Policies and Procedures Section 3 Programming Services (PS)
as of July 17, 2025
REFERENCECODE: PS - 100 - GJRPA
TITLE: Admissions Screening and Access to Services Policy
APPROVEDBY: Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: Update Pending Board of Director Approval
PS-100-GJRPA - Admissions Screening and Access to Services Policy
The George Junior Republic in Pennsylvania (GJR in PA) Admissions Department provides equal opportunity for all persons referred to receive treatment and education based upon a thorough review and evaluation of current and historical documentation in conjunction with the defined program criteria within each level of care. The purpose is to determine the suitability of services offered to persons referred. All eligibility decisions are finalized by the Regional Liaison and Director of Admissions. Persons served not meeting program criteria may be approved for admissions based upon review from the Director of Admission, Vice President of Operations, a GJR in PA psychiatrist, and/or Health Services Director.
REFERENCECODE: PS- 100-001 - GJRPA
TITLE: Admissions Screening and Access to Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-100-001-GJRPA - Admissions Screening and Access to Services Procedure
A. GJR in PA Regional Liaisons will be available to all potential referral sources to educate and provide information regarding treatment services and programming.
B. Referrals will be received by the GJR in PA Admissions Department and/or a Regional Liaison from any contracting agency, managed care provider, mental health office, and/or private payer.
C. Information requested from the referring party is to include, but is not limited to: court documentation, family history, historical and current evaluations (psychiatric, psychological, competency, neurological, fire-setting, sex offending, behavioral), treatment history, placement history, medical background, educational records, and Case Plan and/or Youth Level of Service (delinquent).
D. For all referrals including new and re-referrals, current and historical material is reviewed and, when applicable, missing or supplemental documentation is requested. When possible, all material is reviewed within 3 business days to accommodate and promote accessibility to services.
E. When possible, an interview via face to face, telephone or video, with the person referred and/or family of persons referred will be conducted to determine the appropriateness for eligibility by utilizing the GJR in PA Referral Assessment Form.
F. Pre-approvals for admissions are to be obtained for admissions outside of the identified persons served inclusionary criteria as outlined in the program descriptions or other unusual circumstances. These pre-approvals are to be obtained from one or more of the following as needed: A GJR in PA Health Services Director, Psychiatrist/Psychologist, RTF Campus Director, VP of Operations, and/or Director of Admission
G. All material, pre-approvals and interviews will be documented on the GJR in PA Referral Assessment Form. The form will include documentation of the following:
1. All material received and reviewed
2. An assessment of the interview, including presenting needs, when applicable
3. Information received in discussion with the referral source
4. Pre-approvals from required departments within GJR in PA as identified above, when applicable
5. Identification of funding source
6. Identification of program eligibility or reason for ineligibility
H. Once all material is reviewed and necessary approvals are received, a determination for the appropriate level of care will be finalized by the Regional Liaison, Campus Directors and/or Vice President of Operations utilizing the criteria for ineligibility as defined by each program description.
1. Ineligible Referrals:
a. Any referring agency whose persons referred is not eligible for treatment within GJR in PA’s levels of care will receive a formal letter stating ineligibility with the identified reason(s).
b. A person referred who is not eligible for treatment within GJR in PA’s levels of care must be documented on the GJR in PA Referral Assessment Form and entered into the GJR in PA electronic health record with the identifying reason(s).
c. When possible, alternative recommendations will be made for a person referred who is not eligible for treatment within GJR in PA’s levels of care. This information will be documented on the GJR Referral Assessment Form.
d. All persons referred considered not eligible for services may be re-referred at any time and the procedure for referral will restart.
2. Eligible Referrals:
a. Any referring agency whose person referred is eligible for treatment within GJR in PA’s levels of care will receive a formal letter stating eligibility, identifying the program of acceptance along with requested documents and required completed consent forms.
b. A person referred who is eligible for treatment within GJR in PA’s levels of care must be documented on the GJR in PA Referral Assessment Form and entered into the GJR in PA electronic health record, identifying the program of acceptance.
c. When applicable, Regional Liaisons will provide and/or schedule an on-site visit to the person referred and/or the parent/guardian of the person referred.
c. When possible and applicable, Regional Liaisons are required to attend commitment hearings to facilitate communication and collaboration with the courts, referring agency, person referred and family of persons referred.
d. Prior admissions of persons referred, the following consents must be obtained: Form A Youth Residential Program Handbook Acknowledgement, Form B Placing Agency Case Planning Acknowledgment, Form C Family Visitation Authorization. Form D Medical Consent and Form E Behavioral Health Consent,
Form F Media and Photography Consent, the Allegheny Health Network (AHN) Consent to Treat, and required Education Releases of Information.
3. Urgent/Critical Needs:
Persons referred or served reporting circumstances of abuse will result in a ChildLine. Notification of Child Line calls are to be sent to the VP of Operations and Compliance Department.
I. Following a determination of eligibility, a person referred involved in delinquency or dependency agencies must be committed to and/or provided permission to place within GJR in PA programming. For Managed Care or Private Payers, the person referred and/or parent/guardian of persons referred must be in agreement of services and must be provided the following:
1. The brochure, program description for persons served eligibility and Parent/Guardian Information Guide describing the philosophy of GJR in PA, services provided, geographical coverage, program information, and activities provided
2. Disclosure of conflict of interests, if applicable
3. Cost of services, if applicable
J. Regardless of circumstance, once committed/approved/agreed upon, the following is required:
1. Regional Liaisons are required to update the electronic health record to confirm a person referred has been committed and/or approved based upon individual, state or county requirements.
2. For a person served who is accepted and/or committed from out of the State of PA, an Interstate Compact of the Placement of Children (ICPC) is required prior to admission. The Admissions Department will receive all incoming ICPC notifications and provide a copy of this documentation to the file of the person served.
3. The Admissions Department will determine an admission date based upon program availability, age, and treatment and identified medical needs. Every effort is made to locate an appropriate treatment setting. If the appropriate treatment setting is not immediately available, the next available date is provided.
4. A waitlist is established for each GJR in PA program by date of commitment and state requirements and/or approvals. This waitlist is also inclusive of previously admitted persons served who require a program change/transfer. The following is applicable when a person referred is placed on a waitlist:
a. Each business day, the Admissions Department will review current and upcoming treatment space availability based upon anticipated and/or unexpected discharges and transfers.
b. Each business day, the admissions office will review the waitlist to determine if an appropriate treatment setting can be provided based upon the current or anticipated availability.
c. An Admissions representative, the VP of Operations, and the Campus Directors will review the waitlist weekly along with the needs of the person served to determine appropriate placement in regard to availability. This will be documented by the Vice President of Operations.
d. Regional Liaisons will be notified of any current or upcoming treatment space availability changes.
e. Regional Liaisons are required to update the referring agency and/or persons served/family of persons served on appropriate treatment space availability, and document the date of discussion on the GJR in PA Referral Assessment Form.
K. Regional Liaisons are to ensure that all required documents are completed and provided to the Admissions Office. When possible, the information is to be provided no later than the day prior to admission. Exceptions include late day court hearings/approvals. Material is to include: A completed GJR in PA Referral Assessment Form with identified program of acceptance and insurance eligibility, all material identified in (4) of this procedure, an acceptance letter, and when applicable, the Mental Health Services Request Form and Drug and Alcohol Referral Form.
L. Regional Liaisons are required to notify the campus personnel no later than the day prior to an admission for any person served being admitted from a psychiatric hospital, who is suicidal or having suicidal ideations, thoughts or verbalizations, and/or having court orders authorizing specialized services/evaluations in order to assist in treatment planning.
M. Regional Liaisons are required to schedule transportation for admissions via the GJR in PA Transportation Department, identifying any special transportation concerns/considerations. Providing transportation for admissions assists in promoting accessibility to services and begins to establish rapport via the driver’s interactions and conversations with each person served.
N. Referral Material will be placed into the electronic health record approximately 3 days prior to admission, when possible. Material may be delayed due to late court hearings and/or approvals. The Admissions Department or Program Supervisors will also ensure the demographics of the person served are entered in the GJR in PA electronic health record for accessibility by all GJR in PA treating parties to begin treatment and educational planning.
O. The Admissions Department maintains a weekly meeting with the Campus Directors to present information related to persons served being admitted. The Liaisons will briefly present an assessment of each person served scheduled for admission to the Campus Directors for the purpose of ensuring the proper unit/home has been selected based upon treatment needs and risk-based housing.
P. For all persons served being admitted, the following applies:
1. During business hours, Wellness Center staff will provide an encouraging and welcoming environment to begin relationship building. Upon admission, the Wellness Center staff will be responsible for the following:
a. Greeting the person served in a friendly and welcoming manner
b. Showing care and concern for the belongings of persons served
c. Nursing staff will obtain a photograph of each person served
d. Admission staff will ensure a face card and will provide to the switchboard. This card will also be placed in the electronic health record.
2. After business hours, the Campus Supervisors and/or designated staff member will provide an encouraging and welcoming environment to promote relationship building. The Campus Supervisors and/or designated staff member will provide the admissions office with a photograph and follow procedures (a.) through (c.) above.
Q. The referring placing agency will be mailed an invitation to the Initial Service Plan meeting. The parent/guardian of the person served will be mailed the Initial Service Plan meeting invitation, CHIP health coverage information, necessary consent forms and Parent/Guardian Information Guide. Both referring agency and parent/guardian ISP invitations will be copied to the file of the person served. The Youth Residential Program Handbook includes the following: Program information, service coordination, explanation of persons served and parent/guardian rights and grievance procedures, and other pertinent information.
R. The Admissions Department is responsible for completing the GJR in PA Intake Checklist, Acknowledgement of Documents Provided to Youth and Personal Effects Property Inventory (electronic record). Information will be scanned into the electronic health record.
GJR Secure Detention
A. All eligibility decisions are finalized by the GJR Secure Programs Coordinator. The Vice President of Operations, Health Services Director and psychiatrist are available for admissions consults.
B. GJR Secure Programs Coordinator and Director of Secure Programs and Campus Security will receive referrals from contracting counties and the Juvenile Probation Office.
C. Information requested from the referring agency is to include: a description of the offenses and circumstances that make secure detention necessary, the court order (or D1/D2) committing the child to a secure detention facility and statement of any known medical conditions including information regarding youth being under the influence of alcohol or drugs.
D. The youth may be admitted to the GJR Secure program once a determination is made regarding his acceptance and the GJR Secure program is in receipt of the signed court order placing the youth in detention.
E. E. Eligible Referrals:
1. Youth ages 10-17 years of age, adjudicated delinquent or alleged to be delinquent.
2. A youth may not be admitted to GJR Secure program who is 9 years of age or younger, or who is 18 years of age or older, unless the child is a juvenile as defined in the Juvenile Act.
F. Exclusionary Criteria:
1. Medical needs that are beyond the scope of GJR in PA’s Behavioral Health Technicians.
2. Youth who have a severe intellectual disability who are not self-sustaining or life preserving.
3. Acutely suicidal or homicidal requiring inpatient hospitalization.
REFERENCECODE: PS- 100-002 - OPMH - GJRPA
TITLE: Outpatient Mental Health Admission Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-100-002-OPMH-GJRPA - Outpatient Mental Health Admission Procedure
A. The facility will provide outpatient mental health services to persons served with a primary mental health diagnosis, dual diagnosis of mental health/substance abuse, or mental health/intellectual disability.
B. GJR Admissions personnel, or the following treatment services at the facility can refer persons to the outpatient mental health program: Diagnostic Unit; RTF; Drug & Alcohol Program; or Secure Detention.
C. The person served will participate in an intake session with the assigned outpatient therapist within one (1) week of the initial referral.
D. Staff will review the rights policy, the treatment appeal process policy, and the confidentiality policy which includes the rights of the person served to access their medical records. Staff will also provide basic consumer information. Consents and appropriate releases of information will be signed during this meeting. Additionally, the Therapeutic Assessment, Assessment Note, and preliminary treatment plan will be completed at this initial session.
E. A treatment plan will be developed within 15 days of admission to the Outpatient Program. The treatment plan will be completed during the initial meeting with the therapist in most cases.
F. Admissions practices will also include the collection of certain demographic information from persons served. The admission/referring therapist will routinely collect or verify the following information which will be documented in the medical record:
1. Name of person served
2. Address of person served
3. Telephone number of person served emergency contact information
4. Marital status (if applicable)
5. Gender
6. Ethnicity
7. Religion
8. Date of birth
9. Primary language
10. Social Security Number
11. Primary Care Physician
12. Insurance information
13. Date and time of interview
14. Signature of staff collecting information
REFERENCECODE: PS- 100-003 - GJRPA
TITLE: Informed Consent Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-100-003-GJRPA - Informed Consent Procedure
Informed consent will be obtained for all persons served in the Outpatient Program.
A. The clinician will provide persons served with an explanation of any proposed interventions and treatments including potential prescription of medications during the therapeutic process, as well as any potential benefits, risks, and side effects due to the suggested therapeutic regimen.
B. Persons served will be informed of their rights (to the extent permitted by law) to refuse nonmedication treatment interventions by clinicians. The psychiatrist/physician will be the staff member informing the persons served of their rights to refuse medication.
C. The signed informed consent (Consent to Receive Outpatient Behavioral Health Care Services Form) will be made part of the outpatient records of persons served. A copy of the signed consent will be offered to persons served. Persons served under the age of 14 years will require a parent or legal guardian who has medical rights sign for consent. If parental rights are terminated, then the representative from the agency with custody must sign.
D. In the event persons served require translators, arrangements will be made for one to be provided. The agency maintains contracts with translating service agencies.
