisions about fringe benefits to be paid to laborers and mechanics, limitations on wage withholding, and payroll and record keeping requirements.

Cost Allocation Plan Board Approved: July 1, 2010

Purpose / General Statement

The purpose of this cost allocation plan is to summarize the methods and procedures that this organization will use to allocate costs to various programs, grants, contracts and agreements.

OMB Circular A-122, “Cost Principles for Non-Profit Organizations,” establishes the principles for determining costs of grants, contracts and other agreements with the Federal Government. Center For Family Services, Inc. called herein after as CFS. Cost Allocation Plan is based on the Direct Allocation method described in OMB Circular A-122. The Direct Allocation Method treats all costs as direct costs except general administration and general expenses.

Direct costs are those that can be identified specifically with a particular final cost objective. Indirect costs are those that have been incurred for common or joint objectives and cannot be readily identified with a particular final cost objective.

Only costs that are allowable, in accordance with the cost principles, will be allocated to benefiting programs by CFS.

General Approach

The general approach of CFS in allocating costs to particular grants and contracts is as follows:

  1. All allowable direct identifiable costs are charged directly to programs, grants, event etc.
  2. Allowable direct identifiable costs incurred for more than one program are prorated individually as direct costs using a base most appropriate to the particular cost being prorated.
  3. All other allowable general and administrative costs (costs that benefit all programs and cannot be identified to a specific program) are allocated to programs, grants, etc. using a base that results in an equitable distribution.

Beginning July 01, 2010, the following information summarizes the procedures that are used by CFS:

  1. Salaries & Wages for personal service – The compensation is allocated based on timesheet showing time distribution of regular hours worked including Holiday, Sick and Vacation time by each employee for each program or grant. The compensation cost that benefit directly to the program is allocated 100% to that program or grant. The compensation cost that benefit multiple programs or grants is allocated based on approved budgeted allocated compensation among the programs benefited up to total annual compensation. CFS will routinely check allocations and adjust when appropriate. CFS will regularly review staff charges across cost centers to ensure proper allocation. If necessary a time study may be done.

Fringe Benefits: FICA, SUI, UC, Worker’s Compensation, Health, Dental, Life & Vision Insurance, Payroll Administrative Cost, Retirement Benefit etc. are allocated in the same manner as compensation allocated by employee.

  1. Travel Costs: Allocated based on purpose of travel. All travel costs (local and out-of-town) are charged directly to the program for which the travel is pre-approved and incurred as budgeted. Travel costs that benefit directly to its program is charged 100% to that program. Travel cost that benefit more than 1 program is charged as per base that results in equitable allocation and / or budgeted.
  2. Professional Services Costs (Consultants, Accounting and Auditing Services, Contractors and Professional Service Providers): - Allocated to the program benefiting from the service. All professional service costs are charged directly to the program for which the service is incurred. Costs that benefit multiple programs are allocated to those programs based on approved budgeted amount and / or in the equitable ratio of benefit to each program’s expenses to the total of such expenses.
  3. Office Expense and Supplies (including office equipment and postage): Allocated based on usage. Expenses used for a specific program will be charged directly to that program. Postage expenses are charged directly to programs to the extent possible. Costs that benefit multiple programs are allocated to those programs based on program’s approved budgeted amount and / or in the equitable ratio of benefit to each program’s expenses to the total of such expenses.
  4. Equipment: CFS depreciates equipment when the initial acquisition cost exceeds $5,000 per individual item. Items below $5,000 are charged as an expense in the year it is bought. Unless allowed under approved budget by the contracting agency, the cost of equipment purchased is recovered through depreciation. Depreciation costs for equipment used solely by one program is charged 100% directly to the program using the equipment. In case, multiple programs benefits from its use than, an allocation of depreciation costs is based on either pre-approved budgeted dollar amount or percentage of ratio of equitable benefit to multiple programs.
  5. Supplies: Art, Medical, Household, Program, etc. - Expenses are charged 100% directly to programs that benefit from the service. Expenses that benefit multiple programs are allocated based on either pre-approved budgeted dollar amount or % of ratio of equitable benefit to multiple programs.
  6. Business Insurance: General & Professional Liability, Property, etc. – Under the general liability and umbrella policy of agency covering all program and events it operates, the business insurance cost is allocated based on the % of space used by each program at various individual location throughout the agency that benefit to the program. The automobile insurance is allocated directly to various programs based on its direct use by those programs except for general use of vehicle for agency’s all maintenance purpose which is allocated to all programs based on the ratio of total operating cost of program to agency operating cost during the fiscal year. Professional Liability Insurance is allocated.
  7. Telephone/Communications: Land lines, Pagers, Beepers & Cell phones – Telephone cost is charged to programs if easily identifiable office telephones. Internet cost is allocated to programs based on telephone number assigned to each building location in association with % of space used by the program at the location.
  8. Facilities Cost: Mortgage Interest, Property Tax, Repairs & Maintenance, Materials and Supplies, Utilities - Allocated based upon percentage of square footage used by the program. Facilities costs related to general and administrative activities are allocated to program based on the ratio of each program’s total expenses to agency’s total expenses.
  9. Staff Trainings / Conferences / Seminars / Dues & Subscriptions etc.: Allocated to the program benefiting from the training, conferences or seminars. Costs that benefit multiple more than one program will be allocated to those programs based on the ratio of either attendance of personnel from those programs and / or based on benefit received by each program on an equitable basis.
  10. Other Costs (including advertisements, bank fees, licenses, miscellaneous, etc.) - Allocated to the program benefiting from the particular costs. Costs that benefit all programs will be allocated based on the ratio of each program’s expenses to agency’s total expenses.
  11. Unallowable Costs: Costs that are unallowable in accordance with OMB Circular A-122, including alcoholic beverages, bad debts, advertising (other than help-wanted ads), contributions, entertainment, fines and penalties. Lobbying and fundraising costs are unallowable, however, are identified and recorded as a separate line item expenses as per its nature of activity and off set against revenue, if any, from the same nature of activity in a separate program outside general and administrative expenses of the agency.
  12. General and Administrative Costs (Indirect): All indirect costs are equally charged across programs based on the percentage of the total expenses of the program compared to the total agency budget.

Council on Accreditation Financial Management Standards

Introduction

Sound financial management begins with an organization’s commitment to providing high quality services relative to its mission or purpose. Leadership creates a culture of honesty and ethics in all areas of organizational practice, including the management of the organization’s finances and the manner in which it conducts financial affairs. Accountability is established through clearly defined lines of authority and responsibility, and personnel receive a clear message from the top that internal control responsibilities are to be taken seriously. Additionally, the attention and commitment of the governing body and its audit committee to their fiduciary responsibilities are essential to ensuring that the organization’s financial practices enable it to achieve operational effectiveness and efficiency, accurate and reliable financial reporting, and compliance with applicable laws and regulations.

FIN 1: Governing Body Financial Responsibilities

CFS Board of Trustees:

a. approves the annual budget and any revisions to the budget;

b. reviews fiscal summaries at least quarterly to evaluate expenditures against revenues;

c. ensures that budget-to-actual variance analyses are performed after year end numbers are finalized;

d. reviews fiscal policy and the recommendations of the organization’s auditors; and

e. annually evaluates the executive director’s management of the organization’s fiscal affairs.

FIN 2: Internal Control Environment

CFS establishes an internal control system that includes mechanisms for:

a. review by the governing body’s audit committee, as applicable;

b. management review by more than one individual;

c. assurance that management directives are carried out;

d. prevention of error, mismanagement, or fraud;

e. safeguarding and verification of assets; and

f. segregation of duties to the extent possible.

FIN 3: Financial Risk Assessment

The governing body and management evaluate the organization’s financial capacities, risks, and resources needed to provide services.

FIN 4: Stable Predictable Revenue

CFS pursues stable, predictable sources of revenue through diversification and balance of funding streams consistent with CFS’ mission and programs.

FIN 5: Financial Planning

Planning for the current fiscal cycle is organization-wide and involves key stakeholders.

FIN 5.01 An annual budget serves as a plan for managing CFS’ financial resources.

FIN 5.02 The budget planning process includes participation of management, the governing body, and other relevant organization participants and is base on:

a. direct and indirect operating expenditures;

b. contractual requirements;

c. performance improvement data;

d. changing costs and conditions; and

e. anticipated revenue for the program year.

FIN 5.03 The President / CEO reports to the Board of Trustees on CFS’ finances including:

a. current financial status and any anticipated problems; and

b. financial planning and funding alternatives.

FIN 5.04 Financial information is routinely analyzed and the information includes:

a. monthly analysis of financial performance against budget projection with budget-to-actual variance analyses performed on interim financial statements of activities;

b. service revenues and actual service delivery costs; and

c. an annual inventory of significant assets, including securities.

FIN 5.05 CFS conducts a cost analysis of its various services and can identify:

a. the fixed and variable costs of each unit of service at each program and service delivery site;

b. the average costs or charges of treatment for identified groups of consumers; and

c. the contribution of services to the overall revenue base.

FIN 5.6 The cost analysis is conducted at intervals established by CFS and the information is used to:

a. analyze operational effectiveness and efficiency;

b. monitor trends, current experiences, and changes in costs;

c. budget for the current fiscal cycle.

FIN 6: Financial Accountability

CFS is accountable for the management of its finances to its Board of Trustees, the community, and applicable regulatory bodies.

FIN 6.01 Upon request CFS provides an annual report of fiscal, statistical, and services data that includes summary information regarding its financial position.

FIN 6.02 The non-profit organization with annual revenues at, or in excess of $500,000, undergoes an audit of its financial statements within 180 days of the end of the fiscal year by an independent, certified public accountant approved by the Board of Trustees.

FIN 6.03 NA

FIN 6.04 The Board of Trustees has an independent audit committee that:

a. selects an independent auditor;

b. meets with the auditor to review the findings of the audit, accompanying financial information, and any accompanying management letter;

c. formally accepts the auditor’s report within 180 days of the close of the fiscal year;

d. reports the findings and makes recommendations at the next official meeting of the Board of Trustees;

e. works in partnership with the President / CEO to promptly act on recommendations in the management letter, if any; and

f. does not include organization staff.

FIN 6.05 The organization that undergoes a review of financial statements meets with the reviewing CPA to discuss findings and the management letter, as applicable, and promptly acts on recommendations.

FIN 6.06 The President / CEO and financial officers certify in writing that financial statements are accurate and fairly represent the financial condition and operations of CFS. (Review IRS Form 990 before it is submitted to ensure that it is accurate, complete and filed on time)

FIN 7: Financial Management System

Positive financial outcomes are achieved through a financial management system that receives, disburses, and accounts for funds consistent with sound financial practices.

FIN 7.01 Annual financial statements are prepared in accordance with Generally Accepted Accounting Principles.

FIN 7.02 CFS’ financial reporting system is capable of providing information that:

a. is useful in making business and economic decisions;

b. is understandable and will aid in predicting future cash flows; and

c. includes data about CFS’ economic resources, claims to those resources (obligations), and the effects of transactions, events, and circumstances that changes resources and claims to resources.

FIN 7.03 Accounting practices and procedures include:

a. prompt, accurate, and complete recording of revenues and expenses;

b. an inclusive and descriptive chart of accounts;

c. information on all funds, including source information and pertinent regulations;

d. timely payment of financial obligations;

e. policies for recognizing revenues and expenses; and

f. disbursement and receipt of monies.

FIN 7.04 CFS seeks to conserve its fiscal resources by:

a. taking advantage of tax exemptions, where applicable;

b. maintaining sound practices regarding purchasing and inventory control;

c. coordinating the purchase of goods and services among internal divisions; and

d. using competitive bidding, when applicable, according to governing body policy and law or regulation.

FIN 7.05 Accounting records are kept up-to-date and balanced on a monthly basis, as demonstrated by:

a. reconciliation of the bank statement and subsidiary records to the general ledger;

b. up-to-date posting of cash receipts and disbursements;

c. monthly updating of the general ledger; and

d. review of the bank reconciliation by at least two personnel, one of whom is not involved in maintaining the accounting records.

FIN 7.06 CFS uses the accrual method of accounting, at least at the end of the year.

FIN 7.07 Oversight and management of CFS’ accounting system require:

a. a fiscal officer of business manager who is responsible for maintaining the financial accounts has prior accounting and bookkeeping experience, and / or an accounting degree, CPA credential, or other recognized accounting / financial certification, as appropriate to the size and complexity of the organization;

b. all personnel who use the system to receive initial and ongoing training on its use;

c. a proper audit trail; and

d. secure access, controlled by user IDs, passwords and permissible logon times.

FIN 7.08 Where applicable, CFS makes timely payments to, or provides proof of exemption from, the following taxing authorities:

a. the IRS;

b. state and local employment tax bodies;

c. FICA; and

d. property tax assessors.

FIN 7.09 If CFS assumes fiduciary responsibility for client funds, or disburses client or non-fee-for-serviced funds to service recipients:

a. segregates client funds; and

b. complies with applicable legislative, regulatory, judicial, and governmental requirements.

FIN 7.10 If CFS provides services as a vendor, it establishes safeguards against over- and under-billing that include:

a. an accurate account of units of service provided;

b. timely submission of invoices and requires documents; and

c. compliance with applicable regulations.

FIN 7.11 The organization determines the basis for any denial of coverage or payment under insurance or contractual arrangements and follows up with timely appeals and communication with the service recipient, as applicable.

FIN 7.12 NA

FIN 7.13 NA

FIN 8: Payroll

Payroll practices comply with federal and state wage and hour laws.

FIN 8.01 Payroll practices include:

a. review and approval of payroll expenditures;

b. documentation of changes in time and overtime records;

c. authorization of payment for new hires and severance for terminations;

d. oversight for mandatory deductions and pay rates; and

e. separation of payroll funds.

 

FIN 8.01 CFS assures annual reconciliation of gross pay, FICA withheld, and employer FICA with Federal Forms W-2.

Cash Reserve Fund Policy Board Approved 2014, June 18, 2014

Purpose:

The purpose of the reserve funds policy for CENTER FOR FAMILY SERVICES is to ensure the stability of the mission, programs, employment, and ongoing operations of the organization and to provide a source of internal funds for organizational priorities such as building repair and improvement, program opportunity, capacity building, and ongoing day to day operation.

The reserves fund policy will be implemented in concert with the other governance and financial polices of CENTER FOR FAMILY SERVICES and is intended to support the goals and strategies contained in these related policies and in strategic and operational plans.

Definitions and Goals

Operating Reserve Fund (Unrestricted):

The operating reserve fund is intended to provide an internal source of funds for situations such as a sudden increase in expenses, one-time unbudgeted expenses, unanticipated loss in funding, or uninsured losses including setting aside temporary advance payment of funds by the funder. Funds for operating reserves are not intended to replace permanent loss of funds or eliminate an ongoing budget gap. It is the intention of CENTER FOR FAMILY SERVICES for operating reserves funds to be used and replenished within a reasonably short period of time. The operating reserve fund is defined as unrestricted reserve fund set aside by action of the Board of Trustees at the request of President/CEO. The minimum amount to be designated as operating reserve fund will be established in an amount sufficient to maintain ongoing operations and programs excluding temporary advance payment of fund by the funder measured for a set period of time, measured in months. The operating reserve fund serves a dynamic role and will be reviewed and adjusted in response to both internal and external changes.

The target minimum operating reserve fund is equal to three months of average operating costs amounting to approximately $6 million at present time. The calculation of average monthly operating costs includes all recurring, predictable expenses such as salaries and benefits, occupancy, office, travel, program, and ongoing professional and program services. Depreciation, in-kind, and other non-cash expenses are not included in the calculation.

The amount of the operating reserve fund minimum target will be calculated each year after approval of the annual budget, reported to the Finance Committee/Board of Trustees, and included in the regular financial reports.

Building and Capital Asset Reserve Fund (Unrestricted):

The Building and Capital Asset Reserve fund is intended to provide a ready source of funds for acquisition of property, leaseholds purchases, furniture & fixtures, and equipment necessary including major self-funded capital improvements for the effective operation of the organization and programs.

The target amount of the Building and Capital Asset Reserve fund will be determined by the Finance Committee of the Board of Trustees and President/CEO of Center for Family Services, Inc. The target amount of such reserve fund will be $500,000 at present time. The initial amount is set aside at $50,000 plus a regular monthly installment of $5,000 in such designated account. The amount shall be reviewed and determined based on agency’s most recent year end operational performances.

Opportunity Reserve Fund (Unrestricted):

The opportunity reserve fund is intended to provide funds to meet special targets of opportunity or need that further overall mission of organization which may or may not have specific expectation of incremental or longterm increased income. The opportunity reserve is also intended as a source of internal funds for organizational capacity building such as staff development, research and development, or investment in infrastructure that will build long-term capacity.

The target amount of the opportunity reserve will be determined by the Finance Committee of the Board of Trustees and President/CEO as and when such opportunity exists from time to time. The target amount of such reserve fund will be $500,000 at present time. The initial deposit of $25,000 is to be set aside plus a regular monthly installment of $5,000 in such designated account. The amount shall be reviewed and determined based on agency’s upcoming opportunity needs.

Accounting for Reserve Funds:

The reserve funds will be recorded in the agency’s financial records as reserve fund by title along with account number XXXX1234 and account balance. The reserve fund will be funded and available in cash or cash equivalent funds. Each reserve fund will be titled and maintained in a segregated bank account or investment fund, in accordance with investment policies.

Funding of Reserves:

The operating reserve fund will be funded out of surplus from year end performance of all program operation including advance payment received from the funders. The Board of Trustees may from time to time direct that a specific source of revenue be set aside for operating reserves. Examples could include one-time gifts or bequests, special grants, or special appeals.

The Building and Capital Assets Reserve shall be funded by setting aside funds received from any capital campaigns or similar appeals or setting aside the equivalent amount of cash equal to at least 25% of depreciation in the annual budget or other calculations.

The opportunity reserve fund will be funded with occasional special designations made by the Board of Trustees at the request of President/CEO.

