Celebrating 40 Years! 1974 - 2014

Policy and Procedures




The Mission, Guiding Principles & Expectations of the Agency



Abuse & Neglect 3/13

     Appendix A:      A & N 1 - Notification to Legal Representative/Services Coordination 10/11

     Appendix B:      A & N 2 - Allegation Notification and Follow-Up 10/11

Advance Directives 10/11

     Appendix A:      Living Will 6/10

     Appendix B:      Power of Attorney for Health Care Information Information 6/10

     Appendix B:        Power of Attorney for Health Care Information Form 6/10

     Appendix C:      Do Not Resuscitate (DNR) Orders 6/10

Assessment, Individual  4/16

   Appendix A:  Network Relationship Map 4/16

   Appendix B:  Network Relationship Map with Instructions  4/16

   Appendix C:  Comprehensive Life Skills Assessment  4/16

   Appendix D:  Comprehensive Life Skills Assessment with Instructions  4/16




Community Education and Information 10/11

Complaint Mechanism 10/11

Confidentiality 9/15

     Appendix A:      Confidential Information Release Form 9/15

     Appendix B:      Disclosure of Medical Information

     Appendix C:      HIPAA Privacy Statement 10/11

     Appendix D:      Things You Need To Know About HIPPA

     Appendix E:      Penalties


Diseases, Prevention of Transmission of Chronic Infectious 10/11

Documentation on Agency Forms, Guidelines 10/11

Due Process Committee 10/14



Emergencies/Disasters  6/15


     Appendix A:     Protocol for Head Injuries 11/12

     Appendix B:     Guidelines for Emergency Information Sheet 2/12

     Appendix C:     Emergency Response Report & Instructions 6/15

     Appendix D:     Table of Contents and Review 6/15

     Appendix E:     Emergency Provisions 2/12

Extended Family Home 6/16

     Appendix A:     Extended Family Home Provider Study 12/14

     Appendix B:     Extended Family Home Interview Questions 12/14

     Appendix C:     Extended Family Home Contract

     Appendix D:     Extended Family Home Orientation Checklist 12/14

     Appendix E:     Extended Family Home Monitoring Sheet 12/14

     Appendix F:     Extended Family Home Screening Tool 12/14


Financial Resources of Persons Served 8/16

     Appendix A:     Petty Cash Sheet Instructions 8/16

     Appendix B:     SNAP Record Instructions 8/16

       Appendix C:     Gift/Pre-Paid Card Record Instructions 8/16

     Appendix D:    Income and Expense Sheet Instructions 8/16

     Appendix E:    Notice of Cost  8/16

     Appendix F:    Possessions Inventory Instructions 8/16

     Appendix G:   Clothing Inventory Instructions 8/16

     Appendix H:   Financial Incident Report Instructions 8/16

Food Service 10/11

Format and Retention of Forms (Under R)

Functional Behavioral Assessment 10/14

     Appendix A:     Functional Behavioral Assessment Form 12/13

     Appendix B:     Functional Behavioral Assessment Instructions 12/13



Governing Board 10/11

Guardianship and Conservatorship 10/11



Health & Wellness Manual 10/11

Human and Legal Rights Committee 10/14

     Appendix A:      H & L 1- Human and Legal Referral Form 6/13




Incident Reports 8/16

     Appendix A:      Incident Report 1/13

     Appendix B:      Incident Report Instructions 1/13

     Appendix C:      GER High Notification Levels 1/14

     Appendix D:      Incident Report Review Form & Instructions 7/13

     Appendix 1:      State of Nebraska GER Instructions 1/14

Individual Support Plan, Development, Amendment, and Review 1/16

     Appendix A:     Monthly Review Goal Sheet 10/14

     Appendix B:     Monthly Review Goal Sheet with Instructions 10/14

      Appendix C:     Monthly Review General Information and  Supports Sheet 10/14

     Appendix D:    Monthly Review General Information and Supports Sheet with Instructions 10/14

     Appendix E:    Monthly Review Progress Sheet A 10/14

     Appendix F:    Monthly Review Progress Sheet B with Percentages 10/14

     Appendix G:     Full File Review 1/16

     Appendix H:     Individual Planning Documentation 1/16

Investigations 8/14

     Appendix A:  Central Office Investigators 9/12

     Appendix B:   Interview Qustions 9/12


J - K - L




Medication – See Health & Wellness Manual (H)

