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 10/11




Community Education and Information 10/11

Complaint Mechanism 10/11

Confidentiality 10/11

     Appendix A:      Confidential Information Release/Request Form

     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 11/12

      Appendix A:         Emergency Information Sheet 2/12

      Appendix B:         Guidelines for Emergency Information Sheet 2/12

      Appendix C:         Protocol for Head Injuries 11/12

      Appendix D:         Emergency Provisions 2/12

Extended Family Home 12/14

     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 10/11

     Appendix A:      Petty Cash Sheet and Instructions 10/06

     Appendix B:      Possessions Inventory and Instructions 10/06

     Appendix C:      Income and Expense Sheet  10/06

                                Instructions for Income and Expense Sheet 10/06

     Appendix D:      Financial Incident Report and Instructions 10/06

     Appendix E:      Notice of Cost 12/14

     Appendix F:      Clothing Inventory 10/06

     Appendix G:      Income and Expense Worksheet 10/06

     Appendix H:      Reconciliation Sheet 10/06

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 1/14

     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 Program Plan, Development, Amendment, and Review 10/14

     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

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 1/15

     Appendix A:     Administration Checklist 2/15

     Appendix B:     Emergency Disaster Checklist 1/15

     Appendix C:     Employment Checklist 1/15

     Appendix D:     Financial Checklist 3/13

     Appendix E:     Formal Supports Checklist 1/15

     Appendix F:     Incident Report Checklist 4/12

     Appendix G:    Intake/Termination Checklist 1/14

     Appendix H:    Monthly Review Checklist 1/15

     Appendix I:     Nurse & Medication Checklist 1/15

     Appendix J:     Personal Interview Checklist 1/15    

     Appendix K:    Personnel File Checklist 3/13

     Appendix L:    Psychotherapeutic Med/Committee Review Checklist 1/15

     Appendix M:   Services Checklist 1/15

     Appendix N:   Unit File Checklist 3/13

     Appendix O:   Onsite Follow-Up Checklist 1/14



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 4/12

     Appendix A:      Unit File Format and Retention 4/12

     Appendix B:      Working File Format and Retention 9/12

     Appendix C:      Retention of Regional Forms 4/12

Rights of Individuals Served 10/11

     Appendix A:      My Rights 10/11

     Appendix B:      Rights Restriction Form & Instructions 10/11

Daily/Weekly Routine Documentation 4/12



Safety Committee 4/15

     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

Smoking 8/14

     Smoking Sign 8/14

Social Media for People Supported 4/11

Socialization/Sexuality 9/05

     Appendix A:      Policy Governing Socialization/Sexuality 9/05

Staff Development 10/11

     Appendix A:      Training Requirements 4/14

     Appendix B:      Training/Inservice Participation Signature Sheet 12/07

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 10/11

      Appendix A:      Three Part Consent Form 10/11

Training, Ongoing and Review 10/11

      Appendix A:        Training & Review 5/11

Transportation 6/14

     Appendix A:          Vehicle Damage Report 6/10


U – V - W - X - Y – Z


Service Plans 2/10



4/97; 3/15

Appendix A - Safety Checklist.pdf97.22 KB
Central Office - 1.800.672.8693 - 1202 E. 14th Street, Wayne, NE 68787