Module 6- Policy and Procedures

  1. Mission Statements
  2. Defining Policies and Procedures
  3. Why Do You Need Policies and Procedures?
  4. Reflecting Agency Values, Ethics and Principles in Policies and Procedures
  5. Developing Policies and Procedures
    1. Good Policies
    2. Good Procedures
    3. Writing Style for Policy and Procedure Documents
    4. Design and Layout of Policy and Procedure Documents
  6. Rule 115- CILA Rule
  7. Rule 116- Medication Administration Rule
  8. Rule 119- Community Day Service
  9. Rule 350- ICF/DD
  10. Rule 50- Office of Inspector General: Abuse and Neglect
  11. The Mental Health Code

Mission Statements

Every organization needs to define its fundamental purpose, philosophy, and values. The mission statement clarifies the essence of an organization's existence. It describes the needs an organization was created to fill and answers the basic question of why it exists. The mission statement provides the basis for judging the success of the organization and its programs.

A powerful mission statement attracts donors, volunteers, and community involvement. It helps the organization and its stakeholders to verify whether the organization is doing its intended job and making the right decisions. It provides direction when the organization needs to adapt to new demands, helps the board to stay true to its primary purpose, and serves as a touchstone for decision making during times of conflict. The mission statement can also be used as a tool for resource allocation.

DSPs should be given opportunities to be involved in your agency's Mission Statement. DSP's can provide input into the development or updating of the mission and vision statement; by participating in committees, work groups, and planning sessions. Their involvement will help shape and direct an organization in ways that value, respect, and affirm each employee's input, talent, and creativity to accomplish the mission, vision, and work of the organization.

Some of the benefits of DSPs being involved in carrying out mission and vision statement include:

  • Provide opportunities for DSPs' voices to be heard.
  • Give DSPs and frontline supervisor's perspective about what will or will not work in the development of policies, procedures, and practices.
  • Enable the organization/employer to have broader and more diverse views and creativity in teams, groups, and committees.
  • Creates an environment of openness, integrity, and respect.

What is your mission statement? Is your mission statement on your agency's letterhead? How do you, as the Residential Director, ensure the people you supervise are following the agency mission?

Defining Policies and Procedures

It is important for all individuals within your agency to be involved in the development and implementation of policies and procedures and to understand what policies and procedures are.

Written policies can prevent chaos, confusion, and legal problems. Policies provide less chance that the administrator or executive director will make an illogical, irrational, or possibly an illegal decision. Such decisions may disrupt employee relations and workplace harmony and run afoul of government and agency regulations.

A policy is a definite course or method of action to guide and determine present and future decisions. A policy is also a guide to decision making under a given set of circumstances. Policies are usually based upon accepted, well-defined norms/standards of practice. Norms/standards are needed to establish consistency; expectations and patterns for practice. Norms/standards articulate what is done, who is served, and what services and resources are needed. In addition, standards provide a benchmark for quality measurement and improvement.

A procedure is a way of accomplishing something, an established way of doing things, a series of steps followed in a definite order ensuring the consistent and repetitive approach to actions.

Why Do You Need Policies and Procedures?

The main purpose of having policies and procedures is to establish a high degree of understanding, cooperation, efficiency and unity among employees of your agency or facility, fostered by a systematic application of good procedures in personnel management. Another purpose is to provide uniform policies for all employees with all the benefits such a program ensures, without regard to race, color, creed, religion, national origin, gender, age, disability or political affiliation.

The fundamental objectives of these personnel management policies are to:

  • Promote and increase efficiency and economy among employees;
  • Provide fair and equal opportunity to all employees and qualified applicants based on demonstrated merit and fitness as ascertained through fair and practical methods of selection;
  • Develop a program of recruitment, advancement, and tenure that will make employment with the agency/facility attractive as a career and encourage each employee to render the best service

Reflecting Agency Values, Ethics and Principles in Policies and Procedures

All supervisors should be trained about policies and procedures. Many suits brought against organizations are because, although the organizations had clear policies, supervisors did not enact the policies because they did not understand them.

Below is a CBTA on policies and procedures. Answer the questions based on your agency's policies and procedures.

  • Do our policies and procedures reflect the mission and vision of our organization/agency? How do you verify/incorporate?
  • Are policies and procedures written in a clear, understandable manner-preferably at an 8th grade reading level? Are they "user friendly"? How could you find out?
  • Are they person-centered? How could you find out? What are some "key" words?
  • Do policies and procedures reflect "best practice" in the field of intellectual disabilities? How could you find out?
  • Does your Human Rights Committee review your policies and procedures for rights restrictions?
  • Are policies and procedures written to clearly protect the safety and wellbeing of persons supported?
  • How often are the policies and procedures updated and by whom? Do those who use them the most have input into their creation/revision?
  • Do policies and procedures have built-in prompts for staff to adhere to certain time frames? For example: (twice yearly in January & July, etc.)
  • In what ways do our policies and procedures address the requirements of monitors, surveyors, rules, mandates, etc.?
  • How is staff trained in policies and procedures? Do we use competency- based training materials?
  • Do we follow our own policies and procedures? Do we ever deviate or make exceptions? If so, what method of approval do we have in place? If so, what methods of approval do we have in place?

