table of contentscrjustice.org/sqa/bhpp15.doc · web viewsuch services shall not replace the need...

REVISED 12-31-2014

TABLE OF CONTENTS

Policy 1.1.1. - Contract Authority and Contract Compliance......................................................3Policy 1.1.2. - Resident Admission Criteria................................................................................4Policy 1.1.3. - Equal Access to Programs and Services..............................................................7Policy 1.1.4. - Case Records........................................................................................................8Policy 1.1.5. - Confidentiality and Release of Information.......................................................12Policy 1.1.6. - Intake Process.....................................................................................................15Policy 1.1.7. - Resident Rules and Sanctions............................................................................18Policy 1.1.8. - Resident Grievance and Appeal Process............................................................21Policy 1.1.9. - Resident Rights..................................................................................................23Policy 1.2.1. - Resident Finances...............................................................................................25Policy 1.3.1. - Comprehensive Case Management....................................................................27Policy 1.3.2. - Residential Program Plans.................................................................................30Policy 1.3.3. - Treatment Services.............................................................................................32Policy 1.3.4. - Educational and Vocational Programming........................................................34Policy 1.3.5. - Job Search Assistance........................................................................................36Policy 1.3.6. - Housing and Transitional Assistance.................................................................38Policy 1.3.7. - Recreational Opportunities.................................................................................39Policy 1.3.8. - Program Related Activities................................................................................40Policy 1.3.9. - Resource Manual and Access to Community Services......................................42Policy 1.3.10. - Resident Communications.................................................................................44Policy 1.3.11. - Religious Preferences.........................................................................................46Policy 1.3.12. - Visitation............................................................................................................48Policy 1.3.13. - Release Preparation............................................................................................50Policy 1.4.1. - Staff Availability................................................................................................53Policy 1.4.2. - Resident Accountability.....................................................................................55Policy 1.4.3. - Resident Control Over Other Residents.............................................................58Policy 1.4.4. - Use of Force.......................................................................................................59Policy 1.4.5. - Searches..............................................................................................................62Policy 1.4.6. - Weapons.............................................................................................................65Policy 1.4.7. - Control and Use of Keys, Tools and Equipment................................................66Policy 1.4.8. - Vendor/Contractor Supervision.........................................................................69Policy 1.4.9. - Transporting Residents Returning to Custody...................................................70Policy 2.1.1. - Zoning and Building Code Compliance.............................................................71Policy 2.1.2. - Sanitation And Housekepeing............................................................................72Policy 2.1.3. - Resident Living Environment............................................................................75Policy 2.1.4. - Program Meeting Space.....................................................................................77Policy 2.1.5. - Resident Furnishings..........................................................................................78Policy 2.1.6. - Resident Property Control..................................................................................79Policy 2.1.7. - Personal Hygiene Articles..................................................................................80Policy 2.1.8. - Resident Transportation.....................................................................................81Policy 2.2.1. - Emergency Plans................................................................................................82Policy 2.2.2. - Fire Safety Plan..................................................................................................87Policy 2.2.3. - Work Stoppage Plans.........................................................................................91Policy 2.3.1. - Food Services.....................................................................................................92Policy 2.4.1. - Health Care Services..........................................................................................95Policy 2.4.2. - Serious and Infectious Diseases.........................................................................99

BROOKE HOUSE RE-ENTRY CENTER

A PROGRAM OF COMMUNITY RESOURCES FOR JUSTICE, INC.POLICIES AND PROCEDURES MANUAL – DECEMBER 2014

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Policy 2.4.3. - Prescription/Medication Control......................................................................102Policy 2.4.4. - Suicide Prevention and Intervention................................................................106Policy 2.4.5. - Urine Collection...............................................................................................109Policy 2.4.6. - Emergency contact Notification.......................................................................111Policy 2.4.7. - Drug and Alcohol Use on Premises.................................................................112Policy 3.1.1. - Communications..............................................................................................113Policy 3.1.2. - Advisory Board................................................................................................115

ATTACHMENT 1:

Policy 900.00 - Staff and Resident Sexual Abuse and Sexual Harassment (PREA)…………1-22



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POLICY 1.1.1 - CONTRACT AUTHORITY AND CONTRACT COMPLIANCE

I. POLICY

Brooke House shall honor contractual obligations to provide prescribed services to the population described, and shall exercise due diligence in maintaining its eligibility for contracting to provide criminal justice services.

II. PROCEDURE

A. Service Delivery

1. The Program Director or designee is responsible for seeing that Brooke House provides the services outlined in its various contracts and has admission criteria consistent with the target resident population outlined in the contract. a. The administration should make any necessary adjustments early in each

contracting cycle.

B. Contracting Status

The Chief Executive Officer (CEO) or Chief Financial Officer (CFO) of Community Resources for Justice (CRJ) is responsible for filing the appropriate forms and reports necessary to function as a non-profit corporate entity in order to remain eligible to contract, including renewal of certificates of incorporation once every 2 years and annual IRS filings.

Director’s Signature: Howard H. Jardine II, Program Director Date Issued: April 15, 2009Date Revised: December 17, 2014Issued By: Brooke House/Standards and QA Department Effective Date: December 31, 2014

Reference Standard: ACA: 4th Ed. (PBS): None



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POLICY 1.1.2 - RESIDENT ADMISSION CRITERIA

I. POLICY

An admission process shall be applied to persons referred for admission to Brooke House so as to admit residents who can best benefit from the services available. No person shall be denied admission to the Brooke House based on age, race, religion, creed, national origin, disability, political views or sexual preference. Discrimination is strictly prohibited.

Brooke House shall not discriminate in accepting referrals on the basis of disability, religion, sexual preference, age, race, creed, or national origin. The Program Director has the authority to remove or transfer a resident from Brooke House.

Program admission policies shall be disseminated to all referring agencies regularly, and to other interested parties upon request.

Except where justifiable by program design, admission criteria shall comply with local, state and federal laws on a non-discrimination basis. The Program Director or designee shall annually check admission criteria against local, state, and federal laws to ensure that it is nondiscriminatory.

II. PROCEDURES

A. Development of Admission Criteria

1. The Program Director and/or designee(s) develops admission criteria, including an Individual Service Plan (ISP), which describes the characteristics that would make a resident most likely to succeed in the Brooke House model. The criteria shall be reviewed annually by the governing authority and/or the Program Director with input from direct service staff and revised as appropriate.

2. The governing authority checks the admission criteria against any community covenants or representations that have been made to the community about Brooke House ensure there is consistency.

3. The Program Director checks admission criteria against federal, state and local laws ensure that it is in compliance, at least annually.

4. Certain exceptions may be allowable (such as gender or age specifications) provided there is good programmatic reason for the bias and that comparable services exist somewhere else in the system for other populations.

B. Admission Criteria for Brooke House

1. The admission criteria for Brooke House is determined by the referring agency.2. Admission criteria is as follows:

a. Suffolk & Norfolk County Sheriff’s Department (SCSD & NCSO) i. Male individuals must be 18 years-old or older;ii. The individual must not receive any disciplinary reports during the

classification process;



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iii. The individual must not have a criminal history that includes a conviction of a sexual offense; and

iv. The individual must not have a criminal history that includes an arson conviction.

b. MA Parolei. Individuals must be 18 years-old or older;ii. The individual must not have a criminal history that includes a

conviction of a sexual offense; iii. The individual must not have a criminal history that includes an arson

conviction; andiv. Previous placement in Transitional Housing disqualifies access to a

Transitional Housing Program for two calendar years. c. Department of Correction (DOC/Boston Pre-Release)

i. Individuals must be 18 years-old or older;ii. The individual must not have a criminal history that includes a

conviction of a sexual offense; iii. The individual must not have a criminal history that includes an arson

conviction; andiv. An individual cannot waive parole at any time during their current

sentence.3. In addition, residents must be employable at the time of admission, or be able

to enroll in vocational or educational programming.

C. Dissemination of Admission Criteria

1. The admission criteria will be given to the referral agency when requested. 2. The Program Director is responsible for meeting with referral agents at least

annually to provide them with updated admission criteria, if applicable. 3. Members of the media or of the community who request copies of program

admission criteria will be provided with them as soon as possible, but in no event shall said response take longer than 7 days from the date of the request.

4. Staff will receive training in admission criteria and information pertaining to specific criteria will be distributed during these training sessions.a. The training will consist of the following:

i. Information to be provided during admission; andii. How to disseminate that information to the referring agencies and

others who request it. b. All staff will be instructed generally in the admission criteria and

specifically if directly involved in the referral process.

D. Notifications

1. If an applicant is not accepted into the Transitional Housing Program (THP/Parole), the Program Director or designee will verbally advise, the referring agency of the specific reason(s) for denial of the applicant, consistent with confidentiality requirements.

2. Upon the written request from a rejected applicant, the Program Director or designee will provide, in writing, the specific reasons for non-acceptance.



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3. SCSD, NCSO and DOC applicants go through a classification process while in the institution whereby the Brooke House does not thereafter have authority to deny admittance into the program.

E. Resident Removal or Transfer

1. The Program Director has the authority to recommend removal or transfer of a resident from Brooke House. a. Substantial reasons should exist to justify removal of the resident.b. Incident reports will document the justification for removal.

2. The referring agency will be contacted if/when this situation arises.3. In the event that the governing authority (SCSD, NCSO, DOC, and Parole)

determines that a resident shall be removed or transferred from Brooke House, the Program Director or designee will ensure that all cooperative measures are met.

Director’s Signature: Howard H. Jardine II , Program Director Date Issued: April 15, 2009 Date Revised: December 17, 2014Issued By: Brooke House/Standards and QA Department Effective Date: December 31, 2014

Reference Standard: ACA: 4th Ed. (PBS): 2A-08 6A-125A-06 6B-016A-11 6B-02



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POLICY 1.1.3 - EQUAL ACCESS TO PROGRAMS AND SERVICES

I. POLICY

Brooke House shall treat all residents equally. Discrimination based on a resident’s race, age, creed, sexual preference, religion, national origin, gender, disability or political views is prohibited when making administrative decisions and in providing access to programs.

II. PROCEDURES

A. Staff Responsibilities

The Program Director shall have the responsibility for instructing staff to offer the same or equivalent services to all residents in Brooke House as permissible by the policies of the governing authority.

Director’s Signature: Howard H. Jardine II , Program DirectorDate Issued: April 15, 2009 Date Revised: December 17, 2014Issued By: Brooke House/Standards and QA Department Effective Date: December 31, 2014

Reference Standard: ACA: 4th Ed. (PBS): 6B-01



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POLICY 1.1.4 - CASE RECORDS

I. POLICY

An official confidential case record will be established for all Brooke House residents at the time of admission. All information generated on a resident by other agencies will be placed in his case record. Case assessment and treatment planning by staff will be documented in this file and in SecurManage system. Regular entries concerning staff intervention activities, on-going progress and final outcomes of the resident’s program participation also will be documented. All entries into a case record will be signed and dated by resident and by the staff member making the entry. Individual case records will be audited on a continuing basis by administrative staff and SQA to ensure accuracy. The length of time to maintain inactive case records will be determined by the referring agencies. Residents have access to information in their case records, consistent with applicable statutes.

II. PROCEDURES

A. Initiating a Case File1. The Assistant Program Director is responsible for establishing a system of

maintaining case records as appropriate for Brooke House. 2. At the time of intake, the case file is established. 3. Case files are organized and separated according to the established

format by the assigned Case Manager. B. Organizing the Case File

1. Files will be uniformly organized to ensure effective maintenance of and easy access to this information.

2. The following items may be included in case files: a. Intake information: initial intake information form;

b. Release of information: Signed release of information forms, if needed;c. Chronological history: Case history, if available; Classification Report;

d. Program records (current reports on top): Initial Service Plan (ISP); evaluation & progress reports/notes; current employment, job checks, etc.; pertinent educational information and education plan; visitation passes, urinalysis testing records, etc.

e. Outside treatment records (current reports on top): record of any referrals made, medical records/reports; log (in order) of medical/dental exams; psychological and/or psychiatric reports, if appropriate; record of other treatment received, if relevant;

F. Disciplinary and grievance records (in order of event): program rules and disciplinary policies, signed by resident; Incident Reports, if any, record of grievances filed and their disposition; specific memos, etc;

g. General correspondence (in order): letters; memos; and other miscellaneous records;

h. Termination records: Transition Plan (final summary/aftercare plan).



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C. Transition Plan (Discharge Report)

1. The Case Manager assigned responsibility for a resident’s case management will prepare a Transition Plan on the resident's participation in Brooke House prior to their release.

2. A copy of the plan will be filed in the case record. 3. The Discharge Report should:

a. Outline the reason (s) for the discharge;b. Give the resident's legal status upon discharge;c. Give the resident's new location, if available; d. Summarize resident progress in the program including initial problems

and needs, program plan, accomplishment of goals, program adjustment, final release plans and potential problems anticipated after release;

e. Outline an aftercare plan if the resident is transitioning to community living. (1) This plan should address how housing, employment, medical

needs, treatment needs, childcare (if applicable) and other needs will be addressed.

D. Maintenance of Case Files

1. Staff will ensure information generated as a result of a resident’s participation in the program is properly noted in the case file and SecurManage system.a. The Case Manager assigned case work responsibility for a particular

resident will ensure that the file is properly maintained and make regular notations in the file as appropriate.

b. The initial assessment identifying needs and problems will be recorded in the file as well as the resident’s service/treatment/program plan.

c. Case record information will be placed in the file. d. Regular narrative notations, signed and dated by the individual making the

supervision entry, will be made in the supervision plan. The supervision plan will be updated every fifteen (15) days.

e. Notations of significant events and progress of the resident also will be made.

2. Staff members will file additional information generated on the resident in the file, (e.g., community release forms, home visitation passes, disciplinary reports, reports from outside agencies, etc.). a. Any staff member having such input in the resident’s record is required to

make the appropriate notations in the chronological file and SecurManage.

E. Confidentiality of the Case File

1. All information in the case file is confidential and may be released only after the proper consent forms have been executed during intake.a. The file cabinet containing case files will be clearly marked "confidential".b. Individual case files will be clearly marked "confidential".c. When in use, the case file will be tracked by a sign out system.d. The case file will be replaced at the end of the Case Manager’s day.

2. Case files will not be removed from the premises.

BROOKE HOUSE RE-ENTRY CENTERA PROGRAM OF COMMUNITY RESOURCES FOR JUSTICE, INC.

POLICIES AND PROCEDURES MANUAL – DECEMBER 2014

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3. Authorized staff who need to remove a case file from the Administrative Office will sign the File Sign-Out Sheet with their name on it, designating that they have the file outside of the Administrative Office.

F. Case File Audits

1. The Program Director or designee will audit each case record at least quarterly, on a bi-weekly basis, to assure that appropriate entries have been made.

2. A checklist will be kept of each audit that notes the date the record was checked, status of the record at the time, and any corrective action that was recommended.

3. The case audit will ensure that the record is current, that entries are made appropriately, that the record adheres to confidentiality standards and that the following information is maintained in the file:a. Initial intake formsb. Case information from the referral source, if available c. Basic background information (limited case history)d. Medical Summarye. Psychological and/or psychiatric reports, if appropriate f. Initial program or service plan g. Signed release of information forms, as necessaryh. Evaluation & progress reportsi. Current employment dataj. Program rules & disciplinary policies, signed by residentk. Classification Report (documented legal authority to accept resident)l. Grievance & Incident Reports (disciplinary) recordm. Referrals to other agenciesn. Pertinent educational information o. Transition Plan or Return to Higher Custody report.

G. Inactive Records/Retired Case Files

1. Brooke House will follow the guidelines or directives of the referring agency regarding retiring case records.

2. If no guidelines or directives exist, the following will apply:a. Upon discharge, a resident’s case file will be moved to the designated

closed record file cabinet and maintained until the end of the fiscal year, then placed in storage with Iron Mountain for seven (7) years.

b. The Program Director or designee will manage the closed record file and oversee any destruction of inactive records to ensure that confidentiality is maintained and jurisdictional regulations are complied with.

c. A log of all inactive records that have been destroyed will be kept in the inactive file cabinet.

H. Transferring Active Records



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1. When a resident is transferred back to a Sheriff’s Department, no file goes with the resident. (The Sheriff Departments already maintains their own file for each inmate.)

2. When a resident is transferred to a MA Department of Correction facility, no files go with the resident. (The DOC already maintains their own file for each inmate.)

3. When a Parole (THP) resident is discharged from the program, no files go with the resident. (The MA Parole Board already maintains their own file for each parolee)

4. Upon request of the governing authority, any active resident information in the file will be sent.

I. Resident Access to Official Case Files

1. Consistent with state and county regulations, each resident has a right to see information in his case file with the exception of:a. Information received from other agencies under conditions where this

agency is not allowed to disclose it without prior approval.b. Psychological reports and information unless disclosed in person by the

psychiatrist, psychologist, social worker, or licensed therapist.c. Information from third parties when the disclosure could create a danger

to the third party.2. A resident may request to see the information in his case file.3. The resident’s Case Manager and Program Director/Assistant Director will

review the resident’s request. 4. If allowed, the information will be shown to the resident with the Case Manager

present. a. If any information requested to be seen is not allowed, the Case Manager

will explain this to the resident. 5. The resident will not be allowed to review his file without the Case Manager

present at all times.6. If a resident requests a copy of material in his file, staff will consider this on a

case by case basis.7. A resident may challenge any information in his official case record. If the

information is erroneous, it will be removed in the presence of the resident.

Director’s Signature: Howard H. Jardine II , Program DirectorDate Issued: April 15, 2009Date Revised: December 17, 2014Issued By: Brooke House/Standards and Quality Assurance DepartmentEffective Date: December 31, 2014

Reference Standard: ACA: 4th Ed. (PBS): 7D-087D-097D-107D-11

POLICY 1.1.5 - CONFIDENTIALITY AND RELEASE OF INFORMATION



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I. POLICY

Information released to the general public about residents in Brooke House will be limited to the referring agencies’ specifications. Brooke House will refer all inquiries to the Chief Advancement Officer (CAO) of CRJ. The CAO will then determine what specific information may be released to the general public. All other information about individual residents is confidential and will not be released to another individual without proper authorization. Residents are requested to sign "Release of Information Consent Forms" before specific information is released. A copy of the signed form will be kept in the resident’s case record.