E. Prior to persons served receiving medication, they will be informed by the physician/psychiatrist of the right to refuse medications. The physician or psychiatrist must show evidence of informed consent being provided by documenting on the evaluation or medication progress note the following:
1. The specific name(s) of the medication to be given to the person served
2. Risks, benefits and side effects have been discussed with the person served
3. Reasons supporting the decision for the initial prescription, increase, decrease or discontinuation of a medication have been discussed with the person served
4. Documentation that the person served agrees to the usage of the medication and understands all of the aforementioned information
5. The physician or psychiatrist’s legible signature (or printed signature if not legible) following the entry
6.
REFERENCECODE: PS- 100-004- GJRPA
TITLE: LTSR Admissions Screening and Access to Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-100-004 - GJRPA – LTSR Admissions Screening and Access to Services Procedure
A. LTSR Case Manager and GJR in PA Regional Liaisons will be available to all potential referral sources to educate and provide information regarding treatment services and programming.
B. Referrals will be received by the GJR in PA LTSR Case Manager from contracting counties and the managed care provider.
C. Information requested from the referring party is to include, but is not limited to: court documentation, historical and current evaluations (psychiatric and physical), treatment history, placement history, medical needs, medications history, and reason for placement.
D. For all referrals, including new and re-referrals, current and historical material is reviewed and when applicable, missing or supplemental documentation is requested. When possible, all material is reviewed within 3 business days to accommodate and promote accessibility to services.
E. When possible, an interview with the person served via face to face, telephone, or video will be conducted to determine the appropriateness for eligibility by utilizing the GJR in PA LTSR Intake Interview Packet.
F. All intake material and interviews will be documented on the GJR in PA LTSR Intake Interview Form. The form will include documentation of the following:
1. All material received and reviewed
2. An assessment of the interview, including presenting needs
3. Information received in discussion with the referral source
4. Identification of program eligibility or reason for ineligibility
G. Once all material is reviewed, and necessary approvals are received, a determination of admission will be finalized utilizing the criteria as defined.
1. Ineligible Referrals Procedure:
a. Any referring county whose person served is not eligible for treatment within GJR in PA LTSR’s level of care will receive a formal letter stating ineligibility with the identified reason(s).
b. When possible, alternative recommendations will be made for a person served who is not eligible for treatment within GJR in PA LTSR’s level of care.
c. All persons served considered not eligible for services may be re-referred at any time and the procedure for referral will begin.
2. Eligible Referrals:
a. Any referring county whose persons served is eligible will be notified to send in the LTSR Referral Form.
b. The LTSR Case Manager is to report to the Program Director all persons served eligible for acceptance along with admission status.
c. When applicable, Case Manager will provide and/or schedule an on-site visit to the person served.
d. When possible and applicable, the LTSR Case Manager is required to attend commitment hearings to facilitate communication and collaboration with the courts, referring county, person served, and family of persons served.
H. Regardless of circumstance, once committed/approved/agreed upon, the following is required:
1. The LTSR Case Manager is required to contact the Program Director to confirm a person served has been committed and/or approved based upon individual, state, or county requirements.
2. The LTSR Case Manager and Program Director will determine an admission date based upon program availability, age, and treatment and identified medical needs.
I. The LTSR Case Manager is to ensure that all required documents are completed. When possible, the information is to be completed no later than the day prior to admission. Exceptions include late day court hearings/approvals. Material is to include: A completed GJR in PA LTSR Intake Interview Form with acceptance and insurance eligibility, all material requested from referring parties, and an acceptance letter.
J. The LTSR Case Manager is required to schedule transportation for admissions utilizing GJR in PA transport, identifying any special transportation concerns/considerations.
K. The LTSR Case Manager will disseminate all material to the LTSR Treatment Team no later than the day prior to admission, when possible. Material may be delayed due to late court hearings and/or approvals.
L. For all persons served being admitted, the following applies:
1. During business hours, the LTSR Mental Health Technician and Case Manager will provide an encouraging and welcoming environment to begin rapport building. Upon admission, the Mental Health Technicians and Case Manager will be responsible for:
a. Greeting the person served in a friendly and welcoming manner
b. Showing care and concern for belongings of the person served and doing a thorough inventory of their belongings
c. Obtaining a photograph of each person served
d. Ensuring a face card is created and placed in the file of the persons served, as well as provided to the switchboard
e. The LTSR Case Manager will apply for a birth certificate or social security card unless otherwise provided
M. If applicable, the LTSR Case Manager will send the referring county, legal representative, and participating parties the Initial Service Plan meeting invitation.
N. The LTSR Case Manager is responsible for collecting the GJR in PA Intake Packet and Admissions Packet to ensure the following:
1. Information on the GJR in PA Intake Packet is recorded in the electronic record
2. The completed GJR in PA Intake Packet is provided for the files of persons served
REFERENCECODE: PS- 100-005- GJRPA
TITLE: Limited English Proficiency Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 5/6/2021
DATEREVISED: 6/4/2021
PS-100-005 - GJRPA – Limited English Proficiency Procedure
A. George Junior Republic in Pennsylvania will take responsible steps to ensure that persons with Limited English Proficiency have meaningful access and an equal opportunity to participate in our services.
B. Any client or family member displaying an inability or limited ability to speak, read, write or understand English will be identified as a Limited English Proficiency individual.
C. Under the guidelines of the Title VI Civil Rights Act of 1964, reasonable accommodations for language requirements of Limited English Proficiency individuals shall be made by providing:
1. Oral language interpretation free of charge
2. Translation of written materials free of charge
3. Notice to individuals with Limited English Proficiency of their right to language assistance and the availability of such assistance free of charge D. George Junior Republic in Pennsylvania will then:
1. Obtain a qualified interpreter
2. Provide written translations of materials and information
3. Provide notice to Limited English Proficiency persons
4. Monitor language needs and implementation
REFERENCECODE: PS- 101 - DA - GJRPA
TITLE: Admission to D & A Rehab. Program Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 1/8/2020
DATEREVISED: 9/29/2021
PS-101-DA-GJRPA - Admission to D & A Rehab. Program Policy
It is the policy of this facility to comply with the expectations of client rights protection in 28 Pa Code Section V Chapter 709.30.
REFERENCECODE: PS- 101-001-DA - GJRPA
TITLE: Admission to D & A Rehab. Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-101-001-DA-GJRPA - Admission to D & A Rehab. Program Procedure
Upon admission and during the orientation process, the following procedures will be implemented to safeguard client rights while receiving treatment in the Inpatient Non-Hospital Drug and Alcohol Rehabilitation Facility:
A. The client will be advised that, while receiving treatment under Section 7 of the Act (71 P.S. 1690.107), they retain all civil rights and liberties (except those provided by statute) and that the “reason of treatment” cannot deprive them of a civil right. The client will sign and date an acknowledgement of notification of this information regarding all of their rights during the initial intake process. Clinical staff will sign and date as the witness to the client’s notification of these rights.
B. The client will be informed that they will not be subjected to any discrimination based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
C. The client will be notified that they have the right to inspect their records and will need to request such in writing to the Project and Facility Directors.
D. The client will be informed that the Project Director, Facility Director, or Clinical Supervisor may temporarily remove information from the record if deemed detrimental to the client prior to the client’s inspection, and that the reasons for removal will be documented in the file.
E. Clients shall be notified that they have the right to appeal the decision to limit their access to their record. They must do so in writing to the Project and Facility Directors.
F. Clients will receive notification that they have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. This is done by written request to the Project and Facility Directors.
G. Clients will be informed that they have the right to submit in writing any rebuttal information to their records.
H. Upon receiving all information and notifications of the client rights, the client will sign and date the Client Rights Form signifying acknowledgement of information.
I. Clinical staff will act as witness with an accompanying dated signature and this will be retained in the official client record. Clinical staff will offer a copy to the client for their personal record as well.
REFERENCECODE: PS- 102 - GJRPA
TITLE: Assessment of Persons Served Procedure
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-102-GJRPA - Assessment of Persons Served Procedure
It is the policy of the agency to complete a standard assessment of all persons served following admission in order to develop individualized treatment, safety, and transition plans.
REFERENCECODE: PS- 102-001 - GJRPA
TITLE: Risk Assessments Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-102-001-GJRPA - Risk Assessments Procedure
A. The PREA Vulnerability Assessment Instrument will be administered to each person served upon admission. This will identify risk areas to inform risk-based housing and follow-up with a mental health practitioner.
B. Nurses will complete a Health and Safety Assessment within 24 hours of admission, identifying medical risk areas that are then communicated to the treatment team. Safety plans are created based on the area identified in the Health and Safety Assessment.
C. The Adverse Childhood Experiences (ACEs), Trauma Symptom Checklist for Children (TSCC), Strengths and Difficulties Questionnaire, Massachusetts Youth Screening Instrument (MAYSI), and the Columbia Suicide Severity Rating Scale (CSSR) assessments will be utilized as needed.
D. Commercial Sexual Exploitation of Children (CSEC) Screening completed as part of the referral process.
GJR Secure Detention
A. The PREA Vulnerability Assessment Instrument will be administered to each person served upon admission. This will identify risk areas to inform risk-based housing and follow-up with a mental health practitioner.
B. Nurses will complete a Health and Safety Assessment within1 hour of admission, identifying medical risk areas that are then communicated to the treatment team.
C. The Adverse Childhood Experiences (ACEs), Trauma Symptom Checklist for Children (TSCC), Strengths and Difficulties Questionnaire, Massachusetts Youth Screening Instrument (MAYSI), and the Columbia Suicide Severity Rating Scale (CSSR) assessments will be utilized as needed.
D. Within 48 hours of youth’s admission, the GJR Secure Programs Coordinator will complete an assessment in the electronic health record.
Long Term Structure Residence (LTSR)
LTSR candidates will be assessed for sexual aggression and sexual trauma history through the Intake Interview Form to determine program eligibility prior to program admission.
REFERENCECODE: PS- 103 - GJRPA
TITLE: Admissions Supportive Services Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/29/2021
DATEREVISED: 9/25/2019
PS-103-GJRPA - Admissions Supportive Services Policy
Post admission and post discharge, the agency Admissions Department will provide ongoing support to GJR departments, agencies, and/or parent(s)/guardian(s) of persons served by ensuring information, communication and assistance are provided in a timely manner.
Long Term Structured Residence (LTSR)
Post admission and post discharge, LTSR Case Management and GJR Records Staff will provide ongoing support to GJR departments, agencies, and legal representative of persons served by ensuring information, communication, and assistance are provided in a timely manner.
REFERENCECODE: PS- 103-001 - GJRPA
TITLE: Admissions Supportive Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-103-001-GJRPA - Admissions Supportive Services Procedure
A. The Admissions Department and Program Supervisor will ensure that all incoming documentation received in the Admissions Office regarding the persons served will be recorded in the electronic health record. This documentation will include but is not limited to: birth certificates, social security cards, court orders, treatment documentation, juvenile justice or dependency information, consents, insurance information, and changes in information.
B. The Admissions Department will ensure that all court hearing documents provided to the Admissions Department are tracked by the name of persons served, location of the court hearing, court date, and the date that the notification is received. This is available to all staff in GJR in PA’s Documents
Published (Court Hearings) ShareFile to assist with communication and preparation of court reports.
C. Case Managers, or designated treatment staff, are responsible for scheduling and assisting with execution of all video court hearings/conferences/visits.
D. The Admissions Department facilitates and provides campus tours for parties requesting such.
E. The Admissions Department is responsible for assisting with questions and/or concerns from the family of persons served, placing/secondary/ancillary agencies, GJR website, and outside sources. This information is disseminated to the appropriate departments and follow up is provided to the referring party and/or the parent/guardian of persons serviced.
F. The Pew Counseling Center Reception Desk is responsible for welcoming and directing all visitors to the appropriate location, and managing visitation as required during the hours of 8:00 AM – 4:30 PM, Monday through Friday. Visits should begin at a time that allows them to conclude at the end of the visitation day. Any visitors arriving after 4:30 PM are managed on an individual basis. Visitors are required to:
1. Present identification
2. Have prior written approval to visit from the placing agency and/or family of the person served if considered a secondary agency
3. Sign and date the visitor’s log and receive a visitation badge
G. The Admissions Department is responsible for updating and disseminating the following information to referring parties, parent/guardian of the persons served, and the GJR website controller as needed:
1. Program Brochures
2. Youth Residential Programs Handbook
3. Consent Packets
4. Program Description Books
H. The Admissions Department is responsible for recording all discharges as reported by treatment staff for the purpose of ensuring an accurate census and billing, tracking outcomes, and determining current and future bed space availability. Discharges are maintained and disseminated daily to all necessary departments as well as recorded in the electronic health record.
I. The Outcomes Coordinator is responsible for the collection, yearly reporting, and maintenance of outcome data six (6) and twelve (12) months post-discharge with information requested by the State of Pennsylvania. The outcomes information is compiled by fiscal year and provided as requested/contracted.
J. The Admissions Department is responsible for tracking and disseminating all admissions, transfers, and discharges of all youth to ensure the accurate census for each treatment setting.
GJR Secure Detention
A. GJR Secure Programs Coordinator and GJR Records Staff will provide ongoing support to GJR departments, stakeholders, and legal representative of persons served by ensuring information, communication, and assistance are provided in a timely manner.
B. The GJR Secure Programs Coordinator is responsible for the following procedures:
1. Ensure that all incoming documentation received regarding the persons served will be recorded in the Electronic Health Record and distributed to the appropriate treatment staff to ensure consistency of care. This documentation will include but is not limited to: birth certificates, social security cards, court orders, treatment documentation, juvenile justice information, consents, insurance information, and changes in information.
2. Ensure that all court hearing documents are tracked by the name of the person served, location of the court hearing, the court date, and the date that the notification is received. This is then placed in the admissions share folder to assist with communication and preparation of court reports.
3. Schedule and assist with execution of all video court hearings/conferences/visits.
a. GJR Secure is responsible for welcoming all placing agency visitors. Visitors are required to:
i. Present identification.
ii. Have prior written approval to visit from the placing agency and/or family of the person served if considered a secondary agency.
iii. Sign and date the visitors log and receive a visitation badge.
iv. GJR Secure youth visitations will take place in the unit.