Use of Reserves Funds:

Use of the operating reserves requires three steps:

1. Identification of Appropriate Use of Reserve Funds

The President/CEO and staff will identify the need for access reserve funds and confirm that the use is consistent with the purpose of the reserves as described in this Policy. This step requires analysis of the reason for the shortfall, the availability of any other sources of funds before using reserves, and evaluation of the time period that the funds will be needed and replenished.

2. Authority to Use Reserves

The President/CEO will have authority to use, move funds or withdraw funds once Board of Trustees approves to pay for program opportunity, capital improvement and / or acquisition of property etc. excluding advance payment of funds against contract. The President/CEO will authorize person in charge of handling day to day finance of agency to withdraw, move or use necessary funds when such need arises.

Relationship to Other Policies:

CENTER FOR FAMILY SERVICES shall maintain the following board-approved policies, which may contain provisions that affect the creation, sufficiency, and management of the reserve funds.

  • Fiscal Policy
  • Contingency or Disaster Preparedness Plan
  • Investment Policy

Review of Reserve Fund Policy:

This Policy will be reviewed every other year, at minimum, by the Finance Committee. Changes to the Policy will be recommended by the Finance Committee to the Board of Trustees.

Effective Date: July 01, 2014

File: Cash Reserve Policy 2014.docx

Development & Public Relations

Strong and strategic communication, marketing, and fundraising efforts are essential for a healthy nonprofit organization. At Center For Family Services our Development and Public Relations Department is here to assist and support the work of our staff so they can focus on providing the best services possible to the children, families, and individuals in our community.

The Development and Public Relations team works hard to create, promote, and protect the identity of our organization and its programs by establishing consistent messages throughout the agency and to our clients and the community. By collaborating with program staff on marketing materials, campaigns, events, and volunteer recruitment the Public Relations Department is able to assist our programs spread the great work of Center For Family Services throughout the community.

The Development and Public Relations team also plans and implements an integrated communication and fund development approach to individuals, businesses, corporations and foundations, organizations and other possible funding areas. The overall intent of our Development Department is to build a diversified funding base to enhance Center For Family Services philanthropic capacity, and as a result, increase financial support for the agency in the future.

As with all Center For Family Services’ administrative departments, the Development and Public Relations Departments have policies, protocols, and guidelines that must be followed by all staff in order to facilitate a smooth and clear communication, marketing, and fundraising plan.

In the following pages, you will find information to help you and your staff carry out the communication, marketing, volunteer and fundraising efforts of your program and Center For Family Services.

If you need additional information or clarification on any of the following policies, protocols, and guidelines please contact the Associate Vice President of Public Relations.

Branding

Branding is the way our clients, funders, donors, and community partners perceive us. Branding goes way beyond our logo, flyers and brochures. Our brand is the entire consumer experience: our website, social media interactions, the way we answer the phone, the way our clients experience our staff and services.

Our staff is our greatest piece of branding, and it’s imperative that we work together to convey it appropriately and consistently to our clients, funders and donors, and community partners. 

For an overview of Center For Family Services brand, please review our branding video.

Logo

The cornerstone of our brand is our logo. The Center For Family Services logo creates recognition within the community and should be used on all pieces of communication including but not limited to; agency and program purchased giveaways, clothing and merchandise, flyers, brochures, business cards, letterhead, and referral forms.

Staff are strictly prohibited from altering or recreating Center For Family Services’ logo.

For visuals on how to correctly use our logo or to download the Center For Family Services logo visit https://www.centerffs.org/staff/staff-forms/developmentpr

Stationary – Letterhead

Appropriate use of agency approved stationary such as letterhead is also required by all staff. Center For Family Services approved letterhead is a primary means of communication with donors, funders, employees, and community partners. It is essential that the use of it positively reflects the mission and vision of the organization. Our letterhead plays an important role in communicating our brand image.

Center For Family Services letterhead should only be used for letters, any other usage is strictly prohibited.

To download a copy of Center For Family Services’ letterhead, please click here.

Email and Phone Etiquette

A family's, donor's, or a community partner’s first interaction with staff at Center For Family Services is one they will always remember. Their first impression should be one that is warm, welcoming, and helpful. It should be an interaction that makes the family feel comfortable, the funder or donor feel appreciated, and the community partner want to collaborate. Interactions with these individuals from the community and others should always be positive, a direct reflection of our brand. These interactions also include staff email etiquette, voicemail recordings, and phone interactions.

In an effort to be consistent in our communications as an agency, Center For Family Services has defined a policy regarding email signatures, voice mail greetings, and answering agency phones. All Center For Family Services staff are required to follow these policies.

Standard Staff Email Signature

Staff are required to use a standard Center For Family Services signature line in their emails. The standard signature for all staff is below. Staff should avoid adding any background colors or images to their email signature.

The steps for creating a signature line vary depending on whether you use Gmail or Outlook to access your email. If you use Outlook, the steps are dependent on the version of Microsoft Outlook you use.

Standard Staff Email Signature (use a standard font such as Arial, Calibri or Times New Roman/no italics):

First/Last Name
Pronouns (optional)
Job Title
Center For Family Services
Address/Location (optional)
Email address
P: (work phone)
C: (cell phone – required to include this if you have an agency cell number)
F: (fax)
centerffs.org

Follow Center For Family Services on Facebook! (optional)

This communication, including attachments, is confidential, may be subject to legal privileges, and is intended for the sole use of the addressee. Any use, duplication, disclosure or dissemination of this communication, other than by the addressee, is prohibited. If you have received this communication in error, please notify the sender immediately and delete or destroy this communication and all copies.

Voice Mail Greeting for Agency Cell Phones and Office Phones

(3 options to choose from)

Cell Phones & Office Phones:

Hello/Hi. Thank you for calling Center For Family Services. You have reached the voice mail of (Your First/Last Name, Your Job Title/Program) with Center For Family Services. Please leave your name and phone number and a brief message and I will return your call as soon as possible. Thank you and have a great day.”

Hello/Hi. You have reached the voice mail of(Your First/Last Name, Your Job Title/Program) with Center For Family Services. I am not available to take your call at this time, but please leave your name and phone number and a brief message and I will return your call as soon as possible. Thank you and have a great day.”

Hello/Hi. Thank you for calling Center For Family Services. You have reached the voice mail of (Your First/Last Name, Your Job Title/Program). Please leave your name and phone number and a brief message and I will return your call as soon as possible. If you need immediate assistance, please contact (xx at xxx-xxx-xxxx). Thank you for calling and have a good day.

Office Phones (for staff with agency cell phones):

”Hello/Hi. Thank you for calling Center For Family Services.You have reached the voice mail of (Your First/Last Name, Your Job Title/Program). I am not available to take your call at this time, but please leave your name and phone number and a brief message and I will return your call as soon as possible. Or, feel free to reach me on my cell phone at (xxx-xxx-xxxx).Thank you.”

*Optional statement to include after you state your name: “If this is a true emergency please hang up and call 911 or go to your nearest crisis center. If this is not an emergency please leave me a message and I will return your call as soon as possible. Thank you.

Answering Phones at Center For Family Services

When you answer the phone, be warm and enthusiastic. Your voice on the phone is the first impression of Center For Family Services the caller will get. Speak clearly and slowly, so the caller can understand you easily, and project a cheerful/upbeat tone. The following are the options for answering phones at Center For Family Services:

Good Morning/Good Afternoon/Hello/Hi...Center For Family Services. (Your First/Last Name) speaking. How may I help you?

Good Morning/Good Afternoon/Hello/Hi. (Your First/Last Name) speaking.

Good Morning/Good Afternoon/Hello/Hi...This is (Your First/Last Name).

Hello/Hi…Center For Family Services, XXX Department, Can I help you?

In the following sections you will read more about agency branding procedures as they apply to marketing materials, social media, donations, and fundraising.

Marketing Materials and Promotional Items

Marketing materials are an important means of communication and design necessary to promote your program and the agency as a whole to future and current clients, funders and donors, and community partners. The Public Relations Department is available to assist in the creation and production of the following types marketing materials and promotional items:

  • Brochures
  • Flyers
  • Referral forms
  • Giveaways (totes bags, pens/pencils, notebooks, ceramic mugs, acrylic cups, etc.)
  • T-shirts
  • Gear including clothing and outerwear items of all kinds
  • Lawn Signs
  • Banners
  • Palm Cards
  • Program calendars
  • Newsletters
  • PowerPoint Presentations
  • Tablecloths

Program staff are strictly prohibited from designing and producing any marketing materials promoting their program and/or Center For Family Services. All marketing materials and promotional materials must be reviewed and approved by the Public Relations Department before being distributed to the community.

If you are interested in producing marketing materials or promotional materials for your program, please contact the Public Relations Department to set up a meeting.

Any items created and produced will be charged to the requesting program’s budget.

Please allow for a 1-3 week turnaround time for the creation and production of your requested items.

Media/Social Media

Some of the best ways to promote the great work we do at Center For Family Services is through the media. Print and online newspapers, blogs, local news outlets, billboards, radio, and the various social media platforms provide our organization with the opportunity to share our successes, fundraisers, collaborations and so much more.

The Public Relations Department has worked hard to form solid relationships with local media outlets. When appropriate, the Public Relations Department will reach out to the media to pitch stories, event coverage, Public Service Announcements, and other approved communications. It is important to understand that under no circumstances should staff be reaching out to any media outlets to share information about the work of Center For Family Services. If your program has an upcoming event, success story, Public Service Announcement, or other message that staff feel should be shared with the media please contact the Public Relations Department immediately. They will vet the request and determine if and how it will be shared with media contacts.

Media Protocol

In the instance that a reporter or media contact reaches out directly to staff for comment about Center For Family Services, staff must follow the following Media Protocol.

  1. Thank the person for calling.
     
  2. Take callers name, number, and email address. Find out from where they are calling.
     
  3. Let the person know one of our Associate Vice Presidents will call them back.

“Thank you for your call. May I please take your name, phone number, and email address.”
“May I ask where you are from?”

“One of our Associate Vice Presidents will be in touch with you. Thank you for your call.”

If a reporter is particularly persistent, you may state, “I am not a spokesperson for Center For Family Services, but I will be sure to have one get in touch with you quickly."

      4. Never say, “No Comment".

  1. Do not give any information.
     
  2. Remain calm, polite, and pleasant. Do not appear defensive or fearful.
     
  3. Contact Jen Hammill, Vice President of Development and PR, immediately via phone at (609) 238-1271 or email – to inform her of the call and to share the caller’s contact information. Or, contact Mary Beth Woodward, Associate Vice President - Communications at (609) 977-6332 or [email protected]

Client Photos and Video

Protecting our client's confidentiality is vital to the work we do at Center For Family Services.Taking photos and video of client's is prohibited unless the activity is monitored by the Public Relations Department. In the event photos and videos are produced in conjunction with the Public Relations Department, clients must read and sign the Media Consent Form. If a client is under the age of 18, a parent/guardian must sign the form. A copy of the signed form should be placed in the client's file, the original should be either emailed or interoffice to the Public Relations Department.

Photos and video produced with the involvement of the Public Relations Department may be used in any of the following Center For Family Services media: website, social media platforms, brochures, flyers, annual reports, success stories, etc.

The Media Consent form may be downloaded here.

Social Media

At Center For Family Services we engage our donors, employees, funders, and community partners beyond the walls of our sites; you can find Center For Family Services on Facebook, Twitter, Instagram, YouTube, and our website, centerffs.org. These guidelines will give you a better idea on how to engage with us on social media, best practices on both your personal and organization social media accounts, and what to do if you’re interested in creating a program social media account.

Our social media handles

Twitter: @centerffs

Facebook: @centerffs

Instagram: @centerffs

LinkedIn: Center For Family Services

 

Guidelines for an individual employee’s personal use of social media

As a Center For Family Services employee, you are viewed by our clients, partners, and other outside parties as a representative of Center For Family Services. Whether or not you specifically reference or discuss your work, your participation on social media platforms is a reflection on Center For Family Services.

  • Honor Our Differences. Center For Family Services will not tolerate discrimination (including age, sex, race, color, creed, religion, ethnicity, sexual orientation, gender identity, national origin, citizenship, disability, or marital status or any other legally recognized protected basis under federal, state, or local laws, regulations or ordinances).
  • Social media is a place to have conversations and build connections, whether you're doing it for Center For Family Services or for yourself. The connections you'll make on social media will be much more rewarding if you remember to have conversations rather than push agendas.
  • Everything you post online can be traced back to you, so be sure what you post is appropriate before you post it. Your post may be shared with others and archived even if you delete it later. Even if you put something in your bio about your content being just your own that may not stop someone else online from complaining about your activity and noting that you work for Center For Family Services.
  • Be conscious when mixing your business and personal lives. Online, your personal and business personas are likely to intersect. Center For Family Services respects the free speech rights of all of its employees, but you must remember that clients, partners, colleagues and supervisors often have access to the online content you post. Keep this in mind when publishing information online that can be seen by more than friends and family, and know that information originally intended just for friends and family can be forwarded on. Remember NEVER to disclose non‐public information of Center For Family Services (including confidential information), and be aware that taking public positions online that are counter to Center For Family Services interests might cause conflict.
  • When in doubt, do not post

Click here to view Center For Family Services Internet & Social Media Policy.

 

Internet Use During Work Hours

As is stated in the agency’s “Computer Usage Policy”, employees are generally not permitted to use the internet during work hours for personal reasons. This includes accessing social networking websites from a work computer or another device while at work for personal reasons.

 

Discussion of Work-Related Activities in Agency, Personal Profiles, or Blogs

Center For Family Services Staff should refrain from discussing work-related activities in personal blogs and on all social media platforms including Facebook profiles, Instagram accounts, LinkedIn profiles, and Twitter accounts. Discussing work-related activities, in some cases, may be violation of privacy laws as well as other regulations. Staff should not discuss confidential information within private messages on these sites.

Staff are prohibited from making false or defamatory statements about the agency, any of its employees, or its clients on personal and agency social networking sites.

Staff may not post pictures or other identifying information of clients, their families, or Center For Family Services staff on personal and agency social networking sites unless prior permission is granted.

Prior permission must be obtained through the Public Relations department and with the use of the agency’s Media Consent form.

 

Interactions with Clients on Social Networking Websites

Employees should not befriend or otherwise interact with current or former clients on their personal social networking websites. This is a clear violation of ethical standards and is strictly prohibited.

In most situations, staff does not maintain communication with former clients. If such communication is appropriate or deemed necessary, it must be with the knowledge and oversight of the supervisor. Staff is only permitted to correspond with current clients through agency email, phone, or in person; communication through social networking sites or personal email is prohibited. Professionally licensed employees should also review the ethical standards relating to the nature of interactions with former clients and the time frames relating to such interactions.

 

Interactions with Coworkers on Social Networking Websites

Employees should exercise discretion in befriending or interacting with co-workers on social networking websites. Employees should be aware that in some cases, courts have found employers and their employees liable for conduct that occurred outside of work in some employment-related cases.

Supervisors are discouraged from befriending or interacting with supervisees on social networking websites. Such interactions blur professional boundaries and may result in liability to the supervisor and the agency.

Employees and supervisors may choose to befriend each other on professional networking websites such as LinkedIn. Contacts must be limited to the purpose of professional development and networking information should accurately represent one’s scope of responsibilities and position within the agency.

 

Consequences of Violations

Information posted on social networking websites is considered public. As such, violations of the above stated policies or current law regarding false, misleading, or defamatory information will lead to corrective action up to and including termination.

 

Center For Family Services’ Twitter Engagement Guidelines

Twitter asks a very basic question of its users: “What’s happening?” And we know the answer to that question – we’re working every day to help people live better lives.

Through our Twitter account we aim to provide employees, partners, donors, funders, and volunteers with information on Center For Family Services’ major activities and initiatives – from Project Backpack and the Holiday Gift Project to success stories, the services we offer, and the relationships we’re building in the community.

We invite Center For Family Services employees to follow us on Twitter, engage in conversation, and help us spread the word about the great services we offer.

Here are a few things you should know about our Twitter engagement:

  • Our Official Center For Family Services Twitter team is responsible for engaging followers through our page. To avoid confusion, we ask that you not attempt to respond to inquiries or comments directed specifically to Center For Family Services or asking for an official agency response on this site. We also ask that no employee, volunteer, or program creates their own Twitter account to represent their specific program unless vetted and approved by the Public Relations Department.
  • We are committed to having a dialogue with our followers. We count on you to use @ messages in a way that contributes to the dialogue.
  • We strive to respond to as many relevant questions and comments as possible, but we reserve the right to use our judgment in selecting the messages we respond to.

 

Center For Family Services’ Facebook Engagement Guidelines

We are excited that you are interested in joining us on our Facebook page! At Center For Family Services, our purpose is to help families, individuals, and children in our community live self sufficient, productive lives. Our Facebook page is used to connect community members to our mission; recruit and inspire volunteers, promote events and campaigns, educate our “Fans” about our various programs, share our successes, and connect with our partners. We invite each and every one of our employees to “Like” and “Follow” our Facebook page as an easy way to stay connected to updates and news throughout the agency. We ask all Center For Family Services staff to follow these guidelines:

 

  1. Know the rules. Before engaging in Facebook, or any other social media property, make sure you read and understand Center For Family Services’ Social Media policy. In any and all interactions make sure that you don’t share confidential or private information about the agency’s business operations, services, or clients; respect financial disclosure laws; and do not say you speak for Center For Family Services without express written authorization from the agency to do so.
  2. Remember that we have a dedicated FB team tasked with sharing pictures, news, stories, updates, etc. Our Official Center For Family Services Facebook team is responsible for engaging donors, partners, community members, volunteers, and employees through our page. To avoid confusion, we ask that you not attempt to respond to inquiries or comments directed specifically to Center For Family Services or asking for an official agency response on this site. We also ask that no employee, volunteer, or program creates their own Facebook page to represent their specific program (exceptions are noted below and include further guidelines and expectations). To best represent Center For Family Services’ continuum of care and to show our breadth of services it is important that only one agency Facebook page exists.
  3. Consider using company established channels for job-specific issues. While we encourage employees to join our Facebook community and participate in conversations with our other

users, we encourage you to direct your complaints or concerns about your job or working environment to your supervisor. We encourage staff to review Center For Family Services’ Grievance Policy for further questions regarding the reporting of complaints and concerns in the workplace.