II. PROCEDURES

A. Case File Security

1. The file cabinet containing case files will clearly be marked “confidential.”2. Individual case files will also be clearly marked “confidential.”3. The major pieces of information pertaining to each resident (such as case

management reports, psychological evaluations, etc.) are placed in the confidential case file.

4. The Administrative Office containing the case files will be secured at all times.5. When in use, the staff may remove the case file from the Administrative

Office, however, they must sign the File Sigh-Out Sheet and the files must be returned by the end of the Case manager’s shift.

6. The case file will be replaced immediately after staff have returned completed work.

7. The case files will not be removed from the premises.

B. Approval

1. All staff have access to the case file for the purpose of retrieving relevant information as situations arise.

2. The following case file rules will be observed:a. Access to the case file will be related explicitly to the fulfillment of

specific job functions.b. Oral discussion of the content of the case file with unauthorized

individuals is prohibited.

C. Public Information

1. Staff are prohibited from releasing any information to the general public regarding residents in Brooke House.

2. Staff are advised to refer questions regarding residents to the Program Director, the Suffolk County Sheriff Department, the Norfolk County Sheriff’s Office, the MA Department of Correction, or the MA Parole Board.

D. Confidentiality Waiver

1. Staff must abide with state and federal laws regarding confidentiality.



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2. Each resident signs, as needed, an authorization for the release of information for specific purposes.

a. When signed, this authorization form is explained in detail to the resident.

b. The form indicates that CRJ may disclose information gathered in the course of the resident’s participation in Brooke House and that information may be released for the purpose of obtaining and maintaining employment, training, education and treatment services and a sponsor.

c. If requested, the resident will receive a copy of the release detailed below.

3. The authorization for release of information includes: a. the organization requesting the information, b. the organization releasing the information, c. the information to be disclosed, d. the purpose or need for the information, e. a signature and date by the resident f. a signature and date by the individual witnessing the resident’s

signature. 4. A separate form will be required for each disclosure.5. Information regarding whether a resident has had an HIV test or about a

resident’s HIV status cannot be released without specific written consent from the resident.

a. Residents cannot be required to submit to HIV testing or to release HIV information.

6. The Program Director identifies staff who are authorized to release information under the conditions stipulated in the authorization for Release of Information Form.

7. A copy of all authorizations for release of information will be filed permanently in the applicable resident’s official case file.

E. Special Situations

1. Under certain exceptional conditions, information can be released when specific written consent by the program participant does not exist. These exceptions include:

a. Medical personnel to the extent necessary to meet bona fide medical emergencies.

b. Qualified personnel for the purpose of conducting statistical analysis, management staff, financial auditors or program evaluators.

c. In such instances, personnel must not be able to identify directly or indirectly the name of the individual resident when carrying out audits, evaluations, etc.

d. Individuals authorized by appropriate court order to access specific information contained in the resident’s case file.

e. Parole and probation officers under court order to accomplish pre-sentence investigations, pre-parole investigation, or supervision of the resident in the community after release.



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Reference Standard: ACA: 4th Ed.: 7D-08



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POLICY 1.1.6 - INTAKE P ROCESS I. POLICY

All residents who are admitted to Brooke House will participate in an intake and orientation process conducted by facility staff. At the time of admission, staff discuss program goals, service(s) available, rules governing conduct, access to health care, and program rules with the resident. In addition, staff interview new residents for information used to complete intake forms.

When residents are admitted who have special comprehension needs due to literacy or language barriers, staff will assist residents to ensure comprehension. Residents identified with literacy problems will be referred to a bilingual staff or a bilingual support service in the community. New residents who do not understand English will receive written orientation materials in Spanish or receive translations in their language.

II. PROCEDURES

A. Intake Interview

1. Each resident shall be interviewed by their Case Manager. A review of information provided by the contact agency and other information requested shall be listed on intake forms and includes the following:a. Name;b. Address;c. Social Security Number, if available;d. Date of Birth;e. Gender;f. Race/Ethnic Origin;g. Current Marital Status;h. Reason for referral;i. Whom to notify in case of emergency, with home & employment

telephone numbers, if available;j. Date of information gathered;k. Name of referral source or commitment authority, with resident

identification number or case number;l. Education level completed;m. Skill level;n. Substance abuse history;o. Special medical problems or needs and medical information; p. Name of personal physician, if relevant and available; q. Social/Criminal history, where available;r. Legal Status, including jurisdiction, length and conditions of placement;s. Signature of the resident & the staff person interviewing resident.

2. After the Intake interview, the LSI-SV (Level of Service Inventory-Screening Version, and where indicated, the full LSI-R (Level of Service Inventory-Revised) assessment tool is conducted to better address resident needs and future problem areas that might affect the resident’s successful completion of Brooke House.



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B. Resident Case File/Record

1. All information gathered in the intake process shall be maintained in a confidential, resident case file/record and SecurManage system. This information constitutes the resident's permanent record. Such files shall include the following:a. Initial intake formsb. Case information from the referral source, if availablec. Medical Summary d. Psychological and/or psychiatric reports, if appropriatee. Initial Program Plan (IPP)f. Signed release of information forms for each specific requirement, as

needed g. Evaluation & progress reportsh. Current employment datai. Program rules & disciplinary policies, signed by residentj. Classification Report (documented legal authority to accept resident) k. Grievance & Incident Reports (disciplinary record)l. Referrals and correspondence to other agenciesm. Pertinent educational information, if applicablen. Transition Plan or Return to Custody Report

C. Admission

1. On the day of admission, a Case Manager discusses services available, rules governing conduct and program compliance with each resident. a. Written orientation materials are distributed to all residents.

2. The assigned Case Manager meets with the individual resident within 48 hours of admission to discuss program goals, assessment of needs, and services available. A Treatment Plan will be developed to address employment, education, treatment and housing.

3. Literacy Problemsa. During admission, the Case Manager needs to determine whether the

resident has any literacy problems. In order to determine this, the Case Manager will either find this information documented in the referral materials or should ask the resident to repeat back what has been said to him. Staff need to remain alert and sensitive to the needs of the residents who demonstrate literacy problems.

b. If the Case Manager decides there are literacy problems, assistance will be provided to the resident to help them understand program expectations and their rights. Staff will refer the resident to bilingual staff or to bilingual support services in the community.

c. It is the assigned Case Manager’s responsibility to coordinate the appropriate referrals. (1) All referrals will be recorded in the resident’s case record.



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Reference Standard: ACA: 4th Ed. (PBS): 1A-15 5A-072A-07 6A-103A-04 6A-113A-06 7D-07



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POLICY 1.1.7 - RESIDENT RULES AND SANCTIONS

1. POLICY

Each resident shall be briefed on, sign and receive a copy of Brooke House rules and regulations. All rules, regulations and services shall be applied equally to all residents regardless of age. All rules and regulations shall be detailed in the Resident Handbook. Violation of the written rules shall merit necessary disciplinary action. Serious violations of the program rules may result in termination from the program, and return to the applicable higher custody of the referring agency.

II. PROCEDURE

A. Admission 1. Upon admission, residents will receive a copy of the rules and sanctions for

Brooke House, listed in the Resident Handbook. 2. Residents will sign documentation stating they have received and understand

the Resident Handbook and all of the rules, regulations and policies. a. A staff member shall witness the signature.

3. Disciplinary policies and program rules and regulations that residents are expected to adhere to are detailed in the Resident Handbook.

B. House Rules

Residents are expected to abide by and deal responsibly with all House Rules. The major rules include the following:1. There will be no physical violence or threat of physical violence.2. There will be no possession or use of drugs not prescribed by medical

professionals.3. There will be no possession or use of alcohol. 4. Residents must notify their Case Manager if arrested or questioned by any law

enforcement officer.5. Brooke House is a non-smoking facility. This means that NO tobacco related

products (cigarettes, lighters, or matches) are allowed in the building. There are no scheduled outside smoke breaks at Brooke House. Violations of the no smoking policy may result in termination from Brooke House.

6. Food is not allowed above the first floor of the building. Any beverages purchased in the vending machines for immediate consumption may be brought upstairs in the building. No personal resident food may be stored in Brooke House refrigerators or pantry, or brought up to the resident’s room. No food will be allowed into the building by residents returning from the community.

7. Televisions, radios, etc., are expected to be kept at reasonable noise levels at all times, and shut-off when residents are not in their room.

8. Lights, fans, etc. are to be shut off when the resident is not in their room.9. Lights are out at 12 midnight. All residents are required to remain in their rooms

following completion of the 12 midnight count. TV’s and radios are to be off as well.



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10. Residents are required to be respectful of staff and each other in their interactions. No profanity or obscene language is permitted in the program.

C. Rule Violations and Sanctions

1. Major violation of program rules will result in notification of the appropriate governing authority and possible termination from program. a. A resident's status and progress in Brooke House will always depend on

that individual maintaining responsible behavior.2. When a minor violation has taken place, the resident shall meet with the

Program Director or designee. a. The nature of the violation shall be fully explained and the appropriate

discipline shall be taken. 3. For minor violations of program rules, the Program Director or designee may

impose the following informal sanctions: Verbal warning Additional in-house duties Restricted community access except work and medical releases Restricted to the building

4. For continued minor program rule violations, the resident shall meet with the Program Director or designee.

D. Types of Disciplinary Actions

1. There are two types of disciplinary actions: a. Informal Resolution

(1) The majority of incidents can be resolved through an informal resolution process, resulting in approved minor sanctions.

b. Formal Hearing(1) Any disciplinary incident that cannot be handled informally and

requires a formal hearing will not be handled by Brooke House. (2) The matter will be referred to the referring agency.

E. Violations and Reports

1. An Incident Report shall be written in the SecurManage system when a staff member determines that a violation of a rule has occurred.

2. A copy of the Incident Report will be kept in the resident’s file and provided to the referring agency.

F. Disciplinary Process for Major Sanctions

1. Incident Reporta. An Incident Report will be required when informal resolutions are not

possible or appropriate.b. Residents will be terminated from the program, and transferred to higher

custody of the referring agency. c. Incident Reports will be completed by the end of the shift when the

incident occurred, or as soon as possible thereafter if so determined by the Program Director.



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2. Data collected in an Incident Report will include: a. relevant facts about the incident, including date and time b. resident behavior, c. names of witnesses, d. place of the incident, e. signature of reporting employee, and f. date and time the report is signed.

3. Incident Reports are completed by the witnessing staff member.4. The Incident Report will be promptly forwarded to the Director of Brooke

House.5. Residents have the right to appeal disciplinary decisions to the governing

authority.


Reference Standard: ACA: 4th Ed. (PBS): 3A-01 6C-013A-02 6C-023A-03 6C-033A-04 6C-043A-053A-063A-07

POLICY 1.1.8 - RESIDENT GRIEVANCE AND APPEAL P ROCESS



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I. POLICY

Residents shall have the opportunity to initiate grievance procedures on any condition or action within Brooke House, within 15 days of the original incident or issue of concern.

II. PROCEDURES

A. Grievances

1. Residents have the right to present issues of concern to Brooke House staff if necessary.

2. Upon admission, residents receive an orientation during which grievances and the grievance appeal process will be discussed. a. The grievance process is outlined in the Resident Handbook.

B. Grievance Process

1. Informal Resolutiona. If a resident has a complaint against any staff person or with any aspect of

Brooke House operations, he may refer the matter for informal resolution to his Case Manager, or to the Program Director/Assistant Director if the complaint involves the Case Manager.

b. Residents are encouraged, but not required, to resolve disputes through informal resolution.

2. Formal Resolutiona. If the matter cannot be resolved informally, the resident may submit a

written complaint to the Program Director. b. The written complaint should include the nature of the complaint and any

dates, times, places, and names that are relevant. c. Residents must explain in writing the reason for not following the standard

appeal procedures.d. Residents may file formal written requests to the Program Director within

15 calendar days of the original incident/issue of concern.

C. Appeals

1. The resident can appeal the Program Director’s decision, within 20 days of the response, to the Director of the Social Justice Services Department.

2. Filingsa. Residents can appeal decisions to the Suffolk & Norfolk County Sheriff’s

Department, MA Department of Correction, or the MA Parole Board.

D. Special Conditions



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1. Emergency Appealsa. Requests that are of an urgent nature will be responded to within 48 hours.

E. Annual Review of Grievances

1. On an annual basis, all grievances are aggregated and analyzed to determine any problem areas and take corrective action to prevent grievances.


Reference Standard: ACA: 4th Ed. (PBS): 6B-03



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POLICY 1.1.9 - RESIDENT RIGHTS

I. POLICY

The facility protects the safety and constitutional rights of residents and seeks a balance between expression of individual rights and preservation of order.

II. PROCEDURES

A. Resident Rights

1. Residents shall be accorded equal access to all facility programs and servicesregardless of their sex, sexual orientation, mental or physical handicap, color, religion, creed, or political beliefs.

2. Residents shall not be subjected to sexual harassment.3. Residents shall be entitled to humane, decent, courteous, and professional care.4. Residents shall not be denied access to medical services nor denied medical care

appropriate to their needs.5. Residents are prohibited from being used as subjects in any scientific or medical

research or experiment.6. Residents are entitled to their religious beliefs and shall be accorded voluntary

access to religious services so long as such access does not constitute a threat to facility security and order.

7. Information related to any resident's case is completely confidential and shall not be shared with an outside party, unless:a. the resident signs a written consent to release specific information to an

identified party;b. the resident shares information that indicates alleged child abuse or

criminal activity;c. a duly authorized agency or person requests criminal offender

information;d. the information is subpoenaed by a court order;e. the information to be released is necessary to protect the health and safety

of the resident;f. the information is necessary to comply with periodic audits conducted by

state, local or national agencies; or,g. the information is used for the purpose of conducting legitimate scientific

research and, in so doing, the identity of any resident remains anonymous.8. Residents shall be entitled to a fair and judicious process regarding the handling

of any disciplinary matter. a. Only informal discipline matters are handled by Brooke House.

9. Corporal punishment is prohibited.10. Residents shall be entitled to legal rights that include attorney consultation,

legal correspondence, access to courts and governmental agencies for the purpose of filing legal papers and access to a law library.

11. Residents shall be accorded uninhibited access to the grievance process and shall not be subject to reprisal or the threat of reprisal when engaged in said process.



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12. Residents shall be accorded the right to choose their own dress, subject only to the limitations contained in the dress code.


Reference Standard: ACA: 4th Ed. (PBS): 6A-016A-026A-05



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POLICY 1.2.1 - RESIDENT FINANCES

I. POLICY

Brooke House requires that residents who are employed pay an administrative fee during their stay. Norfolk County Sheriff’s Office and MA Parole residents are exempt from this requirement. Residents may be assisted with immediate and legitimate financial needs when they enter the facility. They shall be assisted also in managing their income. The resident will be advised that non-payment of fees may result in an infraction and possible termination from Brooke House.

II. PROCEDURES

A. Resident Administrative Fee

1. The administrative fee (subsistence) structure is 15% of their gross income after a resident has started outside employment. (This fee amount is subtracted from the resident’s gross income amount and an additional 35% of the gross income amount is required to be maintained in a savings account for the resident)a. Parole residents are required to pay a monthly MA Parole fee of $65 to the

program Parole Officer and save 70% of their gross income.b. Norfolk County Sheriff’s Office residents will turn in their pay checks

which will be processed by NCSO.2. Residents will be informed of this policy at the time of orientation and during

the intake process and again when the resident secures employment. 3. Residents who are unable to pay will be identified to staff responsible for

payment collection. a. If a resident demonstrates economic hardship, program services will not

be denied and a special payment structure will be arranged.

B. Indigent Residents

1. Residents who are admitted to the facility with no money and who do not receive money from their community sources will be determined to be indigent.

2. Indigent resident may receive hygiene articles, public transit passes for job searches and clothes (from community agencies). a. Postage, paper, envelopes, and writing utensils will be provided on an as

needed weekly basis, up to 5 items a week, for legal matters, if requested.b. Prescriptions and over the counter medications will be paid for from the

program petty cash fund, if requested by the resident.

C. Weekly Budgets

1. Each resident shall be responsible for developing a weekly budget that will meet the demands of the Brooke House administrative fee, restitution, child support, and other legal obligations.

2. The Case Manager will assist the resident to complete a written Weekly Budget Sheet for any resident who has court ordered restitution, court fees, or



Page 25

family/child support obligations, to ensure that these obligations are being met and paid according to the required payment schedule.

3. The Case Manager shall be available to assist in setting-up and maintaining the goals of the budget.

4. The budgets shall provide for but not be limited to the following expenditures:a.Administrative fee (subsistence)b. Transportation costsc.Family support (if applicable)d. Outstanding debts (if applicable)e.Restitution or charitable contributions (if applicable)f. Clothing and Items needed for personal hygiene g. Items needed for personal over-the-counter medications.

D. Administrative Fee Payment Process

1. Residents who are employed must submit their administrative fee within 24 hours of receiving their pay check.a. The resident’s administrative fee (15% of their gross pay) is

calculated and the resident obtains a money order in that amount.b. The resident places his paystub and money order into the locked

drop box on the Assistant Program Director’s door. c. The Assistant Program Director makes copies of the pay stub and

money order and provides these copies to the Case Manager to be kept in the resident case record.

d. The original money order and pay stub are logged into the Substistance Report. Both items are locked in the safe until the end of the month when it is submitted to the Finance Department.

e. No pro-rated administrative fee will be calculated prior to a resident’s departure from Brooke House.

E. Fiscal Department Review

1. At the end of the month, the Program Director or designee forwards all pay stubs and money orders to the Finance Department for review by the Accounts Receivable Administrator. a. The Accounts Receivable Administrator reviews all materials, totals all

amounts and approves it by signing the Financial Report. b. The Accounts Receivable Administrator writes a receipt for the total

amount of subsistence and gives it to the Director or designee along with a signed copy of the Financial Report.

Director’s Signature: Howard H. Jardine II , Program Director Date Issued: April 15, 2009 Date Revised: December 17, 2014Issued By: Brooke House/Standards and QA Department Effective Date: December 31, 2014



Page 26

Reference Standard: ACA: 4th Ed. (PBS): 6A-06 6D-01 6D-027D-17 7D-21 7D-31 7D-32 7D-33

POLICY 1.3.1 - COMPREHENSIVE CASE MANAGEMENT

I. POLICY

Comprehensive case management services shall be available to each resident to assist their reintegration into the community. Such services shall not replace the need for resident's attendance in therapy, alcohol, drug and family counseling, etc. Case management, instead, assists the resident in meeting his personalized treatment and/or individual service plan (ISP), offers any necessary guidance and counseling, and provides direction in obtaining those resources needed for successful community living such as additional education, career counseling and training, employment, housing, health care, social and recreational outlets and other supportive services.