4. Assist with questions and/or concerns from the family, placing/secondary/ancillary agencies of persons served, and outside sources. This information is disseminated to the appropriate departments, and follow up is provided to the referring party and/or the parent/guardian of persons served.
5. Record all discharges as reported by treatment staff for the purpose of ensuring an accurate census and billing, tracking outcomes, and determining current and future bed space availability. Discharges are maintained and disseminated daily to all necessary
departments as well as recorded in the Electronic Health Record. Discharges are recorded by “Type” of discharge and “Location” of discharge.
a. Discharge of a person served from the GJR Secure Program will occur only after the treatment staff are in receipt of a signed transportation order from the court.
b. Personal possessions of the youth will be removed from storage, reviewed with youth including signatures and given to transport staff.
c. Switchboard to discharge from program and bed board.
Long Term Structured Residence (LTSR)
The Admissions Department and LTSR Admissions Staff share the procedures listed above. The LTSR Case Manager is responsible for the following procedures:
A. Ensure that all incoming documentation received in the Admissions Office regarding the persons served will be recorded in the electronic health record and distributed to the appropriate treatment staff to ensure consistency of care. This documentation will include but is not limited to: birth certificates, social security cards, court orders, treatment documentation, juvenile justice or dependency information, consents, insurance information, and changes in information.
B. Ensure that all court hearing documents provided to the Admissions Department are tracked by the name of the person served, location of the court hearing, the court date, and the date that the notification is received. This is available to all staff in GJR in PA’s Documents Published (Court Hearings) ShareFile, to assist with communication and preparation of court reports. C. Schedule and assist with execution of all video court hearings/conferences/visits.
D. Assist with questions and/or concerns from the family, placing/secondary/ancillary agencies of persons served, the GJR website, and outside sources. This information is disseminated to the appropriate departments, and follow up is provided to the referring party and/or the parent/guardian of persons served.
E. Record all discharges as reported by treatment staff for the purpose of ensuring an accurate census and billing, tracking outcomes, and determining current and future bed space availability. Discharges are maintained and disseminated daily to all necessary departments as well as recorded in the electronic health record. Discharges are recorded by “Type” of discharge and “Location” of discharge.
F. Complete collection, yearly reporting, and maintenance of outcome data six (6) and twelve (12) months post-discharge with information requested by the State of Pennsylvania. The outcomes information is compiled by fiscal year and provided as requested/contracted.
REFERENCE CODE: PS- 103-002 - GJRPA
TITLE: LTSR Admissions Supportive Services Procedure
APPROVED BY: GJR Administrators
DATE APPROVED: 2/8/2021
DATE REVISED: 1/11/2024
PS-103-002-GJRPA – LTSR Admissions Supportive Services Procedure
A. The LTSR Case Manager will ensure that all incoming documentation received during the Intake and Admissions process regarding persons served will be saved in each corresponding paper record and electronic record. This documentation will include but is not limited to: birth certificates, social security cards, court orders, treatment documentation, consents, insurance information, and changes in information.
B. The LTSR Case Manager and Mental Health Professional are responsible for scheduling and assisting with execution of all video court hearings/conferences/visits.
C. The Admissions Department facilitates and provides campus tours for parties requesting such. The LTSR Case Manager provides tours of the LTSR.
D. The LTSR Case Manager is responsible for assisting with questions and/or concerns from the family, contracted county representative, legal team, and community supports of persons served. This information is disseminated to the appropriate departments and follow up is provided to the referring party and/or parent/guardian of the person served.
E. The Admissions Department Visitation Desk is responsible for welcoming and directing all visitors to the appropriate location and managing visitation as required during the hours of 8:00 AM – 4:30 PM, Monday through Friday. Any visitors arriving after 4:30 PM are managed at the Administration Building Switchboard. Visitors are required to:
1. Present identification
2. Have prior written approval to visit from the placing agency and/or family of the person served if considered a secondary agency
3. Sign and date the visitors log and receive a visitation badge
4. Complete an Agency Registration Form if going off campus for a visit with the person served
F. The LTSR Case Manager is responsible for updating and disseminating the following information to referring parties, legal representatives, and the GJR website controller as needed:
1. Program Brochures
2. Legal Guardian Information Guides
3. Consent Packets
REFERENCECODE: PS- 104 - GJRPA
TITLE: Non-Discrimination of Admissions Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-104-GJRPA - Non-Discrimination of Admissions Policy
It is the policy of the agency to admit persons served based on admission criteria without regard to race, color, sexual orientation/identity/expression, religious beliefs, national origin, or ancestry.
REFERENCECODE: PS- 104-001 - GJRPA
TITLE: Outpatient Mental Health Referral Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-104-001-GJRPA - Outpatient Mental Health Referral Procedure
Persons served are referred for assessment for mental health outpatient services via the following procedures:
A. Outgoing referrals will be made by the clinician or case manager when needs are identified outside the scope of the outpatient setting on behalf of persons served/their family or when persons served are being discharged from services. Persons served must agree to the referral and sign a Release of Information Form documenting that the referral will be made on their behalf and the information to be released. The form will be sent with a cover letter to the referral source with copies placed in the records of persons served. Additional materials will be sent as applicable (e.g., discharge summaries, psychological and/or psychiatric evaluations). Cover letters with Release of Information forms will be sent to document attempts to obtain information from referring agencies as well.
The collection and dissemination of information of persons served both for incoming and outgoing referrals will be in compliance with HIPAA and the Department of Health and Public Welfare Bulletin 99-00-05 dated 11-28-2000.
B. Referral agreements with other network providers will be maintained. The Outpatient Program refers to the current published copy of all Managed Care Organization’s network providers. Given the sheer number of network providers, GJR in PA only maintains referral agreements with local providers from the surrounding geographical community. The Outpatient Program serves persons served from the entire state of Pennsylvania and relies on the MCOs’ provider network handbook to identify referral agencies that can meet the needs of an individual youth.
REFERENCECODE: PS- 104-002 - GJRPA
TITLE: Outpatient Mental Health Intake Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-104-002-GJRPA - Outpatient Mental Health Intake Procedure
A. A person served will be scheduled for an intake appointment within one (1) week of being referred to the Outpatient Mental Health Program. The initial intake appointment will be the official day of admission to outpatient services.
B. The following forms will be reviewed and signed at this first appointment. The person served and clinician must sign and date each form to acknowledge that the forms have been reviewed. The forms include:
1. Rights of Persons Served Policy
2. Grievance Process Policy
3. Statement of Confidentiality
4. Consent to Receive Mental Health Services
5. Consent to Receive Medication Services, if applicable
6. Consent to obtain/release confidential information as appropriate to insurance companies, managed care organizations, GJR residential programs, primary care physicians, hospitals, prior mental health providers, base service units, court systems, and legal guardians.
C. An Initial Treatment Plan will be started with the person served during the intake session. Treatment planning must address discharge planning from the initial treatment plan through all revisions and modifications of the plan. Within 30 calendar days of the intake date, it will be signed by the following: the person served, the parent or legal guardian if the person served is under 14 years of age, the therapist, and the supervising psychiatrist. Any revisions/amendments must be signed by the person served, the parent or guardian if the person served is under 14 years of age, the therapist and the supervising psychiatrist, and documented in a clinical note. The treatment plan must be reviewed every 180 days. The psychiatrist must sign at least once annually.
D. Clinicians will ensure the parent/legal guardian has been informed of the treatment process and expectations from the point of admission through the discharge from service and aftercare planning.
E. All parents/legal guardians will be informed of their role and importance in the treatment process. It is the expectation that parents or the legal guardian of persons served, whenever feasible, will
play an active role in treatment and be part of the treatment team. Documentation of this information being provided to the parent/legal guardian shall be made on a clinical note.
F. Family therapy will be offered to the parent/legal guardian at a minimum of twice per month; however, families will be encouraged to participate in the therapeutic process more often. All contacts with parents/legal guardians will be documented on a clinical note.
G. All clinical notes must include the name of the person served, the date, start and end times of the session, and the therapist signature and credentials.
H. Clinicians will complete an Encounter Sheet that has been signed by the person served or an adult who is not employed by GJR for persons served under the age of 14 years old with all corresponding therapy notes attached. The Encounter Sheets and corresponding session documentation are expected to be kept up to date after each session is completed. The record must contain at a minimum the date of service, start and end time of service, type of service, goal(s) addressed, techniques utilized, the response of the person served to interventions, plan for next service, and be signed by the treating clinician.
REFERENCECODE: PS- 105 - GJRPA
TITLE: Sibling Admissions Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-105-GJRPA - Sibling Admissions Policy
The program advocates for the placement of persons served with their siblings, as appropriate.
REFERENCECODE: PS- 105-001 - GJRPA
TITLE: Sibling Admissions Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-105-001-GJRPA - Sibling Admissions Procedure
A. Placing agencies may request that siblings be placed together upon admission.
B. The request will be considered based on the treatment needs of all siblings.
C. Progress of each sibling will be monitored and reviewed throughout placement to determine the appropriateness of living in the same home.
D. The goal for all siblings living apart will be that they eventually reside together.
E. All efforts will be made to facilitate ongoing connections and visits among siblings.
F. Sibling visits will be supervised when safety issues are identified.
Long Term Structured Residence (LTSR)
Siblings will not be considered for concurrent admission to the LTSR.
REFERENCECODE: PS- 106 - DA - GJRPA
TITLE: D & A Rehab. Program Intake Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 1/8/2020
DATEREVISED: 9/29/2021
PS-106-DA-GJRPA - D & A Rehabilitation Program Intake Policy
It is the policy of the Inpatient Nonhospital Drug and Alcohol Rehabilitation Facility to comply with Chapter 709.51 via the development of a written plan for intake and admission.
REFERENCECODE: PS- 106 - 001 - DA - GJRPA
TITLE: D & A Rehab. Program Intake Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-106-001-DA-GJRPA - D & A Rehab. Program Intake Procedure
The following procedures define the Intake Process that will be completed upon admission in compliance with 28 Pa Code Section V Chapter 709. 51 (b):
A. Within the first 24 hours, the person served will participate in an Orientation process with the assigned unit staff. This process includes the Initial Drug Screen, completion of the Orientation Packet, and assigned recovery work.
B. The Orientation Packet includes the following: all necessary consent forms for all involved parties, Child rights, Facility Rules, Voluntary and Involuntary Discharge Protocols, Community Meeting Rules, Home Visit Rules, Discharge Follow-up Survey, On Campus Visitation Policy, and Consent to Treatment.
C. Staff will orient the person served to the hours of operation, fee schedule, and services provided.
D. The client will be given the opportunity to ask questions, and sign and date all forms. Staff will then offer a copy of the signed and completed Orientation Packet.
E. Upon the completion of consent forms, clients will be given a phone call to their guardian(s).
F. Facility staff will introduce the treatment staff and provide a basic program outline.
G. On the day of admission, the Clinical Supervisor, or designated treatment team member, will complete a Pre-Certification with the identified county MCO, if applicable.
H. Within 14 days of admission, a psychosocial evaluation is to be completed by the Drug and Alcohol Intervention Specialist that includes the following components: initial impression; psychiatric history; chemical history; medical history; treatment history; academic/vocational history; and family history.
I. An initial health and safety assessment is also completed with the client at the Wellness Center.
REFERENCECODE: PS- 107 - DA - GJRPA
TITLE: Drug and Alcohol Intake Documentation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 1/8/2020
DATEREVISED: 9/29/2021
PS-107-DA-GJRPA - Drug and Alcohol Intake Documentation Policy
Upon admission of persons served to the Inpatient Non-Hospital Drug and Alcohol Rehabilitation Program, it is the policy of this facility to both disclose the information and complete necessary documentation as outlined in the following procedures.
REFERENCECODE: PS- 107 - 001 - DA - GJRPA
TITLE: Drug and Alcohol Intake Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-107-001-DA-GJRPA - Drug and Alcohol Intake Documentation Procedure
The facility outlines the following related to the Drug and Alcohol Program:
A. Program criteria for admission, treatment, completion and discharge
B. Orientation for persons served to policies, hours of operation, and services provided
C. To develop histories that address medical, drug and alcohol, and personal information
D. Documentation of consent for treatment
E. Completion of a physical examination
F. Completion of a psychosocial evaluation with fourteen days
G. Completion of a preliminary treatment and rehabilitation plan
REFERENCECODE: PS- 108 - DA - GJRPA
TITLE: Drug and Alcohol Intake Consent Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 1/8/2020
DATEREVISED: 9/29/2021
PS-108-DA-GJRPA - Drug and Alcohol Consent Policy
It is the policy of the Inpatient Non-Hospital Drug and Alcohol Rehabilitation Facility to comply with 28 PA Code Section V Chapter 709.28 (c) (d) with regards to informed and voluntary consent to disclose client’s information.
REFERENCECODE: PS- 108 - 001 - DA - GJRPA
TITLE: Drug and Alcohol Disclosure of Information Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-108-001-DA-GJRPA - Drug and Alcohol Disclosure of Information Procedure
A. The following procedures will be adhered to when disclosing information of persons served:
1. All consents will be in writing and include the following:
a) Name of the person, agency, or organization receiving information
b) Specific information to be released
c) Purpose for disclosure
d) Date and signature of the client
e) Date and signature of the witness
f) Date, event, and condition(s) under which the consent will expire
2. Each client will receive a copy of the signed consent and a copy will be added to the client record.
B. The following procedures will be implemented when consent is not required in accordance to 28 Pa Code Section V Chapter 709.28 (e): 1.
1. Document the disclosure completely in the record of the person served.
2. Inform the client of the disclosure, including information disclosed, purpose of disclosure, and to whom it was disclosed, as soon as possible.