 

Center For Family Services’ Instagram Guidelines

Instagram allows Center For Family Services to share our stories of vision, hope, and strength in a visual way. Our Instagram page is used to share stories of success, connect with and thank donors, highlight our staff’s work, and promote upcoming events and campaigns. We invite all staff to follow us on Instagram and engage with our posts and stories. We ask all staff to follow these guidelines:

 

  1. Review and follow Center For Family Services’s employee social media guidelines. Keep these in mind while using social media and be sure to avoid discussing confidential and private information related to agency’s business operations, clients, and services.
  2. Do not respond to inquiries or comments specifically directed toward Center For Family Services. Our Instagram team is available to handle these matters as they arise. The team is also responsible for sharing photos, stories, and other updates. If you have approved photos you’d like included on the agency’s Instagram page, please forward to a member of the Public Relations team.
  3. We encourage all Center For Family Services’ employees to engage with our interactive Instagram stories but reserve the right to use judgement in selecting those we highlight.

 

Center For Family Services LinkedIn Engagement Guidelines

Specifically aimed at professionals, LinkedIn encourages you to tell others about the work you do and share your passion. Through the social networking site, users can add people as contacts and send them messages, update their personal profiles to notify contacts about their activities, and can join groups in order to communicate with other professionals within the same sector.

Additionally, LinkedIn is both an expression of your personal brand, as well as our organization’s brand. In order to ensure all actions on LinkedIn are aligned and consistent with the organization’s core values, we have come up with a few guidelines to provide helpful and practical advice for you when operating on LinkedIn as an identifiable employee of Center For Family Services.

 

LinkedIn Guidelines:

  1. Understand existing policies. Know and follow Center For Family Services’ employee social media guidelines.
  2. Identify yourself. Add Center For Family Services and your current role to the “Experience” tab of your personal LinkedIn profile; doing so automatically makes you a follower of our Company Page and enables you to easily share organization updates.
  3. Be aware of your association with Center For Family Services. Ensure your profile and related content is consistent with how you wish to present yourself with colleagues and managers. Networking information should accurately represent one’s scope of responsibilities and position within the agency.
  4. Interact with coworkers. Employees may choose to befriend each other on professional networking websites such as LinkedIn. Contacts must be limited to the purpose of professional development.
  • Protect confidentiality. It is important that you do not disclose confidential information belonging to Center For Family Services, partners, and/or the individuals we serve. We strive to maintain privacy and confidentiality and do not want to risk violating this.
  1. Respect your audience. Remember that Center For Family Services is an organization whose employees and program participants reflect a diverse set of customs, values, and point of views. With that in mind, do not use slurs, discriminatory remarks, and obscenities or engage in any similar conduct that would not be appropriate or acceptable at Center For Family Services’ workplace.
  2. Use your best judgment. Always use good judgment and common sense in deciding what you publish. If you are about to publish something that you’re unsure about and it is related to Center For Family Services daily operations, please feel free to discuss with the Development/Public Relations Department prior to posting.
  3. Add value. Center For Family Services is best represented by its staff and everything you publish online reflects upon it. We encourage you to not only share content published by our Company Page, but to also add your unique perspective and insight, and share brand-boosting stories that are best told by you, the social change agent.
  4. Foster community. We are an organization of over 1,000 employees, but even more important, we are one team. We encourage you to connect with your colleagues on LinkedIn and actively promote each other, share congratulations on one another’s achievements, and affirm co- workers’ skills by providing LinkedIn endorsements.

Through LinkedIn interactions and activities, Center For Family Services’ most valuable asset – the expertise of its staff – can be shared with partners, professionals, and the communities in which we operate. LinkedIn offers the opportunity for our staff network to be aware of and participate in the sphere of information and idea exchange.

 

Additional Center For Family Services Facebook Pages, Twitter Accounts, and Instagram Accounts

We understand that certain circumstances allow for additional Center For Family Services’ programmatic social media accounts. Examples may include a requirement in a grant or funding or a special initiative that focuses on a certain demographic or population. Before starting your own page, please contact the Public Relations Department and your Vice President for approval. Public Relations will share the Social Media Manual and work together with you to discuss the pros and cons of creating an account, tips for success, guidelines, page goals and more. By exploring these concepts, the Public Relations team and the program will determine if a program social media account is the best outcome.

 

If your request to create a program social media account has been approved, the following guidelines and expectations are required:

  • The page must clearly mention that its initiative falls under Center For Family Services umbrella of services:
    • Center For Family Services logo must be visible in the cover photo
    • Center For Family Services must be mentioned in page description
  • The page must follow Center For Family Services social media accounts and promote Center For Family Services posts and events (if applicable).
  • Public Relations Department must be made an Administrator of your page so it can track its usage or posts.
  • The page should refrain from posting controversial or offensive language that may tarnish Center For Family Services image.
  • If a staff member who has access to social media account becomes unemployed by Center For Family Services, the Public Relations Department must be notified immediately so that the employee is removed as an administrator from the account.
  • Photos of clients and community members may only be posted on social media accounts if a Media Consent form has been signed and turned into the Public Relations Department.

We ask that all staff that have administrative access to a Center For Family Services run social media account uses good judgment when posting statuses, photos, hashtags, etc. These accounts represent the image of the agency and should always reflect our mission and vision.

If at any time the page no longer falls in line with the agency’s initiatives or if the page doesn’t follow guidelines and expectations, the Public Relations Department has the authority to disable the account.

 

Special Events

Special events are a great way to raise much needed awareness and funds for the services we operate at Center For Family Services.

Throughout the year, Center For Family Services Public Relations and Development Departments assist with various sizes and types of events that benefit both the organization and specific programs.

Any programs interested in planning a special event to benefit their program must contact the Public Relations and Development Departments before any plans have been made to discuss event ideas, reason(s) you are interested in hosting the event, and a sample budget of event expenses.

The Event Planning Application must also be filled out and submitted to the Public Relations Department if you are interested in hosting an event. 

The following procedures must be followed when requesting to host an event:

  • Program Directors should fill out the Event Planning Application. Upon review of the form, the Program Associate Vice President with the assistance of the Public Relations and Development Departments will decide to either approve or deny the request.
  • In limited circumstances, the Public Relations Department will allocate resources to internal program events. This will be decided upon between the Public Relations Department and the Associate Vice President over-seeing the program hosting the event. Once approved, internal program events are coordinated by the program.
  • Any media outreach should be coordinated through the Public Relations Department.
  • Employees should be prepared to follow the risk-prevention and safety measures while planning and hosting an event. Staff should review the Event Safety Checklist to be sure they are complying with Center For Family Services Operations Department’s safety guidelines. The Event Safety Checklist is to be reviewed thoroughly by the program director and program staff. If questions arise regarding safety, the Operations Department should be contacted immediately upon reviewing.

Event Approval Process

Please submit the Event Planning Application to your program’s Associate Vice President and the Public Relations and Development Departments either by email, mail or interoffice mail a minimum of 60 days prior to your event/activity.

You will be contacted with any questions or comments that may result from the evaluation of your application. Please do not move forward with the coordination of your event until you have received a copy of the signed approval.

Internal Event Guidelines

In order to ensure that all events are keeping within Center For Family Services organizational guidelines, and to comply with regulations pertaining to nonprofit organizations, Center For Family Services requires the following:

  • Events must reflect the mission and values of Center For Family Services.
  • The Public Relations and Development Departments are to be provided with all information published or transmitted to the public about the organization and the event. All text used in print and media materials; public relations and/or signage must be approved (or created) by the Public Relations Team.
  • The program coordinating the event/activity should ensure there is a budget to cover event related expenses. An event budget must be drafted prior to any coordination of event activities and turned in with the completed Event Application.
  • If cash or check donations are being accepted at the event, checks must be made payable to Center For Family Services and submitted to the Development Department no more than 5 days after the event. The Development Department will acknowledge the donor and deposit the check with the Finance Department. Use the Fundraising/Cash Record Receipt (found on the Event Application form) when turning cash into the Development Department.
  • If staff are interested in photographing an event that welcomes clients, staff need to ensure that clients or the client’s guardian (if they are under 18 years of age) have signed a Media Release Form which allows us to capture their photograph and possibly use it on our website, social media accounts or other materials.
  • Staff are prohibited from promoting the event through their personal social media platforms without obtaining approval from the Public Relations Department first.
  • Safe and Supportive Housing programs are prohibited from bringing donors to their sites to meet their clients unless approved by the program’s Associate Vice President.
  • If there are less than 50 event attendees, a staff member must be responsible to call 911 in case of an emergency. If there are more than 50 attendees, an EMT must be present.

 

Fairs/Outreach

Each week, Center For Family Services program staff are reaching out to the community through resource tables, speaking engagements, and community events to promote the important work we do in the community. The Public Relations Department wants to give each program the opportunity to speak about Center For Family Services' continuum of care, increase program referrals, and network with community partners.

In an effort to streamline program fair attendance throughout the agency, program staff should follow these guidelines:

  • If you are asked to attend an event to promote your program, notify the Public Relations Department by registering your event through the Outreach form located on Employee Portal.
  • All fair attendance is scheduled on a first come, first served basis. In some cases, another Center For Family Services program may already be scheduled to attend the same event you are interested in attending. If this is the case, your program materials will be included in the fair kit and be promoted by the other Center For Family Services program.
  • In some cases, programs may be permitted to share the table or take shifts during the event.
  • During all outreach events, program staff should not only be promoting their program but Center For Family Services continuum of care and its 80+ programs.
  • Staff should give PR at least a week's notice if materials are needed for an outreach event.
  • Outreach materials can be picked up in the media room (located at 1 Alpha Avenue, Voorhees) the day before the scheduled event.
  • Outreach materials should be delivered back to the media room no more than three days after the event.
  • Programs are responsible for all missing and damaged tablecloths, table displays, cards, and table.

As you attend fairs and community events it's important to engage with attendees and show enthusiasm, and display professionalism. Program staff should follow these etiquette guidelines:

  • Avoid speaking on your cell phone, texting, surfing the internet, etc.
  • Engage attendees in conversation
  • Exude a positive and professional demeanor

If you are unable to answer an attendee's question, refer them to our website (centerffs.org) or get their contact information and share with the Public Relations Department who will follow up with their question. 

For additional resources regarding outreach as a Center For Family Services employee, please review:

Outreach Event Registration Instructions 

Fair & Outreach Tip Sheet 

Outreach Video

Donations, Fundraising, and Grant Writing

As Center For Family Services grows, it is important that as an agency we work together to secure funding and donations for all of our programs. In all of our efforts we must maintain an ethical and legal approach. In order to facilitate smooth and fair solicitation of individuals, corporations and foundations, and other funding sources, please follow the following protocols. Please direct any questions to the Associate Vice President of Development and Public Relations.

As shown by Center For Family Services past success in fundraising, many of our employees have great strengths in submitting grant applications and building fundraising relationships. We want to build on these strengths as an agency without hindering other programs from applying for funding.

Before any contact is made with any private funding agency, individual, corporation, area business or organizations the program or employee needs to contact the Development Department for approval. In the case where there are conflicts, the Executive Team will decide how to move forward. This will be coordinated in such a way that the programs will all have ample opportunity to apply for funding and seek support from community partners.

Grants

The important work of Center For Family Services is largely dependent on grant funding from a variety of public and private sources. The Grants Department exists to assist in securing critical program funding by providing the structure necessary to maintain quality control in both grant applications and grant reporting. Adhering to the grants policy will help Center For Family Services to remain competitive in grant seeking and maintain fidelity to reporting measures required by our funders.

  • All potential funding opportunities must be channeled through the Grants Department. Regardless of who ultimately writes or submits a proposal, the Grants Coordinator must be notified as early in the process as possible. If program staff are interested in a potential funding opportunity, they should contact the Grants Coordinator to initiate the process. Public funding opportunities should also be sent to the Public Funding Proposal Coordinator.
  • The Grants Department will research potential funding opportunities and present them to the Executives for consideration each week.
  • The Exec Team confers on each opportunity and makes a decision to apply or not, as well as where and how to best allocate the potential funding.
  • Funding opportunities approved by the Execs will be recorded in Raiser's Edge, the agency fundraising database by the Grants Department.
  • The Grants Department will coordinated with the appropriate program staff to acquire all necessary proposal elements.
  • Though each application will differ in relation to staff roles and responsibilities, the standard template for proposal generation is as follows:
    • - General Oversight/Editing: Grants Coordinator
    • - Narrative/MOU's/LOS: Collaboration of AVP/Program Staff/Grants Coordinator
    • - Support & Boilerplate Documents: Public Funding Proposal Coordinator & Exec Admin Assistants
    • - Budget and Budget Narrative: Finance Department and Executives
    • - Final Edits and Submission Approval: Executives
  • The Grants Department will assemble the grant submission package, submit upon Executive approval, and furnish a digital copy for upload to Raiser's Edge
  • If a grant request is declined, the Executives, AVP, Finance, and Grants Department will be notified
  • If a grant request is awarded, notify Executives and AVP, Finance, DEV/PR, and Grants Department and furnish reporting requirements and contract to Grants Coordinator for tracking in Raiser's Edge, with copy to the Development Department for acknowledgement

Individual Fundraising/Donation Asks

The employees of Center For Family Services are our most valuable resource and their relationships with the community is vital to the success of our organization, specifically in our fundraising efforts. We encourage staff to share the mission of Center For Family Services, information about our services, and volunteer and fundraising opportunities. However, as our organization grows it is important we streamline our “asks” to ensure a cohesive fundraising system. No letters of request, phone calls, emails, or other contact is to be made with an individual or corporate/foundation representative without prior approval from the Development and/or Public Relations Department.

If you are interested in seeking monetary or in-kind donations of any kind, please reach out the Development and Public Relations Departments to share your needs and they will work with you and your program to identify potential partners in the community, grants, and/or strategies to assist in raising monetary donations or collecting in-kind gifts.

Anyone who contacts the agency interested in donating should be forwarded to the Development Department. All check and cash donations must be submitted to the Development Department immediately to be processed. Do not submit a cash or check donation to the Finance Department. The Development Department will record the donation in the agency’s donor database, process the check and submit to the Finance Department. An acknowledgment will be produced by the Development Department within 3 business days of receiving the donation. The acknowledgment will be signed by the President/CEO, and then mailed to the donor. If a donor wishes to remain anonymous, please note this when forwarding the donation.

If an in-kind gift is made to your program, please give the donor the option to fill out a Donation Receipt. This document provides the donor with tax information and records their gift for the Development Department. When the Donation Receipt is filled out, the donor receives the original while a copy should be either interofficed or scanned and emailed to the Development Department.

In-Kind Donations

We value the support of our partners in the community and rely on in-kind and monetary* donations to assist us in helping the children and families we serve. It’s important that in-kind donations are vetted through the Operations’ Logistics and Public Relations Departments before being accepted. These departments will consider the type and quality of the donation, the immediacy of the need, and the program’s ability to distribute the donation to their clients quickly without having to store it. Due to limited space and limited resources we are unable to accept used or gently items of any kind. This includes used furniture, appliances, clothing, coats, blankets, mattresses, toys, stuffed animals, or books. Only new items are accepted and distributed. 

If it is determined that the organization will accept the donation, the Operations’ Logistics and Public Relations Department will work together with the program to make appropriate arrangements to pick up the items.

Please be mindful that the Operations’ Logistics Department and Public Relations Department is not available regularly to pick up donations. They will only make pickups on a case by case basis once it is determined that the donation is acceptable. It is imperative that all potential donations be communicated to both the Operations and Public Relations Departments before being accepted. Be aware that donation pickups made by the Operations’ Logistics Department or Public Relations Department can only then be delivered to a Center For Family Services’ location and cannot be delivered to the home of an individual receiving services.

If your program is the recipient of donations, a staff member(s) should be designated to oversee the distribution of those items and follow the appropriate guidelines regarding Receipt of Goods outlined in the Public Relations section of this manual.

Script for conversations with community members interested in donating their used items:
Thank you for thinking of Center For Family Services for your donations!  We have certain types of gifts we are able to accept, but due to limited space and limited resources, we are unable to accept used items of any kind. This includes used books, clothing, coats, mattresses and furniture. Our mission at Center For Family Services is to provide counseling, safe housing, and supportive services to help people to heal and follow a path to their own best future.  We do not have the facilities to store, sort and distribute used items.  We recommend donating your used items to Goodwill or Habitat Restore. Please contact us at 856.651.7553 x40110 or 40129 for information about the ways you can help to support our work.

*If you receive a monetary donation, the cash or check should be turned into the Public Relations Department immediately along with the donor’s name and contact information. If you are communicating with someone who is interested in making a monetary donation, please connect them with Jen Hammill, Associate Vice President of Public Relations and Development, at 856.651.7553 x40129. 

Individual Client Solicitation

In general, active clients currently receiving services from Center For Family Services will not be solicited for support of any kind. If program directors feel there is a need to deviate from this norm they must contact the Development Department to initiate a discussion around those circumstances. If unsolicited donations are received from a current, active client, the above protocol for individual donations should be followed.

Outreach and solicitation to former clients, no longer receiving services from Center For Family Services should be approached following the above protocol for individual donors, in close coordination with the Development Department.

If you are interested in hosting an event to raise money for your program or a client need, please review the special events section of this manual.

Volunteers

Volunteers are vital to our mission and extremely important representatives of our agency. We wouldn’t be able to do much of the work we do without the selfless dedication of the hundreds of one-time and long-term volunteers we host each year.

The Public Relations Department is available to assist program staff with the recruitment and onboarding of long-term volunteers and the coordination and execution of one-time volunteer projects.

One-time volunteer projects and long-term volunteers must be communicated to the Public Relations Department so the appropriate steps can be taken to ensure a positive experience for both the volunteer(s) and Center For Family Services.

