First Aid and Safety
Where are the first aid kits located?
What trainings are provided to staff related to privacy, ethics, and compliance? How frequently?
Code of ethics, CMS compliance, MENTOR South Bay compliance, and Privacy and Security. Trainings are provided annually and during orientation.
Where is the Notice of Privacy Practices available?
Summary of Privacy Practices are included in the Person Being Served Orientation Manual. The Notice of Privacy Practices is available to all consumers upon request, copies are maintained in reception. Reminder of Notice of Privacy Practices is posted in the waiting room bulletin board.
What is MENTOR South Bay’s Compliance Hotline used for? Who can call the hotline? Where is this information available?
A) To report any compliance concerns (billing, privacy, etc) B) Anyone can call the hotline C) Posters in the team room, Orientation and annual trainings, Person Being Served Orientation Packet
Who is the Medical Director?
Dr. Killion
Where are the fire extinguishers located?
Across from reception, in the team room, in the hallway by the CBHI offices
What safety related trainings are provided to staff? How frequently?
Health and Safety, Workplace Violence and Crisis Prevention, Community Outreach and Safety. Trainings are provided annually and during orientation. Active Shooter training is provided annually.
Who is allowed to request medical records? When does MENTOR South Bay release records?
Anyone can request records. MENTOR South Bay releases records only with valid release to do so (signed by client/legal guardian), an access request completed by client/legal guardian for their records, or a court order signed by a judge
How can a client/guardian file a complaint? Where is this information available?
Contact a site supervisor, director, QI or MENTOR Network’s Compliance Hotline. This information is shared during the intake process and reviewed as needed. This information is outlined in Grievance Procedure form. If all internal avenues are exhausted or at any time they choose, clients may also file complaints externally through DPH, licensing board, insurance company.
When is an incident report completed?
Any factual occurrence or anticipated event in which a MENTOR client is (or would be) the cause or victim of emotional, physical, or social harm to himself/herself or to others. In the event of an incident which is outlined in the Incident Management Process Procedure, reports are to be completed in 24 hours. Notification requirements are based on Level of crisis
Where are rubber gloves located? When/why would you need to use them?
In the first aid/spill kits. To clean up any bodily fluids
How does a clinician develop a person-centered treatment plan?
After completed a Comprehensive Assessment, the clinician collaborates with the client/family to develop appropriate goals and an individualized action plan.
What are examples of how MENTOR South Bay protects privacy of individuals served?
Administrative, Technical, and Physical Safeguards. Examples include: all records are maintained in locked filing cabinets; electronic records are encrypted; password protection on all devices, EHR, email; HIPAA log in EHR; policies and procedures in place; privacy training provided to all employees.
Where are formal complaint/grievance forms located?
The MENTOR Network Employee Information Guide and Employee Code of Conduct. Reception can provide these forms as well.
What are MENTOR South Bay’s values?
Integrity, Respect, Inclusion, Growth
Where are the evacuation plans located?
By the door in every room
What outcome tools does MENTOR South Bay utilize?
PHQ-9, CANS, PROMIS
When is a client/guardian informed of their rights? How is this done?
During the initial intake session, through the Patient Rights and Privacy Practices. This information is verbally shared and the client/guardian is provided a copy as requested. Information includes Patient Rights, Privacy Practice, Consent to Treat and can be found in the office in a prominent location.
What Code of Ethics does MENTOR South Bay recognize? Where is this located?
MENTOR Code of Conduct, MENTOR Compliance Plan and the Employee Information Guide are available in Salesforce Libraries .Staff are also required to adhere to any professional code of ethics.
What is MENTOR South Bay’s mission?
The MENTOR Network’s mission is to offer adults, children, and their families innovative, quality services and supports that lead to growth and independence, regardless of the physical, intellectual or behavioral challenges they face. Our philosophy emphasizes partnerships—with those we serve, their families, our employees, Mentors, payors and the communities in which we work—in an effort to help individuals shape the direction of their own lives in community-based settings.
Who is the evacuation team leader? What is their role?
Jen Pedro-Ensures authorities and staff are notified during hazard and staff have evacuated.
What is a Consumer Resource Manual? Where is it located?
Available community resources for clients/guardians. It is available in reception. Resources also available on Google Drive.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
Who is The MENTOR Network’s Compliance Officer? How can this person be reached?
Mary Rodenberg-Roberts, email: Mary.Rodenberg-Roberts@thementornetwork.com
Please note: This also includes privacy related concerns
If a CARF surveyor asks you a question you do not know how should you respond?
I do not know off hand, let me find that for you. Let me speak with my manager to get you that information. I will refer you to the appropriate person to obtain that information. Do NOT make up an answer if you are unsure if is ok to need to look something up or get further assistance.