REFERENCECODE: PS- 200 - GJRPA
TITLE: Clinical Treatment Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-200-GJRPA - Clinical Treatment Policy
It is the policy of the agency to provide clinical services to persons served with mental health and/or substance abuse diagnoses, disabilities, or dual diagnoses. Treatment will not be denied on the basis of age, sex, race, religion, ethnic origin, economic status, or sexual identity or orientation. Treatment is designed to assist persons served and their families in addressing mental health and/or substance abuse conditions, and to provide an environment conducive to the overall stabilization of individual and family functioning.
REFERENCECODE: PS- 200-001 - GJRPA
TITLE: Psychiatric and Psychological Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-200-001-GJRPA - Psychiatric and Psychological Services Procedure
If a person served is in need of psychiatric services, therapists will refer this individual by completing the Psychiatric Referral Form and submitting it to Compliance and Outcomes Coordinator.
Psychological services will also be provided for persons served when a need is identified. Psychological services include, but are not limited to, psychological testing to determine IQ/achievement, personality assessment, aptitude test, and other psychological testing. If a person served is in need of psychological services, therapists shall refer them by utilizing the Psychological Referral Form and submitting it to the Compliance and Outcomes Coordinator.
Long Term Structured Residence (LTSR)
Psychiatric services will be provided to all persons served for at least 30 minutes each week by the attending psychiatrist or nurse practitioner. This time will be spent individually to address any medication concerns, treatment plan concerns, competency evaluation, clinical assessment and consultation, and to address any observations made by LTSR direct care staff.
REFERENCECODE: PS- 200-002 - GJRPA
TITLE: Psychiatric Supervision/Consultation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-200-002-GJRPA - Psychiatric Supervision/Consultation Procedure
A. The psychiatric supervision of persons served clinical cases provides for treatment planning, supervision, and the clinical oversight of the therapeutic process from admission to discharge.
B. The clinician responsible for treatment plan oversight conducts the following:
1. Approves all individual treatment plans
2. Reviews updated treatment plans annually by the psychiatrist
3. Signs all treatment plans.
4. Oversees that the plan specifies the appropriate clinical services to be offered to persons served based upon their treatment needs
C. Clinical Supervision/Consultation:
1. Ensures the provision of clinical services offered to persons served is based upon their treatment needs by reviewing the therapist’s written case material, and during consultation sessions and/or staff meetings
2. Includes consultation with the primary physician and/or other direct care providers of the person served when needed or warranted.
REFERENCECODE: PS- 200-003 - GJRPA
TITLE: Clinical Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-200-003-GJRPA - Clinical Services Procedure
A. Clinical Assignments
1. A newly admitted person served referred to a closed unit, except for the Diagnostic Program, will already have a clinician assigned based on the unit placement.
2. If the person served is referred to open campus or the Diagnostic Program, a clinician is assigned to that individual by the Clinical Director based on case count, clinical need, and clinician fit.
B. Beginning Treatment
1. The clinician will meet with the person served within the first five days of their assignment with possible exceptions due to clinician schedules.
2. At the first session, the person served and the clinician will discuss informed consent and complete releases for outpatient services if they qualify.
3. At the first session, a thorough therapeutic assessment will be completed highlighting the strengths, needs, abilities, and preferences of the person served.
4. At the first session, the person served and the clinician will establish an initial treatment plan based on a needs assessment of the person served. This plan will include at least two goals and corresponding objectives to work on the treatment plan. At this time, both the clinician and the person served will complete and sign the Individual Service Plan.
5. Before the second session, the clinician will contact the family/guardian of the person served and provide introductions. At that time, a family therapy session will be scheduled.
6. At the second session, the person served and the clinician will complete the following assessments: Strengths and Difficulties Questionnaire (SDQ), Massachusetts Youth Screening Inventory 2 (MAYSI2), Adverse Childhood Experiences (ACEs), and Trauma Symptom Checklist for Children (TSCC). The interpretative data from these assessments will be included in the Individual Service Plan in a new goal or objective.
7. At the third session, the person served and the clinician will review the data from the assessments and make any further adjustments to the treatment plan based on the results of the assessments. If the person served is in the open campus or Diagnostic program, this may be the time to create an updated Outpatient Treatment Plan, should they require such a plan. Both individuals will sign this treatment plan once it has been created.
8. In the event that a person served requires additional assessments beyond the required ones, there is a section located in the Social Worker Sharefile with additional assessments. These assessments can be used any at time. It is best practice to engage in follow up assessments, using the same tool, at the date of each Individual Service Plan review report.
C. Frequency of Treatment
1. If the person served comes to the Special Needs, Residential Treatment Facility, or Intensive Supervision units, they will receive at least two individual, family-focused, or family therapy sessions per week.
2. If a person served comes to the open campus, diagnostic, or drug and alcohol program, they will receive at least one individual, family-focused, or family therapy session a week.
D. Individual Therapy
1. The clinician will engage the person served during each session in various modalities in an effort to work on the treatment goals of the person served. The clinician will assess each session if the person served is responding to the therapeutic modality used. If there is limited or no response, the clinician will make appropriate clinical decisions on continuing the intervention or switching to something new.
2. Each time therapy is provided, a therapy note will need to be completed within 24 hours of the service.
3. If the session was with the person served alone, it will be completed on an individual therapy note.
E. Group Therapy
1. The clinician is responsible for referring the person served to groups.
2. Persons served will continue to attend group unless it is clinically indicated that group is not appropriate.
3. All group therapy sessions are to be documented on a group therapy note and are to be completed within 24 hours of providing the service.
F. Family Therapy
1. Family therapy will be set up at a minimum of twice a month. This should be set up in advance with the guardian for each session. At the conclusion of the family therapy session, the next time and date will be scheduled for this treatment.
2. Clinical judgment will dictate if the person served and their guardian need additional family treatment beyond the twice a month expectation.
3. There may be cases in which family therapy should be held without the person served present. This is appropriate as indicated by the family needs and the process of the therapeutic modality being used.
4. If the person served does not have a discharge resource initially, but one is established at a later date, the clinician will begin family therapy treatment with them and their guardian at that time.
5. Family Therapy Documentation
a.If the session was conducted with the person served and the family through any means other than direct, face-to-face sessions (over the telephone, using Zoom), the session will be documented on a family-focused individual therapy session note.
b.If the session was a family therapy session that was conducted face-to-face with the family, the session will be documented on a family therapy note.
G. Continuous Documentation
1. Each month, on or around the anniversary date of the person served, the clinician, the person served, and when appropriate the guardian of the person served will update and review the treatment goals and the progress that the person served is making on these treatment goals.
2. Every five months, in conjunction with the above process, the clinician and the person served will complete an Outpatient Treatment Plan, when applicable.
3. Every three months, or according to the Individual Service Plan schedule, prior to the due date of the review ISP report, the clinician will reassess the person served using the TSCC, SDQ, and MAYSI2. This interpreted data will be included in the review ISP under the section of Individual Therapy. All interpretative data from any other assessments will be included in this report as well.
4. The clinician will create the Individual Service Plan in the electronic health record by the 5th of each month and assign the appropriate auxiliary staff to add any pertinent information to the report, including goals and objectives. Whenever an ISP review report is due, the clinician will complete the following information on the report:
a.Psychiatric evaluation
b.Individual therapy
c. Family therapy
d.Group therapy
e.Family contact
f. Goals/objectives
5. After a year of treatment, the clinician and the person served will reexamine the outpatient consent and releases and resign if the person served is appropriate for outpatient services.
H. Therapeutic Transfers
1. At any time that a person served transfers to a new clinician, it is the responsibility of the new clinician to contact the family for introductions and to set up a family therapy session, meet with the person served for introductions, discuss progress on treatment goals and review the plan, and collaborate with the previous clinician on pertinent information for the case.
2. The previous clinician and the new clinician must have a conversation regarding what paperwork is due and when, as well as determining who needs to ensure the completion of the paperwork.
3. This transfer of information must occur within 72 hours of the transfer of the person served.
I. Treatment Plan Modifications
1. At any time during the treatment of a person served, the clinician and the person served can make modifications to the treatment goals and objectives. It is important to review regularly to ensure that treatment is reflective of the needs and progress of the person served.
2. Goals and objectives can be added or deleted at any time that they are no longer deemed appropriate.
J. Clinical Supervision
1. Each clinician is expected to attend weekly supervision. This supervision is either one-onone supervision with the Director or in the form of small group supervision twice monthly.
2. Supervision is designed to help with cases, provide ongoing support and training, and allow the clinician to aid other clinicians with difficult cases.
REFERENCECODE: PS- 200-004 - GJRPA
TITLE: Supportive Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-200-004-GJRPA - Supportive Services Procedure
A primary goal of cognitive therapy is to identify and correct negative, distorted, or irrational thoughts that have become “automatic” through repetition. While persons served are taught in individual and group therapy how to detect cognitive errors/distortions and develop more effective thought patterns, daily programming in the milieu offers a number of supportive services to augment treatment. Some of those services include:
A. Behavioral Management Through Adventure (BMTA)
B. Art2O
C. Recreational Therapy
D. Aggression Replacement Training (ART)
E. Vocational and educational programming
F. Life skills education
G. Clubs
H. Athletics
I. Religious services and/or supports
J. Trauma Art Narrative Therapy (TANT)
Through the utilization of these supportive services, core beliefs of persons served related to self and the world are continually challenged. The services reinforce skills learned in therapy, instill independence, and utilize relapse prevention procedures established in the therapeutic process.
REFERENCECODE: PS- 200-005 - GJRPA
TITLE: 24 Hour Access to Qualified Practitioners Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 5/3/2021
PS-200-005-GJRPA - 24 Hour Access to Qualified Practitioners Procedure
There are a number of employees who are considered qualified practitioners, including those below, who are available 24 hours a day, 7 days per week.
A. Campus Supervisors are on campus 24 hours a day, 7 days per week.
B. Campus Directors are on call 24 hours a day, 7 days per week for emergencies.
C. Nurses are available on campus 24 hours a day, 7 days per week.
D. A psychiatrist is available 24 hours a day, 7 days per week via an on-call schedule.
E. Therapists, Treatment Team Coordinators, Case managers, and Residential Managers each work 40 hours a week and are considered qualified practitioners. These staff members have schedules that vary on days and times worked in order to cover most waking hours of persons served.
Long Term Structured Residence (LTSR)
A. The Program LTSR Director is on call 24 hours a day, 7 days per week for emergencies.
B. The assigned psychiatrist is on call 24 hours a day, 7 days per week for consultation or emergencies.
C. The LTSR Therapists, Case Manager, and Certified Peer Specialist each work 40 hours per week and are considered qualified practitioners. LTSR Mental Health Professionals will be on-site at least 8 out of every 24 hours.
REFERENCECODE: PS- 200-006 - GJRPA
TITLE: Assessment and Evaluation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-200-006-GJRPA - Assessment and Evaluation Procedure
The initial assessment is the document that pulls together the history of the person served and interviews with the person served, family and agencies, as indicated. It results in a comprehensive bio-psychosocial assessment, which is the foundation for the initial treatment plan.
The first meeting with the person served will be an assessment and treatment planning session in which the clinician documents the presenting problems and includes the information listed below. This session will encompass both the residential and outpatient services needs and will not subject the person served to two assessments. At a minimum, the following information will be obtained:
A. Identifying information
B. Family composition
C. History of previous psychiatric treatment
D. Nutritional information
E. Educational/vocational history including last school attended
F. Legal history
G. Sexual history
H. Spiritual history and religion of choice
I. Community and social history
J. Medical history and developmental milestones
K. Comprehensive Drug and Alcohol history and treatment to include all prior treatment, drugs used, age of first use, frequency of use, and date of last use.
L. History of trauma and injuries including emotional trauma and physical injuries
M. Prior service and intervention history including mental health and drug and alcohol treatment, placements, and outpatient services for person served and their family
N. Strengths which will assist the person served in their treatment, discharge, and aftercare planning
O. Concerns and weaknesses of the person served which must be considered during treatment and discharge planning
P. A discussion of the support system of the person served
Q. Presenting problems
R. Barriers to treatment
S. Projected discharge plan
The treatment goals will be developed by the clinician, person served, family, and agency if indicated. These goals will be the foundation of the initial treatment plan.
The treatment plan will be forwarded to the psychiatrist to ensure the transmission of information is completed for the psychiatric assessment and evaluation of the person served as indicated. The psychiatrist will review the information and materials collected by the clinician.
The Psychiatric Evaluation will include the following information:
A. Historical information gathered by the clinician
B. Interim history and current functioning
C. Medical history, concerns and allergies
D. Mental status exam
E. Discussion and case formulation
F. Diagnostic formulation
G. Recommendation for treatment
H. Reasons for medications, if applicable
REFERENCECODE: PS- 200-007 - GJRPA
TITLE: Clinical Services Access Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-200-007-GJRPA - Clinical Services Access Procedure
Persons served will have access to clinical services as indicated:
A. Emergency Situations: Emergency situations, defined as a person served endorsing suicidal thoughts, acting to further suicidal thoughts, or experiencing major exacerbation of symptoms or new significant psychiatric symptoms, will be assessed immediately, placed on suicide watch and kept under 24/7 direct observation. Psychiatrists are available 24 hours per day, 7 days per week.
B. Acute/Post Hospital Follow-up care: A person served will be seen within seven (7) days of release from an acute care hospital setting by the assigned primary clinician or treating psychiatrist.
C. All other requests for service will be responded to as quickly as possible but must occur within seven (7) days of contact.
REFERENCECODE: PS- 200-008 - GJRPA
TITLE: Collaboration of Clinical Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-200-008-GJRPA - Collaboration of Clinical Services Procedure
Services are developed with the person served, the family/legal guardians of the person served, the mental health system, the academic center, the primary care physician of the person served, and all other agencies involved in the treatment process. Facility employees providing direct clinical services to persons served are responsible for ensuring, with the appropriate written consent, collaboration and coordination with such entities during the treatment and aftercare processes.
A. During the intake process, the therapist will obtain the names, addresses, and phone numbers of service providers actively involved in the care of persons served. Releases of information to permit collaboration will be requested. The release of information will specify the nature of the information to be obtained or released.