One-Time Volunteer Projects

If you have a need within your program that would make a good one-time volunteer project, please contact the Public Relations Department. Projects may include but are not limited to gardening, weeding, painting, building, and yard work. In the event a corporation, business, or community group reaches out to Center For Family Services inquiring about volunteering, your project may be proposed. If, accepted, the Public Relations Department will notify the program director and coordinate the project, materials, etc. with both the program and volunteers.

One-time volunteer projects generally take place over the course of one day, at one location. However, large groups have volunteered over the course of one day at multiple Center For Family Services site.

Long-Term Volunteers

Long-Term volunteers are individuals who will be serving within a program on an ongoing basis. Long-term volunteers may be readers in our Head Start classrooms, domestic violence advocates for our SERV program, or a mentor with Reach for Success.

If you are interested in recruiting volunteers for your program please reach out to the Volunteer Manager. The Volunteer Manager can assist with recruiting potential volunteers and walk programs through the onboarding process.

Depending on the nature of your program, volunteer role, and/or population your volunteer will be working with, your volunteer may be subject to a background check.

Regardless of the kind of long-term volunteer you are hosting in your program, all volunteers must have a volunteer position description, completed volunteer application, and complete both an on-site and online orientation.

For more information on Center For Family Services volunteer processes, please click here

Information Technology

Center For Family Services’ Information Technology (IT) Department is a vital and integral part of the planning and operating of our organization’s infrastructure. It is because of the IT Department and their oversight of the agency’s technological network that we are able to carry out our jobs efficiently, productively, and securely.

The IT Department is responsible for the overall management of Center For Family Services computers, copiers, desk phones, network equipment, and security cameras as well as the moving and relocation of these items. All IT purchases must be made by the IT Department.  They will setup of these systems, as well as support any technological issues you may face while utilizing them.

As with all Center For Family Services administrative departments, the IT Department has policies, protocols, and guidelines that must be followed by all staff to ensure the agency’s network runs smoothly to allow for fast and effective communication and also to protect the confidentiality of not only those we serve but of our employees and the work we do.

In the following pages, you will find information to help you navigate the IT Department.

If you need additional information or clarification on any of the following policies, protocols, and guidelines please contact the Associate Vice President of Information Technology by emailing [email protected].

IT Work Order System

Any and all IT related issues must be submitted through the IT Work Order System. The IT Work Order System may be accessed either from a shortcut on the desktop of all agency computers or on the staff section of the website. Direct calls to the IT department should only be used in the case of a network outage where submitting a work order would not be possible.

To directly connect to the IT Work Order System, visit https://itspice.cffsapps.net/portal

Email & Computer Accounts

Email is the primary means of communication at Center For Family Services. Every employee, intern, and AmeriCorps member will receive a Center For Family Services email account upon beginning their position with the agency and are expected to check messages and respond accordingly on a daily basis.

Account Creation

The means of your account creation is dependent upon your position at Center For Family Services. Please see below for specifics:

  • Employee (part-time, full-time and fee for service): Employee accounts will be created by the Human Resources Department upon hiring. Supervisors will receive the new employee’s computer password and email information via email before their start date and should share this information with them on their first day.
  • Intern: Supervisors must submit a work order through the IT Work Order System with the intern's full name, program, location, and an estimated term of service in order to create an email and computer account. Staff are not to log in an intern with their own credentials while waiting for an account to be created.
  • AmeriCorps Members: Upon beginning their term of service, supervisors must submit a work order through the IT Work Order System with the AmeriCorps members full name, program, and location in order to create an email and computer account.
  • Volunteers: Typically, volunteers are not given Center For Family Services email accounts as most volunteer positions don’t require access to email. If there is a need to create an email for a volunteer, please reach out directly to the Volunteer Manager, Del Densley.

Email Signatures

In an effort to be consistent in our communications and presentations on behalf of the agency, Center For Family Services has defined a policy regarding email usage and standard email signatures. All Center For Family Services staff are required to use a standard agency signature line in their emails.

To view the required standard email signature and step by step instructions on setting up your Center For Family Services email signature, click here https://www.centerffs.org/staff/staff-forms/email-signatures

Account Disablement

Supervisors who need to disable an employees’ account should follow these steps:

  1. Enter an IT Work Order requesting the disablement of the account. Be sure to enter your work phone number and extension or cell phone number on the work order. 
  2. Once the IT Department receives the work order a support representative from IT will contact you by phone.
  3. The change will be made and a Work Order reply will be sent with a confirmation that the account has been disabled.

Should you need to retrieve email or date from a disabled account, please contact the IT Department through a Work Order as soon as possible. The IT Department can forward emails for this account temporarily. If forwarding is required, please submit an IT Work Order and specify the supervisors’ Center For Family Services email address and time frame.

Please note that if a work order is not received by the IT Department within 90 days, email and data from your former employee’s accounts may no longer be accessible.

Password/Account Sharing

Staff members should never share their email or computer password with any other person, unless it is specifically requested by the IT Department. The IT Department will never request your password to be sent though an email. Staff are also strictly prohibited from logging in any other person with their login credentials. The sharing of login information is the highest form of security breach and is prohibited to protect the agency, as well as the staff member.

Acceptable Computer Use Policy

Center For Family Services’ Acceptable Computer Use Policy sets forth the standards by which all employees may use agency computers and the agency network. In this document, Center For Family Services’ network applies to all agency owned equipment (desktops, laptops, tablets, phones, etc.) and internet services provided in agency locations.

Center For Family Services network is provided to support the agency’s mission of providing high quality, life altering services to children, families and individuals throughout southern New Jersey. Any other uses, including uses that jeopardize the integrity of the network, the privacy or safety of other users/employees, or the privacy of protected health information of the individuals receiving our services, is strictly prohibited.

By using or accessing the agency’s network, employees agree to comply with this document and other applicable Center For Family Services policies which may be implemented from time to time, as well as all federal, state, and local laws and regulations. Only employees are authorized to use and/or access the agency network. Outside users, including the individuals we serve should not be granted access to an employee’s computer or the network.

General requirements for acceptable use of Center For Family Services network are based on the following principles:

  • Each Employee is expected to use their Center For Family Services provided equipment responsibly and with their best judgment.
  • Each Employee is expected to respect the integrity and the security of Center For Family Services Network.
  • Each Employee is expected to ensure the security of all agency equipment located at their facility.
  • Each Employee is expected to not use their agency provided equipment for personal uses.
  • Each Employee is expected to report any concerns or breaches of their computers to the IT Department.
  • Each Employee is expected to respect the rights and privacy of all users and individuals being served by Center For Family Services by making sure to maintain HIPPA compliance in regards to protected health information.

While maintaining employment with Center For Family Services and using the agency network, employees are prohibited from doing the following.

  • Employees may not log on another user to their machine using their own logon credentials. If there is an issue with an employee’s logon, that employee needs to contact the IT Department for resolution.
  • Employees may not attempt to alter or destroy any files on their machine, and should consult the IT Department if data removal is necessary.
  • Employees may not use the agency network to stream or view non-work related media.
  • Employees may not distribute or send threatening communication of any kind, including but not limited to cyberstalking, threats of violence, obscenity, or other illegal communications.
  • Employees may not attempt to bypass network security mechanisms, including those present on the network.
  • Employees are not permitted to connect any network devices or systems (e.g., personal cell phones, or personal computers) to the network.
  • Employees are responsible for maintaining minimal security controls on their agency computer. Examples include allowing updates to run when prompted and keeping passwords secure.

Disciplinary action may be taken if it is found that an employee continually ignores the guidelines set forth in this policy.

Center For Family Services reserves the right to update or revise the Acceptable Computer Use Policy or implement additional policies in the future. Employees are responsible for staying informed about agency policies regarding the use of computers and the network as well as complying with all applicable policies.

Agency Equipment

Policy

During the course of employment, you may be issued agency equipment necessary for the performance of your job.  All equipment is for the use of agency operations and not for personal use and/or benefit. Staff are required to sign for these items and are responsible for their general maintenance and security.  Staff may be personally responsible for the financial cost to replace any issued agency equipment that is lost, damaged or stolen.  Upon separation or a leave of absence from the agency, all agency issued equipment must be returned to the agency.  Staff are personally financially responsible for the cost of replacement for any equipment that you fail to return to the agency upon separation.  

Protocols

Center For Family Services may issue agency equipment for staff to perform their job responsibilities.  The most common equipment includes cell phones and computer equipment.  All equipment is inventoried and allocated per the agency’s IT and Finance policies.  

When the staff person signs for equipment issued by the Center For Family Services, they are
acknowledging receipt of equipment and authorizing any replacement cost to be applied should
they fail to return the issued equipment.

Obtaining Equipment
A work order must be submitted for all newly purchased or allocated equipment to be distributed.  

New Hires - As part of the onboarding process, the supervisor submits a work order to obtain the necessary equipment for a new employee.  

An appointment is made with the IT Department.  All equipment is inventoried and tracked per IT protocols.  Staff are required to sign out all equipment and agree to the agency equipment policy and procedures.  

All equipment is for the use of agency operations and not for personal use and/or benefit. Staff are required to sign for these items and are responsible for their maintenance.  Staff may be personally responsible for the financial cost to replace any issued agency equipment that is lost, damaged or stolen. Staff are expected to adhere to the IT and IT Security policies.  

In the event of a staff transfer, all equipment must be reviewed with the IT Department.

Returning Equipment
All agency equipment must be returned to the Center For Family Services.  Equipment can be returned for a number of reasons, including, but not limited to: separation from the agency, voluntarily or involuntarily, extended leave of absence, position transfers and/or equipment upgrades/changes.  All technology equipment must be returned to the IT department.  Per IT protocols, the staff will sign off on the equipment being surrendered and all equipment will be inventoried.  A signed copy of all items relinquished should be maintained and a copy provided to the staff.  

In the event of an extended planned staff absence or voluntary separation, the staff should schedule time to meet with the IT department to appropriately relinquish the equipment.  This must occur prior to the employee’s last day with the agency to ensure that a proper inventory is maintained.  

In the event that there is not adequate time to conduct this exit process, such as an unexpected leave or involuntarily separation, the immediate supervisor, or their designee, will coordinate with the staff for the surrender of all equipment.  The supervisor should immediately inform the HR Department if a staff is in possession of agency equipment.  HR will contact the employee to inform them that the supervisor will need to coordinate the surrender of the equipment to the agency.  

If a staff member fails to, or refuses to, return agency equipment, staff may be financially responsible for the replacement cost of that equipment.  The immediate supervisor, and/or Human Resources, is responsible for ensuring that the IT Department is immediately notified for information security protocol.  In addition, the supervisor must inform the HR Department immediately.  The IT Department will conduct a replacement cost analysis and provide HR with the report.  HR will coordinate with the Payroll Department if the replacement cost needs to be deducted from the employee’s vacation pay out.  Center For Family Services reserves the right to pursue a civil claim or file legal charges for the intentional destruction or failure to return company property.

If staff are found in violation of any of these conditions, they may be subject to disciplinary action, up to and including termination.

Revised 7/2023
 

Equipment

Purchases

All IT related purchases must be made by the IT Department.  Purchase requests for any IT Equipment should be submitted through the IT Work Order System. Purchases under $500 require Program Director or Associate Vice President approval. Purchases over $500 require Senior VP or COO approval. Any IT equipment purchases made outside of the IT Department will not be supported or permitted on our network.

Reassigning Equipment

When a staff member leaves the agency or relocates to another program, their equipment should be returned to the IT Department by the terminating/transferring employee on or before their termination date.  This is so that the department can properly inventory and inspect the equipment and provide the employee with a receipt as proof that they returned it. The IT Department will reallocate the equipment once a request is submitted through the work order system.

Use of Personal Devices

The IT Department is unable to verify the security of personally owned computing equipment.  Therefore, the use of Personally owned computing equipment such as laptops, tablets and cell phones for Agency Business is strictly prohibited unless expressly approved by the AVP of IT.

The use of personal computers are ONLY permitted when ALL of the following conditions are met: 

  • A Center For Family Services issued computer is not available.
  • Only web applications are used for Center For Family Services' work.
    • EHR (AWARDS, Carelogic)
    • Video conferencing (Google Meet, Bluejeans, Doxy.me, Zoom)
    • Google Apps (Gmail, Docs, Calendar)
  • Passwords for applications are not to be auto saved. They need to be typed in each time the application is accessed. 
  • Personal laptops must have a secure password set on them. 
  • No files are to be worked on or saved locally to the machine. If you do need to edit or save files, that should be done using Google Docs.  

If staff are found in violation of any of these conditions, they may be subject to disciplinary action, up to and including termination. 

Security

Information security management is one of the most important IT functions at Center For Family Services. The protection of our client’s confidentiality is of utmost importance so it is imperative all employees follow agency security measures.

File Storage

Staff must not save or store any information, in particular sensitive or confidential information such as Social Security numbers, Driver's License numbers, credit/debit card numbers and Client medical records on their desktop, My Documents folder, or C: drive. These areas are not protected in case of theft or loss and could be compromised and used in identity theft or theft of legally protected information.

All files should be saved to either the user’s home (or U: drive) or the appropriate network shared drive. Be mindful that files shared to a network drive other than the U: drive are visible by other staff members who also have access to that drive.

The use of flash drives or other removable storage is strictly prohibited, because they pose a grave risk to the security of the agency network.

Secure Email Message

In the case that you are sending an email that contains moderate, or high-risk, confidential information like client data, passwords, social security numbers, etc. you should make your email secure. To make your email secure include the word “secure” in the subject line, followed by a colon and then continue typing your email subject line. Example: Secure: Client Documents.

 

Information Security Policy

The following document contains the policies and procedures designed to ensure all users and networks within the Center For Family Services meet minimum security and data protection security requirements. 

1. Employee Responsibilities

1.1 Employee Requirements

Unattended Computers - Unattended computers should be locked by the user when leaving the work area. This feature is discussed with all employees during yearly security training. CFS policy states that all computers will have the automatic screen lock function set to automatically activate upon ten (10) minutes of inactivity. Employees are not allowed to take any action which would override this setting. If you must leave your computer unattended between those10 minute intervals, lock it manually by pressing the Windows Key and the L key simultaneously.

Home Use of CFS Corporate Assets - Only computer hardware and software owned by and installed by the CFS IT Department is permitted to be connected to or installed on CFS equipment. Only software that has been approved for agency use by the CFS IT Department may be installed on CFS equipment. Computers supplied by the CFS IT Department are to be used solely for business purposes. All employees and contractors must read and understand the list of prohibited activities that are outlined below. Modifications or configuration changes are not permitted on computers supplied by the CFS IT Department for individual use.

Retention of Ownership - All software programs and documentation generated or provided by employees, consultants, or contractors for the benefit of CFS are the property of CFS unless covered by a contractual agreement. Nothing contained herein applies to software purchased by CFS employees at their own expense.

1.2 Prohibited Activities

 

Personnel are prohibited from the following activities. The list is not inclusive. Other prohibited activities are referenced elsewhere in this document.

  • Crashing an information system. Deliberately crashing an information system is strictly prohibited. Users may not realize that they caused a system crash, but if it is shown that the crash occurred as a result of user action, a repetition of the action by that user may be viewed as a deliberate act. 
  • Attempting to break into an information resource or to bypass a security feature. This includes running password-cracking programs or sniffer programs, and attempting to circumvent file or other resource permissions. 
  • Introducing, or attempting to introduce, computer viruses, Trojan horses, peer-to-peer ("P2P") or other malicious code into an information system
    • Exception: Authorized information system support personnel, or others authorized by the CFS Privacy Officer, may test the resiliency of a system.  Such personnel may test for susceptibility to hardware or software failure, security against hacker attacks, and system infection. 
  • Browsing. The willful, unauthorized access, or inspection of, confidential, or sensitive, information to which they, staff or user, have not been approved on a "need to know" basis is prohibited.  CFS has access to patient level health information, which is protected by HIPAA regulations which stipulate a "need to know" before approval is granted to view the information. The purposeful attempt to look at or access information to which you the user have not been granted access by the appropriate approval procedure is strictly prohibited.
  • Personal, or Unauthorized, Software. Use of personal software is prohibited. All software installed on CFS computers must be approved by CFS.
  • Software Use. Violating or attempting to violate the terms of use or license agreement of any software product used by CFS is strictly prohibited.  
  • System Use. Engaging in any activity for any purpose that is illegal or contrary to the policies, procedures or business interests of CFS is strictly prohibited.

1.3 Electronic Communication, Email, Internet Usage

As a productivity enhancement tool, CFS encourages the business use of electronic communications. However, all electronic communication systems and all messages generated on or handled by CFS owned equipment are considered the property of the CFS – not the property of individual users. Consequently, this policy applies to all CFS personnel and contractors, and covers all electronic communications including, but not limited to, telephones, e-mail, voice mail, instant messaging, Internet, fax, agency assigned computers, personal computers, and servers. 

CFS provided resources, such as individual computer workstations or laptops, computer systems, networks, e-mail, and Internet software and services are intended for business purposes.  However, incidental personal use is permissible as long as:

  1. it does not consume more than a trivial amount of employee time or resources, 
  2. it does not interfere with staff productivity, 
  3. it does not preempt any business activity, 
  4. it does not violate any of the following:
    • Copyright Violations - This includes the act of pirating software, music, books and/or videos or the use of pirated software, music, books and/or videos and the illegal duplication and/or distribution of information and other intellectual property that is under copyright.
    • Illegal Activities - Use of CFS information resources for or in support of illegal purposes as defined by federal, state or local law is strictly prohibited.
    • Commercial use - Use of CFS information resources for personal or commercial profit is strictly prohibited.
    • Political Activities - All political activities are strictly prohibited on CFS premises. CFS encourages all of its employees to vote and to participate in the election process, but these activities must not be performed using CFS assets or resources.
    • Harassment - CFS strives to maintain a workplace free of harassment and that is sensitive to the diversity of its employees.  Therefore, CFS prohibits the use of computers, e-mail, voice mail, instant messaging, texting and the Internet in ways that are disruptive, offensive to others, or harmful to morale.  For example, the display or transmission of sexually explicit images, messages, and cartoons is strictly prohibited.  Other examples of misuse include, but are not limited to, ethnic slurs, racial comments, off-color jokes, or anything that may be construed as harassing, discriminatory, derogatory, defamatory, threatening or showing disrespect for others.
    • Junk E-mail - All communications using IT resources shall be purposeful and appropriate.  Distributing “junk” mail, such as chain letters, advertisements, or unauthorized solicitations is prohibited.  A chain letter is defined as a letter sent to several persons with a request that each send copies of the letter to an equal number of persons.  Advertisements offer services from someone else to the recipient or user.  Solicitations are when someone asks you for something.  If any of the above are received, delete the e-mail message immediately.  Do not forward the e-mail message to anyone.