No policies and procedures manual should ever be regarded as "complete" in the sense that it will never change. The best manual is the one that is geared to continuous growth over time and incorporates design features that make this kind of growth possible. A well thought out manual can enable just about everyone in your organization the ability and flexibility to make the right decisions in his or her job responsibilities.

Developing Policies and Procedures

Agencies develop policies and procedures to define issues relevant to the agency or facilities programs and services, including: goals and objectives, services provided, roles and responsibilities of staff, and existing regulations, standards, and guidelines important to the care of individuals served. The contents of your policies and procedures manual will depend on the nature and needs of your organization. Each policy should include wording to the effect that the policies are for general guidance in the relationships between employees and the organization, the board has authorized the policy, that policies can be changed at any time and that the policies do not constitute a contract between the organization and the employee.

A policies and procedures manual guides both managers and employees as to what is expected and can prevent misunderstandings about what is permissible and what will work well. In addition, supervisors and managers are more likely to consistently apply policies that are clearly communicated in writing.

Good Policies

  • Policies are written in clear, concise, simple language
  • Policy statements address what is the rule rather than how to implement the rule
  • Policy statements are readily available to staff and their authority is clear
  • Designated "policy experts" are identified and readily available to interpret policies and resolve problems
  • As a body, they represent a consistent, logical framework for action

Good Procedures

  • Procedures are tied to policies. Making explicit the relationship along with how the procedure helps the agency achieve its goals or strategic plan helps ensure understanding and compliance
  • Procedures are developed with the user in mind
  • There is a sense of ownership among procedure users.
  • The procedures are understandable.

Writing Style for Policy and Procedure Documents

  • Concise, minimum of verbiage
  • Factual, double-checked for accuracy
  • Don't include information that may be quickly outdated
  • If you use an acronym, spell it out the first time you use it
  • Include step-by-step instructions for completing forms (procedures only)
  • Not too technical - simple enough to be understood by a new employee

Design and Layout of Policy and Procedure Documents

  • Generous use of white space
  • Presentation is structured so that the user can quickly focus on the aspect of policy or procedure relevant to the task at hand
  • Use a flexible outline style to make the document easy to modify (and therefore keep up-to-date)
  • Use labels to introduce key points (headings and labels in margins need to be consistent) the policies and procedures must adhere to the mandates of the following Rules. Rule 115, 119, 116, 350.

Rule 115- CILA Rule

Rule can be found at Rule 115

Licensure and Certification Act [210 ILCS 135] is to license agencies to certify living arrangements integrated in the community in which individuals are supervised and provided with an array of needed services.

Rule 116- Medication Administration Rule

Rule can be found at Rule 116

The purpose of this Part is to ensure the safety of individuals in programs funded by the Department of Human Services (DHS) by regulating the storage, distribution, and administration of medications in specific settings; training of non-licensed staff in the administration of medications. This applies exclusively to all programs for individuals with a intellectual disability in settings of 16 persons or fewer that are funded or licensed by the Department of Human Services and that distributes or administers medications and all intermediate care facilities for the intellectual disabled with 16 beds or fewer that are licensed by the Illinois Department of Public Health.

Rule 119- Community Day Service

Rule can be found at Rule 119

Programs shall be located to promote integration of individuals into their communities. Some examples of integration include locations near public transportation, shopping, restaurants, and recreation. Programs shall provide a minimum of five hours of programming per day, excluding transportation time to and from the program, and excluding mealtime unless training during meals is a documented part of the plan. Individuals may attend less than 5 hours if required and documented by a physician or the interdisciplinary team. Transportation required for individuals shall be the responsibility of the provider. Programs shall not be in buildings where individuals reside.

Rule 350- ICF/DD

Rule can be found at Rule 350

This Part applies to the operator/license of facilities, or distinct parts thereof, that are to be licensed and classified to provide intermediate care for persons with intellectual disabilities. The license issued to each operator/licensee designates the number of beds authorized for each level, the date the license was issued and the expiration date. The operator may not admit residents more than the licensed capacity of the facility. An intermediate care facility licensed and classified under the Act shall not use in its title or description "Hospital", "Sanitarium", "Sanatorium", "Rehabilitation Center", "Skilled Nursing Facility.

Rule 50- Office of Inspector General: Abuse and Neglect

Rule can be found at Rule 50

The Mental Health Code

The Illinois Mental Health Code is an Illinois law which establishes the rights of persons who are recipients of services from mental health facilities and intellectual disability facilities. Its purpose is to make sure that people who are receiving mental health treatment or intellectual disability habilitation services are treated in a humane manner, free from abuse and neglect, with the greatest possible degree of freedom of individual choice. The basic principle established by the Mental Health Code is that, people with disabilities do not lose any of their legal rights simply because they are a recipient of mental health (MH) treatment or intellectual disability (DD) habilitation services. Rights as citizens are guaranteed by the U.S. Constitution and the Illinois Constitution. The Mental Health Code provides that those rights can be limited only to the extent necessary to prevent serious harm to self or others.

The Code can be found at Mental Health and Developmental Disabilities Code