B. All communications will be documented and placed in the record of the person served.
C. The person served has the right at any time during treatment to prohibit or discontinue contact between the facility’s practitioners and other identified providers, both medical and nonmedical. This will be done in writing indicating the date/time the release was revoked and witnessed by a member of the agency’s staff.
REFERENCECODE: PS- 200-009 - GJRPA
TITLE: Mental Health Commitment Process Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-200-009-GJRPA - Mental Health Commitment Process Procedure
A. Persons served who are in need of emergency examination and treatment, pursuant to Section 302 of the Mental Health Procedures Act will be referred to:
1. Mercer County Behavioral Health Commission, Crisis Delegate
2. Sharon Regional Medical Center
B. In the event that a person served is referred for an emergency evaluation and treatment, the supervising psychiatrist and clinician will consult with the examining physician and assist in the process as needed.
C. Should Sharon Regional Medical Center, the Mercer County involuntary commitment receiving facility, not have inpatient availability, then GJR in PA will support the Mental Health Crisis Delegate and Sharon Regional in finding an appropriate inpatient facility.
Contacts:
Sharon Regional Medical Center
Emergency Care and Inpatient Psychiatric Services
740 East State Street
Sharon, PA 16146
724-983-3911
Mercer County Behavioral Health Commission, Crisis Delegate
8406 Sharon-Mercer Road
Mercer, PA 16137-3138
724-662-2227 or1-888-275-7009
REFERENCECODE: PS- 200-010- GJRPA
TITLE: LTSR Clinical Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS- 200-010- GJRPA – LTSR Clinical Services Procedure
A. Clinical Assignments
1. Persons served will be assigned to a therapist upon their admission to the LTSR.
2. The treatment team shall review treatment plans at least every 30 days or more frequently as the progress of the person served changes. A report of the review, findings, and progress toward meeting program goals and objectives shall be documented by the interdisciplinary team in the record of the person served.
B. Beginning Treatment
1. The Mental Health Professional will meet with the person served within the first 48 hours days of their admission.
2. At the first session, the person served and the clinician will discuss informed consent.
3. At the first session, a thorough therapeutic assessment will be completed highlighting the strengths, needs, abilities, and preferences (Biopsychosocial Interview) of the person served. 4. At the first session, the person served and the clinician will complete the Strengths and Needs Assessment.
5. At the second session, the person served and the clinician will establish an initial treatment plan based on a needs assessment of the person served, including problem areas, initial goals and objectives for the person served to meet, modalities of treatment, and responsible staff indicated in helping the person served meet their goals.
6. Within ten days of admission, the Mental Health Professional and treatment staff will develop a comprehensive treatment plan. It will meet the following:
a. Be formulated, to the extent feasible, with the participation of the person served. With the consent of the person served, designated persons could participate in the planning process.
b. Be based upon diagnostic evaluation of the medical, psychological, social, cultural, behavioral, legal, familial, educational, vocational, and developmental strengths and needs.
c. Set forth measurable time-limited treatment goals and objectives, and prescribe an integrated program of therapies, activities, experiences and appropriate education designed to meet these goals and objectives.
d. Specify the person responsible for carrying out the modalities described in the plan.
e. Result from the collaborative recommendation of the interdisciplinary treatment
team.
f. Be easily understood by a lay person and a copy of the current treatment plan shall be available for review by the person in treatment.
g. Address significant psychiatric, psychosocial, medical, behavioral and rehabilitative needs of the person served and the manner in which they are to be met, including those needs to be addressed by contractors who are not employed by the LTSR.
C. Individual Therapy
1. The Mental Health Professional will engage the person served during each session in various modalities in an effort to work on treatment goals of the person served. The clinician will assess each session if the person served is responding to the therapeutic modality used. If there is limited or no response, the clinician will make appropriate clinical decisions on continuing the intervention or switching to something new.
2. Each time therapy is provided, a therapy note will be completed within 24 hours of the service.
3. If the session was with the person served alone, it will be completed on an individual therapy note.
D. Group Therapy
1. All persons served who enter the GJR in PA LTSR program will be expected to participate in groups that are reflective of their clinical needs.
2. The clinician is responsible for assigning the person served to appropriate groups.
3. Persons served will continue to attend group unless it is clinically indicated that group is not appropriate.
4. All group therapy sessions are to be documented on a group therapy note and are to be completed within 24 hours of providing the service.
E. Continuous Documentation
1. Every 30 days, the clinician, the person served, and, if applicable, other members of the treatment team, will update and review the treatment goals and the progress that the person served is making on these treatment goals.
2. Changes to the treatment plan and the reasons for the changes shall be made by the interdisciplinary treatment team and recorded in the record of the person served as a progress note, or on another form specifically designed for that purpose.
3. Whenever a treatment plan review report is due, the assigned clinician will complete the following information on the report:
a. Psychiatric evaluation
b. Individual therapy
c. Family therapy
d. Group therapy
e. Family contact
f. Goals/objectives
g. Competency restoration, if applicable
4. After a year of treatment, the clinician and the person served will reexamine the consent and releases, and resign.
F. Therapeutic Transfers
1. At any time that a person served transfers to a new clinician, it is the responsibility of that clinician to meet with the person served for introductions, discuss progress on the treatment plan goals and review the plan, and collaborate with the previous clinician on pertinent information for the case.
2. The previous clinician and the new clinician must have a conversation regarding what paperwork is due and when, as well as determining who needs to ensure the completion of the paperwork.
G. Treatment Plan Modifications
1. At any time during the treatment of a person served, the clinician and the person served can make modifications to the treatment goals and objectives. It is important to review regularly to ensure that treatment is reflective of the needs and progress of the person served.
2. Goals and objectives can be added or deleted at any time that they are no longer deemed appropriate.
H. Clinical Supervision
1. Supervision is designed to help with cases, provide ongoing support and training, and allow the clinician to aid other clinicians with difficult cases.
2. Each clinician is expected to attend weekly supervision. This supervision is either one-onone supervision with the LTSR Program Director or in the form of small group supervision with their peers.
REFERENCECODE: PS- 201 - DA - GJRPA
TITLE: Treatment & Rehabilitation within the D & A Program Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 8/6/2020
DATEREVISED: 4/1/2021
PS-201-DA-GJRPA - Treatment & Rehabilitation within the D & A Rehab. Program Policy
It is the policy of the Inpatient Non-Hospital Drug and Alcohol Rehabilitation Facility to comply with 28 Pa Code Section V Chapter 709.52 regarding treatment and rehabilitation services, which includes treatment planning, compliance with treatment plans scheduled, consistent services, and provision of support systems.
REFERENCECODE: PS- 201 - 001 - DA - GJRPA
TITLE: Treatment & Rehabilitation within the D & A Rehab. Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-201-001-DA-GJRPA – Treatment & Rehabilitation within the D & A Rehab. Program Procedure
The following procedures will be implemented in compliance with 28 Pa Code Section V Chapter 709.52 (a) regarding the development of the treatment plan:
A. During the first individual therapy session, short- and long-term goals will be created by the person served and the Clinical Supervisor and/or their designee that identify the treatment needs within the ASAM 6 dimensions.
B. The treatment plan will identify who will receive the services provided, the frequency of services, and person responsible to provide the identified service.
C. The treatment plan will identify the support system of each person served.
D. The treatment plan can be updated at any time to reflect goal progress or newly added goals stemming from treatment needs. However, all treatment plans must be updated a minimum of every 30 days with the client and the Clinical Supervisor and/or their designee dated signature.
REFERENCECODE: PS- 201 - 002 - DA - GJRPA
TITLE: Treatment Methodology within the D & A Rehab. Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-201-002-DA-GJRPA – Treatment Methodology within the D & A Rehab. Program Procedure
The following procedure defines the process of implementing both formal and informal treatment methodology in compliance with 28 Pa Code Section V Chapter 709. 51 (a) (2):
A. The 6 dimensions of the ASAM Criteria, 3rd edition are the foundation for case conceptualization.
B. Evidence-based therapies such as CBT, MI, and DBT will be used in individual and group formal therapy sessions.
C. Self-discovery, self-awareness and understanding of addiction, relapse and recovery are supported by the daily ‘Recovery Hour” completed by the client within each unit.
D. Self-accountability is practiced through self-monitoring and a daily delivery of service log.
E. Completion of workbooks that target addiction education, understanding of personal cycles of use, addictive thinking patterns, introduction to the 12 Steps of Recovery, communication, family systems and relapse prevention may be utilized as indicated via the treatment plan and/or the recommendation of the treatment team.
F. Journaling assignments are completed daily and reviewed weekly with the person served.
G. Life Skills curriculum assignments are utilized to practice and instill sober living skills.
H. Attendance biweekly at community 12 Step meetings promotes the practice of recovery living outside of the confines of treatment.
I. Principles of CARE (CDEFRT: Competence-Centered; Developmentally-Focused; Ecologically Oriented; Family-Involved; Relationship-Based, and Trauma-Informed) will aid in teaching basic skills such as following instructions, accepting no for an answer, and accepting feedback and redirection, as well as provide structure and monitoring of behavioral progress or regression.
REFERENCECODE: PS- 201 - 003 - DA - GJRPA
TITLE: Scheduling of Services within the D & A Rehab. Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-201-003-DA-GJRPA – Scheduling of Services within the D & A Rehab. Program Procedure
The following procedure will be implemented to meet compliance with 28 Pa Code Section V Chapter 709.52 (c) (d) ensuring that scheduled consistent services are provided:
A. To assure that the counseling services are provided as established within the treatment plan and program description, clients will sign the Encounter Form at the end of each session with time and date of session. The Clinical Supervisor and/or their designee will then record the session date and amount of time in the Client’s Delivery of Service Log, which is maintained in the Client Record.
B. Each person served will be provided a weekly (1) hour minimum individual/familyfocused/family therapy session with a treatment staff meeting qualifications per regulations.
C. Each person served will be provided (2) hours of group therapy weekly facilitated by a treatment staff meeting qualifications per regulations.
REFERENCECODE: PS- 201 - 004 - DA - GJRPA
TITLE: Scheduling of Services within the D & A Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-201-004-DA-GJRPA – Supportive Services within the D & A Rehab. Program Procedure
The following procedures will insure that each client is provided the following supportive services based upon their individual needs in compliance with 28 Pa Code Section V Chapter 709.52 (e):
A. Medical and Dental services are initially provided through the Wellness Center with referrals made to community resources as needed.
B. Psychiatric evaluation and monitoring are provided by Board Licensed Psychiatrists through the Wellness Center
C. Educational and Vocational needs are met through appropriate educational providers. Recreational/Social needs are addressed through the on-campus Program Department, which provides daily structured activities.
D. Clients are afforded the right to talk privately with their attorneys and are not denied access to any legal services.
E. Clothing, shoes, bedding, and food are all necessities provided by this Facility.
F. Legal financial obligations including court fees, restitution and or community service hours will be addressed through the on-campus BARJ program.
REFERENCECODE: PS- 202 - DA - GJRPA
TITLE: D & A Program Residential Compliance Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/29/2021
DATEREVISED: 1/11/2024
PS-202-DA-GJRPA - D & A Rehab. Program Residential Compliance Policy
It is the policy of the George Junior Republic Inpatient Non-Hospital Drug and Alcohol Rehabilitation Program to comply with the Pennsylvania Department of Drug and Alcohol Program’s Chapter 705 Subchapter A Physical Plant Standards for Residential Facilities.
REFERENCECODE: PS- 202-001-DA - GJRPA
TITLE: D & A Rehab. Program Residential Compliance Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-202-001-DA-GJRPA - D & A Rehab. Program Residential Compliance Procedure
This facility will comply with the following procedures in order to maintain its licensure:
A. Meet all expectations of licensure with the Department of Drug and Alcohol Programs and maintain a license under Chapter 709 and Chapter 711
B. Maintain a certificate of occupancy from the Department of Labor and Industry or the local equivalent
C. Comply with all applicable Federal, State and local laws and ordinances
D. Maintain the exterior of the buildings and the physical grounds
E. Manage the grounds by tending to the upkeep of the buildings and building grounds (This procedure includes that all buildings and building grounds will be clean, safe and free of hazards.)
F. Maintain that all indoor living room and lounges be clean, in good repair, and free from safety hazards for the use of persons served and guests
G. Provide each unit with a counseling office and a group room that extends from floor to ceiling for the purposes of ensuring privacy for the counseling and group sessions
H. Ensure that counseling and group session areas are clean and the furnishings are in good repair
I. Bedrooms of persons served contain the following to meet the standards:
1. A bed with a solid foundation, a fire-retardant mattress with a pillow and bedding, meeting temperature needs, in good repair
2. Storage space for clothing and 60 square feet of floor space per person served measured wall to wall, including space occupied by furniture.
3. Direct access to a corridor or external exit without access to any other part of the facility, stairways or basements
4. Ventilation provided by a window or mechanical means and shall have a window with source of natural light
5. Flamed candles and smoking are prohibited in the bedrooms J. Facility’s bathrooms will meet the following standards:
1. Each bathroom will be functional, clean and sanitary at all times.
2. Bathrooms will be provided for all persons served, staff, and guests of the facility with a sink, wall mirror, an operable soap dispenser, and individual paper towels or a mechanical dryer.
3. Privacy will be provided for toilets and showers by doors, partitions, or curtains and shall include slip-resistant surfaces in all showers.
4. Water shall be under pressure and the hot water will not exceed the temperature of 120 degrees.
5. Ventilation will be provided by either window or exhaust fan.
6. Toilet paper shall be provided at all times.
K. Onsite food preparation area will meet the following standards:
1. Have an area with a refrigerator, sink, stove oven, and cabinet space for storage.
2. Clean and disinfect food preparation area and appliances following each prepared meal.
3. Clean all utensils and food preparation areas, and store utensils in a clean enclosed area. Ensure that storage areas for foods are free of food particles, dust, and dirt.