Generally, while it is NOT the policy of the CFS to monitor the content of any electronic communication, CFS is responsible for servicing and protecting CFS’s equipment, networks, data, and resource availability and therefore may be required to access and/or monitor electronic communications from time to time.  Several different methods are employed to accomplish these goals.  For example, an audit or cost analysis may require reports that monitor phone numbers dialed, length of calls, number of calls to / from a specific handset, the time of day, etc.  Other examples where electronic communications may be monitored include, but are not limited to, research and testing to optimize IT resources, troubleshooting technical problems and detecting patterns of abuse or illegal activity.

CFS reserves the right, at its discretion, to review any employee’s files or electronic communications to the extent necessary to ensure all electronic media and services are used in compliance with all applicable laws and regulations as well as CFS policies.

Employees should structure all electronic communication with recognition of the fact that the content could be monitored, and that any electronic communication could be forwarded, intercepted, printed or stored by others. 

1.4 Reporting Software Malfunctions

Users should inform the appropriate CFS personnel when the user's software does not appear to be functioning correctly. The malfunction - whether accidental or deliberate - may pose an information security risk. If the user, or the user's manager or supervisor, suspects a computer virus infection, the CFS computer virus policy should be followed, and these steps should be taken immediately:

  • Stop using the computer 
  • Do not carry out any commands, including commands to <Save> data.
  • Do not close any of their computer's windows or programs. 
  • Do not turn off the computer or peripheral devices.
  • If possible, physically disconnect the computer from networks to which it is attached. 
  • Inform the CFS IT Department as soon as possible. Write down any unusual behavior of the computer (screen messages, unexpected disk access, unusual responses to commands) and the time when they were first noticed.
  • Do not attempt to remove a suspected virus!

The CFS IT Department should monitor the resolution of the malfunction or incident, and the result of the action with recommendations on action steps to avert future similar occurrences. 

1.5 Report Security Incidents

It is the responsibility of each CFS personnel or contractor to report perceived security incidents on a continuous basis to the appropriate supervisor or security person. A user is any person authorized to access an information resource. Users are responsible for the day-to-day, hands-on security of that resource. Users are to formally report all security incidents or violations of the security policy immediately to the Privacy Officer. Users should report any perceived security incident to either their immediate supervisor, or to their department head, or to any member of the CFS IT Department.

Reports of security incidents shall be escalated as quickly as possible. Each member of the CFS IT Department must inform the other members as rapidly as possible. Each incident will be analyzed to determine if changes in the existing security structure are necessary. All reported incidents are logged and the remedial action indicated. It is the responsibility of the CFS IT Department to provide training on any procedural changes that may be required as a result of the investigation of an incident.

Security breaches shall be promptly investigated. If criminal action is suspected, the CFS Privacy Officer shall contact the appropriate law enforcement and investigative authorities immediately, which may include, but is not limited to the police or the FBI.

1.6 Transfer of Sensitive/Confidential Information

When confidential or sensitive information is transmitted from one individual to another while conducting official business, the receiving individual shall maintain the confidentiality or sensitivity of the information in accordance with the conditions imposed by the providing individual. All employees must recognize the sensitive nature of data maintained by the CFS and hold all data in the strictest confidence. Any purposeful release of data to which an employee may have access is a violation of CFS policy and will result in personnel action, and may result in legal action.

1.7 Transferring Software and Files Between Home and Work 

Personal software shall not be used on CFS computers or networks.  If a need for specific software exists, submit an IT work order so the software and need can be evaluated.  Users shall not use CFS purchased software on home or on non-CFS computers or equipment.

CFS proprietary data, including but not limited to patient information, IT systems information, financial information or human resource data, shall not be placed on any computer that is not the property of the CFS without written consent of the respective supervisor or department head.  It is crucial to CFS to protect all data and, in order to do that effectively, we must control the systems in which it is contained.  In the event that a supervisor or department head receives a request to transfer CFS data to a non-CFS computer system, the supervisor or department head should notify the Privacy Officer or appropriate personnel of the intentions and the need for such a transfer of data and then wait for approval.

The CFS Wide Area Network (“WAN”) is maintained with a wide range of security protections in place, which include features such as virus protection, e-mail file type restrictions, firewalls, anti-hacking software, etc. Since CFS does not control non-CFS personal computers, CFS cannot be sure of the methods that may or may not be in place to protect CFS sensitive information, hence the need for this restriction.

1.8 Use of Secure Email System

When Email Encryption Should Be Used

You should encrypt any emails containing client or staff PHI (Protected Health Information).  PHI includes, but is not limited to the following:

  • The individual's past, present or future physical or mental health or condition.
  • The provision of health care to the individual.
  • The past, present, or future payment for the provision of health care to the individual.

You should also encrypt any emails containing client or staff personally identifiable information, such as, but not limited to, SS#, birthdate or home address.  Emails containing confidential information such as, but not limited to, incident reports, performance reviews, or legal correspondence should also be encrypted.

How to Send an Encrypted Email at Center For Family Services

Sending an Encrypted email at CFFS is a very easy process.  Simply type the word “Secure” anywhere in the subject line of the email (no quotation marks required).  If the message is being sent to a centerffs.org email address, the encryption will be completely transparent to the recipient.  In fact, the only indication that a message is encrypted will be a notice at the bottom of the email as shown in the picture here.

Retrieving an Encrypted Email from Center For Family Services on a Different Domain

In order to view the deciphered message, the recipient will need to do the following:

  1. Click the Open Message button in the body of the received email (refer to this picture for the location of this button).  A browser window will display on the recipient’s PC as pictured here.

Note: In the rare event that the Open Message button does not display the browser window pictured above, copy and paste the link from the body of the message into the address bar of the browser!

  1. The recipient will now register their email account with the Google Encryption service.  This is a one-time process and as a result future encrypted emails received from CFS will open without the need to create a new password each time. However, the recipient will need to enter their password each time they attempt to open an encrypted email from CFS. 
  2. Enter a password and confirm it.  Passwords must contain at least 6 characters, with at least 1 symbol and 1 number.
  3. Click the Register button.  The decrypted message will now display on the recipient’s PC in the same browser window.   A sample is pictured here.

Forwarding an Encrypted Email

Staff can use the standard Gmail or Outlook client to forward an encrypted email to someone outside of the centerffs.org domain.  When the encrypted email is sent, the recipient will need to follow the steps outlined above in order to view the contents of the email.

2. Identification and Authentication

2.1 User Logon IDs 

Individual users shall have unique logon IDs and passwords. An access control system shall identify each user and prevent unauthorized users from entering or using information resources.  Security requirements for user identification include:

  • Users shall be responsible for the use and misuse of their individual logon ID.
  • Logon ID’s are created at the time of hire and will be provided on the first day of work.

The CFS E3 HR system sends a notification to the IT department upon the departure of all employees and, at which time login IDs are revoked. All user logon IDs are audited at least twice yearly and all inactive logon IDs are revoked.

The logon ID is locked or revoked after a maximum of five (5) unsuccessful logon attempts.  After thirty (30) minutes, the ID is automatically unlocked.

2.2 Passwords

User Account Passwords

User IDs and passwords are required in order to gain access to all CFS networks and workstations. All passwords are restricted by a corporate-wide password policy to be of a "Strong" nature. This means that all passwords must conform to restrictions and limitations that are designed to make the password difficult to guess. Users are required to select a password in order to obtain access to any electronic information both at the server level and at the workstation level. When passwords are reset, the user will be automatically prompted to manually change that assigned password.  See Tips on Creating a Strong Password

Password Length – Passwords are required to be a minimum of fourteen (14) characters in length.

Content Requirements - Passwords must contain a combination of three of the following four categories:

  • Uppercase alphabetic letter (A through Z)
  • Lowercase alphabetic letters (a through z)
  • Numeric characters - base 10 digits (0 through 9)
  • Non-alphanumeric characters (special characters): (~!@#$%^&*_-+=`|\(){}[]:;"'<>,.?/)
    • Currency symbols such as the Euro or British Pound are not counted as special characters for this policy setting.

Complexity Requirements - Passwords must meet the following requirements:

  • Password cannot be particularly weak. Example: "password123".
  • Passwords cannot start or end with a blank space.
  • Password cannot contain the user’s account name or parts of the user’s full name.
  • Different passwords are needed for Login and Email.

Change Frequency – Passwords must be changed every 180 days.  Compromised passwords shall be changed immediately.

Reuse - The previous twenty-four (24) passwords cannot be reused.

Restrictions on Sharing Passwords - Passwords shall not be shared, written down on paper, or stored within a file or database on a workstation and must be kept confidential.

Restrictions on Recording Passwords - Passwords are masked or suppressed on all online screens, and are never printed or included in reports or logs. Passwords are stored in an encrypted format.

It is important to note that the same password requirements are in effect for Gmail passwords as well.  

2.3 Access Control

Information resources are protected by the use of access control systems. Access control systems include both internal (i.e. passwords, encryption, access control lists, constrained user interfaces, etc.) and external (i.e. port protection devices, firewalls, host-based authentication, etc.).

Rules for access to resources (including internal and external telecommunications and networks) have been established by the information/application owner or manager responsible for the resources.  Access is granted only by the completion of an IT Work Order. This work order can only be initiated by the appropriate program director

This guideline satisfies the "need to know" requirement of the HIPAA regulation, since the supervisor or department head is the person who most closely recognizes an employee's need to access data. Users may be added to the information system, network, or EHR only upon the signature of the Security Officer or appropriate personnel who is responsible for adding the employee to the network in a manner and fashion that ensures the employee is granted access to data only as specifically requested.

2.4 User Login Entitlement Reviews

If an employee changes positions at CFS, the CFS E3 HR System notifies the Information Technology (“IT”) Department of the change of roles.  The CFS IT Department then removes the security access of the vacated role and adds the security access for their new role, so that the employee has access to the minimum necessary data to effectively perform their new job functions. The effective date of the position change should also be noted on the Form so that the IT Department can ensure that the employee will have appropriate roles, access, and applications for their new job responsibilities. For a limited training period, it may be necessary for the employee who is changing positions to maintain their previous access, as well as adding the roles and access necessary for their new job responsibilities.

No less than annually, the AVP of IT shall facilitate entitlement reviews with department heads to ensure that all employees have the appropriate roles, access, and software necessary to perform their job functions effectively while being limited to the minimum necessary data to facilitate HIPAA compliance and protect patient data.

2.5 Termination of User Logon Account

Upon termination of an employee, whether voluntary or involuntary, the CFS E3 HR system sends a notification to the CFS IT Department. The employee’s supervisor shall be responsible for insuring that all keys, ID badges, and other access devices as well as CFS equipment and property is returned to CFS prior to the employee leaving CFS on their final day of employment.

No less than biannually, the AVP of IT or their designee shall provide a list of active user accounts, for network and email access, to the program directors for review.  Program Directors shall review the employee access lists within ten (10) business days of receipt. If any of the employees on the list are no longer employed by their program at CFS, the program director will immediately notify the IT Department of the employee’s status.

No less than biannually, the AVP of MIS or their designee shall provide a list of active user accounts with access to all Electronic Health Records used by CFS to the program directors for review.  Program Directors shall review the employee access lists within ten (10) business days of receipt. If any of the employees on the list are no longer employed by their program at CFS, the program director will immediately notify the MIS Department of the employee’s status.

3. Network Security / Endpoint Protection 

3.1 Antivirus Software Installation

Antivirus software is installed on all CFS personal computers and servers.  Virus update patterns are updated daily on the CFS servers and workstations. Virus update engines and data files are monitored by appropriate administrative staff that are responsible for keeping all virus patterns up to date.

Configuration - The antivirus software currently implemented by the CFS is Symantec Endpoint Protection. Updates are received directly from Symantec and are scheduled to download every four (4) hours.

Remote Deployment Configuration - Through Microsoft System Center Configuration Manager, Windows updates are pushed out to individual workstations and servers on an as needed basis.  The AVP of Information Technology is responsible for monitoring the status of updates to active workstations and taking the appropriate action to rectify failed updates.

Monitoring/Reporting – A record of virus patterns for all workstations and servers on the CFS network is maintained. Appropriate administrative staff is responsible for providing reports for auditing and emergency situations as requested by the Privacy Officer or appropriate personnel.

3.2 New Software Distribution

Only software created by CFS application staff, if applicable, or software approved by the AVP of Information Technology, or appropriate personnel, will be used on internal computers and networks. All new software will be tested by appropriate personnel in order to ensure compatibility with currently installed software and network configuration. In addition, appropriate personnel must scan all software for viruses before installation.

Although shareware and freeware can often be useful sources of work-related programs, the use and/or acquisition of such software must be approved by the AVP of Information Technology or appropriate personnel. Because the software is often provided in an open distribution environment, special precautions must be taken before it is installed on CFS computers and networks.  These precautions include determining that the software does not, because of faulty design, “misbehave” and interfere with or damage CFS hardware, software, or data, and that the software does not contain viruses, either originating with the software designer or acquired in the process of distribution. 

All data and program files that have been electronically transmitted to a CFS computer or network from another location must be scanned for viruses immediately after being received.  Contact the appropriate CFS personnel for instructions for scanning files for viruses.

Every CD-ROM, DVD and USB device is a potential source for a computer virus.  Therefore, every CD-ROM, DVD and USB device must be scanned for virus infection prior to copying information to a CFS computer or network. 

Computers shall never be “booted” from a CD-ROM, DVD, network, or USB device received from an outside source.  Users shall always remove any CD-ROM, DVD or USB device from the computer when not in use.  This is to ensure that the CD-ROM, DVD or USB device is not in the computer when the machine is powered on.  A CD-ROM, DVD or USB device infected with a boot virus may infect a computer in that manner, even if the CD-ROM, DVD or USB device is not “bootable”.

3.3 Retention of Ownership

All software programs and documentation generated or provided by employees, consultants, or contractors for the benefit of CFS are the property of CFS unless covered by a contractual agreement. Employees developing programs or documentation must sign a statement acknowledging CFS ownership at the time of employment. Nothing contained herein applies to software purchased by CFS employees at their own expense.

4. VPN / Remote Access

This policy is applicable to all employees and contractors who work either permanently or only occasionally outside of the CFS office environment. It applies to users who work from their home full time, to employees on temporary travel, to users who work from a remote office location, and to any user who connects to the CFS network and/or hosted EHR, if applicable, from a remote location.

While VPN/Remote access can be an advantage for users and for the organization in general, it presents new risks in the areas of confidentiality and security of data.  Workers linked to the CFS’s network become an extension of the wide area network and present additional environments that must be protected against the danger of spreading Trojans, viruses, or other malware.  This arrangement also exposes the corporate as well as patient data to risks not present in the traditional work environment.

4.1 General Requirements

VPN/Remote access workers are required to follow all corporate, security, confidentiality, HR, or Code of Conduct policies that are applicable to other employees/contractors.

  • Need to Know: Telecommuting Users will have the access based on the same ‘need to know’ as they have when in the office.
  • Password Use: The use of a strong password, changed at least every 180 days, is even more critical in the telecommuting environment.  Do not share passwords or write them down where a family member or visitor can see it.
  • Training: Personnel who telecommute must complete the same annual privacy training as all other employees.
  • Contract Specific: There may be additional requirements specific to the individual contracts to which an employee is assigned.

4.2 Required Equipment

Employees approved for telecommuting must understand that the CFS may not provide all equipment necessary to ensure proper protection of information to which the employee has access; however, the following lists define the equipment and environment required:

CFS Provided:

  • CFS supplied workstation.
  • If approved, a CFS supplied printer. 
  • If approved, a CFS supplied scanner. 
  • If approved by your supervisor, a CFS supplied phone. 

Employee Provided:

  • Paper shredder.
  • Secure office environment isolated from visitors and family.
  • A lockable file cabinet, or safe, to secure documents when away from the home office. 

4.3 Hardware Security Protections

VPN Use: Established procedures must be rigidly followed when accessing CFS information of any type. CFS requires the use of VPN software to access network resources when working remotely. 

Lock Screens: No matter what location, always lock the screen before walking away from the workstation.  The data on the screen may be protected by HIPAA or may contain confidential information.  If using a non CFS computer be sure the automatic lock feature has been set to automatically turn on after ten (10) minutes of inactivity.

Location awareness:  Please be aware of your surroundings. Staff must never leave equipment unattended in a public place or in a vehicle and must be aware of their surroundings.

4.4 Data Security Protection

Data Backup: Backup procedures have been established that encrypt the data being moved to an external media, do not create one on your own media.

Transferring Data to CFS: Transferring of data to CFS requires the use of an approved VPN connection to ensure the confidentiality and integrity of the data being transmitted. Do not circumvent established procedures, nor create your own method, when transferring data to CFS.

External System Access: If you require access to an external system, contact your supervisor or department head. Privacy Officer or appropriate personnel will assist in establishing a secure method of access to the external system.

E-mail: Do not send any individual-identifiable information (PHI or PII) via e-mail unless it is encrypted.  If you need assistance with this, contact the Privacy Officer or appropriate personnel to ensure an approved encryption mechanism is used for transmission through e-mail.

Non-CFS Networks: Extreme care must be taken when connecting CFS equipment to a home or hotel network. Although CFS actively monitors its security status and maintains organization wide protection policies to protect the data within all contracts, CFS has no ability to monitor or control the security procedures on non-CFS networks.