II. PROCEDURES

A. Assignment of Primary Case Manager

During a resident's first week in the facility, the resident is assigned a primary Case Manager.

B. Scheduled Bi-Weekly Session

1. The assigned Case Manager develops a meeting schedule with the resident on a bi-weekly basis. a. Flexible contacts also shall be available.

C. Case Manager Responsibilities

1. The Case Manager should:a. Introduce himself/herself to the resident as soon as possible and attempt to

open communications.b. Discuss facts and limitations of confidentiality with the resident.c. Discuss if there are any questions concerning program operations, rules

and regulations.d. Determine and reinforce the resident's level of understanding of rules and

procedures.e. Discuss the resident's concerns and needs initiating problem identification

and problem solving techniques.f. Review the resident's options effecting:

(1) Work role - means of attaining economic independence as well as work. Also includes addressing any educational needs.

(2) Interpersonal relationships(3) Leisure activities(4) Housing arrangements after release(5) Health care and other treatment needs(6) Other supportive services that may be required (e.g. birth certificate,

photo ID, clothes, substance abuse evaluation and counseling)



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g. Discuss and develop resident's Individual Service Plan (ISP) within 14 days, involving the resident, the referring agency, and other facility staff as appropriate; (1) Ensure clear understanding of specific expectations and assist in

resolving any areas of concern (type of counseling, finances, specific release plans, etc.);

(2) modify the plan with the resident; (3) Include, as appropriate, reintegration processes suggested through

staff-resident discussions.h. Provide personal counseling requested by the resident;

(1) Provide emotional support and encouragement.i. During bi-weekly meeting with residents, make appropriate notes of Case

Notes in SecurManage and evaluate the resident's behavior. Notes shall reflect the following:(1) New issues as they arise including progress/problems in the program

during the week.(2) Actions taken by resident to resolve issues and difficulties

experienced.(3) Completed tasks/goals.

j. Coordinate activities with other staff especially Case Managers and the referring agency, as necessary. (1) Attend meetings related to the resident’s needs; (2) Monitor progress in all aspects of Brooke House.

k. Assist resident in developing a budget and monitor resident's expenditures on a monthly basis.

l. Assist the resident in identifying alternative leisure activities in the community when appropriate.

m. Monitor resident's performance relative to his ISP; (1) Provide appropriate feedback and assistance as necessary; (2) Prepare weekly counseling, involving other staff as appropriate; (3) Prepare progress reports that are required by referral agencies,

involving other staff as appropriate.n. Assist resident in locating a suitable job, housing and other supportive

services as needed.o. Train resident in how to make appropriate contacts with community

resources. (1) When absolutely necessary, help resident to make the initial contact

and offer support at planning meetings.p. Ensure that the resident receives another LSI prior to release (or after 6

months at Brooke House).q. Prepare the Discharge Plan prior to a resident's release from Brooke House.r. Meet with resident prior to release and conduct a final counseling session

providing feedback to the resident prior to his being discharged to the community. If applicable, discuss any Probation or Parole conditions.

.



Page 28


Reference Standard: ACA: 4th Ed. (PBS): 5A-07



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POLICY 1.3.2 - RESIDENTIAL PROGRAM PLANS

I. POLICY

Brooke House assists residents and develops an Individualized Service Plan (ISP) to enhance the growth and development of each resident. Weekly assessments of a resident's progress shall be conducted and necessary adjustments made.

II. PROCEDURES

A. Individual Service Plan

1. Each resident and Case Manager develops an ISP including among other things: educational, vocational, financial, medical and dependency needs, as identified through the LSI-R: SV assessment (Level of Services Inventory – Revised: Short Version Assessment Tool). a. The LSI-R: SV assessment tool is used to identify and prioritize areas of

need known to correlate with an individual’s likelihood of re-offending.2. Following a general explanation and discussion in the initial intake orientation,

each resident shall discuss their ISP with their Case Manager. 3. The plan may be changed and expanded as the resident becomes more aware of

his needs and options. a. It is important, though, that the resident have a sense of direction from the

beginning of program participation and staff have an established base from which to provide assistance.

b. The resident's program plan is the key to progress and, hence, must be realistic and specific.

B. Plan Development

1. The assigned Case Manager, in conjunction with the resident shall develop the ISP within 14 days of the resident’s arrival to the facility.

2. The plan shall have the following characteristics:a. Measurable objectives based on resident needs to be achieved and

timetables for meeting those objectivesb. Identify individuals including case manger and substance abuse counselor

who are responsible for assisting in the implementation of the planc. Obtain signatures of both the resident and case management staff

signifying that the plan was agreed upond. Be documented, and placed in the resident’s file, with a copy for the

resident available upon request.e. Provisions for changes in the plan allowing for input from the resident.

C. Plan Monitoring

1. The plan shall be monitored by the assigned Case Manager who completes the reports and includes them in the residents’ case file.



Page 30

2. Revisions shall be made with resident input based on changes of circumstances, achievement of goals, and/or additional problems identified.

3. Input from the Suffolk County Sheriff’s Department, Department of Correction, or Parole Officer is accepted and encouraged.

4. Resident progress and ISP reviews are conducted during the bi-weekly counseling sessions and documented in case notes.

5. The LSI-R shall be re-administered after 6 months, or prior to the resident’s release.

D. Plan Changes

1. All changes shall be documented in the case file and shall be signed by the Case Manager and resident.

2. Residents will participate in any changes.3. Residents may request a plan review at any time.

E. Final Release

1. A final review shall occur prior to the resident being discharged to the community.

2. The Case Manager, with input from the resident, will prepare a transitional plan that outlines additional services needed (if necessary) upon discharge.

F. Annual Review

1. Designated staff shall evaluate the collective needs of residents and programs at least annually.

2. Staff shall determine the collective service needs of residents from a well-planned information system; careful screening of case records and discussion with other staff, residents, and other persons concerned with programming.


Reference Standard: ACA: 4th Ed. (PBS): 5A-015A-025A-035A-045A-055A-07



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POLICY 1.3.3 - TREATMENT SERVICES

I. POLICY

Brooke House provides or arranges for treatment services that, at a minimum, may include: individual mental health counseling, therapy, legal assistance or health care if determined necessary; substance abuse counseling and other treatment through certified substance abuse counselors/programs; group counseling and/or group therapy; family counseling; and, access to self-help groups for residents with alcohol, substance abuse and/or other problems.

The treatment services that an individual resident receives are specified in his individualized service plan (ISP) and shall be coordinated by an assigned Case Manager. Staff use community resources either through referrals for service or by contractual agreement, to provide residents with the services to meet their program needs. Residents are also encouraged to use resources in the community to the greatest extent possible.

Residents have the opportunity for involvement with their families. Brooke House believes that a resident's family can be a critical resource in assuring effective treatment and reentry into the community.

II. PROCEDURES

A. Arrangement of Services

1. The assigned Case Manager is responsible that the treatment options specified above are developed or arranged.

2. Case Managers maintain a current list of treatment resources along with eligibility and enrollment procedures and other information about the service.

B. Documentation and Monitoring of Services Received

The services that a particular resident receives will be documented in the individualized service plan (ISP) and monitored on a bi-weekly basis.

C. Community Resources

1. Residents will be encouraged to use resources in the community to the greatest extent possible.

2. The assigned Case Manager shall assist the resident in gaining access to community resources.

3. A “Resource Manual” will be made available to all residents and staff.

D. Family Involvement

1. The Case Manager is responsible for developing and/or arranging an ongoing program of family involvement, where appropriate and feasible, which may



Page 32

include, but shall not be limited to: opportunities for family members to visit the resident at the facility or while on program related activity release.

2. The resident’s family history, and their interest in and need for family involvement will be assessed at intake and throughout their stay at Brooke House. a. The services that a particular resident receives will be documented in the

ISP and monitored on a weekly basis by the assigned Case Manager.


Reference Standard: ACA 4th Ed. (PBS): 5A-11



Page 33

5A-16



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POLICY 1.3.4 - EDUCATIONAL AND VOCATIONAL PROGRAMMING

I. POLICY

Residents needing educational and vocational programs shall be encouraged to enroll in such programs. All diploma/certificate programs approved for residents must meet generally accepted community standards.

II. PROCEDURES

A. Educational Planning

1. Residents shall be encouraged to participate in appropriate educational programs. 2. The resident's Case Manager shall assist the resident in locating and using

educational/vocational counseling services, if necessary, to assist the resident in identifying appropriate options.

B. Educational Options

1. Adult Education a. Case Managers shall assist residents seeking information about adult

education programs in the area. 2. College Courses

a. Courses may be taken at local community colleges, state colleges/universities, and private schools in close enough proximity to allow residents to participate in the program and still attend school.

b. Case Managers will assist residents in exploring these options. 3. Vocational/Technical Training

a. Case Managers will assist residents interested in vocational/technical services to explore.

C. Financial Aid

1. While Brooke House cannot pay for a resident to take college and/or post secondary school courses, financial aid should be available to most of our residents from federal, state and private sources and the school itself.

2. Case Managers shall familiarize themselves with basic financial aid application procedures, eligibility, and resources and should assist residents in taking advantage of these opportunities.

D. Approval to Participate in Educational and/or Vocational Training

1. All residents will be required to secure formal approval from their assigned Case Manager prior to enrolling in any course or training program. a. While CRJ will make every effort to accommodate resident needs, courses

must be scheduled at times that will allow the resident to participate in the



Page 35

treatment program and transportation and accountability issues must be addressed prior to enrollment.

2. Diploma/certificate programs selected by residents must meet generally accepted community standards.

3. Case Managers and/or the Assistant Program Director should check with the Better Business Bureau and/or other sources to obtain information on questionable programs prior to granting approval.

4. All educational counseling and actual courses taken should be documented in the resident's ISP.





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POLICY 1.3.5 - JOB SEARCH ASSISTANCE

I. POLICY

Program resources and staff shall assist residents in finding suitable jobs.

II. PROCEDURES

A. Vocational Counseling

1. After a pre-employment interview with the resident, Brooke House’s staff shall determine what type of employment the resident is suitable for. a. The resident also may be referred to an outside agency for vocational

counseling. b. Local agencies (including Mass. Rehab, One Stop Career Centers, Bunker

Hill Community College, and the Department of Employment and Training) provides counseling and employment assistance and may be used by staff as additional resources.

c. An employment plan will be formulated with the resident that will become part of the resident's individual service plan (ISP).

B. Job Search Preparation

1. The Case Manager may arrange or provide job search training for a resident with no job prospects.

2. The job search training shall be designed to help residents identify job opportunities, secure an appointment for an interview, prepare them for actual job interviews, and enhance their employability skills.

3. The program shall consist of the following:a. Locating job openings through both the advertised and unadvertised

markets.b. Securing job interviews.c. Completing an employment application successfully and preparing a

resume.d. Grooming and dressing appropriately for the job interview.e. Handling various interview questions and becoming familiar with

interview techniques.f. Negotiating actual terms of employment.g. Learning basic employment skills - how to keep a good job.

C. Job Placement

1. The program staff shall utilize the following resources for job placement:a. Classified Ads

(1) Staff shall review newspapers daily for possible jobs. (2) Residents also shall be encouraged to review the papers for job

opportunities.



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b. Employment Services (1) Staff shall maintain ongoing liaisons with the Offender Re-Entry

Program (ORP) through the Suffolk County Community Corrections Department and other private employment services.

c. Resident Training(1) Residents shall receive training in accessing the unadvertised job

market from staff and outside consultants.d. In-house Job Bank

(1) Designated staff shall maintain a directory of employers who have employed residents in the past and post, on a regular basis, any notices of job openings.

D. Employment Evaluation

1. The Program Director or the Assistant Program Director shall evaluate all jobs offered to residents.

2. All employment offers may be subject to approval by the Program Director or designee.

3. For MA Parole resident, jobs are verified by staff to ensure the employer is aware of the resident’s status, and to obtain contact information. The program Parole Officer will be notified of the parolee’s employment.

4. For SCSD, NCSO and DOC residents, the employer fills out an employer agreement form which is approved by the contractor.





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POLICY 1.3.6 - HOUSING AND TRANSITIONAL ASSISTANCE

I. POLICY

Brooke House staff and program resources shall assist residents in finding suitable housing and in transitional services.

II. PROCEDURES

A. Housing

1. Staff shall assist residents with locating and arranging suitable housing prior to the resident’s release from Brooke House.

2. Staff shall work with supervising authorities such as Suffolk County Sheriff’s Department, Norfolk County Sheriff’s Office, MA Department of Correction, or MA Parole in cases where their approval of housing options is required.

3. Assigned Case Managers will ensure that all residents have housing in place at the actual time of completion or release from Brooke House.

B. Identification of Assistance

1. The Coming Home Directory contains references to housing options for residents including shelters, subsidized housing, homeless service assistance providers, and social services agency housing.

2. This manual is available to all residents and staff will encourage all residents to use it.





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POLICY 1.3.7 - RECREATIONAL OPPORTUNITIES

I. POLICY

Indoor leisure time activities and outdoor recreation will be available for all eligible residents. A recreational area within the facility is maintained for leisure time activities. With input from the Case Managers, eligible residents also may be allowed to independently participate in outside activities in the community.

II. PROCEDURES

A. Recreation Area

1. Brooke House maintains recreation areas that contains the following:a. television and VCRb. tables and an assortment of gamesc. collection of paperback books for readingd. weight equipment

B. Outside Recreation

1. Resident can utilize the recreational facilities across the street from the program. Each resident may use this recreational opportunity based on the contractor’s guidelines. Each resident is required to sign out / in to recreational breaks and should be visible in the recreational area.

2. Residents who are in full compliance with their Individual Program Plan, can request to use outside recreational opportunities on program related activity release, if allowed by the contractor.

C. Identification of Opportunities

1. The Coming Home Directory contains an updated listing of recreational facilities and programs in the community.

2. This manual is available to all residents and staff will encourage all residents to use it.


Reference Standard: ACA: 4th Ed. (PBS): 5A-215A-23



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POLICY 1.3.8. - PROGRAM RELATED ACTIVITIES

I. POLICY

As part of the reentry process, eligible residents shall have the opportunity to maintain family and community involvement. Residents may be given gradually increased responsibility in the community prior to release, dependent upon his compliance with his Individual Program Plan and his ability to accept responsibility. Program related activities (PRA) providing eligible residents with an opportunity to strengthen family and community ties shall be available.

II. PROCEDURES

A. Eligibility and Accessibility

1. Basic rules and procedures covering PRAs shall be accessible to eligible residents. a. The rules shall be discussed fully during orientation and by the Case

Manager on a one-to-one basis.b. Rules covering PRAs are located in the Resident Handbook.

B. Types of PRA’s Available

1. Program related activities may include, but are not limited to, the following;a. Going to the barbershop for a hair cut b. Going to the gym or organized sporting eventc. Going to churchd. Going shoppinge. Going to the hospital to visit an immediate family member who is

seriously ill or dying.f. Going to the funeral of an immediate family memberg. Family/children visits

C. Family Member/Friend Identified

Before a resident is approved for a PRA, he will identify the person or persons with whom time is to be spent.

D. PRA Processing/Itinerary

1. PRA Request Application and Reviewa. Residents shall submit their weekly itinerary to their Case Managers on

Thursdays by 2:00 PM. b. The Case Manager shall review the itinerary for completeness.c. The Case Manager shall sign/approve the itinerary and record a

recommendation for approval or disapproval. (1) Activities questioned by the Case Manager shall be discussed with

the resident.



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2. Itinerary Approvala. The Program Director or designee shall approve or deny PRA based upon

the following criteria:(1) Specific rules/restrictions of the Suffolk County Sheriff’s

Department, Norfolk Sheriff Office, MA Department of Correction, or MA Parole

(2) Staff recommendations.(3) Previous successfully/unsuccessfully completed PRAs. (Case

Managers are expected to check the resident's case records to confirm this.)

(4) Length of residency in the program.(5) Conduct and adjustment at Brooke House.(6) Any conditions placed upon resident by the courts and/or referral

agency.3. Notification

a. When the itinerary has been approved, the resident shall be notified. 4. PRA Spot Checks

a. Spot checks are conducted on a random basis for all residents participating in PRAs.

E. Record Keeping

1. The signed itinerary shall be filed in the resident's confidential case record.2. Approved itineries shall be entered into the SecurManage system by the

assigned Case Manager.





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POLICY 1.3.9 - RESOURCE MANUAL AND ACCESS TO COMMUNITY SERVICES

I. POLICY

Brooke House maintains the Coming Home Directory that includes an inventory of active community resources. Utilization of community resources assists residents in successfully complying with the requirements of their Individual Service Plan, learning to find and effectively use the services available to them in the community and establish relationships with these programs prior to release. All staff are knowledgeable of the contents of the manual, which will be beneficial to residents and shall assist residents in accessing these services. The manual shall be reviewed annually and updates shall occur as needed.

II. PROCEDURES

A. Responsibility

1. The Crime and Justice Institute shall develop and maintain a current inventory of all state and local resources and community services (including prevention services).

2. All staff are knowledgeable of the contents of the Resource Manual. 3. This manual will be used by Case Managers to assist residents.4. Residents will be encouraged to use this manual.

B. Content of Resource Manual

1. The inventory of community resources (Coming Home Directory) is maintained in the Intake / Release Coordinator’s office and in the loose-leaf binder reserved for this information.

2. Public and private organizations and agencies listed include, but not be limited to, the following:a. Employment servicesb. Educational institutionsc. Vocational training organizationsd. Mental and physical health agenciese. Substance abuse organizationsf. Recreational organizationsg. Social welfare agenciesh. Civic associationsi. Parent education and support servicesj. Housing assistance servicesk. Legal servicesl. Self-help groups

C. Updates

1. The Coming Home Directory is evaluated annually and updated as needed.2. Updates include eliminating out-dated resources and adding new and

appropriate resources.



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D. Resource Development

1. Staff will strive to develop resources needed by Brooke House and its residents.2. At the Case Manager meeting with the Assistant Program Director, resources can

be discussed and suggestions made for the manual.