4. Keep cold food at or below 40 degrees Fahrenheit, hot food at or above 140 degrees Fahrenheit, and frozen food at or below zero degrees Fahrenheit.
5. Store all food items off the floor.
6. Prohibit pets in the food preparation area.
7. Prohibit smoking in food preparation areas.
8. Heating and cooling will meet the following standards:
a. Heating and cooling ventilation system to maintain a temperature of at least 65 degrees Fahrenheit in the winter
b. Provide air conditioning or fans if the indoor temperature exceeds 90 degrees Fahrenheit and prohibit portable heaters
L. General Safety and emergency procedures: Please refer to the safety and emergency information in the EOC section of the Policy and Procedure Manual.
M. Fire Safety procedures: Please refer to the fire safety section of the Policy and Procedure Manual.
REFERENCECODE: PS- 203 - GJRPA
TITLE: Adventure Based Counseling Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-203-GJRPA - Adventure Based Counseling Policy
It is the policy of the agency to utilize the Adventure Based Counseling facility according to industry standards and regulations as contained in the program-specific operating manuals.
REFERENCECODE: PS- 204 - GJRPA
TITLE: Discharge Planning Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-204-GJRPA - Discharge Planning Policy
It is the policy of the agency to begin the discharge process upon admission and continue it throughout treatment in order to collaborate with persons served to identify and implement an effective discharge plan.
REFERENCECODE: PS- 204-001 - GJRPA
TITLE: Continuity of Care and Discharge Planning Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-204-001-GJRPA - Continuity of Care and Discharge Planning Procedure
It is the responsibility of the therapist of the person served, in conjunction with the treatment team, to begin to develop a discharge plan which includes aftercare services recommended to maintain stability and continue with the recovery process. Discharge criteria must include the outcome measures to be achieved for discharge, and will be included in the Assessment, initial Individual Service Plan, and all service plan reviews. The aftercare plan includes specific recommendations to maximize continued personal growth and support in the established treatment areas. Discharge planning is an ongoing process, which is documented on the Individual Service Plan. It must be initiated during the therapist’s first session with a person served.
Discharge Planning:
Discharge planning will begin upon admission as it is considered essential to goal development and treatment planning. The persons served and their families, if appropriate, will be educated regarding the importance of discharge and aftercare planning throughout participation in treatment. The criteria to be met by the person served for successful completion of treatment will begin to be established at the initial team meeting. The treatment team is comprised at a minimum of the person served, parent and/or legal guardian, therapist, psychiatrist, and Campus Director. A projected discharge date will also be established at this time. All members of the treatment team will sign the Treatment Team Signature Sheet indicating how they participated (in person or by telephone) and whether they are in agreement with the plan. The discharge plan will be reviewed and updated, as necessary, at each treatment plan review meetings.
Aftercare Planning:
Approximately one to two months prior to anticipated discharge, the person served will participate in an aftercare plan meeting with the treatment team, service providers, family, and identified significant others. The aftercare planning meeting will be documented in the record of the person served on an individual therapy note. The plan will include the services necessary to maximize continued personal growth and support in the established treatment areas. The clinical staff will assist the person served and family in the implementation of the plan.
An Aftercare Plan will be included in the Discharge Summary addressing the following:
A. All identified remaining problems of the person served and family
B. The method in which the person served will obtain their prescription medication, if applicable, upon discharge
C. Persons served discharged from the agency on prescription medications will be provided with any medication remaining on their prescription. Wellness Center staff will ensure that a 30-day prescription is sent to the family/guardian’s pharmacy of choice.
D. All discharge follow-up appointments
E. A crisis plan if required
Aftercare plans will not be required in cases in which the person served has left the program prematurely and/or against medical advice.
Follow-Up Services:
Formal contacts by the identified agency staff with the person served following discharge will continue for a minimum of thirty days. If the former person served wants to talk to the treatment team, the program will maintain an “open door” policy. During each contact, staff will:
A. Review the status of each component of the aftercare plan
B. Identify and attempt to aid the person served in resolving any issues that may have developed and make appropriate referrals as necessary
C. Document (on an individual therapy note) each interaction with the understanding that formal documentation will end after a thirty (30) day time period
REFERENCECODE: PS- 204-003 - GJRPA
TITLE: Outpatient Mental Health Discharge Planning Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-204-003-GJRPA - Outpatient Mental Health Discharge Planning Procedure
A. An outpatient discharge plan will be developed with persons served and their treatment team.
B. Persons served will be considered discharged from treatment upon meeting one of the following criteria:
1. Successful completion of the treatment goals and objectives, as measured by the outcome specified in the treatment plan
2. Upon mutual consent between the person served and their treatment team which can include transfer to another level of care
3. Based upon the decision of the person served alone against treatment team and/or against medical advice
4. Consistent failure of the person served to comply with treatment recommendations justifying an Administrative Discharge (An administrative discharge can include the need of a person served for a higher level of care.)
C. Prior to an administrative discharge, the clinician must notify the behavioral health managed care organization (MCO) involved in the treatment of the person served. The following criteria must be met for an involuntary discharge/termination and/or administrative discharge:
1. The person served is in need of more restrictive services as determined by their treatment team and it is no longer in their best interest to be served in an outpatient setting. The facility shall not terminate said services until a more restrictive level of care is identified and can be implemented.
2. The person served has failed to adhere to agency policies which place them and/or other residents at risk, and/or the agency is in a state of non-compliance with the outpatient regulations.
3. A person served shall be notified in writing of the facility’s decision to terminate their outpatient services. This notification will include a reason for their termination.
D. A clinician must document in their last formal clinical note with a person served the following:
1. A discussion was held regarding the termination of the therapeutic relationship
2. A description of the behavior and attitude of the person served upon discharge
3. A review of the treatment goals, objectives, and outcomes related to the person served
4. A review of all follow-up appointments with referring agencies or other facility staff
E. Upon discharge, a Discharge Summary will be completed and disseminated if required to the appropriate parties, such as referring agencies, and supportive and aftercare resources.
F. The Discharge Summary must be completed two weeks prior to discharge or at a minimum, within one week after discharge. It is essential that the Discharge Summary be completed within this time frame for the provision of timely discharge information to aftercare providers. The Discharge Summary must be reviewed and signed by the attending psychiatrist and/or clinical director. The discharge plan must include the following:
1. Reasons for referral to treatment
2. Initial and final diagnosis or diagnoses
3. Services offered and provided
4. Summary of treatment progress or lack thereof
5. Medication information, if applicable
6. Recommendations for aftercare
7. Special needs of the person served
8. Status or condition of person served upon discharge
9. Medical and psychosocial problems of person served
10. Anticipated problems/concerns for future compliance 11. Primary Care Physician if known
REFERENCECODE: PS- 204-004 - GJRPA
TITLE: LTSR Discharge Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-204-004-GJRPA – LTSR Discharge Procedure
The LTSR Case Manager is responsible for developing a discharge plan which includes aftercare services recommended to maintain stability to continue with the recovery process. The discharge plan includes specific recommendations from treatment team staff for continued personal growth and support in treatment areas. Discharge planning begins upon admission of the person served and is an ongoing process, documented every 30 days through treatment plan review and evaluations.
Discharge Planning:
Discharge planning will begin upon admission as it is considered essential to goal development and treatment planning. The persons served, legal representatives, and community supports will be educated regarding the importance of discharge and aftercare planning throughout participation in treatment. All members of the treatment team will sign the treatment plan for each person served. The discharge plan will be reviewed and updated, as necessary, at each treatment plan review meeting. The LTSR Discharge Plan will be initiated and completed as part of admissions process by the treatment team, and will continue as a working document throughout their treatment process.
A Discharge Summary will be completed with the LTSR Discharge Plan at time of discharge. Copies will be given to the person served, county representative, legal representative, and family supports, if applicable. Discharge documents are saved in the files of persons served.
Aftercare Planning:
Approximately one to two months prior to anticipated discharge, the person served will participate in an aftercare plan meeting with the LTSR Case Manager, county and legal representatives, family and community support, as applicable. The initial aftercare planning meeting will be documented in the record of the person served on the Initial Aftercare Planning Form. The plan will include the services necessary to maximize continued personal growth and support in the established treatment areas. The treatment team will assist the person served and family in the implementation of the plan.
An Aftercare Plan will be included in the Discharge Summary addressing the following:
A. All identified remaining concerns and needs of the person served
B. The method in which the person served will obtain their prescription medication, if applicable, upon discharge. Persons served discharged from the agency on prescription
medications will be provided with a 30-day prescription and scheduled for a follow-up appointment for ongoing medication management in the area of planned residence;
C. All discharge follow-up appointments and contact information
D. All necessary resources needed to safely and effectively transition to community setting or appropriate level of care, such as the following:
a. Housing
b. Food resources, if applicable
c. Physical health care
d. Psychiatric health care
e. Any supports needed for individual success pertaining to goals
f. A recovery plan, safety plan, or crisis plan, if applicable
Follow-Up Services:
The LTSR Case Manager will continue contact with the person served following discharge for a minimum of thirty days. If the former person served wants to talk to the treatment team, the program will maintain an “open door” policy. During each contact, staff will:
D. Review the status of each component of the aftercare plan
E. Identify and attempt to aid the person served in resolving any issues that may have developed and make appropriate referrals as necessary
F. Document (on an individual therapy note) each interaction with the understanding that formal documentation will end after a thirty (30) day time period
REFERENCECODE: PS- 205 - GJRPA
TITLE: Clinical Documentation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-205-GJRPA - Clinical Documentation Policy
It is the policy of the agency that all services delivered to persons served are documented for placement in the record of the person served by specific, determined timeframes.
REFERENCECODE: PS- 205-001 - GJRPA
TITLE: Clinical Documentation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-205-001 GJRPA - Clinical Documentation Procedure
The following must be completed in the electronic health records by the identified time frames:
A. Individual, Group, Family Therapy, and ART session notes are due no more than 24 hours after the service is completed.
B. Outpatient consents, assessments, and Initial Service Plans are due at the first session held with persons served and are to be completed in the electronic health record within 24 hours of the session.
C. Victim Awareness and Drug and Alcohol group notes are due at the end of the group cycle.
The following are due to the Campus Director by the specified time frame:
A. All Initial and Review ISP's are due by the date published on the ISP schedule for the month.
B. Monthly Progress Summaries are due by the date published on the ISP schedule for the month.
REFERENCECODE: PS- 205-002 - OPMH - GJRPA
TITLE: Outpatient Mental Health Clinical Documentation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-205-002-GJRPA - OPMH - Outpatient Mental Health Clinical Documentation Procedure
Outpatient mental health clinical services must be documented as follows:
A. Encounter Forms
1. For each type of billable clinical service, the date, start time, end time, and type of clinical service must be signed for by the person served and clinician (with credentials) offering the clinical service
2. The encounter form will be completed and maintained in the electronic health record.
3. The completed encounter form must then be associated with the clinical documentation (therapy note, psychological, or psychiatric evaluation) in the electronic health record.
B. All clinical therapy summaries, treatment plans, psychiatric and/or psychological evaluations, medication reviews, or psychiatric updates must be completed in the electronic health record, signed with credentials, and dated by the clinician.
C. Individual Service Plans must be signed by the clinician completing the plan with the person served. The initial treatment plan and updates will be reviewed and signed by the psychiatrist at least annually in the electronic health record.
REFERENCECODE: PS- 205-003 - GJRPA
TITLE: ISP/Treatment Plan Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-205-003-GJRPA - ISP/Treatment Plan Procedure
A. George Junior Republic in PA will notify the parents, person served, significant others to the person served or family, the educational provider, involved agencies, the Managed Care Organization (if applicable), and other appropriate clinical and support staff of the Interagency Service Planning (ISP) Team Meeting 10 days in advance of the scheduled meeting.
B. When necessary, phone notification of meeting will be documented in the contact note section of the electronic health record. Team members will be given the opportunity to participate in the meeting through conference calling if they are unable to travel to the meeting.
C. All participants attending the ISP meeting will sign the Interagency Team Meeting Attendance Sheet. If a person has participated in the meeting over the phone, their name and method of participation will be documented on the Attendance Sheet.
D. The goals and objectives agreed upon by the team members must be based upon an evaluation of the skill level (strengths, needs, attitudes and preferences) and assessed baseline performance capacity of the person served. The team members must ensure the goals and objectives are developmentally appropriate and address the psychiatric and psychological needs of the individual. The team must ensure that the identified goals and objectives are measurable and time limited.
E. The ISP Team must address in the plan the educational services to be provided to the person served to include the current educational placement and school district, and if special education services will be provided.
F. The ISP Team must develop and/or review a Restrictive Procedures Plan, if applicable.
G. The completed ISP report, which includes the goals and objectives of the person served, is mailed or emailed to the parents, person served, placing agency, and/or the Managed Care Organization in a reasonable time frame.
REFERENCECODE: PS- 205-005 - OPMH - GJRPA
TITLE: Outpatient Mental Health Treatment Plan Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 1/11/2024
PS-205-005-GJRPA - OPMH - Outpatient Mental Health Treatment Plan Procedure
The outpatient mental health treatment plan will be developed and updated in accordance with the 55 Pennsylvania Code Chapter 5200.
A. Specific treatment interventions and expected outcome measures on the Outpatient Treatment Plan must be clearly identified for each goal.
B. The staff position responsible for the implementation of each intervention will be identified on the plan but must reflect input from all disciplines including the person served.
C. All plans must be developed based upon the direct input of the person served, the person served family/legal guardian (if applicable), and the GJR in PA clinical team.
D. The Treatment Plan, comprised of mental health treatment goals, is completed during the first session with the person served. Thus, the outpatient intake and consent packet, therapeutic assessment, and initial mental health treatment plan are completed in the first meeting.
E. It is the responsibility of the primary therapist of the person served to ensure the treatment plan is completed within the required time frames.