Data Entry When in a Public Location: Do not perform work tasks that require the use of sensitive corporate or patient level information when you are in a public area, i.e. airports, airplanes, hotel lobbies.  Computer screens can easily be viewed from beside or behind the user.

Sending Data Outside CFS: All external transfer of data must be associated with an official contract, non-discloser agreement, or appropriate Business Associate Agreement.  Do not give or transfer any patient level information to anyone outside the CFS without the written approval of your supervisor.

4.5 Disposal of Paper and/or External Media

Shredding:  All paper which contains sensitive information that is no longer needed must be shredded before being disposed. Do not place in a trash container without first shredding. All employees working from home, or other non-CFS work environment, MUST have direct access to a shredder.

Disposal of Electronic Media: All external media must be sanitized or destroyed in accordance with HIPAA compliant procedures.

  • Do not throw any media containing sensitive, protected information in the trash.
  • Return all external media to your supervisor.
  • External media must be wiped clean of all data.  The Privacy Officer or appropriate personnel has very definitive procedures for doing this – so all external media must be sent to them.

5. Specific Protocols and Devices

5.1 Use of Transportable Media

The use of transportable media, including flash drives or other removable storage, is strictly prohibited, because they pose a grave risk to the security of the agency network.  

In the rare event that an external mandate requires the use of a transportable media device, an exception request must be approved in writing from the President or Chief, and the AVP of the IT Department

6. Disposal of External Media / Hardware

6.1 Disposal of External Media 

It must be assumed that any external media in the possession of an employee is likely to contain either protected health information (“PHI”) or other sensitive information. Accordingly, external media (CD-ROMs, DVDs, USB drives) should be disposed of in a method that ensures that there will be no loss of data and that the confidentiality and security of that data will not be compromised.

The following steps must be adhered to:

  • It is the responsibility of each employee to identify media which should be shredded and to utilize this policy in its destruction.
  • External media should never be thrown in the trash.
  • When no longer needed, all forms of external media are to be sent to the Privacy Officer or appropriate personnel for proper disposal.
  • The media will be secured until appropriate destruction methods are used based on NIST 800-88 guidelines. 

6.2 Requirements Regarding Equipment

All equipment to be disposed of will be wiped of all data, and all settings and configurations will be reset to factory defaults. No other settings, configurations, software installation or options will be made.  Asset tags and any other identifying logos or markings will be removed.

6.3 Disposition of Excess Equipment

As older CFS computers and equipment are replaced with new systems, the older machines are held in inventory for a wide assortment of uses:

  • Older machines are regularly utilized for spare parts.
  • Older machines are used on an emergency replacement basis.
  • Older machines are used for testing new software.
  • Older machines are used as backups for other production equipment.
  • Older machines are used when it is necessary to provide a second machine for personnel who travel on a regular basis.
  • Older machines are used to provide a second machine for personnel who often work from home.

7. Change Management

Statement of Policy

To ensure that CFS is tracking changes to networks, systems, and workstations including software releases and software vulnerability patching in information systems that contain electronic protected health information (“ePHI”).  Change tracking allows the Information Technology (“IT”) Department to efficiently troubleshoot issues that arise due to an update, new implementation, reconfiguration, or other change to the system.

Procedure

  1. The IT staff or other designated CFS employee who is updating, implementing, reconfiguring, or otherwise changing the system shall carefully log all changes made to the system.
    • When changes are tracked within a system, i.e. Windows updates in the Add or Remove Programs component or electronic health record (EHR) updates performed and logged by the vendor, they do not need to be logged on the change management tracking log; however, the employee implementing the change will ensure that the change tracking is available for review if necessary
  2. The employee implementing the change will ensure that all necessary data backups are performed prior to the change.
  3. The employee implementing the change shall also be familiar with the rollback process in the event that the change causes an adverse effect within the system and needs to be removed.

8. Audit Controls

Statement of Policy

To ensure that CFS implements hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain electronic protected health information (“ePHI”).  Audit Controls are technical mechanisms that track and record computer activities.  An audit trail determines if a security violation occurred by providing a chronological series of logged computer events that relate to an operating system, an application, or user activities.

CFS is committed to routinely auditing users’ activities in order to continually assess potential risks and vulnerabilities to ePHI in its possession.   As such, CFS will continually assess potential risks and vulnerabilities to ePHI in its possession and develop, implement, and maintain appropriate administrative, physical, and technical security measures in accordance with the HIPAA Security Rule.

Procedure

  1. The IT Department shall enable event auditing on all computers that process, transmit, and/or store ePHI for purposes of generating audit logs.  Each audit log shall include, at a minimum: user ID, login time and date, and scope of patient data being accessed for each attempted access.  Audit trails shall be stored on a separate computer system to minimize the impact of such auditing on business operations and to minimize access to audit trails.
  2. CFS shall utilize appropriate network-based and host-based intrusion detection systems.  The IT Department shall be responsible for installing, maintaining, and updating such systems.

Corporate Compliance Program

Corporate Compliance Program

Center For Family Services is dedicated to maintaining excellence and integrity in all aspects of its operations and its professional and business conduct. Accordingly, Center For Family Services is committed to conformance with high ethical standards and compliance with all governing laws and regulations, not only in the delivery of service to consumers, but in its business affairs and its dealings with board members, employees, volunteers, contractors, agents, and payors. Anyone associated with Center For Family Services will be held responsible for adhering to the terms of the Center For Family Services’ business practices, Code of Ethics, and related policies, procedures and standards developed by Center For Family Services in connection with the Corporate Compliance Program.  

Center For Family Services is comprised of a variety of professionals.  It is required that each individual comply with the highest ethical standards of their profession. Center For Family Services has adopted and is committed to the National Association of Social Worker Code of Ethics as our guiding principles.

 Center For Family Services’ Corporate Compliance Program is intended to provide reasonable assurance that Center For Family Services:

  1. complies in all material respects with all federal, state and local laws and regulations that are applicable to its operations;
  2. satisfies the conditions of participation in behavioral health care and social service programs funded by the state and federal government and the terms of its other contractual arrangements;
  3. detects and deters criminal conduct or other forms of misconduct by Board of Trustees, officers, employees, agents and contractors that might expose Center For Family Services to significant civil liability;
  4. promotes self-auditing and self-policing, and provides for, in appropriate circumstances, voluntary disclosure of violations of laws and regulations;
  5. establishes, monitors, and enforces high professional and ethical standards.

The Center For Family Services Compliance Program contains several elements. All elements are designed to prevent, detect, and respond to business conduct that does not conform and adhere to applicable laws, regulations, and Center For Family Services Policies and Procedures. Training on how to conform to the Program will be provided to Center For Family Services staff and documented.
Center For Family Services intends its compliance program to significantly reduce the risk of unlawful conduct in our operations. This program demonstrates its good faith effort to comply with applicable statutes, regulations, and other Federal health care program requirements.  This includes Section 6032 of the Federal Deficit Reduction Act of 2005, 42 U.S.C. §1396a(a)(68) and the following Federal and State statutes:

Federal Deficit Reduction Act of 2005, 42 U.S.C. §1396a(a)(68)

The Deficit Reduction Act (DRA) provides that: 

  1. Governmental, for-profit and non-profit providers, and other entities that receive Medicaid funding, are required to establish written policies for all employees and contractors or agents and to provide detailed information about federal and state laws on: false claims; fraud, waste and abuse; and whistleblower protections.

  2. Include as part of the written policies, detailed provisions regarding the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse. Administrative Bulletins 7:22 and 7:23 detail the DMHS standards for compliance and specific implementation and programs for those standards.

  3. Provide employees with a specific discussion of the rights of the employees to be protected as whistleblowers and the entity’s policies and procedures for preventing and detecting fraud, waste, and abuse. 

  4. Under Section 6032, the DMHS contracted providers must adopt and comply with DMHS policies when providing Medicaid funded services to DMHS. Administrative Bulletins 7:22 and 7:23 must be made available to contactors’ employees and managers, regardless of how much funding the organization receives from DMHS. All of DMHS contractors must adhere to the Administrative Bulletins referenced in this paragraph when providing MHS funding services, regardless of whether the contractor has separate policies because it meets the Medicaid funding threshold independently of DMHS. 

Under Section 6032 of the Deficit Reduction Act of 2005 (DRA), codified at 42 U.S.C. § 1396a(a)(68), DMHS contracted providers shall follow federal and state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs, including programs through New Jersey Medicaid
 

  1. Federal False Claims Act, 31 U.S.C. § 3729 – 3733

    The Act established liability when any person or entity improperly receives from or avoids payment to the Federal government- In summary, the Act prohibits:
     

    1. Knowingly presenting, or causing to be presented to the government, a false claim for payment;
    2. Knowingly making, using, or causing to be made or used, a false record or statement to get a false claim paid or approved by the government;
    3. Conspiring to defraud the government by getting a false claim allowed or paid; 
    4. Falsely certifying the type or amount of property to be used by the government;
    5. Certifying receipt of property on a document without completely knowing that the information is true; 
    6. Knowingly buying government property from an unauthorized officer of the government, and; 
    7. Knowingly making, using, or causing to be made or used a false record to avoid, or decrease an obligation to pay or transmit property to the government.


     Any individual or entity engaging in any of the seven categories of prohibited actions listed in 31 U.S.C. §3729(a), including the submission of false claims to federally-funded health care programs, shall be liable for a civil penalty, of not less than $5,500 and not more than $11,000 per false claim, plus three times the amount of damages sustained by the Federal Government. The amount of the false claims’ penalty is to be adjusted periodically for inflation in accordance with a federal formula. 

    The U.S. Attorney General may bring an action under this law. In addition, the law provides that any “whistleblower” may bring an action under this Act on his own behalf and for the United States Government. These actions, which must be filed in the U.S. District Court, are known as “qui tam” actions. The government, after reviewing the complaint and supporting evidence, may decide either to take over the action, or may decline to do so, in which case the whistleblower may pursue the action. If either the government or the whistleblower is successful, the whistleblower is entitled to receive a percentage of the monetary recovery. If prosecuted by the Federal Government, these “qui tam” actions are generally handled by the Office of the U.S. Attorney, or by the U.S. Justice Department. 

    Whistleblower Protections:

    31 U.S.C. §3730(h) provides that any employee who is subject to retaliation or discrimination by an employer in the terms and conditions of employment because the employee lawfully sought to take action, or assist in taking action, under this Act “shall be entitled to all relief necessary to make the employee whole.”  This includes reinstatement with seniority restored to what it would have been absent the retaliatory or discriminatory conduct, double the amount of back pay owed, interest on back pay, and compensation for any special damages sustained as a result of the employer’s actions, including litigation costs and reasonable attorney’s fees.

  2. Federal Program Fraud Civil Remedies Act, 31 U.S.C. § 3801 – 3812

    Provides federal administrative remedies for false claims and statements, including those made to federally-funded health care programs. Current civil penalties are $13,508 for each false claim or statement made, and an assessment in lieu of damaged sustained by the Federal Government of up to double damages for each false claim for which the government makes a payment.  The amount of the false claims’ penalty is to be adjusted periodically for inflation in accordance with a federal formula. 
     
  3. New Jersey Medical Assistance and Health Services Act – Criminal Penalties, N.J.S. 30:4D-17(a) – (d)

    Provides criminal penalties for individuals and entities engaging in fraud or other criminal violations relating to Title XIX-funded programs.  They include: (a) for fraudulent receipt of payments or benefits, a fine of up to $10,000, imprisonment for up to 3 years, or both; (b) for false claims, statements of omissions, or conversion of benefits or payments, a fine of up to $10,000, improvement for up to 3 years, or both; (c) for kickbacks, rebates and bribes, a fine of up to $10,000, imprisonment for up to 3 years, or both; and (d) for false statements or representations about conditions or operations of an institution or facility to qualify for payments, a fine of up to $3,000, or imprisonment for up to 1 year, or both. Criminal prosecutions are generally handled by the Medicaid Fraud Section within the Office of Insurance Fraud Prosecutor, in the N.J. Division of Criminal Justice.

    New Jersey Medical Assistance and Health Services Act – Civil Remedies, N.J.S. 30:4D-7.h.; N.J.S. 30:4D-17(e) – (i); N.J.S. 30:4D-17.1.a.

    In addition to the criminal sanctions discussed in section 3 above, violations of N.J.S.A. 30:4D-17(a)-(d) can also result in the imposition of the following civil sanctions: (a) for unintentional violations, a recovery of overpayments with interest thereon; (b) for intentional violation, a recovery of overpayments with interest thereon, up to treble damage, and up to $5,000 for each false claim. As indicated in section V.D.8. below, this penalty was increased to between $5,500 and $11,000 per false claim as a result of the New Jersey False Claims Act. Recovery actions are generally pursued administratively by the Division of Medical Assistance and Health Services, with the assistance of the Division of Law in the N.J. Attorney General’s Office, and can be obtained against any individual or entity responsible or receiving the benefit or possession of the incorrect payments.  Participants engaging in civil violations may be excluded from participation in Medicaid and other health care programs under N.J.S.A. § 30:4D-17.1(a).
     

  4. Health Care Claims Fraud Act, N.J.S. 2C:21-4.2 and 4.3; N.J.S. 2C:51-5

    Provides the following criminal penalties for health care claims fraud, including the submission of false claims to programs funded in whole or in part with state funds:
     
    1. A practitioner who knowingly commits health care claims fraud in the course of providing professional services is guilty of a crime of the second degree, and is subject to a fine of up to 5 times the monetary benefits obtained or sought to be obtained and to permanent forfeiture of his/her license;
    2. A practitioner who recklessly commits health care claims fraud in the course of providing professional services is guilty of a crime of the third degree, and is subject to a fine of up to 5 times the pecuniary benefit obtained or sought to be obtained and the suspension of his/her license for up to 1 year; 
    3. A person who is not a practitioner subject to paragraph (a) or (b) above (for example, someone who is not licensed, registered or certified by an appropriate State agency as a health care professional) is guilty of a crime of the third degree;
    4. If that person knowingly commits health care claims fraud. Such a person is guilty of a crime of the second degree of that person knowingly commits 5 or more acts of health care claims fraud, and the aggregate monetary benefit obtained or sought to be obtained is at least $1,000. In addition to all other criminal penalties allowed by law, such a person may be subject to a fine of up to 5 times the monetary benefit obtained or sought to be obtained;
    5. A person who is not a practitioner subject to paragraph (a) or (b) above is guilt of a crime of the fourth degree if that person recklessly commits health care claims fraud. In addition to all other criminal penalties allowed by law, such a person may be subject to a fine of up to 5 times the monetary benefit obtained or sought to be obtained.  
       
  5. Uniform Enforcement Act N.J.S.A. 45:1-21. b. and o. 

    Provides that a licensure board within the N.J. Division of Consumer Affairs “may refused to admit a person to an examination o may refuse to issue or may suspend or revoke any certificate, registration or license issued by the board” who has engaged in “dishonesty, fraud, deception, misrepresentation, false promise or false pretense, or has “[a]dvertised fraudulently in any manner.”
     
  6. N.J. Consumer Fraud Act N.J.S.A. 56:8-2, 56:8-31., 56:8-14 and 56:8-15

    Makes unlawful the use of “any unconscionable commercial practice, deception, fraud, false pretense, false promise, misrepresentation, or the knowing concealment, suppression, or omission of any material fact”, with the intent that others rely upon it, in connection with the sale, rental or distribution of any items or services by a person, or with the subsequent performance of that person. 

    Permits the N.J. Attorney General, in addition to any other penalty provided by law, to assess a penalty of not more than $10,000 for the first offense and not more than $20,000 for the second and each subsequent offense. Restitution to the victim also can be ordered.  
     

  7. Conscientious Employee Protection Act, N.J.S. 34:19-1 et seq.

    New Jersey law prohibits an employer from taking any retaliatory actions against an employee because the employee does any of the following:
     

    1. Discloses, or threatens to disclose, to supervisor or to a public body an activity, policy or practice of an employer or another employer, with whom there is a business relationship, that the employee reasonably believes is in violation of a law, or a rule or regulation issued under the law, or, in the case of an employee who is licensed or certified health care professional, reasonably believes constitutes improper quality of patient care; 
    2. Provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into any violation of law, or a rule or regulation issued under the law by an employer or another employer, with whom there is a business relationship, or, in the case of an employee who is a licensed or certified health care professional, provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into quality of patient care; or 
    3. Provides information involving deception of, or misrepresentation to, any shareholder, investor, client, patient, customer, employee, former employee, retiree or pensioner of the employer or any governmental entity;
    4. Provides information regarding any perceived criminal or fraudulent activity, policy or practice of deception or misrepresentation which the employee reasonably believes may defraud any shareholder, investor, client, patient, customer, employee, former employee, retiree or pensioner of the employee or any governmental entity; and 
    5. Objects to, or refuses to participate in, any activity, policy or practice which the employee reasonably believes:

      1. Is in violation of a law, or a rule or regulation issued under the law or, if the employee is a licensed or certified health care professional, constitutes improper quality of patient care; 
      2. Is fraudulent or criminal; or
      3. Is incompatible with a clear mandate of public policy concerning the public health, safety or welfare or protection of the environment. N.J.S.A. 34:19-3.
         

    When a disclosure is made to a public body, the protection against retaliation does not apply unless the employee has brought the activity, policy or practice to the attention of a supervisor of the employee by written notice and has given the employer a reasonable opportunity to correct the activity, policy or practice. However, disclosure is not required where the employee reasonably believes that the activity, policy or practice is known to one or more supervisors of the employer or where the employee fears physical harm as a result of the disclosure, provided that the situation is emergent in nature. 

  8. New Jersey False Claims Act, N.J.S.A. sA:32C-1 et seq; and 

    The New Jersey False Claims Act (NJFCA), which was enacted on January 13, 2008 and became effective on March 13, 2008, has three parts: (1) it authorizes the NJ Attorney General and whistleblowers to initiate false claims litigation similar to what is authorized under the Federal False Claims Act, and has similar whistleblower protections; (2) it amends the NJ Medicaid statue to make violations of the NJFCA give rise to liability under NJS 30:4D-17(e); and (3) it amends the NJ Medicaid statute to increase the amount of civil penalties for each false claim under NJS 30:4D-17(e)(3) to between $13,508 and $27,018 per false claim.
     