Reference Standard: ACA: 4th Ed. (PBS): 5A-10 5A-125A-11 5A-13



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POLICY 1.3.10 - RESIDENT COMMUNICATIONS

I. POLICY

Residents are provided with the opportunity to communicate with friends and family through the mail and telephone. Residents have access to staff telephones on the facility premises in order to make and receive business calls. Residents may use the pay telephones for personal calls in accordance with Brooke House rules.

Residents have the opportunity to send and receive mail while at the facility. Incoming mail may be opened and inspected for contraband or inappropriate correspondence. When based on legitimate facility interests of order and security, incoming mail may be read and/or rejected. The resident will be notified when incoming mail is returned or withheld. Indigent residents may receive a specified postage allowance to maintain community ties.

II. PROCEDURES

A. Telephone Calls

1. Residents shall be allowed to make and receive calls from:a. Their attorneyb. Family members or significant others, in cases of genuine emergency.

2. Residents shall be permitted reasonable access to the public telephone(s) for both personal and business related calls.

3. Program/Business Phonesa. Program/business phones are located in staff offices and the front desk. b. These phones are not to be used for personal calls by residents except

when authorized by the staff or during an emergency.4. Limited monitoring by staff will take place to ensure the use of program phones is

not abused for “social calls”.5. Pay Phones

a. Coin-operated telephones are located in the common areas of Brooke House.

b. Phone calls are generally held to a limit of fifteen (15) minutes per call on pay phones and are allowed only during posted hours.

c. Phone privileges are incorporated in Brooke House's Resident Handbook, to which the resident must agree and sign with his Case Manager.

6. TTY Telephonesa. Residents may have access to the TTY phone located at the Front Desk.

7. Telephone Informationa. Residents will be informed during orientation regarding the use of

telephones. (The Resident Handbook contains information regarding telephone use.)

B. Mail (Letters and Packages)

1. Information regarding resident mail is available to visitors, residents and their correspondents in the Brooke House Resident Handbook.



Page 45

2. Residents are prohibited from corresponding with inmates confined in a correctional facility, or who reside in Brooke House or any other CRJ program, unless authorized.

3. Residents are able to mail correspondence at mailboxes while outside of the facility.

4. Incoming mail will be processed by the Intake / Release Coordinator. Resident mail for distribution will be kept at the Front Desk. a. To retrieve mail, the resident will ask the Program Monitor staff for any

mail on a daily basis.5. Incoming mail and packages will be opened and inspected for contraband.

a. All packages sent to residents will be opened by the resident in front of the front desk staff.

6. When based on facility interests of order and security, mail may be read and/or rejected.

7. The Intake / Release Coordinator will provide the resident with a written notification when incoming mail is returned or packages withheld.

8. Forwarding First-Class Mail a. Prior to a transfer or release, the Case Manager will advise the resident of

the process for forwarding mail and packages, including change of address cards that should be completed and mailed to the post office.

b. Failure to complete and mail a change of address form will result in mail and packages being returned to the sender.

9. Indigent Residents a. If a resident is determined to be indigent, he may receive stamps, paper,

pen and envelopes, as necessary, but not to exceed 5 items each per week, unless authorized by staff and for program related issues.

Director’s Signature: Howard H. Jardine II , Program DirectorDate Issued: April 15, 2009 Date Revised: December 17, 2014 Issued By: Brooke House/Standards and QA Department Effective Date: December 31, 2014

Reference Standard: ACA: 4th Ed. (PBS): 5A-19 5A-19-1

6A-06 6A-07

6A-086A-09



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POLICY 1.3.11 - RELIGIOUS PREFERENCES

I. POLICY

Residents are encouraged to follow their religious beliefs and have the opportunity to practice their religion. Residents may be able to attend the religious services provided adequate notice is given and he is authorized to participate in outside activities.

II. PROCEDURES

A. Coordination

1. The Case Manager is responsible for coordinating religious support for their assigned residents.

2. If unusual circumstances exist for a resident to attend religious activities, the Program Director will be consulted.

B. Religious Services

1. No services are conducted at the facility but if a resident requests, they are allowed to attend religious services on their own outside the facility.

2. Contacts can be made with clergy to come to the facility for pastoral counseling.

C. Special Dietary Needs

1. Residents having special dietary needs because of their religious beliefs should bring such needs to the attention of their Case Manager.

2. The Case Manager shall advise the Assistant Program Director regarding a special menu for the resident and will determine the authenticity of the claim by consulting with a representative from the religious group. (See Food Service Section)

D. Resident Participation in Outside and/or Program Activities

1. A resident's participation in work, school and/or program activities also may be affected by their religious beliefs.

2. Clergy from the designated faith may consult with program staff regarding these issues.

E. Resident Accountability

1. Resident participation in religious activities will be monitored similar to other outside resident activities. a. Staff will conduct telephone checks to verify the resident’s location.b. SecurManage system will record all resident religious activities.



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POLICY 1.3.12 - VISITATION

I. POLICY

Residents will be permitted visits during designated hours so long as they do not pose a threat to the safety of residents or the security of Brooke House. Provisions are made for special visits by the Program Director or designee.

II. PROCEDURES

A. A "visitor" is a person approved by Brooke House staff and the contracting agency to enter the premises for the purpose of spending a short duration of time with a resident. All visitors previously approved by the contracting agency, must reapply to visit at Brooke House.

B. Visiting Hours

1. Visitation times for Suffolk County and Norfolk County Sheriff Department residents are Saturday and Sunday from 2:00 PM to 7:00 PM.

2. Visitation times for MA DOC and MA Parole residents are Saturday and Sunday from 9:00 AM to 11:45 AM.

3. These times will be adjusted as needed and approved by the Program Director. 4. Special visits may occur after normal visiting hours with the approval of the

Program Director or Assistant Program Director.

C. Visiting Areas

1. The Day Room on the first floor of Brooke House is used for visits. a. This area provides privacy but allows for staff supervision at all times.

D. Visiting Rules

1. The staff member at the Front Desk must check-in the visitor (s). 2. A visitor who does not produce a photo ID shall not be admitted to the facility. 3. All visitors are registered in a visitor's log at the Front desk.4. Children are not allowed to roam and should be supervised by their parents or

guardians at all times.5. Visits are held in the Day Room on the first floor of Brooke House.6. The actual amount of visiting time will be determined by staff present based on

the volume of visits on that day and space available to accommodate as many authorized visitors as possible.

7. Once a visitor has left Brooke House after a visit, he/she may not return for another visit on the same day.

8. Bags and packages are not allowed into the program unless authorized on an approved property drop off sheet. All property coming into the facility must be thoroughly searched for possible contraband and added to the resident’s property inventory.

9. If use of alcohol or drugs may be influencing the behavior of a visitor, permission to visit shall be denied.



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10. Any problems relating to visits shall be resolved, if possible, by the responsible staff persons on duty and if need be, by notifying the Program Director or Assistant Program Director.

11. Visitors who are disruptive shall have their visits terminated immediately. Repetitive disruptions shall result in having future visits denied. Staff shall obtain assistance from the Boston Police Department to remove visitors who threaten the safety of residents or the security of Brooke House.

E. Special Visits

1. Residents with special circumstances relating to their visitors may be provided with visits during non-visiting hours. Special visits must be approved by the Program Director or Assistant Program Director and documented in their file and in the SecurManage system Shift Log.

2. Visits from attorneys, members of the clergy and other social service agency representatives shall be recorded in the Visitor’s Log and in the SecurManage system Shift Log.

F. Monitoring of Visits and Visitors

1. Visits and visitors will be monitored by Program Monitors. 2. Front Desk staff will monitor the cameras that cover the entrance to the Day

Room area.3. Staff will conduct periodic walk-throughs in the common area to ensure

appropriate conduct by residents and visitors.

G. Visiting Information

1. Residents will be made aware of the rules regarding visits during orientation and through the Resident Handbook and memos.

2. Visitors shall be made aware of the rules concerning visits by postings at the Front Desk and visiting area.


Reference Standard: ACA: 4th Ed. (PBS): 2A-01 5A-172A-02 5A-185A-16 5A-23



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POLICY 1.3.13 - RELEASE PREPARATION

I. POLICY

Staff will work with the resident throughout his stay to create a discharge plan prior to the resident’s release which includes verifications of residence, employment or training programs and relapse prevention plan.

A Discharge Plan is completed within 14 days of a resident’s release from Brooke House and reviews the resident’s performance. The Plan is filed in the resident’s case record.

Prior to his release, the resident will return all facility property that was issued.

II. PROCEDURES

A. Transition Plan

1. Prior to the release date, the Case Manager will create a written Transition Plan (Final Summary Report) with the resident.

2. The Transition Plan will vary for specific cases.3. Plans will specify the following:

a. proposed residenceb. employment/training program,c. relapse prevention plan, andc. family situation of the resident.

4. A Transition Plan will be completed by the responsible Case Manager within fourteen days of a resident’s release and will include the following information: a. identifying information (i.e., name, release date, legal status); b. the reason(s) for the discharge.c. the resident's new location, if available.d. determination of needs; e. employment and finances; f. community supports; g. program adjustment; and a summary of the resident’s progress in Brooke

House, including:(1) initial problems and needs(2) program plan(3) accomplishment of plans and progress(4) final release plans, potential problems anticipated after release, and

any additional services needed upon discharge.h. Signatures of Case Manager and resident (if available).

5. The Case Manager will forward a copy to the Assistant Program Dirctor and file a copy of the report in the resident’s case record.

6. All residents will have a Transition Plan prior to release from Brooke House.



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B. Release Types and Plan Approval

1. Supervised Release/Parolea. The Parole Office contacts Brooke House (usually a day before the release

date) and notifies the Program Director which resident will be released on Parole.

2. Certificates of Dischargea. The Suffolk County Sheriff’s Department, Records Department contacts

Brooke House (usually a day before the release date) and notifies the Program Director which resident will be released on expiration of sentence.

b. The Norfolk Sheriff Office assigned Case Manager notifies the Director of a pending release.

c. The MA Department of Correction notifies Brooke House in writing up to a week in advance of the resident’s release date.

3. The resident is advised of his release date as soon as Brooke House is notified. a. The Case Manager tells the resident he has to go to the Suffolk County

House of Correction or to Boston Pre-Release and sign his parole papers or pick up his release papers. Norfolk Sheriff Office will fax Certificate of Discharge papers to Brooke House.

b. Residents will provide their Case Managers with completed release documents following their return from the Suffolk County House of Correction or from Boston Pre-Release.

c. A copy of all release documents are filed in the resident’s file.

C. Verification of Release Dates

1. The Case Manager will verify the release date of their assigned resident with the Suffolk County Sheriff’s Department prior to each resident’s release.

2. Release dates will not be changed without the consent of the Sheriff’s Department.

D. Release Clothing and Transportation

Prior to release and in limited circumstances, CRJ will provide release clothing and transportation to the resident.

E. Release Process

1. The Case Manager will brief the resident on his release status and the conditions prior to the time of release. a. For parole releases, those residents will be informed by the Parole Office

at the Suffolk County House of Correction if they must report to the Parole within 24 hours of their release.

b. All residents will be advised that they must remove their personal property from Brooke House upon release.(1) All residents will be advised to complete a change of address form

which is available with the Intake / Release Coordinator, and leave it at the Front Desk for pick up by the US Mail Service. Residents will



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be advised that if they fail to do this, any mail sent to the facility for them will be returned to sender after their release.

F. Property Disposition

1. On the day of the resident’s discharge/ parole, the resident shall turn in all linens (sheets, towels, blankets and pillows) that were distributed to him that belong to the program. The resident will be reminded to take all of his property with them when they leave, including medication. The Shift Supervisor will check the resident’s living area to ensure it is clean.

2. Property of residents terminated from the program will be collected and inventoried by the Shift Supervisor. a. This inventory will be kept until items can be collected by a family

member or designee authorized by the resident.b. A family member or designee will sign the original inventory list and

takes possession of the property. c. Brooke House will retain a copy of this inventory list on file. d. For residents returned to higher custody or escape, property left after thirty

days may be considered abandoned and may be donated to a local charity or destroyed. It is the resident’s responsibility to coordinate the pick up of their property.

G. File Disposition

1. Released resident files will be forwarded to the Assistant Program Director for inactive filing.

2. Brooke House will retain all public information and program generated information about residents. Information will be kept and maintained by Iron Mountain.





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POLICY 1.4.1 - STAFF AVAILABILITY

I. POLICY

The facility shall be adequately staffed at all times. Staffing pattern concentration shall be at those times that the greatest number of residents are present in the facility and in need of services. There are two staff person on the facility premises 24 hours a day who are readily available and responsible for the residents’ needs.

The Program Director determines the staff requirements for the facility and systematically reviews them on an annual basis.

II. PROCEDURES

A. Responsibility

1. The Program Director or designee is responsible for the following staffing issues:a. Determining staffing requirementsb. Scheduling staff time and attendance.

2. The Program Director is responsible to ensure that there is adequate coverage for each shift to meet basic requirements.

B. Staffing Requirements

1. The Program Director develops staffing requirements based on the contract requirements and the number of residents housed in the facility and PREA regulations.

2. Staffing levels are reviewed on an as needed basis and at least quarterly in conjunction with budget reviews between the Program Director and the Fiscal Department.

C. Staff Scheduling

1. Staff scheduling assures around-the-clock coverage of the facility, seven days a week.

2. At all times, two staff member are alert and awake, accessible and appropriately responsive to resident needs.

3. Normal days off, holidays, vacations and average sick leaves are considered and backup coverage made available as needed.

4. Schedule changes are approved by the Program Director or Assistant Program Director.

5. The staff work schedule is maintained in the Operations Book by the Program Director or Assistant Program Director at least one week prior to the commencing of the schedule.



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D. Schedule Review

1. Staff schedules are reviewed by the Program Director, and adjusted as needed, to determine if adequate staff is available for case management and other program activities during the hours when most residents are in the facility.

2. All staff are treated equitably as to days off, holidays, annual leaves, etc.





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POLICY 1.4.2. - RESIDENT ACCOUNTABILITY

I. POLICY

Brooke House provides adequate supervision of its residents by maintaining a system of accounting for their whereabouts in the SecurManage system. Resident accountability shall be maintained around-the-clock by the staff on duty. Program staff monitors all resident movement into and out of the facility. Staff are responsible to account for the whereabouts of all residents at all times.

Access to and egress from the facility is controlled at all times.

Brooke House staff take measures to prevent residents from absconding from the program. Any Suffolk County Sheriff’s Department resident that cannot be accounted for within 45 minutes (or immediately) will be reported to the Suffolk County Community Supervision Unit. Any MA DOC resident that cannot be accounted for within 15 minutes (or immediately) will be reported to the Director of Treatment or the Shift Commander at Boston Pre-Release. Any parole resident that cannot be accounted for will be reported to the supervising Parole Officer on the next business day.

II. PROCEDURES

A. Facility Access and Egress

1. Staff are on duty at the front desk 24 hours a day, 7 days a week.2. Security doors are used throughout the facility. 3. Cameras are positioned in all hallways and other designated locations.

B. System for Resident Accountability

1. Staff Checks a. Staff make periodic rounds to be sure that residents who are in the facility

are, in fact, where they should be. b. When a resident leaves the facility, he needs to report to the Front Desk.

The staff person working the Front Desk will verify the release information is in the SecurManage system and sign the resident out, giving him a copy of his itinerary sheet which contains his location, expected time of arrival/ departure and required call ins.

c. A resident returning to the facility checks-in with the staff member on duty at the Front Desk. Staff on duty record the resident’s return time in the SecurManage system and search the resident and any items he may have with him.

2. Head Countsa. The counts are completed seven times in a 24-hour period.b. The 7-3 shift conducts a count at 8 AM and Noon. c. The 3-11 shift conducts counts at 4 PM, 8 PM and 10 PM. d. The 11-7 shift completes counts at 1 AM and 4 AM.



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e. The Shift Supervisor generates a Head Count sheet from the SecurManage system. Staff utilize this count sheet to account for all residents. At the conclusion of the count and all residents are are accounted for, the count sheet is signed, dated and time the count was completed. All information must be legible. The Head Count is entered into the SecurManage system.

f. Periodic walk-throughs and room checks are conducted throughout the shifts on a random basis and logged into SecurMange.

g. If the whereabouts of any resident is in question, a review of the SecurManage system and accompanying documentation is to be immediately conducted and cross-checked. (1) If the resident is not signed out and is supposed to be present in the

facility, a thorough search of the facility will take place. (2) If the resident can’t be located, found or accounted for

according to the approved SecurManage system, the Program Director or Assistant Director (on-call) is contacted.

(3) The Program Director or Assistant Program Director will then contact the appropriate authorities.

C. Verification of Resident's Participation in Program Related Activities/Monitoring

1. When a resident is out of the facility for employment or to attend a community activity, staff periodically shall monitor that resident to ensure he is participating in the stated activity.

2. Such activities as counseling, community and education programs, etc. shall be checked randomly and noted in the SecurManage system.

D. Unauthorized Absences

1. The following conditions are considered unauthorized absence from Brooke House:a. Failure to report for admission to Brooke House at the scheduled time by

parolees;b. Out-of-place or absent from a specified approved location during

stipulated hours;c Late return to Brooke House from an authorized release; d. Violation of any condition of Brooke House curfew;e. Arrested while in a Brooke House program or for either new crimes or

outstanding warrants; and/or otherwise willfully escapes or are absent without leave.

E. Detection and Reporting of Escapees

1. If any verification indicates a resident's absence, the staff person on duty shall immediately try to locate the individual by calling his authorized location and speaking to the person in charge.

2. If he is not contacted, the Shift Supervisor should be notified. 3. The Shift Supervisor will review the resident information in SecurManage and

notify the Program Director and the Assistant Program Director.



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4. The Director will notify the appropriate contract agency. The appropriate authorities are: a. Suffolk County Sheriff Department Field Supervision Unit Sergeantb. MA DOC Boston Pre-Release Center Shift Commander c. Norfolk County Sheriff Office Shift Commander d. MA Parole Brooke House Parole Officer.


Reference Standard: ACA: 4th Ed. (PBS): 2A-01 2A-112A-12



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POLICY 1.4.3 - RESIDENT CONTROL OVER OTHER RESIDENTS

I. POLICY

No resident or group of residents is in a position of control or authority over other residents in Brooke House.