Psychotherapeutic Medication – see P




Orientation to Services 5/14

     Appendix A:  Orientation Checklist 10/11



Positive Behavioral Supports 10/14

     Appendix A:      Positive Behavioral Support Form 5/13

     Appendix B:      Positive Behavioral Support Instructions 5/13

Psychotherapeutic Medication 10/14


Quality Assurance 3/16

     Appendix A:     Administration Checklist 3/16

     Appendix B:     Emergency Disaster Checklist 3/16

     Appendix C:     Employment Checklist 3/16

     Appendix D:     Financial Checklist 3/16

     Appendix E:     Formal Supports Checklist 3/16

     Appendix F:     Incident Report Checklist 3/16

     Appendix G:    Intake/Termination Checklist 3/16

     Appendix H:    Monthly Review Checklist 3/16

     Appendix I:     Nurse & Medication Checklist 3/16

     Appendix J:     Personal Interview Checklist 3/16    

     Appendix K:    Personnel File Checklist 3/16

     Appendix L:    Psychotherapeutic Med/Committee Review Checklist 3/16

     Appendix M:   Services Checklist 3/16

     Appendix N:   Unit File Checklist 3/16

     Appendix O:   Onsite Follow-Up Checklist 3/16

     Appendix P:  Quality Assurance Plan of Action 3/16




Recruitment and Retention 1/14

     Appendix A:      New Staff Survey and Guidelines 3/12

     Appendix B:      Exit Survey and Guidelines 1/11

Referral and Intake 5/14

Regional Advisory Committee  10/11

Format and Retention of Forms 1/16

     Appendix A:      Unit File Format and Retention 1/16

     Appendix B:      Working File Format and Retention 1/16

     Appendix C:      Retention of Regional Forms 4/12

Rights of Individuals Served   7/15

     Appendix A:      My Rights 7/15

     Appendix B:      Rights Restriction/Protection Form & Instructions 7/15

Daily/Weekly Routine Documentation 4/12



Safety Committee 5/15

     Appendix A:      Safety Checklist 4/15

     Appendix B:      Temperature Checklist 10/14

     Appendix C:      Evacuation Drills Report 4/15

     Appendix D:      Employee Accident Report 4/15

     Appendix E:      Life Safety Code 5/1

Social Media for People Supported 4/11

Socialization/Sexuality 9/05

     Appendix A:      Policy Governing Socialization/Sexuality 9/05

Staff Objectives 4/12

     Appendix A:      Staff Objective Form 4/12

Staff Recruitment and Retention (see R)

Support Programs 5/14

     Appendix A:      SP 1- Support Program Form & SP 1a- Support Program Form (if needed) 3/07

     Appendix B:      SP 2 – Task Analysis Form 7/05

     Appendix C:      SP 3 – First Objective Methodology Form 7/05

     Appendix D:      SP 4 – Subsequent Objective Methodology Form 7/05

      Appendix E:     SP 5 – Baseline Information 12/08

      Appendix F:     SP 6 – Positive Behavioral Support or Program Orientation Sheet Instructions 5/14

      Appendix G:      SP 7 – Positive Behavioral Support Signature Sheet Instructions 7/13


Termination of Services 10/11

Three Part Consent 9/15

      Appendix A:      Three Part Consent Form 6/16

Tobacco Free Workplace  8/14

     Tobacco Free Workplace Sign 8/14

Staff Training 8/16

     Appendix A:     Regulatory Training Requirements 8/16

     Appendix B:     Required Staff Training  8/16

     Appendix C:     Orientation and Training  Competency Record 8/16

     Appendix D:     Training Participation Signature Sheet 8/16

     Appendix E:     Ongoing Staff Training 8/16

Transportation 6/14

     Appendix A:          Vehicle Damage Report 6/10


U – V - W - X - Y – Z


Service Plans 2/10








4/97; 8/16

Central Office - 1.800.672.8693 - 1202 E. 14th Street, Wayne, NE 68787