  9. New Jersey Insurance Fraud Prevention Act, N.J.S.A. 17:33A-1 et seq.

    The purpose of this act is to confront aggressively the problem of insurance fraud in New Jersey by facilitating the detection of insurance fraud, eliminating the occurrence of such fraud through the development of fraud prevention programs, requiring the restitution of fraudulently obtained insurance benefits, and reducing the amount of premium dollars used to pay fraudulent claims. 
     

Effective 07/21

Revised 4/24

Risk Management

Center For Family Services deals with numerous regulatory bodies, and is exposed to various risks. Multiple individuals and groups throughout the organization are charged with managing our compliance with various agencies. All necessary resources are engaged to fully realize our various responsibilities throughout the organization. The compliance program is designed to focus on those areas of potential risk that are most relevant as a result of our participation in Federal and State programs. Accordingly, while not an all-inclusive list, following is an inventory of risk areas that are primarily addressed through the compliance program:

  1. Submission of accurate claims and the Federal False Claims Act
  2. HIPAA Privacy and Security Rules
  3. Inducements to Medicare and Medicaid beneficiaries
  4. Payments to reduce or limit services, including suspect gain sharing arrangements
  5. Quality of care which fails to meet professionally recognized standards of care
  6. Billing Medicare or Medicaid in excess of usual charges
  7. Conflict of Interest

Other functional areas within Center For Family Services may develop specific compliance programs and/or policies that address issues pertinent to those areas. These area-specific compliance programs and policies will augment and further support this Program.

Center For Family Services Shall Comply With All Applicable Laws.

It is the duty of Center For Family Services and all members of the Center For Family Services community to uphold all applicable laws and regulations. Center For Family Services and all members of the Center For Family Services community must be aware of the legal requirements and restrictions applicable to their respective positions and duties.  Center For Family Services expects each of its directors and employees to refrain from engaging in activity, which may jeopardize the tax-exempt status of the organization, including inappropriate lobbying and political activities.  
Center For Family Services shall implement trainings and programs necessary to further such awareness and to monitor and promote compliance with such laws and regulations.
Any questions about the legality or propriety of any actions undertaken by or on behalf of Center For Family Services should be referred immediately to your program manager or the Center For Family Services Compliance Officer.  Should anyone feel uncomfortable reporting violations or ethical concerns to any of the above, Center For Family Services has implemented a Compliance Line, a confidential telephone service that can be reached by:

Telephone: 1-800-401-8004 (English) or 1-800-216-1288 (Spanish)

Web reporting:  www.lighthouse-services.com/centerffs

Email: [email protected] (must include company name with report)

Fax: 1-215-689-3885

Additionally, any consumer who believes that Center For Family Services has violated any federal or state laws governing our operations can report that action to the program manager or to the compliance officer by:

Telephone: 1-800-401-8004 (English) or 1-800-216-1288 (Spanish)

Web reporting:  www.lighthouse-services.com/centerffs

Email: [email protected] (must include company name with report)

Fax: 1-215-689-3885

In order to detect, prevent, and report fraud, waste and abuse, additional reporting methods include:

New Jersey Medicaid Fraud Division: 888-937-2835 or https://www.nj.gov/comptroller/about/work/medicaid/complaint.shtml

New Jersey Insurance Fraud Prosecutor Hotline: 877-55-FRAUD or https://njinsurancefraud2.org/#report

Center For Family Services Shall Conduct Its Affairs in Accordance With the Highest Ethical Standards.

Center For Family Services and all members of the Center For Family Services community shall conduct all activities in accordance with the highest ethical standards and their respective professions at all times and in a manner which shall uphold Center For Family Services’ reputation and standing. Center For Family Services and all members of the Center For Family Services community shall not make false or misleading statements to any consumer, person or entity doing business with Center For Family Services.

Center For Family Services Shall Support the Goals of Center For Family Services and Avoid Conflicts of Interest.

Center For Family Services is a non-profit, charitable organization dedicated to the provision of quality care. Center For Family Services and all members of the Center For Family Services community are to perform their duties, in their assigned roles and tasks, for the purpose, benefit and interest of Center For Family Services and those that it serves. 
Center For Family Services and all members of the Center For Family Services community have a duty to avoid conflicts with the interests of Center For Family Services and may not use their positions and affiliations with Center For Family Services for personal benefit. Center For Family Services and all members of the Center For Family Services community must consider and avoid not only actual conflicts but also the appearance of conflicts of interest.

Center For Family Services Shall Strive to Attain the Highest Standards for All Aspects of Consumer Care.

Center For Family Services and all members of the Center For Family Services community must support its mission to provide services of the highest quality, in a cost-effective manner, in settings appropriate to consumer and payor needs under a variety of behavioral health care and social services financing arrangements. The service provided must be reasonable and necessary to the care of each consumer, as appropriate to the situation, and, such service must be provided by properly qualified individuals. All service must be properly documented as required by law and regulation, payor requirements and professional standards.

Center For Family Services Shall Provide Equal Opportunity and Shall Respect the Dignity of all of Its Members and Consumers.

Center For Family Services is committed to providing treatment services and employment opportunities free from prohibited discrimination or harassment.  Forms of discrimination or harassment based upon the following protected categories are prohibited and will not be tolerated:  race, creed, color, national origin, nationality, ancestry, age, sex/gender (including pregnancy), marital status, civil union status, domestic partnership status, familial status, religion, or sexual orientation, gender identity or expression, atypical hereditary cellular or blood trait, genetic information, liability for service in the Armed Forces of the United States, disability or any other classification protected by federal or state law.  Center For Family Services is committed to providing an environment that respects the dignity of each individual in the community; therefore, sexual harassment and any other types of prohibited discrimination in any form or context will not be tolerated

Center For Family Services Shall Maintain the Appropriate Levels of Confidentiality for Information and Documents.

Center For Family Services and all members of the Center For Family Services community respectively possess and have access to a variety of sensitive and proprietary information the confidentiality of which they are obligated to protect. Center For Family Services and all members of the Center For Family Services community must adhere to the applicable laws, regulations, policies and procedures designed to safeguard confidential information and to prevent inappropriate or unauthorized release. Center For Family Services and all members of the Center For Family Services community shall not use, disclose or discuss confidential health information unless consistent with applicable laws, including but not limited to the Health Insurance Portability and Accountability ACT (HIPAA). Center For Family Services and all members of the Center For Family Services community shall create and keep records and documentation that conform to the applicable legal, professional and ethical standards and all relevant Center For Family Services policies.

Maintain a Relationship of Integrity With Each Payor Source.

Center For Family Services and all members of the Center For Family Services community shall verify all requests for payment are for services that are reasonable, necessary and appropriate, are provided by properly qualified persons, and the claims for such services are billed in the correct amount and supported by appropriate documentation.

Center For Family Services Shall Conduct All Business Practices With Honesty and Integrity.

All business practices of Center For Family Services must be conducted with honesty and integrity and in a manner that promotes Center For Family Services’ reputation with consumers, payers’, vendors, competitors and the community. Center For Family Services and all members of the Center For Family Services community must:

  • adhere to proper business practices, Center For Family Services policies, and federal and state false claims, fraud and abuse, and referral prohibitions in dealing with payors, vendors and referral sources;
  • conduct business transactions without accepting, giving, offering or soliciting gifts, favors, kickbacks or other improper inducements or remunerations.

Center For Family Services shall abide by the policies and procedures regarding prevention and detection of fraud, waste and abuse.

Center For Family Services and all members of the Center For Family Services community must abide by the policies and procedures regarding prevention and detection of fraud, waste and abuse in federal healthcare programs in compliance with Section 6032 of the Deficit Reduction Act.

The Center For Family Services’ policies regarding Section 6032 of the Deficit Reduction Act are disseminated to all employees, supervisors, board members, contractor, vendors and agent on an annual basis.

Center For Family Services shall conduct monthly background checks to prevent and detect fraud, waste and abuse.  These checks are conducted using the following databases, as outlined in the New Jersey Division of Medical Assistance and Health Services Newsletter Volume 26, Number 14:

Anyone who believes that Center For Family Services has violated any federal or state laws governing our operations can report that action to the program manager, compliance officer or confidential reporting by:

Telephone: 1-800-401-8004 (English) or 1-800-216-1288 (Spanish)

Web reporting:  www.lighthouse-services.com/centerffs

Email: [email protected] (must include company name with report)

Fax: 1-215-689-3885

In order to detect, prevent, and report fraud, waste and abuse, additional reporting methods include:

New Jersey Medicaid Fraud Division: 888-937-2835 or https://www.nj.gov/comptroller/about/work/medicaid/complaint.shtml

New Jersey Insurance Fraud Prosecutor Hotline: 877-55-FRAUD or https://njinsurancefraud2.org/#report

Center For Family Services shall conduct business in such a way that Center For Family Services does not violate laws and regulations.

Center For Family Services and all members of the Center For Family Services community must:

  1. maintain and protect the property and assets of Center For Family Services, including intellectual property and proprietary information, substances and pharmaceuticals, equipment and supplies, and funds of Center For Family Services and refrain from converting Center For Family Services assets to personal use;
  2. maintain the confidentiality of proprietary information belonging to other persons or entities doing business with Center For Family Services; and
  3. prepare accurate financial reports, accounting records, research reports, expense accounts, time sheets and other documents so that they completely and accurately represent the relevant facts and true nature of all Center For Family Services business transactions.

Furthermore, all Center For Family Services electronic assets and communications technology, including but not limited to Center For Family Services internet access, intranet, email, computers, PDAs, copiers, fax equipment, telephones, and voice mail are subject to Center For Family Services Code of Conduct.

Center For Family Services Shall Have Proper Regard for Safety Within and Without the Community.

Center For Family Services and all members of the Center For Family Services community shall maintain a workplace that conforms to regulations regarding occupational health and safety. All medical waste, hazardous waste and other products shall be used and disposed of in accordance with all applicable environmental laws and regulations. Acts of violence, threats, harassment, intimidation and other disruptive behavior are prohibited in the workplace and during the course of Center For Family Services business. Center For Family Services and all members of the Center For Family Services community may not keep weapons (including, but not limited to, guns, knives, ammunition, and other dangerous materials) on Center For Family Services property, including buildings, lockers, desks, work spaces, parking facilities and storage areas, or possess them during the course of Center For Family Services business. Center For Family Services and all members of the Center For Family Services community can obtain information about Safety Policies and Procedures in the Policy Manual located on the Center For Family Services Intranet, accessible from all Center For Family Services computers. 

Political and Governmental Activity shall be Conducted in Accordance with Law.

Center For Family Services recognizes the rights of its members as citizens to participate in the political process. However, consistent with the requirements of the Internal Revenue Service and Center For Family Services’ tax-exempt status, Center For Family Services may not participate in, or intervene in (including the publishing or distributing of statements), any political campaign on behalf of (or in opposition to) any candidate for public office. Therefore, Center For Family Services and its member’s participation in political activities must be on an individual basis, on the individual's own time, and at the individual's own expense.

Federal and state laws restrict the use of corporate funds and assets in connection with elections. Consequently, Center For Family Services and all members of the Center For Family Services community may not donate Center For Family Services funds, property, services, or other financial or non-financial resources to any political candidate, nor may they use Center For Family Services resources for any political activity. Such Center For Family Services resources include facilities, work time, telephones, or Center For Family Services business addresses. Center For Family Services and all members of the Center For Family Services community may not make any political contribution to any candidate, office holder, or political organization for or on behalf of Center For Family Services. 

Center For Family Services regularly interacts with government agencies, and in connection therewith, Center For Family Services and all members of the Center For Family Services community must comply with applicable laws, regulations, and Center For Family Services policies and act honestly and ethically. Any improper attempt to influence the decisions of a government representative is prohibited. 

If Center For Family Services or its members receives an inquiry, a subpoena or other legal document from a governmental Agency or judicial authority regarding Center For Family Services, Center For Family Services or its members must immediately contact Center For Family Services CEO and President. As a general rule, it is a crime to impede or obstruct a government agent in the lawful exercise of the agent's duties, including altering, destroying, concealing, or falsifying documents sought in an investigation. Accordingly, if a Center For Family Services community member becomes aware of an imminent or ongoing investigation, audit, or examination, Center For Family Services and its member’s should retain all documents (including computer records) in the individual's custody or control relating to the matter under review.

Effective 07/21

Obligation to Report

It is the duty of Center For Family Services and all members of the Center For Family Services community to uphold the standards set forth in the Corporate Compliance Program and to report violations by following the reporting procedures outlined by Center For Family Services as then in effect. Alleged violations of the Corporate Compliance Program or other policies and procedures of Center For Family Services will be investigated by persons designated by, and pursuant to procedures established by Center For Family Services.

The Code of Conduct Shall Be Integral to the Operation of Center For Family Services and the Activities of the Community

The Code of Conduct exists for the benefit of Center For Family Services and all members of the Center For Family Services community.  All are encouraged to suggest changes or additions to the Code.  The Code must be incorporated into the daily activities of Center For Family Services and all members of the Center For Family Services community.

As an organization, we are committed to delivering superior behavioral health and social services within the appropriate regulatory framework and in compliance with all applicable laws, statutes, regulations and guidance.  All Center For Family Services and its community members have a responsibility to report possible compliance issues.  This obligation extends to, and includes, any Center For Family Services employee who is a licensed or certified health care professional who reasonably believes that an activity, policy or practice of Center For Family Services constitutes improper quality of patient care.

Anti-retaliation laws, including the New Jersey Conscientious Employee Protection Act (CEPA) prohibits Center For Family Services from retaliating against any Center For Family Services employee who discloses or threatens to disclose, an activity, policy or practice of Center For Family Services that the employee reasonably believes is in violation of a law, rule, regulation, that the employee reasonably believes is fraudulent or criminal activity; who provides information to, or testifies before, any public body conducting an investigation or hearing into a potential violation of law by Center For Family Services or its business associates or who objects to or refuses to participate in any activity, policy or practice which the Center For Family Services employee reasonably believes is in violation of a law, rule or regulation promulgated pursuant to law; is criminal or fraudulent; or is incompatible with a clear mandate of public policy concerning the public health, safety or welfare or protection of the environment.

This policy protects Center For Family Services employees from adverse actions or credible threats of adverse action being taken against them as a result of a reasonable and good faith allegation of misconduct.

Effective Date: 07/21

Reporting Procedures

Violations of the Corporate Compliance Program

Any illegal, unethical, or improper activities need to be reported, investigated and rectified. Violations of the Center For Family Services Compliance Program include, but are not limited to, violations of any of the following:

  1. Reimbursement regulations
  2. Health, safety and environmental laws
  3. Harassment/discrimination laws
  4. Conflicts of interest
  5. Unauthorized access and/or wrongful disclosure of confidential information
  6. Other HIPAA related privacy matters
  7. Internal accounting controls
  8. Governmental contracts
  9. Agency policies and procedures, including the Code of Ethics and Confidentiality
  10. Exploitation of agency resources (financial, equipment, property)
  11. Federal, State and Local laws and regulations
  12. Serious and proper conduct

Disciplinary Action

Disciplinary action for violations of the Corporate Compliance Program, which shall include but is not limited to, the Code of Conduct and other Center For Family Services policies and procedures shall be enforced through the disciplinary policies and procedures of Center For Family Services.  Disciplinary actions will be determined on a case-by-case basis and will utilize progressive disciplinary action, up to and including termination of employment. Center For Family Services will cooperate with law enforcement authorities in connection with the investigation and prosecution of the offender.

Deliberately making a false statement is a serious violation of Center For Family Services policy and the intent of these procedures and will lead to disciplinary action, up to and including termination of employment.

Board Members

Board Members have a special duty to adhere to the principles set forth in the Corporate Compliance Program, to support Center For Family Services and all members of the Center For Family Services community in their adherence to the Program, to recognize and detect violations of the Program, and to enforce the standards set forth herein.  Board Members should report a violation of the Program to the Corporate Compliance Officer, President and/or the CEO. Board Members may also report via the anonymous, confidential hotline.

Employees and Volunteers

Officers, managers and supervisors of Center For Family Services have a special duty to adhere to the principles set forth in the Corporate Compliance Program, to support Center For Family Services and all members of the Center For Family Services’ community in their adherence to the Program, to recognize and detect violations of the Program, and to enforce the standards set forth herein. 

Center FFor Family Services’ employees, contractors, volunteers, interns and all members of the Center For Family Services community have a duty to uphold the standards set forth in the Corporate Compliance Program and to report violations by following the reporting procedures outlined by Center For Family Services.  Employees should report any violations as outlined below. 

  • Program Management
    You should report a violation of the Program to your program manager.
     
  • Agency Management / Human Resources

If you are not comfortable talking with your program manager or not satisfied with the answer, go to the next higher level. You are encouraged to seek out another Center For Family Services resource, such as senior management or Human Resources.

Telephone: 856-651-7553 x40290
Fax: 856-964-3702
 

  • Corporate Compliance Officer

If your previous reports have not been acted upon, or for any other reason, you should call or notify:

Center For Family Services’ Corporate Compliance Officer
Cindy Herdman-Ivins, Chief Administrative Officer at (856) 651-7553 x 40124
 

  • Center For Family Services’ 24-hour Confidential Compliance Hotline:

Telephone: 1-800-401-8004 (English) or 1-800-216-1288 (Spanish)
Web reporting:  www.lighthouse-services.com/centerffs
Email: [email protected] (must include company name with report)
Fax: 1-215-689-3885

Reporting Protections

As stated above, all reports to the Compliance Hotline may be made on a confidential, no-name basis.  It is a violation of the Code of Conduct to take any action in retaliation against anyone who reports, in good faith, suspected violations of the Code of Conduct or other Center For Family Services policies and procedures. Please refer to Center For Family Services’ Code of Conduct and our Whistleblower Protection Policy.