II. PROCEDURES

A. Assumption of Duties

1. No resident shall be requested to assume any staff person's assignment for any purpose.

2. No resident shall be requested to supervise any residents for any purpose.

B. Orientation

Through both staff and resident orientation, it will be stressed that no resident will be placed in situations where one has authority or perceived authority over another.

C. Actual Occurrence

If this situation presents itself, it should be brought to the attention of the ProgramDirector or Assistant Program Director.





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POLICY 1.4.4 - USE OF FORCE

I. POLICY

The use of physical force to control residents shall be restricted to instances of justifiable self-protection and protection of others, or to protect a resident from harming himself. In those instances, the force used shall be only to the extent necessary to control the situation. All uses of force shall be reported in writing, dated and signed, and reviewed by the Program Director. Immediate medical examination and treatment is given to any person injured in an incident. Incidents involving the use of force are investigated, findings are gathered and analyzed.

The use of corporal punishment is absolutely prohibited.

II. PROCEDURE

A. Crisis Intervention

All incidents shall be managed with the use of crisis intervention skills, beginning with verbal and non-physical intervention as the incident dictates.

B. Use of Physical Force

1. Management and control of residents by the use of force is inappropriate. a. A staff member shall use force only when no other option exists. b. Staff shall try to use their interpersonal skills to calm an irate resident. c. The staff member believing a resident is about to inflict serious physical

harm shall summon other staff, and simultaneously dial “911”. d. Staff shall continue to attempt to defuse the situation while waiting for the

911 response. 2. Physical force shall be used only in the following instances and, only when no

other option is available:a. to protect selfb. to protect other staff, residents or visitorsc. to prevent a resident from harming him or herself

3. When absolutely required, the use of force shall be only to the extent necessary to subdue the resident and bring the situation under control.

4. Any staff member using physical force shall immediately report this to his/her supervisor who will notify the Program Director. A full report shall be immediately written by the staff person and submitted to the Program Director prior to going off duty.

5. All staff members who witness the use of force shall submit a written report to the Program Director.

6. A copy of the report shall be filed in the resident's case record.7. All reports shall be forwarded to the Program Director, SJS Department

Director and SQA Department Director for review. The results of the review will be attached to the initial report.



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8. The contracting agency should be notified as soon as possible concerning the use of force on one of their residents.

9. Immediate medical examination and treatment will be arranged for anyone needing it as a result of the use of force.

C. Mechanical Restraints

No mechanical restraining devices will be maintained at Brooke House and therefore any use by program staff would be considered a violation of policy.

D. Chemical and Medical Restraints

Both are prohibited in Brooke House.

E. Personal or Mental Abuse and Corporal Punishment

1. Personal or mental abuse and corporal punishment are strictly prohibited. This includes: a. Physical punishment, such as spanking, hitting or using a mechanical

instrument to inflict pain; b. Discipline that adversely affects a resident's dignity or pride, or brings

about shame; a. Sanctions that deny residents regular meals, sleep, exercise, medical care,

correspondence privileges or legal assistance.2. Staff persons having knowledge of policy violations shall report any incident to

the Program Director immediately and prepare a written report within 24 hours.

F. Resident Reports of Policy Violations

Residents should report allegations of excessive force or discipline to the Program Director, who is responsible for coordinating a review of the allegations and reporting to the CEO Officer for a final review and follow-up.

G. Staff Discipline

Staff members who engage in inappropriate disciplinary activities are themselves subject to disciplinary action up to including termination and may be suspended pending the investigation.

H. Staff Training

All direct care staff will be required to receive annual training on crisis intervention techniques including the proper and safe use of verbal intervention, physical intervention, and search procedures.

I. Mandated Reporting



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Staff members who suspect that residents are being abused shall have the obligation of reporting this to the Program Director who shall then notify the contracting agency.

J. Use of Force Monitoring, Review and Analysis

1. When actual use of force incidents occur, the Program Director will meet with the Assistant Program Director to review and analyze the situation. a. The results will be used to initiate or revise policy and procedure to

prevent future occurrences.2. The Program Director will complete a report with the results of the use of force

analysis and submit a copy to the SJS Department and SQA Department Director.


Reference Standard: ACA: 4th Ed. (PBS): 2B-01 M2B-022B-03 6A-03



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POLICY 1.4.5. - SEARCHES

I. POLICY

Facility/Room searches shall be conducted to control contraband or locate lost or stolen property. Searches shall be conducted as frequently as required to control contraband or when contraband is suspected to be present. Residents will be asked to step out of the room and be searched prior to staff conducting a search.

Resident searches may be conducted on residents at any time or if there is reasonable suspicion that they may be concealing contraband. In addition, resident searches will be done randomly to maintain a drug and weapon free environment.

All bags and packages carried into the facility by residents entering the facility shall be searched.

II. PROCEDURES

A. Staff Responsibilities

1. Staff shall be alert for the presence of contraband at Brooke House.2. Staff shall respond to any resident behavior, investigate and report any situation,

which indicates the presence of contraband on site.

B Resident Bag Searches

1. Any bag or package carried into the facility by a resident entering the facility shall be inspected by a Program Monitor at the Front Desk post.

2. Any bag/package dropped off by family or friends will be inspected also.

C Facility Searches

1. A facility search can be done any time.2. A search shall be done with a minimal disruption of regular program operations

whenever possible.3. The Shift Supervisor shall document findings of the search and forward the

report to the Program Director or Assistant Program Director.

D. Resident Room Searches

1. The search of a resident's room may be conducted when the resident is in the facility or outside the facility.

2. If present, the resident will be search and then asked to step out of the room while staff conducts the search.

3. The search of a resident's room shall be thorough and orderly. a. Care shall be taken to avoid damage or destruction of property. b. The room shall be left in the condition found prior to the search.



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c. Items are to be returned as neatly as possible to the positions in which they were found.

4. The employee conducting the search shall report any damage of a resident's property to the Shift Supervisor immediately.

5. Any articles confiscated shall be forwarded to the Program Director or Assistant Program Director and secured until he/she arrives.

6. The Shift Supervisor shall record the search and contraband found in the SecurManage system Resident Incident Report and the Search Log at the Front Desk. The information to be included on the form is as follows:a. The number of the room that was searchedb. Date of searchc. Name of staff conducting the search d. List of contraband founde. List of restrictions, if any.

E. Body Searches

1. Brooke House authorizes only one type of body search, a pat frisk.a. A pat frisk may be made randomly by staff on residents at any time

by same sex. b. The employee conducting this type of search shall be thorough, yet not

offend the dignity of the resident being searched. 2. Strip searches and body cavity searches are prohibited.

F. Contraband

1. All staff and residents are advised of what constitutes contraband in the facility.a. The Resident Handbook lists items not allowed in the resident’s room.

2. Any contraband found is reported to the Program Director or Assistant Program Director.

3. When contraband is found, staff will perform the following duties:a. Depending on the type of contraband found and if there is reason to

believe a new crime has been committed, the area or resident room will be sealed off and no residents will be allowed into the room or area.

b. Staff will not touch the contraband and will contact the Director On-Call who will then contact the Suffolk County Sheriff’s Department, Norfolk Sheriff Office, MA Department of Correction, or MA Parole.

c. Staff will notify the Shift Supervisor and notification of additional staff will follow the chain of command.

d. Any physical evidence obtained in connection with a violation of law and/or facility regulation is preserved, controlled and a disposition is made.(1) Any contraband of value or safety concern that remains in the

facility for a non-criminal offense may be placed in the drop box or safe in the Assistant Program Director’s office and secured until disposition is made and per the situation warrants.



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Reference Standard: ACA: 4th Ed. (PBS): 2C-01 2C-042C-02 2C-052C-03 2C-06



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POLICY 1.4.6 - WEAPONS I. POLICY

The use of weapons in the facility is prohibited except in the case of an emergency. Staff, residents, and their visitors are strictly forbidden from having firearms and any other weapons on the premises. Suffolk and Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole officers and other law enforcement personnel shall be advised of this policy and asked to take special precautions with weapons in their possession.

II. PROCEDURES

A. Strict Guidelines on Weapons

1. Staff, residents, and their visitors shall be advised that possession of firearms and other weapons on the premises is strictly forbidden.

2. Any firearm or weapon found on the premises shall be confiscated and turned over to law enforcement authorities.

3. Staff found with firearms or weapons on the premises shall be subject to disciplinary action and even termination.

4. Residents found with firearms or weapons on the premises shall be turned over to law enforcement authorities and visiting privileges also will be suspended in cases where visitors are found in violation of this policy.

5. Suffolk and Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole officers or other law enforcement personnel entering the facility shall be advised of Brooke House's firearm and weapon prohibition and shall be asked to take special precautions with firearms and weapons in their possession.

6. Only during an emergency (the removal of a resident from the facility and return to higher custody), weapons may be carried by officials and are not prohibited.

7. During routine visits, officers may secure their weapons in the gun lock box in the Admin. Office or the Intake / Release Coordinator’s office if they are going beyond the first floor of the building.

8. If they choose not to secure their weapons when leaving the first floor area, they are not permitted inside the facility.

9. Staff will immediately notify the Program Director or Assistant Program Director of any violation of this policy by any Sheriff’s Department, MA Department of Correction, or MA Parole officers or other outside law enforcement personnel.


Reference Standard: ACA: 4th Ed. (PBS): 2A-10 M



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POLICY 1.4.7 - CONTROL AND USE OF KEYS, TOOLS AND EQUIPMENT

I. POLICY

Keys, tools, and equipment shall be strictly controlled and used accordingly. An inventory system for staff keys shall be in effect to maintain the security of the facility and the privacy of staff, residents, their property and records.

II. PROCEDURES

A. Types of Keys

Master keys are those keys that, if lost or duplicated, would jeopardize the security of the facility or the privacy of residents and their records. Duplication of master keys is limited to the City Lock Company.

B. Key Inventory

1. The Program Director/ designee will be responsible to maintain an accurate key inventory of all keys and key rings on a monthly basis.

2. The key control system will be audited monthly by the Program Director.

C. Storage of Keys

1. A key for each lock shall be stored in a master key box located in the Director’s office.

2. All keys in this box shall be accounted for and any keys with numbers on them shall be recorded.

3. Whenever possible, only duplicate keys shall be issued for use.

D. Twenty-Four Hour Keys

1. All 24 hour keys permanently assigned to a staff member shall be signed for, and the receipt shall be kept by the Program Director.

2. When leaving a position, the employee will return their 24 hour assigned key to the Program Director or designee who will record their return.

3. Staff is responsible for these keys while off duty.

E. Shift Keys

1. There are five key boxes which contain keys and key rings for the program staff.a. Front Desk Key Box- contains six key rings: One set for Program

Monitor Supervisor, Two sets for Program Monitors, One set for the elevator, one set for all DETEX alarm boxes, and one set for outside water faucet. The Program Monitor Supervisor/ shift supervisor is responsible to maintain control of these key rings.

b. Intake / Release Coordinator Key Box- contains one key ring.c. Case Managers Key Box- contains three key rings.



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d. Director / Assistant Program Director Key Box- contains two key rings.e. Master Key Box- contains all the keys and duplicate key used in the

program.2. The Program Monitor Supervisor / Shift Supervisor are responsible to issue key

rings from the Front Desk Key box and ensure the key rings are returned at the end of the shift. Key rings should be accounted for on the Shift Report.

F. Lost or Misplaced Keys

1. A verbal report of any lost or misplaced key or key ring shall be made to the Program Director or designee immediately.

2. A written Incident Report shall be completed as soon as possible and submitted to the Program Director. The report shall state when the loss was discovered, circumstances surrounding the loss, the key or key ring identification and the steps taken to try to recover the key ring.

3. When keys are lost or misplaced, proper security precautions must be taken to preclude use of the key(s) for unauthorized purposes. Locks may have to be modified after the reported loss of a key ring.

G. Key Control

1. Staff will observe the following key control procedures:a. When on duty, staff shall keep facility keys in their possession at all times.b. Staff shall be vigilant when carrying and using keys.c. Residents are never permitted to handle facility key rings. d. The only exception is for residents with ADA or medical conditions, the

Director will issue an elevator key and advise staff. No other residents are to ride the elevator with this resident. Staff will escort residents who need to use the elevator for house details or deliveries.

H. Types of Tools

1. Basic maintenance tools are maintained and shadowed in the Tool Crib located in the Boiler Room.

2. Access to the Tool Crib is restricted to the Program Monitor Supervisor / Shift Supervisor.

3. Staff who use any of the tools or issue any of the tools to a resident will sign them out on the Tool Sign-Out Sheet located in the Tool Crib. All tools used / issued must be returned to the Tool Crib at the end of the shift.

4. Program Monitor Supervisor / Shift Supervisor must check for tool accountability during his/her tour of duty and make a Shift Log entry. An incident report should be written for any missing tools. Efforts should be made to locate the missing tool as soon as it is discovered missing.

I. Utensils

1. Brooke House does not maintain metal utensils in the kitchen.2. All serving utensils are sent in with food and are plastic and do not remain in

the facility.



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Reference Standard: ACA: 4th Ed. (PBS): 2D-01 M2D-02 M2D-03 M

POLICY 1.4.8 - VENDOR/CONTRACTOR SUPERVISION



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I. POLICY

When it is necessary to bring service contractors, delivery or maintenance personnel in Brooke House, staff will take precautions to see that the security of the visitor, residents and the facility are ensured.

II. PROCEDURES

A. Admission into Facility

1. All contractors will be required to check in at the desk and state their business. 2. All those entering the facility shall be required to present a photo

identification. 3. The staff at the front desk will record the contractor’s name in the

SecurManage Shift Log. 4. Vendors and contractors are required to sign in and out of the program in the

Visitor’s Log.5. Contractors will be advised to keep close watch over their tools and

equipment while in the facility.

B. Supervision of Vendors/Contractors

1. All contractors will be escorted to where they need to work. The escort may stay with the contractor and will be decided on a case by case basis.

2. When feasible, staff shall ensure that residents are kept clear of the contractor and the work being done.

3. The staff on duty will make periodic checks of the work area.





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POLICY 1.4.9 - TRANSPORTING RESIDENTS RETURNING TO CUSTODY

I. POLICY

Brooke House shall not be responsible for transporting residents who are returning to the custody of the Suffolk and Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole.

II. PROCEDURES

A. Coordination

The Program Director or Assistant Program Director shall be responsible for all activities necessary to transport a resident when warranted.

B. Return to Custody Transfer Procedure

1. The Program Director or Assistant Program Director shall contact the Suffolk or Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole when a resident needs to return to their custody.

1. Suffolk or Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole will decide when the resident will be picked-up at Brooke House.

2. All transfer paperwork shall be ready and available at the time the resident is to be transported.

a. The resident shall not be informed ahead of time about the pending transfer.

4. Whenever a resident is to be transported, the Program Director or Assistant Program Director shall ensure that Suffolk or Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole receives a copy of the Incident Report, stating the reason for transfer.

C. Transfer to another Agency

A resident cannot be transferred to any other agency except the Suffolk or Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole.





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POLICY 2.1.1 - ZONING AND BUILDING CODE COMPLIANCE

I. POLICY

Brooke House shall continually strive to meet all applicable zoning ordinances and building codes, including special provisions for persons with disabilities, to the extent possible due to the age of the building. The facility shall comply with all life safety codes.

II. PROCEDURES

A. Responsibility

Contact shall be made by the Program Director with the appropriate local official(s) to acquire documentation when the facility is in compliance with zoning ordinances and building codes. If this approval has not been obtained, all correspondence shall be retained to show efforts are being made toward compliance.

B. Compliance

All documentation of compliance will be posted at the front entrance and kept on file at the facility.

C. Americans with Disabilities Act (ADA) Compliance

1. Due to the age of the building, the facility will strive for compliance with all ADA requirements.

2. If residents with disabilities are classified to Brooke House from the Sheriff’s Department, MA Department of Correction, or MA Parole they will be housed in a manner that provides for their safety and security. a. Housing used by offenders with disabilities is designed for their use and

provides for integration with other offenders. b. Programs and services are accessible to offenders with disabilities who

reside in the facility.


Reference Standard: ACA 4th Ed. (PBS): 1A-096A-047A-05



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POLICY 2.1.2 - SANITATION AND HOUSEKEEPING

I. POLICY

Brooke House complies with the sanitation and health codes of the Commonwealth. The facility has a system for controlling vermin and pests and handling trash and garbage removal. Facility sanitation and safety inspections are conducted on a weekly basis. A housekeeping and maintenance plan shall remain in effect to ensure that the facility is continuously clean and in good repair.

II. PROCEDURES

A. Sanitation and Health Code Compliance

1. The Program Director ensures that the appropriate local and state officials (Boston Inspectional Services) inspect the facility on a regular basis for compliance with applicable sanitation and health codes. a. Staff will correct any deficiencies noted in the inspections.

2. The Program Director shall obtain annual documentation from these officials that the facility meets such codes and post at the building entrance and keep this documentation on file.

B. Pest and Vermin Control

1. An outside contractor inspects, treats and eliminates any signs or breeding places of rodents and insects, on a periodic and as needed basis.

2. Effective chemical agents shall be used to bring an affected area under control.3. Records of misting/spraying shall be maintained.

C. Trash and Garbage Removal

1. The facility contracts with an outside vendor for trash and garbage removal. a. Trash, garbage pick-up is provided 5 days a week by a vendor.

2. The Program Director shall review the provisions of the contract annually and assess the services provided.

3. The facility contracts with an outside vendor for one stream recycling materials to be removed as needed.

D. Needle Collection (HAZMAT)

1. Residents that need to take insulin (or other prescribed medication) will be allowed to self-administer the medication using a syringe.

2. During medication distribution, staff hand an envelope (that contains the syringe) to the resident to use.

3. The resident uses the syringe, puts the cover back on and places it into the hazmat container (bucket) located in the Program Monitor Supervisor’s office.

4. When the container is full, the vendor is contacted to come and pick up the container.



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E. Water Supply

The facility’s potable water source and supply (Boston Sewer & Water) is in compliance with local regulations.

F. Housekeeping and Maintenance Plan

1. The Program Director or designee is responsible for maintaining and posting a housekeeping and maintenance plan on the bulletin boards to ensure that all areas of the facility are cleaned and maintained on a regular basis.

2. The Program Director, in conjunction with the CRJ Facilities Director will maintain an ongoing preventive maintenance plan and will identify and secure contractors, as necessary, and materials to implement this plan.