F. The treatment plan must have the input and written approval of the supervising psychiatrist.
G. Pertinent information for the formation and development of the plan must include:
1. Referral information
2. Interviews with the person served seeking treatment
3. Interviews with the family members, legal guardians, caretakers and/or other providers of the person served when possible
4. Diagnostic evaluations such as medical, psychiatric, psychological, educational, vocational or other relevant and available assessments
5. Recommendations made by the psychiatrist and/or members of the clinical team
H. Activities related to the development and review of the treatment plan must be documented in the clinical note each time goals are reviewed.
I. The treatment team must maintain the rights of confidentiality and privacy of the person served throughout the treatment planning process.
J. The treatment plan and all updates or addendums must be signed by the person served, therapist, and at least annually by the psychiatrist.
K. Modifications to the plan, when indicated, will be made at the time of the review and documented in the record of the person served.
L. The treatment plan can be reviewed by the therapist at any time and, should the goals and objectives be deemed inappropriate and/or unnecessary for any reason, goals may be changed, added, or deleted. Persons served, parent or legal guardian if persons served are under 14 years of age, and the therapist must sign all treatment plan updates, additions, and changes.
REFERENCECODE: PS- 205-006 - OPMH - GJRPA
TITLE: Outpatient Mental Health Treatment Plan Appeal Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-205-006-GJRPA - OPMH -Outpatient Mental Health Treatment Plan Appeal Procedure
A. Persons served will be encouraged to use this process if they believe the treatment plan does not appropriately address identified needs or is not being implemented in an acceptable manner. All rights of persons served will be enforced during any appeal process. If formal objections are raised, it is the responsibility of the Outpatient Clinical Director/Campus Director to ensure that the issues are resolved in a timely manner.
B. The persons served will be advised to bring their objections, orally or in writing, to their therapist whenever possible. The GJR in PA Client Grievance Procedure Form should be completed by the person served unless they are unable to write it themselves.
C. The therapist will document the concern(s) and attempt to resolve with persons served and/or their families within 48 hours. The outcome of the meeting will be documented in the records of the person served.
D. If the complaint cannot be resolved at the primary therapist level, persons served will be scheduled to meet with the Outpatient Clinical Director/Campus Director within 48 hours of the meeting with the clinician. The Outpatient Clinical Director/Campus Director must bring the appeal to resolution within 48 hours of the meeting with the person served whenever possible. The resolution of the appeal must be documented in the medical record and a copy given to the Vice President of Operations. The outcome will be reviewed with the person served and the primary therapist.
E. If the complaint cannot be resolved at the Outpatient Clinical Director/Campus Director, the person served will be scheduled to meet with the Vice President of Operations within 48 hours following the meeting with the Outpatient Clinical Director/Campus Director. The Vice President of Operations must bring the complaint to resolution within 48 hours of the meeting whenever possible. The resolution must be documented in the medical record. The outcome will be reviewed with the person served and the primary therapist.
F. If the concerns are still not resolved, the person served has the right to appeal to the Department of Human Services.
G. If the concerns cannot be resolved and results in termination of treatment, it will be the responsibility of the Outpatient Clinical Director/Campus Director to refer the person served to an appropriate treatment facility.
H. All documentation regarding any level of appeal must become a part of the permanent treatment record of the person served.
I. Persons served have the right to have individuals of their choice present with them during any level of the appeal.
REFERENCECODE: PS- 205-007 - GJRPA
TITLE: Therapy Summaries/Progress Notes Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 1/11/2024
PS-205-007-GJRPA - Therapy Summaries/Progress Notes Procedure
A. Therapy notes must be completed in the facility’s electronic health record. The electronic health record contains templates for each service to be utilized by staff in completing clinical documentation.
B. Therapy Summaries will include the following:
1. Date of Session
2. Start time of session and end time of session (total time of session)
3. Name of the person served
4. Clinician’s full name and credentials
5. Type of therapy session that occurred (e.g. individual therapy, family therapy, and individual family-focused session).
6. Location of service
7. Note the evidenced-based practice utilized during the session
8. Goal and objective were discussed during this session and the level of progress made on this goal
9. Current condition during the session on the note through check boxes following the question, to include harm to self, others, and property
10. Review of safety plan(s)
11. Completion of the Intervention/Progress Section (focus of session, interventions utilized, client’s response to the interventions, plan for next session)
C. A Therapy Note must be written for the following: individual, family-focused, family, group (therapeutic or psycho-educational) within 24 hours of the service provision.
D. Group Progress Notes shall contain the group topic and the individual response of the person served to the group session.
E. All Progress Notes will be signed and dated by the therapist in a legible manner. Handwritten entries must be LEGIBLE.
F. Errors in record must have a single line through the material needing to be changed or corrected, the word “error” or “change,” signature with credentials of the clinician, and date of the change. No white-out or correction tape may be used in any part of the permanent record.
G. Addendums will be signed with credentials and dated in a legible manner prior to be filed in a record.
Long Term Structured Residence (LTSR)
LTSR direct-care and clinical staff will document therapy notes and progress notes in the electronic and paper records of the person served. A daily log will be completed to document all services provided and stored in the electronic records.
REFERENCECODE: PS- 205-008 - GJRPA
TITLE: LTSR Documentation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-205-008-GJRPA - LTSR Documentation Procedure
Daily documentation will be completed using paper forms and then uploaded via scan to each electronic record of persons served located in the LTSR Share Staff drive. After the physical document is scanned, it is sent to the Records Office for placement in the paper record of the person served.
All physical documents must be submitted to electronic records within 24 hours of completion, including the following:
1. Progress Notes
2. Individual Therapy Notes
3. Group Therapy Notes
4. Incident Reports
5. Admissions Packet
6. Treatment Plans
7. Medication Forms
REFERENCECODE: PS- 206 - GJRPA
TITLE: Clinical Therapy Coverage Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 8/6/2020
DATEREVISED: 4/1/2021
PS-206-GJRPA – Clinical Therapy Coverage Policy
It is the policy of the organization to provide clinical therapy coverage in those instances when a therapist will be unable to perform their duties due to vacation or illness.
REFERENCECODE: PS- 206-001 - GJRPA
TITLE: Accessibility of Personnel Information by Employees and Others Procedures
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 1/11/2024
PS-206-001-GJRPA - Accessibility of Personnel Information by Employees and Others
In the event that a clinician anticipates that they will be out of the office for one week or more for a planned absence, the following actions steps will be taken:
A. The Campus Director will be notified of the absence by the clinician’s supervisor at least one week in advance.
B. Providing that there is available clinical space, the clinicians at Pew Counseling Center will provide this coverage during the week the assigned clinician is absent.
C. If the person served is provided therapy typically twice a week, attempts will be made to continue to meet with the person served at this rate. However, if there is a shortage of available clinical space, the person served will be seen once a week by the Pew Counseling Center clinician.
D. In the event that the Pew Counseling Center clinicians do not have available clinical hours, the clinician’s supervisor and the Campus Director will work in a coordinated effort to assign this clinical coverage to another clinician outside of Pew Counseling Center.
E. The assigned clinician will begin working with persons served the week that they return to work.
In the event that a clinician anticipates that they will be out of the office for an extended period of time for a planned absence, or if a clinician is not assigned to the unit where persons served reside, the following action steps will be taken:
A. The Campus Director will be notified of the absence/needed coverage by the clinician’s supervisor/unit supervisor at least two weeks in advance.
B. Providing that there is available clinical space, the clinicians at Pew Counseling Center will provide this coverage the first week of the assigned clinician’s absence.
C. If the person served is provided therapy typically twice a week, attempts will be made to continue to meet with the person served at this rate. However, if there is a shortage of available clinical space, the person served will be seen once a week by the Pew Counseling Center clinician.
D. In the event that the Pew Counseling Center clinicians do not have available clinical hours, the clinician’s supervisor and the Campus Director will work in a coordinated effort to assign this clinical coverage to another clinician outside of Pew Counseling Center.
E. The Clinical Director will work with the assigned clinician upon their return to transition the persons served back to their therapeutic care.
In the event that a clinician is going to be out of the office unexpectedly for an extended period of time, the following action steps will be taken:
A. Providing that there is available clinical space, the clinicians at Pew Counseling Center will provide this coverage and begin providing clinical services as soon as possible.
B. If the person served is provided therapy typically twice a week, attempts will be made to continue to meet with the person served at this rate. However, if there is a shortage of available clinical space, the person served will be seen once a week by the Pew Counseling Center clinician.
C. In the event that the Pew Counseling Center clinicians do not have available clinical hours, the clinician’s supervisor and the Campus Director will work in a coordinated effort to assign this clinical coverage to another clinician outside of Pew Counseling Center.
D. The Campus Director will work with the assigned clinician upon their return to transition the persons served back to their therapeutic care.
Long Term Structured Residence (LTSR)
The LTSR Program Director is responsible for addressing clinical staffing needs and providing coverage as needed.
REFERENCECODE: PS- 207-DA - GJRPA
TITLE: Notification of Termination Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 1/8/2020
DATEREVISED: 9/29/2021
PS-207-DA-GJRPA - Notification of Termination Policy
It is the policy of the Inpatient Non-Hospital Drug and Alcohol Rehabilitation Facility to comply with 28 Pa Code Section V Chapter 709.33 when treatment is involuntarily terminated.
REFERENCECODE: PS- 207-001 – DA - GJRPA
TITLE: Notification of Termination Procedures
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/1/2020
DATEREVISED: 8/1/2020
PS-207-001-DA-GJRPA – Notification of Termination Procedures
The following procedures will be implemented in the Involuntary Termination of Treatment or Involuntary Discharge with a client:
A. Upon Admission and during the Orientation Process, the client will be informed of the reasons for involuntary termination of treatment and the process of Involuntary Discharge. B. The client will acknowledge receipt of this information with a dated signature.
C. Clinical Staff reviewing the information with the client will witness with a dated signature and offer a copy to the client while retaining a copy for the Client Record.
D. The Project staff will notify the client in writing the reasons for and the decision to involuntarily terminate treatment.
E. The client shall have the opportunity to provide a written request asking the Inpatient NonHospital Drug and Alcohol Rehabilitation Facility to reconsider any decision to involuntarily terminate treatment.
REFERENCECODE: PS- 208 - GJRPA
TITLE: Continuum of Care Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-208-GJRPA - Continuum of Care Policy
It is the policy of the agency to offer persons served a continuum of care to meet their treatment needs, managing transfers across the continuum of care in a manner that attends to the treatment and safety needs of each persons served.
REFERENCECODE: PS- 208-001 - GJRPA
TITLE: Requesting Transfer to a Lower Level of Care Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-208-001-GJRPA - Requesting Transfer to a Lower Level of Care Procedure
A. The Treatment Team determines that the needs of the person served can best be met in a lower level of care (i.e., Campus or Special Needs).
B. During monthly contact with placing agency (Probation Officer/Caseworker), the Residential Manager or Case Manager will discuss the recommendation for a lower level of care.
C. The Residential Manager or Case Manager will ask the Probation Officer or Caseworker if they are in agreement.
1. If they are in agreement, ask them what is required for transfer: i.e. a court order, written permission, or other county requirements.
2. Communicate to the Probation Officer or Caseworker that staff will get back to them within a specified time frame regarding the transfer.
D. The Campus Director informs the Vice President of Operations and Director of Admissions that there is a need for a lower level of care.
E. Bed availability and the time frame for the transfer will be determined by the Admissions Department or other county requirement.
F. Campus Director is to inform the assigned Psychiatrist of a step-down transfer. The Psychiatrist will them complete the order in the electronic health record.
G The transfer of the persons served will happen based on agency approval and bed availability.
H. Upon transfer, staff at new residential unit will contact the agency representative and family to notify them of the completion of the transfer.
Long Term Structured Residence (LTSR)
All admissions will be provided with the LTSR level of care. If external transfer is needed for lower or higher level of care, LTSR staff will communicate with appropriate external contacts to ensure transfer is provided.
REFERENCECODE: PS- 208-002 - GJRPA
TITLE: Requesting Transfer to a Higher Level of Care Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-208-002-GJRPA - Requesting Transfer to a Higher Level of Care Procedure
A. A discussion among the treatment staff must first take place outlining the reasons that the current level of care is not meeting the needs of the person served.
B. The Residential Managers and/or Case Managers will report the lack of the progress of the person served to the placing agencies and suggest that a higher level of care may have to be considered. At no time should the Residential Manager or Case Manager ask for permission for a step-up without full consultation of the treatment team.
C. Once the Treatment Team determines the need for a request for a higher level of care, a summary of the lack of progress of the person served, including details about general behaviors, restraints, and fights, will be written.
D. The Campus Director informs the Vice President of Operations and the Director of Admissions that there is a need for a transfer to a higher level of care.
E. Bed availability and time frame will be determined by Admissions.
F. Once the bed space availability is determined, a phone call and an email will be sent to the placing agency outlining the details of the necessity for the transfer and the time frame of that transfer.
G. Counties will act upon the request according to their policies (i.e.: court order for transfer, permission granted by email).
H. Verbal permission to move a person served is never sufficient. Written correspondence from the placing agency is required.
Long Term Structured Residence (LTSR)
All admissions will be provided with the LTSR level of care. If external transfer is needed for lower or higher level of care, LTSR staff will communicate with appropriate external contacts to ensure transfer is provided.
REFERENCECODE: PS- 208-003 - GJRPA
TITLE: Transfer Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 1/11/2024
PS-208-003-GJRPA - Transfer Procedure
When a person served is transferred from one residence to another, all of the personal belongings of a person served are to be sent along with them at the time of the transfer to prevent belongings being lost. It is staff’s responsibility to ensure that all the items listed on the Youth Personal Affects Inventory are forwarded to the home the person served is transferring to on the day of the transfer.
A. The following steps occur when a person served is being considered for step down or step up in level of care:
1. A Transfer Planning Meeting is held in which the treatment team discusses the need for a change in level of care.
2. The Campus Director will then communicate with the psychiatrist the need for a change in level of care and request that a transfer form be completed by the psychiatrist in the electronic health record.