Employees who, in good faith, report possible compliance violations will not be subjected to retaliation or harassment as a result of their reports. Retribution related to reporting of compliance concerns is prohibited and anyone who engages in such prohibited activity will be subject to disciplinary action. Concerns about possible retaliation or harassment should be reported to the Center For Family Services CCO or in their absence, the President or CEO. All such communications will be kept as confidential as possible but there may be times when the reporting of an individual's identity may become known or may have to be revealed if governmental authorities become involved.

Duty to Warn – Mandatory Reporting

In the event that there is a concern about the abuse, neglect, or exploitation of a minor or adult, the organization is mandated to report those concerns to the proper authorities.  Under the law, any person having reasonable cause to believe that a child has been subjected to abuse, neglect, and/or exploitation shall report this information to the Division of Child Protection and Permanency (DCP&P). Health care professionals, law enforcement officers, firefighters, paramedics, or emergency medical technicians are required by law to report suspicion of adult abuse to Adult Protective Services. 

Staff are then able to activate a complaint or report of concern using the internal reporting mechanisms or confidential ethical hotline.

Effective Date: 07/21

Corporate Compliance Officer

The Corporate Compliance Officer ("CCO") reports to the Center For Family Services President, CEO and the Board of Trustees through regular meetings. The CCO has primary responsibility for developing and implementing the compliance program as commissioned by the President and CEO. The CCO is assisted by others in the corporate compliance committee. The CCO's primary responsibilities include:

  1. Overseeing and monitoring the implementation of the Center For Family Services’ Compliance Program. The CCO will work with the President and CEO and appropriate staff to develop a Compliance Work Program to guide implementation of the Compliance Program. Elements of the Compliance Work Program includes:
    1. An annual identification of areas which require review and monitoring with timetables and personnel assigned. The Work Program will be reviewed on an annual basis with the President and President and CEO or his/her designee and be approved by the Board;
    2. Program and timetables for educational and training programs relating to legal and regulatory areas;
    3. Program and timetables for implementation of departmental compliance policies or Programs, where appropriate;
    4. Program and timetables for continued monitoring of areas under corrective action based on prior compliance assessments;
  2. Reporting as necessary to Board on the progress of Compliance Program implementation. Included in such reports will be new compliance issues noted, Programs for investigation, status of previously initiated investigations, timing and adequacy of corrective action Programs implemented, and designs for ongoing and future monitoring;
  3. Obtaining from the Board, required commitment of resources to carry out review and monitoring activities identified in Compliance Work Program;
  4. Performing an annual review of the Compliance Program Description and periodically revising the Compliance Program in light of changes in the needs of the organization, and in the laws and policies and procedures of government and private payor health Programs;
  5. Developing, coordinating, and participating in a multifaceted educational and training program that focuses on the elements of the Compliance Program, and ensures that all appropriate employees and management are knowledgeable of, and comply with, pertinent federal and state standards;
  6. Ensuring independent contractors and agents who furnish services to Center For Family Services are aware of the applicable requirements of the Center For Family Services Compliance Program with respect to coding, billing, and marketing;
  7. Coordinating personnel issues with Center For Family Services’ Human Resource;
  8. Independently investigating and acting on matters related to compliance, including the design and coordination of internal investigations that respond to reports of problems or suspected violations, and any resulting corrective action with Center For Family Services departments, providers and sub-providers, agents and, if appropriate, independent contractors. The CCO and his/her designee have the authority to review all documents and other information that are relevant to compliance activities;
  9. Monitoring the Compliance Line to ensure that Center For Family Services and all members of the Center For Family Services community  are able to report suspected improprieties without fear of retribution, and implementing processes to investigate, resolve and document all issues reported via  the Compliance Line;
  10. Monitoring activities related to the Center For Family Services Compliance Program and Compliance Work Program and reporting progress and relevant information to the Board;
  11. Responding, in conjunction with the President and CEO, to external Agency requests regarding compliance issues.

Effective Date: 07/21

Corporate Compliance Committee

Center For Family Services shall have a Corporate Compliance Committee composed of the CEO, President and the senior executive committee. The purpose of the Compliance Committee is to provide tactical leadership to the program. This includes identifying risk areas, initiating audits and reviewing the results of investigations.

The Committee assists the CCO, President and CEO in fulfilling responsibilities in developing, implementing and monitoring the Compliance Program. The purpose of the Committee is to provide strategic direction for the program. This includes monitoring changes in the environment and identifying the impact of such changes on specific compliance risk areas, recommending the adoption or revisions of policies and procedures necessary for an effective Compliance Program, and monitoring internal and external compliance audits and investigations and calls coming through the Compliance Line telephone service.

Effective Date: 07/21

Board Member Oversight

Center For Family Services’ Board provides overall monitoring with respect to the compliance program.  Center For Family Services Board Members will receive annual training on the Corporate Compliance Program. 

Center For Family Services shall have a Board Corporate Compliance Committee composed of the CCO, President, CEO and board members.  This Board Compliance Committee shall meet no less than once a quarter.   The purpose of the Committee is to provide review and oversight of the Corporate Compliance Program.

Specific oversight activities include receiving reports directly from the CCO on a quarterly basis.

The Board Compliance Committee will make a report at the first Joint Board meeting following the Committee’s regular meeting.

Effective Date: 07/21

Training

The CCO in conjunction with Human Resources has developed a policy on the dissemination and implementation of the Program and other compliance education/training initiatives. The policy states that:

All employees and volunteers will be introduced to and trained in the Program, the Center For Family Services Code of Conduct and compliance policies and procedures. Such training will reinforce the need for strict compliance with the law and will advise employees that any failure to comply will be documented on the employees' performance evaluation and may result in disciplinary action.

Within 120 days of their dates of hire, new employees and volunteers will be introduced to the Code of Conduct, informed of the Program and informed of the ways in which they may access the CCO and the Compliance Line service.

Focused in-service training will be provided annually to employees involved in the assignment of diagnosis and procedure codes for billing government and private payor programs.

Center For Family Services will make compliance training available to physicians, to the extent feasible, and will use its best efforts to encourage physician attendance and participation.

Center For Family Services Board Members will receive annual training on the Corporate Compliance Program.

Attendance at all training programs will be monitored and properly documented.  Training materials and a system to document that such training has occurred will be developed jointly by the CCO and Human Resources.

Effective Date: 07/21

Contact Information

Direct Access to the Compliance Officer

Center For Family Services recognizes that an open line of communication between the Compliance Officer and Center For Family Services personnel is critical to the success of the Program. In addition to using the Compliance Line, Center For Family Services and all members of the Center For Family Services community are strongly encouraged to report incidents of potential fraud or to seek clarification regarding legal or ethical concerns directly from the Compliance Officer. The Center For Family Services’ Compliance Officer can be directly contacted at (856)-651-7553 x 40124, fax (856)-964-3702.

The Corporate Compliance Officer is:  Cindy Herdman-Ivins, Chief Administrative Officer

Employees who, in good faith, report possible compliance violations will not be subjected to retaliation or harassment as a result of their reports. Retribution related to reporting of compliance concerns is prohibited and anyone who engages in such prohibited activity will be subject to disciplinary action. Concerns about possible retaliation or harassment should be reported to the Center For Family Services CCO or in their absence, the President or CEO. All such communications will be kept as confidential as possible but there may be times when the reporting of an individual's identity may become known or may have to be revealed if governmental authorities become involved.

The CCO will seek advice and guidance directly from the President and CEO to assist in the investigation of fraud and abuse reports concerning Center For Family Services and all members of the Center For Family Services community who may have participated in illegal conduct or committed other malfeasance.

Compliance Line - Hotline Service

A key element of the Center For Family Services’ Compliance Program is the telephone service called the Compliance Line that can be accessed by:

Telephone: 1-800-401-8004 (English) or 1-800-216-1288 (Spanish)

Web reporting:  www.lighthouse-services.com/centerffs

Email: [email protected] (must include company name with report)

Fax: 1-215-689-3885

The CCompliance Line is a completely confidential resource that can be used anonymously to allow all Center For Family Services and all members of the Center For Family Services community to voice concerns over any situation that may conflict with Center For Family Services’ commitment to excellence or to report misconduct that could give rise to legal liability if not corrected.  Impartial independent company records information reported by callers and communicates this information to the CCO or his/her designee so that appropriate verification, investigation and resolution can take place. A unique code is assigned to each call for follow-up communication by the anonymous caller.

A log is maintained of all Compliance Line calls, the results of investigations and continued monitoring, if applicable. Reports of Compliance Line calls, summarized by category and by operational area, will be provided at least annually to identify any significant trends or patterns for members.

The CCO provides regular reports to the Corporate Compliance Committee and the Board that summarizes the Compliance Line’s usage as well as any material findings from investigations resulting from calls and other relative communications.

New Employee and Volunteer Policy

For all new employees and volunteers, Center For Family Services conducts a reference check as part of the hiring and screening process.  Upon hire, Center For Family Services will ensure that any necessary background checks are completed prior to the employee's orientation.

Communications with Government Agencies

Center For Family Services shall document and retain records of all requests for information regarding payment policy from a government Agency and all written or oral responses received. Such records are critical if Center For Family Services intends to rely on such responses to guide them in future decisions, actions or claim reimbursement requests or appeals, while further underscoring Center For Family Services’ commitment to compliance with the law.

Record Retention for Corporate Compliance Cases

Center For Family Services is committed to complying with the record and documentation requirements under federal or state law and to the maintenance and retention of records and documentation necessary to confirm the effectiveness of Center For Family Services’ Compliance Program. Such documentation includes, but is not limited to, a Compliance Line log, minutes of Internal Compliance Committee meetings, minutes of Board Compliance Committee meetings educational presentation overviews, handouts and attendance sheets and documentation of ongoing auditing and monitoring efforts.

Effective Date: 07/21

Investigations

The CCO has the authority to investigate any potential compliance issues and to direct others to do so and shall report the results to the CEO and President. The CCO or his/her designee will:

  1. promptly initiate an investigation of a potential compliance issue to make a case-by-case determination as to whether a violation has occurred. The CCO will either personally conduct the investigation or refer the complaint to a more appropriate area, within Center For Family Services or outside, such as legal counsel, auditors or behavioral health care and social service consultants with appropriate expertise. The CCO may request assistance in the investigation from the person or persons who filed a complaint, other personnel or external sources, as appropriate;
  2. prepare a report of each investigation which will include documentation of the issue and, as appropriate, a description of the investigative process, copies of any and all interviewing notes and key documents, a log of the witnesses interviewed and the documents reviewed, the results of the investigation, any disciplinary action and the corrective action implemented to prevent recurrence. Reports of each investigation and the status of the corrective action will be presented to the Center For Family Services Board Compliance Committee.
  3. work with relevant areas within Center For Family Services to ensure return of discovered overpayments to the relevant government programs.
  4. report violations of criminal, civil or administrative law to the appropriate federal and/or state authority within a reasonable time period after determining there is credible evidence of such violation.

Effective Date: 07/21

Monitoring

As outlined in Section V, one of the principal responsibilities of the CCO is to oversee and monitor the implementation of the Center For Family Services Compliance Program. The CCO develops a Compliance Work Program to track implementation of the Compliance Program. The Compliance Work Program will include an annual identification of areas which require monitoring, with proposed timetables and personnel assignments. Progress reports of the ongoing monitoring activities, including identification of suspected noncompliance, will be maintained by the CCO and shared with the Compliance Committee, the Management Committee and the Center For Family Services Board Compliance Committee.

Monitoring techniques that will be used by the CCO include, but are not limited to the following:

  1. compliance audits focused on those areas within Center For Family Services that have potential exposure to government enforcement actions as identified in (i) Special Fraud Alerts issued by the Office of Inspector General (OIG), (ii) OIG Annual Work Program, (iii) Medicare/Medicaid fiscal intermediary or carrier reviews and (iv) law enforcement initiatives.
  2. benchmarking analyses which provide operational snapshots from a compliance perspective that identify the need for further assessment, study or investigation.
  3. periodic reviews in the areas of Program dissemination, communication of Center For Family Services compliance standards and Code of Conduct, availability of the Compliance Line and adequacy of compliance training and education to ensure that the Program's compliance elements have been satisfied in terms of Center For Family Services conformance.
  4. subsequent reviews to ensure that corrective actions have been effectively and completely implemented.

Effective Date: 07/21

Corrective Action Plans

When a compliance issue has been identified requiring remedial action, the appropriate department or administrative personnel responsible for the activity should develop a Corrective Action Program that specifies the tasks to be completed, completion dates and responsible parties. In developing such a Program, the responsible personnel will obtain advice and guidance from the CCO, and other appropriate personnel, as necessary.  Each Corrective Action Program must be approved by the CCO or his/her designee prior to implementation. The CCO has the obligation to report directly to the Center For Family Services Board Compliance Committee on (i) the implementation of all corrective action Programs; ii) compliance issues for which corrective action Programs have not been implemented; and (iii) the results of the corrective action Programs.

A Corrective Action Program should ensure the specific issue is addressed and similar problems will not occur in other areas or departments, to the extent possible. Corrective Action Programs may require compliance issues be handled in a designated way, relevant training takes place, restrictions be imposed on particular employees, or the matter be disclosed externally. Sanctions or discipline, in accordance with the standard disciplinary policies and procedures of Center For Family Services may also be recommended. If it appears certain individuals have exhibited a propensity to engage in practices that raise compliance or competence concerns, the corrective action Program should identify actions that will be taken to prevent such individuals from exercising substantial discretion in that area.

Center For Family Services believes all Center For Family Services and its community members are responsible for complying with the Center For Family Services Corporate Compliance Program, Code of Conduct and related policies and procedures. Corrective action for noncompliance will be initiated by the appropriate management personnel, who must notify Human Resources in accordance with the standard disciplinary policies and procedures of Center For Family Services. Enforcement will be administered by the parties identified by the CCO in consultation with the immediate supervisor and, if appropriate, Human Resources. Disciplinary actions will be determined on a case-by-case basis and will be taken appropriately, equitably and consistently, given the underlying circumstances and the degree of negligence or reckless conduct.

Effective Date: 07/21

Effectiveness Review

Periodic reviews of the effectiveness of the Center For Family Services Compliance Program shall be conducted by outside counsel, auditors or consultants.  Internal reviews coordinated by the CCO of Center For Family Services and shall be conducted annually.

Effective Date: 07/21

Adopted by the Board on July 28, 2021

 

Service Provision

Suicide Prevention and Care

Policy:  

Center For Family Services is committed to Suicide Prevention and Care for all individuals in our care.  We are committed to providing a safe, supportive, and culturally responsive environment for everyone that we work with.  All staff receive gatekeeper training to learn how to recognize and identify warning signs, ask if someone is thinking about suicide, and connect those at risk with services and resources. Center For Family Services believes that suicide is preventable and is committed to helping and supporting those at higher risk for suicide.

Purpose:

Center For Family Services is dedicated to providing quality of care with a priority on the safety of our employees and the community of people we serve in regards to suicide care and prevention.  Center For Family Services has adopted the Zero Suicide Framework to guide the organization in this effort.  The foundational belief is that suicide deaths for individuals under the care of health systems and behavioral health organizations is preventable.  As an organization that is focused on client and employee safety, the Zero Suicide Framework presents an aspirational challenge and practical framework for system wide transformation toward safer suicide care.

Center For Family Services has created a Zero Suicide Committee that is focused on moving this initiative and framework forward throughout the agency.  The Committee is also a resource for Center For Family Services programs to utilize for assistance with the development and implementation of suicide prevention and care in their services.

https://www.centerffs.org/staff/zero-suicide

Seven Elements of Zero Suicide:

  • Lead – Creating a system wide culture change committed to reducing suicides.
  • Train – Having a competent, confident, and caring workforce that is up to date in suicide care.
  • Identify – Creating procedures for agency programs and staff to identify at risk individuals through 
    screening and assessment processes.
  • Engage – Creating procedures for at risk individuals for suicide that have been identified to engage in suicide prevention and care.
  • Treat – Provide suicide treatment to at risk individuals that is guided by evidenced based 
    practices for suicide.
  • Transition – Provide support to at risk individuals as they transition between different levels of care 
    and services.
  • Improve – Provide ongoing quality improvement through policies and procedures that are 
    routinely reviewed and monitored.

Procedures:

It is the expectation of Center For Family Services that programs will develop and implement suicide screenings within their settings that identify at risk individuals.  Procedures will be documented and included in Program Manuals.  

Dependent upon the type of programming, suicide assessment will also be developed and implemented and documented within Program Manuals.  

Treatment programs will develop and implement evidenced based practices focused on suicide treatment that will be included in service plans of those who have been identified as high risk for suicide.  

All programs will have procedures for when individuals are assessed to be a danger to themselves and procedures on transitioning them to emergency care.

Incident Reporting:

Center For Family Services has an internal incident reporting system (Clarity) where all incidents of suicidal behavior is documented.  The Zero Suicide Committee is responsible to review agency’s data on suicidal behavior to help inform the organization on suicide prevention and care, identify trends, and identify areas that need improvement.  Programs that are required to report incidents of suicidal behavior to their funders (DCF, DMHAS) shall do so according to their specific regulations.

In the event that a Duty to Warn arises, CFS employees are to follow the organization's operation guidelines on Duty to Warn.

Training:

All new employees at Center For Family Services are required to attend Question, Persuade, Refer (QPR) training during their “New Hire Experience”.

Staff are to refer to their program policy and procedure manual for specific policies and protocols regarding screening, assessment and treatment for suicide prevention and care. 

Staff receive training during their 90-day orientation period, as appropriate to their position or job category, on suicide screening, assessment and/or treatment, based on each program’s identified tools.  These may include:

  • Safety Planning
  • Access to Lethal Means
  • Columbia Suicide Severity Rating Scale

The completion of this training will be documented on the employee’s program orientation checklist.    

Human Resources

At Center For Family Services, our employees are our greatest resource. It is only because of your hard work, dedication, and talent that we are consistently recognized as a nonprofit leader in New Jersey.

The Human Resources Department is committed to providing you with the support needed to be successful from the moment of hire and throughout their entire journey at Center For Family Services.

As an employee of Center For Family Services, please familiarize yourself with the following documents.