3. Closets are provided on each floor for janitorial supplies. a. The basement and second floors have mop sinks within the closets. b. The other three floors have closets with cleaning materials for the

resident’s use. c. These areas are accessible to the living and common areas by residents

and staff.

G. Facility Sanitation and Safety Inspections

1. The Program Monitors will inspect the facility weekly, to ensure that the facility is maintained, equipment is functional and in good repair and sanitation and safety codes are enforced. a. The outside perimeter will be included in this inspection.

2. In addition, the Program Monitor Supervisor will inspect areas not accessible to residents. These areas include, but are not limited, to: a. roofb. back alley and shed

3. These inspections will be logged with any deficiencies listed and the resulting follow-up noted.

H. Requests for Maintenance

1. Non-Emergency Repairsa. Any staff member having knowledge of a repair need in the facility shall

identify that area to the Program Director via e-mail.b. The Program Director or designee shall submit a Facilities Request

through the online database where the Facilities Director coordinates the necessary repairs with department facilities maintenance people or outside contractors.

2. Emergency Repairs a. An emergency repair is defined as a situation which, if not corrected

immediately, may endanger the health or safety of employees or residents; may cause a major disruption of facility functions and operations; or may cause excessive property loss or damage.

b. The following steps are taken in the event of an emergency:



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(1) Staff shall contact the Program Director or Assistant Program Director (whoever is on-call) by telephone with an emergency.

(2) A written Incident Report shall be forwarded within 24 hours.(3) The on-call staff member shall contact the appropriate personnel

without delay to perform the necessary repairs.


Reference Standard: ACA: 4th Ed. (PBS): 1A-01 M 1A-05 M1A-02 M 1A-061A-03 1A-111A-04 M



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POLICY 2.1.3 - RESIDENT LIVING ENVIRONMENT

I. POLICY

All sleeping areas shall have adequate ventilation, lighting and space to provide a good living environment. The facility has sufficient sanitary facilities.

II. PROCEDURES

A. Lighting

In resident rooms, at least 20 foot-candles of lighting is available at the desk level and in the personal grooming areas.

B. Ventilation

In resident rooms, air circulation is at least 15 cubic feet of outside or re-circulated filtered air per minute per person.

C. Rated Bed Capacity

The number of offenders does not exceed the facility’s rated bed capacity of 65.

D. Sleeping Arrangements

1. Residents are assigned rooms as they are admitted. 2. Rooms housing more than one resident will all be of the same gender.

a. No female residents are housed at Brooke House.

E. Toilet Facilities

The number of operable toilets shall be equal to or in excess of the Health Department requirements.

F. Wash Basin

Operable wash basins with hot and cold running water shall be provided for residents.

G. Bathing Facilities/Showers

1. Operable showers with hot and cold running water shall be provided for residents with a 1:8 ratio of showers to residents.

2. The temperature of water shall be between 100-120.

H. Washer/Dryer

Residents can use the local laundromat to wash their clothing, or, bring clothing home on PRA.

I. Maintenance



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Plumbing and other maintenance repairs for the fixtures listed above is obtained as needed.

J. Alterations

1. The Program Director is responsible for ensuring that necessary alterations needed to comply with the sanitation regulations shall be completed accordingly.

2. Staff is responsible for reporting all problems with sanitary facilities in writing to the Program Director or Assistant Director.

K. Inspections

Weekly inspections of all sanitary facilities shall be conducted. (See Sanitation P&P)

L. Assessment of the Facility's Physical Plant

1. Through weekly inspections, the Program Monitor Supervisor or designee shall monitor the facility's compliance with the above stated policy.

2. All inspections shall be logged with findings and follow up plans, if required, noted.


Reference Standard: ACA: 4th Ed. (PBS): 1A-07 1A-141A-08 4B-021A-10 4B-031A-12



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POLICY 2.1.4 - PROGRAM MEETING SPACE

I. POLICY

Brooke House shall allocate sufficient space and furnishings for case management counseling and other activities such as group meetings. Space also will be set aside, during designated times, for visits with relatives and friends.

II. PROCEDURES

A. Counseling Space

1. Private, individual counseling space is available to all Case Managers and staff offices are available for this purpose.

2. Residents needing to meet with approved visitors from outside the facility (at times other than scheduled visiting hours) shall reserve space through the Program Director or Assistant Program Director.

B. Activity Space

The common room (first floor Day Room) in the facility is used for resident activities, meetings and visits.

C. Furnishings

1. Counseling rooms and the first floor Day Room shall be appropriately furnished with the necessary chairs and tables.

2. Staff should report any problems with the rooms or furnishings to the Program Director.


Reference Standard: ACA: 4th Ed. (PBS): 5A-235A-245A-25



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POLICY 2.1.5 - RESIDENT FURNISHINGSI. POLICY

Each resident shall be assigned clean sleeping quarters and shall have appropriate bedding which includes bed, mattress, pillow and bed linen. Storage space for personal items shall be available and residents shall be allowed to place personal items on the inside of their closet doors so long as it complies with appropriate fire flammability ratings. Writing and seating space shall be accessible to residents in the facility.

II. PROCEDURES

A. Sleeping Quarters

1. At the time of admission, each resident shall be assigned a designated room and issued the following:a. one bed frame b. one mattressc. one pillowd. linens e. storage space (closet)

B. Issue of Bed Linen

1. Each new resident shall be provided with bedding and linens including:a. two sheets b. one pillow casec. one bath towel d. one hand towele. one blanket

C. Exchange of Bed Linen

1. Any resident with ripped or damaged bed linen(s) should notify the 7-3 Program Monitor Supervisor of this situation, bring the damaged linen to a Program Monitor Supervisor and the resident will be given a replacement.

2. Provisions for linen exchange shall be available on a weekly basis for indigent residents.

3. Residents who are not indigent are able to launder their clothing at the local Laundromat. In addition, linen exchange will be provided, if requested.

D. Access to Writing and Seating Space

Residents are provided access to writing and seating space in their rooms or in the resident day room and dining hall.

Director’s Signature: Howard H. Jardine II , Program DirectorDate Issued: April 15, 2009 Date Revised: December 17, 2014Issued By: Brooke House/Standards and QA Department Effective Date: December 31, 2014 Reference Standard: ACA: 4th Ed. (PBS): 1A-13 1A-15 4B-04



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POLICY 2.1.6 - RESIDENT PROPERTY CONTROL

I. POLICY

A resident may possess personal property as authorized by the Program Director or Assistant Program Director upon admittance to Brooke House. Property held by a resident is that resident’s responsibility. Property that is misused or contributes to an unsafe or unstable program environment may be confiscated or removed. Removed or confiscated property must be picked-up by friends or family within 30 days or it will be discarded.

II. PROCEDURES

A. Admission

1. Upon entrance to Brooke House, all property is the responsibility of each individual resident.

2. During orientation, the resident is informed of the rules and regulations regarding property. (This information is listed in the Resident Handbook.)

3. When a resident’s personal property that is not contraband is confiscated, the resident will be given a receipt, a copy of which will be kept in the resident’s file.

B. Removed or Confiscated Property

1. Personal property that is removed from a resident’s possession will be kept in the Property Room (5th Floor) for no more than 30 days and until arrangements have been made for the property to be picked up by the resident’s family/friends.

C. Release

1. The resident will take all property belonging to him upon his departure from Brooke House.a. Any property remaining in the resident’s room will be either:

(1) Removed and discarded or donated to a local charity.(2) Stored for a period of not less than 30 days, during which time the

resident will be notified. After 30 days, resident property not claimed may be disposed of at the discretion of the Brooke House Director.


Reference Standard: ACA: 4th Ed.: 7D-13 7D-14



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POLICY 2.1.7 - PERSONAL HYGIENE ARTICLES

I. POLICY

Basic personal hygiene articles are distributed to all residents who are unable to purchase them. Adequate storage space exists for bedding and personal hygiene items.

II. PROCEDURES

A. Hygiene Articles

1. Residents who do not have sufficient funds to purchase personal hygiene articles shall be issued any of the following needed items:a. soapb. toothbrushc. toothpaste, or denture cleanerd. shaving equipment (razor and shaving crème)e. deodorantf. other articles as approved by the Program Director

2. Residents will be informed about hygiene articles during their orientation period. 3. Adequate supplies of the necessary items will be ordered and maintained by the

Program Director.

B. Storage Space

The 7-3 Program Monitor Supervisor maintains storage space for bedding and personal hygiene items and advises the Program Director when items are needed.


Reference Standard: ACA: 4th Ed. (PBS): 4B-014B-05



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POLICY 2.1.8 - RESIDENT TRANSPORTATION

I. POLICY

Residents, when allowed to travel independently, shall be expected to use public transportation during the day unless other means of transportation has been approved.

Residents shall not be transported by staff in personally owned vehicles regardless of the situation. In urgent (non-routine) situations, an ambulance shall be called to transport a resident for medical emergencies.

II. PROCEDURES

A. Transportation Issues

1. Transportation schedules (MBTA subway and bus) are available at Brooke House and the assigned Case Manager will assist the residents with the schedules and any trip planning.

2. Suffolk County Sheriff's Department, Norfolk County Sheriff Office and MA Department of Correction provide transportation passes for their residents.

3. Indigent residents can get subway/bus fare from staff for use during releases.4. Under special circumstances, the Program Director may approve vehicle

transportation for a resident. A copy of the person’s driver’s license and automobile registration must be submitted to the Case Manager in advance for approval. The contracting agency must approve this transportation request.


Reference Standard: ACA: 4th Ed. (PBS): 1B-01M1B-02

1B-03



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POLICY 2.2.1 - EMERGENCY PLANS

I. POLICY

Facility emergency plans are communicated to all employees and residents. The facility evacuation plans are posted conspicuously and include directions to, and locations of, emergency exits. All Brooke House employees shall be trained in the implementation of these written plans. Monthly emergency drills are conducted. Emergency plans shall be disseminated to local authorities.

A system of fire inspections and testing shall be established. Brooke House complies with local and state fire safety regulations and codes. The facility's fire and smoke detection alarm system shall be tested annually.

II. PROCEDURES

A. Emergency Plans

1. Building EvacuationCopies of the evacuation routes shall be posted in each hallway on each floor of the facility. These plans shall use directional arrows to show traffic flow. In addition to floor plans, a written narrative of the evacuation routes are available in English and Spanish.

2. Fire PlanThe plan shall be posted conspicuously throughout the facility and include but not be solely limited to:a. method of notifying residents, staff and the fire departmentb. information that shall be reported to the fire departmentc. means of egressd. location of emergency equipment

3. Severe Weather Condition PlanThe plan shall include but not be solely limited to:a. obtaining information regarding severe weather conditions reportb. following the instructions of the CEO c. method of notifying residents and staff of severe weather reportd. instruction to staff and residents for different weather conditions, i.e.,

hurricanes, blizzards, etc.e. location of emergency equipment

4. Natural Disaster PlanThe plan shall include but not be solely limited to:a. method of obtaining assistance for staff and residentsb. instructions to staff and residents for different conditions, i.e., flood,

earthquake, life threatening severe damage to facility structure.c. location of emergency equipment

5. Intruder Plan a. If an intruder should enter the facility, staff will direct him/her to leave. b. If staff perceives any threat to staff, residents or property, they should call

the police via 911 and request assistance.



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c. They should make the appropriate follow-up contacts and complete an Incident Report.

6. Toxic Contamination Plan The plan shall include but not be solely limited to:a. means of notifying environmental response authoritiesb. means of obtaining notification of toxic contamination conditionsc. method of notifying residents and staff of toxic contamination and

possible evacuationd. instruction to staff and residents for different toxic contaminants, i.e., air-

borne, water supply, etc.

B. Dissemination of Emergency Plans

1. The Program Director will send copies of all emergency plans to the following applicable authorities:a. Boston Fire Department

(1) Building Evacuation Plan(2) Fire Plan(3) Severe Weather Plan(4) Natural Disaster Plan(5) Toxic Contamination Plan

b. Boston Police Department (1) Intruder Plan

c. Emergency Management(1) Toxic Contamination Plan

2. The Suffolk and Norfolk County Sheriff’s Department, the MA Parole Board, and the MA Department of Correction will receive copies of all emergency plans.

C. Staff Training

1. Staff shall receive training in the implementation of the above plans both during orientation and during annual training.

2. All emergency procedures training will be documented in each employee's training file.

D. Evacuation Drills

1. The Program Director is responsible to ensure that evacuation drills are:a. conducted monthly and for each shift on a quarterly basisb. include employees, and residentsc. attempts will be made to conduct drills at times when most residents are in

the buildingd. coordinated by the Program Monitor Supervisor who is responsible for

conducting such drills. 2. The 7-3 Program Monitor Supervisor is responsible for on a quarterly basis:

a. scheduling drills which cover each shift, and b. reporting to the Program Director on the effectiveness of the drill.



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3. Staff involved in evacuation drills will be mindful of the potential need to designate individuals to assist disabled persons during a drill and actual emergencies.

E. Analysis of Emergencies

1. When actual emergencies occur, the Program Director will meet with the Assistant Director and the Program Monitor Supervisor for a debriefing and analyze the emergency. The results will be used to initiate or revise policy and procedure to prevent future occurrences.

2. The Program Director will complete a report with the results of the emergency analysis and submit a copy to the the Director of Social Justice Services, Director of Standards and QA.


Reference Standards: ACA: 4th Ed. (PBS): 1C-011C-01-11C-02 M1C-04 M1C-05 M1C-09 M



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FIRE EMERGENCY EVACUATION PLAN AND FIRE ALARM PROCEDURES

If a fire alarm sounds, all residents must immediately exit Brooke House. The Shift Supervisor must coordinate available staff to ensure that all residents have been

evacuated. Exit signs and diagrams are posted throughout Brooke House on each floor.

Residents and staff may use either of the two exits located on each floor. Through the main stairwell, or, Through the rear stairwell through alarmed doors.

The main stairwell exit leads to the front of the building, past the front desk area.

The rear stairwell leads to the basement and out to the back alley in the rear of Brooke House.

After exiting Brooke House all residents must proceed immediately to the median strip on Park Drive, opposite the front of the building.

Once across the street, all residents must remain there for a count.

All residents must remain across the street until Brooke House Shift Supervisor authorizes re-entrance to the building. (If authorized by the Fire Department.)

When residents re-enter the building, they must remain in the first floor Day Room for a second count. No one is allowed upstairs until permission is given by Brooke House Shift Supervisor.

Failure to follow any of the steps in this procedure may result in disciplinary actions.

SEVERE WEATHER

In the event of a blizzard, hurricane or severe weather conditions, staff shall tune in to local radio stations (and television if available) for information.

The CRJ Chief Executive Officer or designee will make the decision to implement severe weather procedures that could include the following: Notification of residents and staff of weather conditions. Instructions to notify residents to return to the facility. Reassignment of corporate office and non-residential staff to Brooke House. Notification of custody authorities.

In addition, staff will follow instructions given regarding securing doors and windows or evacuation to community shelters, etc.

The Shift Supervisor shall inform all staff and residents on the premises of the instructions given either by use of a general announcement or by gathering everyone on the premises to a common area.

Emergency equipment such as flashlights, tools, fire extinguishers, etc. shall be gathered from storage and prepared for use as appropriate for the circumstances.



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NATURAL DISASTER

In the event of a natural disaster, staff shall seek assistance from local authorities (i.e. Civil Defense, Police, Fire Department, Red Cross, Armory, etc.) or from other local half-way houses, Salvation Army or shelters to assist everyone on the premises to evacuate or to go to the safest place possible.

Instructions during natural disasters shall be made by staff moving throughout the facility passing instructions by word of mouth or gathering everyone in the Day Room and making a general announcement.

Staff shall make all appropriate emergency equipment available to those on the premises.

INTRUDERS

Staff should be aware of outsiders who present themselves at the facility at “off-hours”. If it appears there may be a problem with anyone, staff should call 911 immediately to

request assistance from the police. There may be times when a simple request to leave the facility will resolve the issue but

staff should not take any chances with staff or resident safety if there are any questions as to what the person might do.

TOXIC CONTAMINATION

In the event of a toxic material spill or contamination, staff should immediately contact the Department of Environmental Protection, Bureau of Waste Site Cleanup, Response and Remediation at (617) 556-1133 and await instructions.



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POLICY 2.2.2 - FIRE SAFETY PLAN

I. POLICY

Brooke House maintains a written plan, which provides for fire prevention, safety and intervention in the event of a fire or other fire related situation. The facility complies with the regulations of the Commonwealth of Massachusetts and the City of Boston. There is a written fire evacuation plan to be used in the event of a fire. The plan is certified by the governing authority, the Boston Fire Department (BFD). The BFD conducts annual fire inspections of the facility. Fire protection equipment is located throughout the facility, approved by the BFD, and inspected and tested by an independent, licensed contractor as required by code. A fire protection alarm system, an automatic smoke and heat detection system and a sprinkler system are provided in the facility and are operational.

Furnishings comply with fire safety performance requirements. Smoking is prohibited inside the facility. Flammable, toxic, and caustic materials are strongly discouraged from being stored in the facility, however, if they are in the facility, they are stored for the shortest time possible and safely stored in a nonflammable storage cabinet (in the Tool Crib). Staff are properly trained in the proper use and safe handling of toxic and caustic materials. Residents are prohibited from using or handling flammable toxic and caustic materials.

II. PROCEDURES

A. Fire Prevention and Safety

1. Fire safety and prevention measures enhance efforts to save lives and prevent property damage during an actual fire.

2. The following preventive fire safety measures shall be met:a. Brooke House is a NON-SMOKING building and smoking is prohibited

in any part of the building. b. Wiring and appliances shall be kept in good repair.c. Only non-combustible trash baskets are allowed in resident rooms. d. The use of plastic liners in trashcans or the storage of plastic bags in any

resident room is strongly discouraged. e. Paper products shall not be allowed to accumulate in excess.f. Flammable liquids and other combustible materials shall be kept in secure

storage areas or out of the facility.g. Electrical appliances (shaver, hair dryer, fan, etc.) shall be unplugged

when not in use. h. Residents are not allowed to move furniture so that it blocks room doors

or emergency exits. i. All staff and residents must familiarize themselves with the emergency

exits, fire doors and fire extinguishers.



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B. Fire Inspections

1. Annual inspections of the facility shall be conducted by the Boston Fire Department.

2. Fire and emergency equipment shall be tested as on a periodic basis (as required by code) by an independent, licensed contractor.

3. The BFD shall receive a copy of the fire plan and any updates.

C. Fire Evacuation Plans

1. Evacuation plans (diagrams) are located in the hallways on each floor. 2. The plan (diagram) reflects:

a. the primary and secondary evacuation routes on each floorb. the location of fire extinguishers on each floor c. the location of alarm boxes on each floord. the location of emergency exits on each floore. the location of first aid equipment (1st floor - front desk)

3. Residents receive a written description of the evacuation plan (in the Resident Handbook) upon admission to the facility.

D. Fire Drills

1. Fire drills are conducted each month. 2. All residents must evacuate the building as instructed by staff and according to

the Fire Emergency Evacuation Plan and Fire Alarm Procedures.a. When the fire alarm sounds, everyone must leave the building and meet on

the median strip across the street on Park Drive.

E. Fire Protection Services and Equipment

1. In the event of a fire, the Boston Fire Department will respond to the facility.2. Fire extinguishers are available on each floor at the following locations:

a. Two on each floor: 1 by the elevator and 1 in the hallwayb. Three in the basement: 1 by the elevator, 1 in the kitchen, 1 in the dining

area3. Fire alarms boxes, heat and smoke detectors and sprinklers are located

throughout the facility.

F. Emergency Exits

1. Exits are clearly marked with signs throughout the facility.2. Emergency exits are located on each floor as follows:

5th Floor • rear fire stairwell to the first floor or basement; • main staircase to the first floor;

4th Floor: • rear fire stairwell to the first floor or basement; • main staircase to the first floor;

3rd Floor: • rear stairwell to the first floor or basement; and,



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• main staircase to the first floor.

2nd Floor: • rear stairwell to the first floor or basement; and • main staircase to the first floor.

1st Floor: • rear stairwell to the basement; and • front stairs to outside.

Basement: • rear door to alley at back of building;• emergency window exit to front of building

G. Fire Doors

1. There is one fire door leading to the roof and one in the basement.2. Fire doors must remain closed at all times.

H. Furnishings

1. All furnishings in living quarters comply with fire safety performance requirements.

2. Furnishings used in the resident living quarters shall be subjected to careful fire safety evaluation before purchase by the Program Director or Assistant Director.

3. Documentation will be maintained that reflects all furnishings in resident living quarters meet fire safety requirements.

4. Furnishings will be inspected on a periodic basis to ensure they are properly maintained and replaced when needed.

I. Flammable, Toxic and Caustic Materials

1. Storagea. If any flammable, toxic and caustic materials are stored, they will be in

their original containers in the Tool Crib. (1) The manufacturer’s label must be kept intact on the container.

2. Usea. Flammable, toxic and caustic materials must conform to the provisions

and precautions listed on the Material Safety Data Sheets (MSDS). b. Flammable, toxic and caustic materials can be dispensed only by an

authorized staff member. 3. Disposal

a. Excess flammable, toxic and caustic materials must be disposed of properly. (1) The MSDS for each material prescribes the proper method of

disposal and related precautions.4. If needed, a special container will be provided for flammable liquids and for

rags used with flammable liquids.5. Contractor Responsibility

a. Each contractor shall be responsible for any flammable, caustic or toxic

materials used in the completion of any construction or renovation projects.



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b. The Program Director, Assistant Director or designee shall oversee all contractors to see that they comply with this policy.

J. Training in Fire Safety and Other Related Materials

1. Staff receive training in fire prevention and evacuation during employee orientation.

2. Residents receive fire prevention and safety information at the time of admission/orientation. a. Residents sign an acknowledgement form stating that they have read the

fire evacuation plan, understand it and agree to abide by it.3. All staff receive training in the use, storage and handling of all flammable,

caustic and toxic materials. a. Residents are prohibited from using or handling any of these materials.


Reference Standard: ACA: 4th Ed. (PBS): 1C-08 M 1C-14 M1C-09 M 1C-15 M1C-10 M 1C-16 M

1C-11 M 1C-17 M1C-12 M 1C-181C-13 M



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POLICY 2.2.3 - WORK STOPPAGE PLANS

I. POLICY

Brooke House shall maintain a written plan that provides for continuous facility operation in the event of a concerted work stoppage or other job action.

II. PROCEDURES

A. Plan Availability and Review

1. Copies of CRJ’s work stoppage plan shall be available to all supervisory personnel who are required to familiarize themselves with its contents.

2. Since the plan is of a confidential nature, only the elements basic to creating a plan shall be detailed in this procedure.

3. The plan shall be reviewed annually, and, if necessary, revised or developed.

B. Elements of the Work Stoppage Plan

1. Maintain a listing of all essential personnel to be contacted in the event of an action (located at the Front Desk).

2. Notify agency personnel of the emergency as appropriate.3. Notify referring and transferring authorities to discontinue referrals.4. Maintain an organization chart depicting the chain of command for such use. 5. Assign supervisory staff to strategic areas within the facility.

a. If necessary, coordinate the reassignment of Corporate Office and non-residential staff to Brooke House. Staff from the Suffolk or Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole may also be utilized, if approved.

6. Determine which operations can be discontinued.7. Determine sleeping areas for staff who remain on duty.

C. Staff Responsibilities

1. The Program Director or Assistant Director informs key staff as to their roles, if and when there is an actual work stoppage or sufficient information to believe one might take place.

2. The Program Director also coordinates with the the Director of Social Justice Services and the Chief Operations Officer on a contingency plan for work stoppage.


Reference Standard: ACA: 4th Ed. (PBS): 1C-06 1C-07



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POLICY 2.3.1 - FOOD SERVICES

I. POLICY

Brooke House provides residents with meals that are well balanced, nutritious and sufficient in quantity. Brooke House uses ICater Food Service to provide lunch, dinner and bag meals for those working in the community. Residents are provided a Continental Breakfast by program staff. A menu cycle which is reviewed by a registered dietitian is posted outside the kitchen. If a food item is not available, the substitute shall be equivalent in nutritional value and shall be from the same food group. Special medical and religious dietary needs of residents shall be met.

Brooke House shall comply with all applicable local and state regulations relating to health and sanitation in the provision of food service.

III. PROCEDURES

A. Dietician Review

1. A certified dietitian working for ICater Food Services is responsible for reviewing menus that meet or exceed nationally recommended allowances for basic nutrition for the residents at Brooke House.

2. Documentation of the dietician’s review will be kept at Brooke House.

B. Special Diets and Meals

1. Medical Diets a. Medical diets shall be provided as prescribed by a Physician or Dentist. b. Expressed needs shall be documented by the Physician, recorded in the

resident's file and transmitted to the person in charge of food preparation at ICater.

c. Meals shall be provided for residents who must meet the requirements of a particular religious faith.

d. Alternative meals are always provided when there are any issues involving religious requirements. (1) The alternative meals provided shall be equal in quality to meals

provided for other residents.

C. Licensing and Certification

The Program Director shall ensure compliance with licencing and certifications of the food service operations.

D. Inspections

1. The 7-3 shift Program Monitor Supervisor shall make weekly, documented inspections of the food service areas to ascertain whether hygienic conditions are being maintained.



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2. Local health officials also shall make required inspections. 3. Inspections shall be conducted which include the following elements:

a. A daily check for cleanliness and ventilation in both the cooking and dining areas;

b. A weekly check of the food service areas and equipment, which shall be sanitary, in good repair and have adequate space for preparation and dining;

c. A daily check of the refrigerator, freezer and water temperatures;d. A daily check of the attire and health of food handlers (All food handlers

shall be healthy and practice basic hygiene in connection with food handling);A check of food storage areas for proper temperature, cleanliness and rotation of foods; and random check of food being served for portions, appearance, and resident eating preferences.Food Service Plan

E. Food Service Plan

The Program Director annually shall review and, if necessary, revise or rewrite the food service plan, which includes but is not solely limited to the following points:1. Specific hours for serving meals.2. Process for removing all foods from the dining and cooking areas after meals. 3. Indication of appropriate space and equipment available for storage and

refrigeration of food supplies. The following items shall be included:a. Dry food supplies shall be stored in a clean, dry, ventilated room.b. Foods requiring refrigeration shall be stored at 40F or below.

4. Provision for rotation of stock and use of food while fresh and canned goods.

F. Responsibilities

1. The Program Director shall be responsible for the following activities:a. Supervision of all food service personnel.b. Instruction of food service staff members as well as residents concerning

their duties in the kitchen and dining areas (along with the Program Monitor Supervisor).

c. Preparation and maintenance of all records and reports concerning food service operation.

2. The Program Monitor Supervisor shall be responsible for the following activities:a. Instruction of food service delivery staff members as well as residents

concerning their duties in the kitchen and dining areas.b. Sanitation and maintenance of the food service equipment.c. Purchase and storage of food stuffs.

3. Kitchen staff shall check/monitor resident details to ensure that the food service areas are maintained in sanitary condition and the equipment is in good working order. a. Any discrepancies will be noted in the SecurManage Shift Log.

E. Bathroom Facilities



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1. A toilet and sink is available to the assigned food service personnel and located

close to the kitchen on the basement floor. 2. All food service staff MUST wash their hands after using the bathroom and

returning to work in the food service operations.


Reference Standard: ACA: 4th Ed. (PBS): 4A-01 M 4A-054A-02 M 4A-064A-03 4A-074A-04 M 4A-08



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POLICY 2.4.1 - HEALTH CARE SERVICES

I. POLICY

Brooke House provides access to routine health care and emergency health care on a 24-hour a day basis. Residents are encouraged to receive an annual physical exam and regular dental care. Access to mental health services is made available to residents.

Case Managers and other staff shall be trained to respond to health related issues. A basic health screening shall be completed when the resident arrives at the facility. A resident suspected of having a communicable disease or debilitating condition shall be required to submit to a medical examination.

All staff members on each shift shall be trained in emergency first aid procedures, cardiopulmonary resuscitation and signs and symptoms of mental illness, retardation and chemical dependency. Brooke House's emergency back-up plan shall be communicated to staff and resident. An active inventory of all first aid supplies shall be maintained.

Brooke House maintains an AED (Defibrillator) at the Front Deskand staff are trained in its use.

II. PROCEDURES

A. Access to Medical, Dental and Mental Health Care

1. The Program Director is responsible for developing relationships with local health care providers and referral sources to assure that all residents have access to routine and emergency health care, dental services and mental health for residents with a demonstrated need for these services. a. The Program Director or designee shall develop and keep up to date

(at least annually) a list of these resources, the type of services provided, and how to access them. This list will be available in the Community Resource Directory.

b. The Case Manager will assist the resident in arranging for this care. (1) Staff members on duty will be the contacts for residents

requiring emergency care.

B. Medical Costs

1. While in Brooke House, residents will be covered by MassHealth. After orientation residents will go to Whittier Community Health Center to enroll in health care.

2. All residents are encouraged to participate in health insurance programs as available through their employer.

C. Resident Intake 1. During the intake process, a Case Manager completes an Intake form and notes

any special problems or needs requiring medical attention. This form includes



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the following information:a. any medical and/or dental problemsb. medications currently prescribedc. name of personal physician or clinicd. date and place of last physicale. history of past suicide attempts, including any current gestures or actions

and any family history of suicides2. The Case Manager or designee will then review each newly admitted resident’s

file to ensure that a copy of the resident’s medical summary is in place. 3. If the medical summary is not in the resident’s file, staff will contact the Suffolk

or Norfolk County Sheriff’s Department, MA Department of Correction, or MA Parole and request a copy be sent.

4. The Program Director shall be notified of any problems or special needs by the medial authority when a health concern exists.

D. Medical Examinations

1. All residents transferred from the Suffolk County Sheriff’s Department and MA Department of Correction do not require a medical examination within 14 days. a. A medical summary from the Sheriff’s Department and MA Department

of Correction listing that the resident is medically cleared for Brooke House is required with the admission paperwork that accompanies each resident.

2. All Parole residents not transferred from an institution require a medical examination within 14 days.

3. Any residents who remain in Brooke House for more than 1 year are required to have a medical examination conducted.

E. Communicable Disease

1. When a staff member or resident is suspected of a communicable disease, the Program Director shall direct the individual to obtain a medical examination.

2. The results of such examination must be made available to the Program Director.

F. Medical Emergencies

1. Shift Coveragea. All staff assigned to work in the facility are responsible to receive

CPR and first aid training and maintain certification. b. The Assistant Program Director shall be responsible for ensuring that

each staff member maintains their certification and will maintain documentation of such.

c. Staff will also receive the following training: (1) Awareness of potential emergency situations(2) How to determine when a situation is an emergency(3) Notification of an ambulance via #911 for transportation to an

appropriate medical provider.(4) Specific notification process of staff

G. Emergency Medical Response Plan



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1. Call 911 and have an ambulance take the resident to the hospital.2. Notify the Program Director or the Director on call.3. Notify the CRJ Administration of the incident via the chain of command.4. Notify the resident’s contracting agency as soon as possible.5. Notify the emergency contact person for the resident as soon as possible but not

later than 24 hours of the incident. 6. Document the incident in the SecurManage Shift Log and write an Incident

Report.

H. Non-Emergency Medical Response

1. For all non-emergency situations that cannot wait to the 7-3 shift, a cab is called for the resident and petty cash is given to the resident for the ride to the hospital.

I. First Aid Equipment

1. Brooke House maintains two first aid kits in the following locations:a. at the front desk b. in the kitchen

2. Brooke House maintains an AED (defibrillator) at the front desk.

J. Supply and Equipment Inventory

1. First aid supplies and equipment shall be inventoried on or about the first day of each month and supplies shall be replenished as needed. a. An inventory list is to be kept inside

2. If the utilization of supplies is unusually high over a short period of time (1-3 weeks), supplies shall be replenished as the shortages become apparent to the staff using the box.

3. Assigned staff shall conduct inventory inspections and initial that he/she has made the inspection.

4. The inventory shall be completed on a special First Aid Supply Inventory Form and shall be kept in a designated file.

K. Health Education

1. Health education is provided to the residents while at Brooke House.2. Medical information is available to residents:

a. in the Resource Directory maintained by staff at Brooke House.b. at the Whittier Community Health Center where residents receive medical

services. c. at Fenway Health Center, where residents receive medical services.

L. Training

1. Staff will receive training in health related issues during orientation and annual training events.

2. Training includes but is not limited to the following:a. CPR and First Aid



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b. Use of an AED (defibrillator)c. Signs and symptoms of mental illness, retardation and chemical

dependency.d. Suicide prevention


Reference Standard: ACA: 4th Ed. (PBS): 4C-01 M 4C-074C-02 M 4C-084C-03 M 4C-104C-04 M 4C-114C-05 4C-124C-06 M 4C-13

4C-15POLICY 2.4.2 - SERIOUS AND INFECTIOUS DISEASES



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I. POLICY

The facility shall maintain current information on the Centers for Disease Control and local City Health Department recommended practices to protect against exposure to infectious diseases such as tuberculosis, hepatitis B, hepatitis C and AIDS. The recommended practices include precautions for the appropriate handling of blood and other body fluids as well as items soiled with blood and other body fluids. Recommended practices will be reviewed annually and updated as new information becomes available. All new employees and residents shall be informed of practices to provide against exposure to infectious diseases such as tuberculosis, AIDS and hepatitis B and C.

II. PROCEDURES

A. Current Practices

1. Maintain current recommended practices for protection against exposures to infectious diseasesa. The Program Director or designee is responsible for maintaining up-to-

date information regarding the appropriate handling of blood and other body fluids as well as items soiled with blood and other body fluids, which he/she reviews annually and updates when new information becomes available.

b. Current information is readily available to both staff and residents within Brooke House.

B. Recommended Precautions and Practices for Residents and Staff

1. Personal Protective Equipment a. Gloves are to be used where blood, blood products or body fluids will be

handled.b. Packet masks, resuscitation bags or other ventilation devices will be used

to resuscitate a patient in order to minimize exposure that may occur during emergency mouth-to-mouth resuscitation.

2. Work Place Practices – Universal Precautionsa. All blood and body fluids are to be treated as potentially infectious.b. Wash hands thoroughly:

(1) after removing gloves, (2) before and after patient contact, (3) Immediately after contact with blood and/or body fluids.

c. Clean up blood spills immediately with detergent and water. (1) Use household bleach diluted between 1:10 and 1:100 parts of water

for disinfecting.d. Linen precautions are necessary when there are draining wounds or the

patient is unable to control excretions. (1) The linen will be placed in specifically marked bio-hazardous bags

and disposed of appropriately in accordance with hospital procedure.



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e. General disinfecting, housekeeping and waste disposal guidelines will be followed. (1) Potentially infected waste will be placed in impervious bags and

disposed of as local regulations require.f. The Program Director or designee will ensure that if any staff or resident

appear to have symptoms of communicable diseases: (1) they will be advised to go to a medical center for examination, or,(2) the sending agency will be advised of the situation and asked to pick

the resident up and return him to the facility

3. Education and Traininga. Staff and residents will receive ongoing education and training (at least on

an annual basis) in order to know the modes of transmission prevention, control, treatment and the confidentiality issues regarding infectious diseases and HIV.

b. HIV vaccination information will be available for those who feel at risk of acquiring HIV infection.

c. Residents shall receive training on a regular basis on communicable diseases and HIV education to be conducted by a recognized group/agency in the area.

C. HIV

1. Brooke House shall maintain current information on the Center for Disease Control recommended practices to protect against exposure to HIV.

2. Residents that have tested positive for the HIV virus will be allowed equal access to Brooke House services.

3. Testing of Residents for HIV Infectiona. Residents requesting HIV testing will be referred to the appropriate testing

sites (medical centers).b. Residents cannot be required to submit to HIV testing.

(1) Testing can be conducted only with consent of the resident.4. Safeguard Procedures for Protection against Exposure to HIV

a. Staff shall maintain precautions and practices listed under exposure to infectious diseases.

5. Supervision of HIV Positive Residentsa. Staff is required not to discriminate in the delivery of services to HIV+

residents.b. Residents that are HIV+ shall not be separated from the general

population.c. Medical referrals for treatment will be provided through the referral source

and local hospitals.

D. Confidentiality

1. Staff must abide with state and federal laws of confidentiality. 2. Medical information regarding a resident's HIV status cannot be released

without written consent from the resident.



Page 101


Reference Standard: ACA: 4th Ed. (PBS): 4C-09 4C-10



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POLICY 2.4.3 - PRESCRIPTION/MEDICATION CONTROL

I. POLICY

Residents are not allowed to possess prescription medications without program permission. Residents are prohibited from using or possessing controlled substances without fully documented, self-disclosure of the resident’s status – including any substance abuse history to the prescribing physician. Prescription medications are stored in a locked file cabinet that is located in the Shift Supervisor office. Staff dispense prescribed medications to individual residents, who self-administer per the written instructions of the physician. Residents may individually maintain creams, nasal sprays, and inhalers. MA DOC residents can maintain their medications in their locked closets as outlined in the DOC’s Keep On Person policy.

II. PROCEDURE

A. Definitions

1. As used in this document, the following definitions shall apply: Prescription Medication:

Any medication requiring a written prescription listing the prescribing physician's or dentist's name and the name of the prescribing facility

Controlled Substance:Specific medications commonly understood to include narcotics and other medications with a potential for abuse or addiction

Providing (Dispersing) Medication:Handing a single dose of medication to an individual resident to self-administer according to the direction of the prescribing doctor or dentist

Self-Administration of Medication:Medications taken by residents in accordance with the written prescribed instructions on the specific medication

Prescription Drugsa. Prescribed drugs shall be logged in the SecurManage Medication

Section of the resident. b. Prescribed drugs shall be distributed daily at a designated time to

residents for self-administration. The medications distributed to the resident shall be taken in strict accordance with the instructions on the prescriptions.

c. Controlled Substances shall be distributed to the resident on a dose-by-dose basis. The only exception is the minimal quantity sufficient to cover the prescribed amount scheduled to be taken during a resident’s absence from the program.

B. Staff ResponsibilitiesBrooke House will monitor medication use by residents as it may impact duties and responsibilities such as the advisability of operating equipment and tools while taking a medication that causes drowsiness, etc.

C. Prescription Management



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1. The Program Director shall require that a qualified health authority that prescribed the drug specifies all medication dispersing instructions.

2. Staff shall adhere to the following guidelines when checking in a prescription medication:a. Review all prescriptions to determine if they are prescribed by qualified

and known health professionals. (1) If there are any questions concerning the legitimacy of a medication,

follow-up phone calls may be made to confirm the prescription is authentic.

b. Be alert to any medication that might be a stimulant, tranquilizer, psychotropic (for treatment of mental illness), and any drug that may contain alcohol or opiate derivative.

c. Any drug or substance that is being prescribed as part of an experiment or research project is not allowed.

d. Enter new medications into the SecurManage system of the resident.

D. Medication Distribution

1. Medication should only be provided to a resident under the following circumstances:a. On an individual (case by case) basis and only to the resident named on

the prescription package.b. At designated times, developed by the program, in order to best ensure

that the medication is being taken as authorized by the prescribing medical doctor or dentist.

c. The resident shall take the prescribed medication in the presence of the staff person administering it. The only exception shall be when a resident legitimately is to be absent from Brooke House at times when the drug is prescribed to be taken (ex. Home or PRA).

2. The distribution of all prescribed medications shall be recorded in the designated log. a. Each dose shall be documented in the SecurManage system. b. This shall also be done for doses, which may be carried by the

resident to work or such things as job search.3. All prescription medications shall be stored and maintained in the original

container. a. This container shall be identified with the resident’s name, the times the

medication is to be administered, any special instructions, the name of the medication, and the prescribing physician’s name.

4. Controlled Substancesa. If authorized by the contract agency, controlled substances shall only be

distributed as expressly prescribed by the authorizing medical doctor or dentist.

b. Residents who will be absent from the program at the time of the scheduled distribution shall sign-out the medication for that distribution only prior to leaving the program.

5. Medication Refusals



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a. Whenever a resident refuses his medication, staff record in SecurManage system

b. When a resident refuses medication, staff should notify the Program Director or Assistant Program Director.

c. The Program Director or Assistant Program Director notifies the contract agency regarding the refusals and may result in the resident’s return to higher custody.

d. The Program Director or Assistant Program Director will write an Incident Report regarding the situation.

E. Security, Storage, and Disposal of Prescribed Medications

1. All prescription medications shall be stored in a safe location in an area inaccessible to residents. a. Access shall be limited to staff members as authorized by the Program

Director.b. A sign out sheet will record distribution of over-the-counter medications.

2. Over-the-counter medications purchased by Brooke House shall be stored in limited supply in the cabinet designated by the Program Director. a. Any over-the-counter substance with alcohol such as cough medications

or sleep aids will not be allowed.3. Staff shall store insulin, pre-filled syringes, and other medications requiring

refrigeration in a locked storage refrigerator.4. Needles and syringes, (when any are in Brooke House) shall be stored in the

locked file cabinet. Used needles and syringes shall be stored in an approved sharps disposal container. a. Residents that need to take insulin or other prescribed medication will be

allowed to self administer the medication using a syringe. b. During medication distribution, staff hand an envelope (that contains the

syringe) to the resident to use. c. The resident uses the syringe, puts cover back on and puts the needle(s)

into the hazmat container.d. When the container is full, the vendor is contacted to come and pick up the

container. 5. All prescribed medications shall be disposed of when their prescription time has

run out. a. Brooke House will not store any prescription medication for any purpose

other than for an individual resident who is still here and still in need of the medication.

b. If a resident leaves Brooke House without taking his medication, said medication shall be destroyed within 30 days by two (2) staff members and a notation of the destruction and disposal will be made on the resident’s SecurManage Shift Log.

F. Audits

1. Bi-weekly Random Spot Checks



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a. These medication audits are conducted and documented by any staff authorized to distribute medications and includes the following:(1) The authorized staff will conduct a visual count of all medications in

the locked medication cabinet.(2) The authorized staff will look at the SecurManage for the last count

recorded by the last staff to disperse the medication to the resident.(3) The bottle of medication will be opened and the remaining pills

counted.(4) If the count is accurate, the authorized staff will make an entry in

SecurManage.(5) If the count is not accurate, the authorized staff will recount all pills.

b. Following the visual count, the authorized staff will submit an Incident Report of their findings to the Program Director.

2. Monthly Auditsa. On a monthly basis, the 7-3 Program Monitor Supervisor shall audit all

medications and report to the Program Director the results. An Incident Report should be written if discrepancies are found. If none are found the Audit should be entered into SecurManage system Shift Log.


Reference Standard: ACA: 4th Ed. (PBS): 4C-124C-13



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POLICY 2.4.4 - SUICIDE PREVENTION AND INTERVE NTION

I. POLICY

A written suicide prevention and intervention plan is developed, maintained, available and approved by a qualified medical or mental health professional. All staff with resident supervision responsibilities are trained in the implementation of the plan. Staff will be aware of indications of self-harm and/or suicidal ideation when dealing with residents and immediately report any situations of this nature to their supervisor.

All Brooke House staff shall receive on-going training in suicide prevention and intervention.

II. PROCEDURES

A. Admission

The Program Director will be advised prior to admission if a resident has a history of suicidal behavior.

B. Intake

1. Case Managers shall be alert to any indication of self-harm or suicide ideation during the intake process and during all interaction with residents.

2. Staff shall conduct an intake interview and have the resident complete an LSI-R as soon as possible upon a new arrival including:a. obtaining information of prior suicide attempts, ideational gestures,

ideation or any family history of suicideb. completing the approved intake forms

3. Staff shall be alert to and observant of resident behavior that may indicate a resident is at risk, including the following behavior:a. dramatic change in appearanceb. changes in appetite or eating habitsc. changes in sleeping patterns d. mood swings such as depression to improvement in mood isolation e. sudden packing up and giving away of possessions f. changes in legal status which may have serious resultsg. increased and/or questionable injuriesh. bizarre or uncharacteristic behavior or conversations, such as:

(1) severe agitation or aggressiveness(2) talks about or threatens suicide or death related statements(3) projects hopelessness or helplessness or no sense of future(4) expresses or evidences strong guilt and/or shame over offense(5) expresses unusual or great concern over what will happen to them

(with extreme anxiety)i. behavior during significant holidays or anniversaries



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4. Staff shall notify the Program Director or Assistant Program Director if there are any at-risk residents (with indication of self-harm or suicide ideation) during the intake process.

5. The Program Director or Assistant Program Director will then notify the contract agency for the resident to be returned to higher custody for medical evaluation.

C. Notification

1. Staff shall notify the Program Director or Assistant Program Director immediately after determining a resident is at risk.

2. The Program Director or Assistant Program Director shall notify the the contracting agency, resident’s emergency contact, his Case Manager and the Director of CRJ Social Justice Services.

3. Communication shall be continuous and timely if the resident’s risk level is increased or decreased and if suicide precautions have been taken.

4. Appropriate information regarding the resident at risk shall be documented in the resident's case file.

D. Housing

1. The Program Director will notify the Program Monitor Supervisor if any resident is admitted with a prior suicidal history.

2. When the Program Monitor Supervisor or Intake / Release Coordinator assigns a resident to a room, any resident with a prior suicidal history shall be:a. assigned a room with another resident.b. assigned a room in closest proximity to staff.

E. Supervision

Any resident determined to be a suicide risk and in need of specific supervision and/or observation will be transferred to the referring contract agency.

F. Intervention

1. All staff are certified in CPR and First Aid. 2. The facility maintains a first aid kit at the front desk that includes gloves, pocket

masks, mouth shields.3. Any staff who discovers a resident attempting suicide should:

a. immediately respond, b. survey the scene to ensure the emergency is genuine, c. alert other staff to call medical personnel (911), and d. begin standard first aid and/or CPR.

4. Staff should never presume that the resident is dead, but rather initiate and continue appropriate life-saving measures until relieved by arriving medical personnel.

G. Notification and Reporting



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1. Appropriate officials should be notified through the chain of command.2. Following the incident the resident’s emergency contact should be immediately

notified, as well as appropriate outside authorities. 3. All staff that came into contact with the resident prior to the incident and/or in

responding to the incident are required to submit an Incident Report as to their full knowledge of the resident and incident.

H. Debriefing/Follow-up

1. All staff involved in the incident shall be referred to the Employee Assistance Program and offered critical incident stress debriefing.

2. Any suicide attempt or successful suicide shall be reviewed by the Chief Operating Officer and an investigation made into the following:a. Review of actual events b. Review of facility procedures relevant to the incidentc. Review of all relevant training received by involved staffd. Review of pertinent medical and mental health reports involving the

resident, and e. Recommendations, if any, for change in policy, training, physical plant,

medical or mental health services, and operational procedures.

I. Staff Training

1. Staff receive initial (first year) training in suicide prevention and intervention with annual follow-ups.

2. Training will include the following:a. why correctional environments are conducive to suicidal behavior, b. potential predisposing factors to suicide, c. high-risk suicide periods, d. warning signs and symptoms, and e. components of the facility’s suicide prevention policy.

J. Plan Approval

1. The plan shall be approved by a medical or mental health professional. 2. Any changes to the plan will also be approved by this type of professional.

APPROVED: _____________________, Terry Burch, ________, Director of Clinical Services


Reference Standard: ACA: 4th Ed. (PBS): 4C-16 M



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POLICY 2.4.5 - URINE COLLECTION

I. POLICY

The basic method utilized to control resident substance abuse in Brooke House is urinalysis testing done on a random and incidental basis.

II. PROCEDURES

A. Random Testing

1. Random tests shall be conducted on residents at any time a staff member requests one.

B. Incidental Testing

1. Tests shall be given when resident behavior is unusual or not consistent with other observed behavior and staff suspect’s drug use.

a. The staff member observing the behavior shall document the unusual behavior.

b. If the urinalysis resulting from unusual behavior reveals drug use, the resident shall receive an Incident Report and be terminated from Brooke House.

C. Test Procedure

1. Residents shall be allowed two hours maximum to produce a urine sample. a. If they have not produced a sample within two hours, the Director and

Assistant Director will be notified. b. The staff member shall write an Incident Report and make appropriate

SecurManage Shift Log entries.2. Staff shall prepare the collection bottle just before collecting the sample3. Staff will conduct a pat search of the resident which includes the following:

a. The resident empties his pocketsb. Staff conducts a pat search

4. The staff member shall personally observe the stream of urine flowing into the collection bottle. a. The resident in the bathroom shall fill the urinalysis bottle at least

halfway. b. The staff member shall observe the resident close the lid on the bottle.

The resident should wash his hands.5. The staff member shall return to the Shift Supervisor office and read the test cup

for any positive results. After providing the sample the resident has completed the process.

6. If a urine specimen test is positive, a report shall be written and forwarded immediately to the Program Director or Assistant Director who shall initiate action for the resident’s return to higher custody.

7. Only a staff member of the same sex shall collect urine specimens for analysis from a resident.



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8. The percentages of random urine specimens required shall be established by each Program Director to ensure that all residents are monitored in accordance with Program need.

D. Refusal to Give or Tampering with a Urine Sample

When a resident simply refuses to give a urine sample, is found to have tampered with a sample or exceeds the 2 hour limit of submitting a sample, it is considered the same as "positive" and the resident will be returned to higher custody.

E. Resident Notification of Policy

Residents will be informed of the urine policy during their orientation period and is listed in the resident handbook.





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POLICY 2.4.6 - EMERGENCY CONTACT NOTIFICATION

I. POLICYIn the case of a verifiable death or critical illness of a resident’s immediate family member, the resident is informed of this situation in a timely manner.

In the case of serious illness, injury, need for immediate surgery or death of a resident, the resident's emergency contact and the sending contract agency shall be promptly notified. Any resident’s death is reported immediately to the proper officials.

II. PROCEDURES

A. Resident Illness

1. Whenever a resident becomes seriously ill, requires surgery or dies, the emergency contact and the sending contract agency shall be notified promptly by telephone call, fax or other rapid means of communication. a. If the resident does not want his emergency contact notified, the staff will

respect his wishes. 2. During admission to Brooke House, the resident shall be requested to designate

an emergency contact to be notified. 3. The Program Director shall be responsible for ensuring that communication

with the resident's designated emergency contact and the sending agency is made.

4. Communication, as described above, must be completed as soon as possible if circumstances prohibit.

5. The CRJ CEO and COO shall be notified by the Director of CRJ SJS of a resident's death as soon as possible. a. If circumstances warrant, the coroner and appropriate law enforcement

officials shall be notified.

B. Resident Family Illness

1. In cases of illness in the resident’s family, the sending agency may return the resident to the facility and advise the resident there.a. In some cases the resident may go to the family member’s bedside in the

hospital.


Reference Standard: ACA: 4th Ed. (PBS): 4C-215A-18-17D-15



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POLICY 2.4.7 - DRUG AND ALCOHOL USE ON PREMISES

I. POLICY

Recreational drug and alcohol use on the premises by staff and residents is strictly prohibited.

II. PROCEDURES

A. Definition

"Recreational drug use" refers to use of controlled substances or alcohol without a prescription from a medical doctor or dentist.

B. Residents Use

1. Residents who are caught engaging in recreational use of drugs or alcohol on the premises shall be subject to disciplinary action. a. Residents will be immediately returned to higher custody by the

contracting agency.

C. Staff Use

Staff who are caught engaging in recreational use of drugs or alcohol on the premises, at the discretion of the Program Director, may either be suspended pending successful completion of a drug treatment program or terminated.





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POLICY 3.1.1 - COMMUNICATIONS

I. POLICY

The Brooke House SecurManage Shift Log is used to formally record incidents of facility operations and for staff to communicate essential information across shifts and days. The use of CRJ e-mail system allows all staff to communicate. To aid communication, monthly staff meetings are held with the Program Director and staff. Communication exists between staff and residents.

II. PROCEDURES

A. SecurManage Shift Log

1. The Shift Log is located in SecureManage under the Security tab. 2. All staff are expected to enter important, essential and pertinent information,

including but not limited to the following:a. Notices of meetingsb. General notes about programs and activitiesc. Schedule of planned eventsd. Residents admissions and releasese. Visitors, Vendors, Contractors, Consultants, Volunteers coming and goingf. Usual eventsg. Unusual events or emergency situation

(1) Any emergency situation or unusual event should be written up on an Incident Report in SecurManage addition to being listed in the Shift Log.

h. Important communicationi. Resident information (when essential to the smooth operation of Brooke

House)3. Staff supervisors are expected to write a Shift Summary, before the end of their

shift that includes a brief report on the program “climate” and the count during their shift.

4. All staff are expected to read the Shift Log at the beginning of their shift.5. All Resident Counts are to be documented in the Shift Log.

B. Monthly Staff Meetings

1. Monthly staff meetings will be held according to schedule.2. The Program Director will prepare an agenda for all meetings3. The Program Director will designate a staff member to take minutes of the

meeting. 4. Minutes will be distributed to all staff, especially those absent from the meeting.

C. Staff and Resident Communications

1. Staff and residents use the following methods to communicate:a. discussions



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b. meetingsc. memorandumsd. written reports e. other verbal and written exchanges

2. Memorandums will be sent out periodically. a. All staff and residents (if applicable) are expected to read the memos and

are responsible for their content.


Reference Standard: ACA: 4th Ed. (PBS): 7D-347D-357D-36



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POLICY 3.1.2 - ADVISORY BOARD

I. POLICY

Brooke House has an Advisory Board that ensures continuing active community input into the facility. Brooke House recruits and maintains an Advisory Board that include members that are representative of the community. The Board meets at least annually.

II. PROCEDURES

A. Staff Responsibility

The Program Director is responsible for recruiting and maintaining an Advisory Board.

B. Board Members

1. The members of the Advisory Board will be appointed annually. 2. All efforts are made to have the membership reflect the profile of the

community by relevant data included in the agency's equal employment opportunity action plan.

C. Board Meetings

1. Meetings will be held on a quarterly basis (and not less than annually). a. Minutes of the meetings will be recorded and maintained by the Program

Director.

D. Board Responsibilities

1. The Advisory Board will have responsibility for the following:a. to recommend policyb. to assist in evaluating existing programs and funding needsc. to assist in securing needed funds from public or private sourcesd. to provide input about community issues which affect the public.

Director’s Signature: Howard H. Jardine II , Program DirectorDate Issued: April 15, 2009 Date Revised: December 17, 2014Issued By: Brooke House/Standards and Quality Assurance DepartmentEffective Date: December 31, 2014

Reference Standard: ACA: 4th Ed.: 7F-05



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