3. The Campus Director is responsible for coordinating all transfers with the Admissions Department to ensure conflicts do not arise with incoming admissions and to ensure an accurate census of all treatment settings.
4. The receiving unit will notify the Admissions department of the room and bed the youth will be staying in so that it can be added to the bed board in the electronic health record.
5. Directly following the transfer, staff at the former residence must call the Switchboard and communicate that the person served has left the residence. Upon receiving the person served, staff at the new residence must call the Switchboard to confirm that the transfer was successfully made.
6. When the person served arrives at the new residence, the following must be completed:
a. Thoroughly search all belongings
b. Review and confirm the accuracy of the personal affects inventory completed with the person served present
c. Issue clean bedding
d. Place the initial phone call to the parent or guardian and have the person served sign-up for additional phone calls for the month
e. Provide a Rule Packet and review expectations
f. Introduce the person served to everyone in the building
g. Review any safety plans or health needs of the person served, and post the safety plans in the residence’s Log Book
h. Add the person served to the Emergency Contact Sheet in the Log Book
i. Add the person served to the Evening Security Roster in the Log Book
j. The staff in the new residence contacts the Wellness Center to inform that the person served has been transferred
k. New residence staff contacts the placing agency to inform that the person served has been transferred and to provide direct contact information
l. The placing agency is notified of the transfer and the rationale. The Admissions Department will follow up with a transfer letter the next business day.
B. The following will occur for a lateral transfer (same level of care)
1. All transfers are communicated to the appropriate departments via the Admissions Department.
2. Directly following the transfer, staff at the former residence must call the Switchboard and communicate that the person served has left the residence. Upon receiving the person served, staff at the new residence must call the Switchboard to confirm that the transfer was successfully made.
3. When the person served arrives at the new residence, the following must be completed:
a. Thoroughly search all belongings
b. Review and confirm the accuracy of the personal affects inventory completed with the person served present
c. Issue clean bedding
d. Place the initial phone call to the parent or guardian and have the person served sign-up for additional phone calls for the month
e. Provide a Rule Packet and review expectations
f. Introduce the person served to everyone in the building
g. Review any safety plans or health needs of the person served, and post the safety plans in the residence’s Log Book
h. Add the person served to the Emergency Contact Sheet in the Log Book
i. Add the person served to the Evening Security Roster in the Log Book
j. The staff in the new residence contacts the Wellness Center to inform that the person served has been transferred
k. New residence staff contacts the placing agency to inform that the person served has been transferred and to provide direct contact information
l. The placing agency is notified of the transfer and the rationale. The Admissions Department will follow up with a transfer letter the next business day.
Long Term Structured Residence (LTSR)
The LTSR only provides external transfers for appropriate levels of care and does not utilize the internal transfers procedure.
REFERENCECODE: PS- 209 - GJRPA
TITLE: Rights of Persons Served Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-209-GJRPA - Rights of Persons Served Policy
It is the policy of the agency to communicate and protect the rights of all persons served.
REFERENCECODE: PS- 209-001 - GJRPA
TITLE: Rights of Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-209-001-GJRPA - Rights of Persons Served Procedure
The following rights must be reviewed with each person served. Additionally, they must be offered a copy and these rights must be posted for all persons served to review in their residences. By the Children in Foster Care Act of 2010, children in placement have the following personal rights:
1. You have the right to be treated with fairness, dignity, and respect.
2. You may not be discriminated upon due to race, color, religious creed, disability, handicap, ancestry, sexual orientation, national origin, limited English proficiency, age, or sex. These issues have no bearing on the quality of services recommended or provided to you. You have the right not to be deprived of any civil, legal, or human rights due to a mental health/mental intellectual/developmental disability diagnosis.
3. You have the right as a minor to not be physically or emotionally abused, mistreated, unreasonably restrained, threatened, harassed, or subjected to corporal punishment. You may not be subjected to unusual or extreme methods of discipline, which may cause psychological or physical harm to you. It is the obligation of the agency to turn all allegations of child/adult abuse into the Child Registry Hotline of the DHS. Allegations of abuse will be investigated by the Department of Human Services Office of Children, Youth, and Family Services.
4. You have a right to be informed of the rules of the facility/program.
5. You have the right to be given enough food and food of good quality.
6. You have the right to clothing that is clean, seasonal, and age and gender appropriate.
7. You have the right to appropriate medical, dental, vision, and behavioral health treatment. You have the right to agree to medical and mental health treatment, including medication.
8. You have the right to take part in developing your Individualized Service Plan which includes medical, drug and alcohol, and/or mental health treatment if applicable. You have a right to a copy of your Individualized Service Plan.
9. You have the right to receive and send mail. Outgoing mail shall not be opened or read by staff persons. Incoming mail from federal, state or county officials, or from your attorney, shall not be opened or read by staff persons. Incoming mail from persons shall not be opened or read by staff persons unless there is a reasonable suspicion that contraband, or other information or material that may jeopardize your health or safety may be enclosed. Mail may be opened by you in the presence of a staff person.
10. You have the right to visit your parents at least every other week unless prohibited or restricted by court order.
11. You have the right to have contact with your family.
12. You have the right to have all the contact information for your guardian ad litem, attorney, court appointed special advocate, and members of your planning team. You have the right to communicate and visit privately with your attorney.
13. You have a right to communicate with others by telephone. This will be based on a reasonable policy and at times written instructions from your contracting agency or court, if applicable, regarding circumstances, frequency, time, payment, and privacy.
14. You have the right to be in a place that maintains your culture as reasonably accommodated.
15. You have the right to attend school and be able to take part in extracurricular, cultural, and personal enrichment activities.
16. You have the right to have the opportunity to work and develop job skills at an age appropriate level which may be reasonably accommodated.
17. You have the right to get life skills training and independent living services.
18. You have the right to be protected from unreasonable search and seizure. The facility may conduct search and seizure procedures, subject to reasonable facility policy.
19. You have a right to confidentiality and release of information with informed, written consent, except as required by legal authority.
20. You have the right to get notices of court hearings from your placing agency or county court house for your case, and have the ability to attend the hearing.
21. You have the right to practice a religion or faith of your choice, provided it is a bona fide religion; or not to practice any religion or faith. You have the right to communicate and visit with your clergy in private.
22. You have the right to receive the agency’s grievance policy and to have your rights and the grievance policy explained to you in way that you understand. You have the right to lodge a grievance with the facility for an alleged violation of specific client or civil right(s), or a complaint regarding your behavioral health treatment plan, without fear of retaliation.
23. You have the right to exercise parental and decision-making authority for your child (if you are a parent).
24. Your rights may not be used as a reward or sanction.
25. You have a right not to participate in research projects.
Program services shall be made available to individuals with disabilities through the most procedural and economically feasible methods possible.
*Child rights 26 through 32 apply to non-delinquent youth.
While the agency supports the following child rights for dependent and/or dependent/delinquent youth*, they are outside of the agency’s jurisdiction to enforce, therefore you must file a grievance with your placing agency should you believe one or more of these rights has been violated. If you need assistance in completing a grievance form to your placing agency your therapist or case manager can help you:
26. You have the right to live in the most family-like setting that meets your needs.
27. You have the right to be placed with your kin and relatives if possible.
28. You have the right to be placed with families that have supported you before if possible.
29. You have the right to be placed with your siblings, or visit with them at least every other week as arranged by your placing agency. GJR will make available to you contacts by phone with your siblings per the placing agency’s family service plan.
30. You have the right to be able to stay in the same school when you change placements.
31. You have the right to a permanency plan that you helped create and that you can review.
32. You have the right to get notice that you can ask to stay in care after you turn 18.
REFERENCECODE: PS- 209-002 - GJRPA
TITLE: Rights of Persons Served Outpatient Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-209-002-GJRPA - Rights of Persons Served Outpatient Procedure
The following rights of persons served are reviewed with them to ensure they are followed in Outpatient Mental Health Services:
1. Persons served may not be discriminated upon due to race, color, religious creed, disability, handicap, ancestry, sexual orientation, national origin, limited English proficiency, age, or sex. These issues will have no bearing on the quality of services recommended or provided to persons served.
2. Persons served have the right to lodge a grievance with the facility for an alleged violation of specific civil rights without fear of retaliation.
3. A minor person served may not be abused, mistreated, threatened, harassed, or subjected to corporal punishment. It is the policy of GJR in PA to turn all allegations of abuse into the Child Registry Hotline of the Department of Human Services. Allegations of abuse will be investigated by the Office of Children, Youth, and Family Services
4. Persons served have the right to be treated with fairness, dignity, and respect.
5. Persons served have a right to be informed of the rules of the facility/program.
6. Persons served have the right to communicate with others by telephone within reasonable policy and written instructions from the contracting agency or court, if applicable, regarding circumstances, frequency, time, payment, and privacy.
7. Persons served have the right to visit with family, at a time and location convenient for families, the persons served, and the facility, unless visits are restricted by court order.
8. Persons served have the right to receive and send mail. Outgoing mail will not be opened or read by staff persons. Incoming mail from federal, state or county officials, or from attorneys of persons served, will not be opened or read by staff persons. Incoming mail will not be opened or read by staff persons unless there is a reasonable suspicion that contraband, or other information or material that may jeopardize the child’s health or safety, may be enclosed. Mail may then be opened by persons served in the presence of staff.
9. Persons served have the right to practice the religion or faith of choice, provided it is a bonafide religion; or not to practice any religion or faith.
10. Persons served have the right to communicate and visit privately with attorneys and clergy.
11. Persons served have the right to be protected from unreasonable search and seizure. The facility may conduct search and seizure procedures, subject to reasonable facility policy.
12. Persons served have the right to clean, seasonal clothing that is age and gender appropriate.
13. Persons served have the right to appropriate medical, dental, and behavioral health treatment. Persons served have the right to be free from excessive medication.
14. Persons served have the right to rehabilitation and treatment. Persons served have the right to refuse treatment at any single time and, to the extent possible, can expect the facility’s help in exploring and securing alternative treatment resources.
15. Persons served may not be subject to unusual or extreme methods of discipline, which may cause psychological or physical harm to the persons served.
16. Persons served may not be deprived of specific civil rights. Persons served have the right not to be deprived of any civil, legal or human rights due to his mental health/substance abuse/intellectual disability diagnoses.
17. Rights of persons served may not be used as a reward or sanction.
18. Persons served have the right to confidentiality and release of information with informed, written consent EXCEPT as required by the legal authority.
19. Persons served have a right NOT to participate in research projects.
Program services will also be made available to persons served with disabilities through the most procedural and economically feasible methods available. These rights extend to George Junior Republic Outpatient Psychiatric Services and will be explained to persons served during the intake process.
1. The above inherent rights will be reviewed and discussed with the persons served by designated GJR in PA staff member upon admissions.
2. The Outpatient Rights Form outlining the inherent rights will be signed by the individual therapist.
3. Persons served will be asked to sign the Outpatient Rights Form to indicate being informed of their inherent rights.
4. A copy of the form will be offered to the persons served with the original filed in the outpatient record.
REFERENCECODE: PS- 209-003- GJRPA
TITLE: LTSR Rights of Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-209-003-GJRPA – LTSR Rights of Persons Served Procedure
The following rights must be reviewed with each person served. Additionally, they must be offered a copy and these rights must be posted for all persons served to review in their residences. By law, (Pa. Code Chapter 5100 and Pa. Code Chapter 5320) adults in placement have the following personal rights:
1. You have the right to unrestricted and private communication inside and outside this facility including the following rights:
a. To a peaceful assembly and to join with other patients to organize a body of or participate in patient government when patient government has been determined to be feasible by the facility.
b. To be assisted by any advocate of your choice in the assertion of your rights and to see a lawyer in private at any time.
c. To make complaints and to have your complaints heard and adjudicated promptly.
d. To receive visitors of your own choice at reasonable hours unless your treatment team has determined in advance that a visitor or visitors would seriously interfere with your or others’ treatment or welfare.
e. To receive and send unopened letters and to have outgoing letters stamped and mailed. Incoming mail may be examined for good reason in your presence for contraband. Contraband means specific property which entails a threat to your health and welfare, or to the hospital [LTSR] community.
f. To have access to telephone designated for patient use.
2. You have the right to practice the religion of your choice or to abstain from religious practices.
3. You have the right to keep and to use personal possessions, unless it has been determined that specific personal property is contraband. The reasons for imposing any limitation and its scope must be clearly defined, recorded, and explained to you. You have the right to sell any personal article you made and keep the proceeds from its sale.
4. You have the right to handle your personal affairs including making contracts, holding a driver’s license or professional license, marrying or obtaining a divorce, and writing a will.
5. You have the right to participate in the development and review of your treatment plan.
6. You have the right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals.
7. You have the right to be discharged from the facility as soon as you no longer need care and treatment and you are following your court order.
8. You have the right not to be subjected to any harsh or unusual treatment.
9. If you have been involuntarily committed in accordance with civil court proceedings, and you are not receiving treatment, and you are not dangerous to yourself or others, and you can survive safely in the community, you have the right to be discharged from the facility.
10. You have a right to be paid for any work you do which benefits the operation and maintenance of the facility in accordance with existing Federal wage and hour regulations.
11. You have the right to an understanding of the program philosophy, mission statement, goals, and objectives.
12. You have the right to receive contract upon admission stating the following:
a. The actual amount of allowable resident charges for each service or item
b. The party responsible for payment
c. The method for payment of long distance or collect charges for telephone calls
d. The conditions under which refunds will be made
e. The financial arrangements if assistance with financial management is to be provided
f. Limits on access to personal funds
g. The LTSR ‘‘house rules’’
h. The conditions under which the contract may be terminated, including cessation of operation of the LTSR
i. A statement that the resident is entitled to at least 30 days’ advance notice, in writing, of the provider’s intent to change the contract
13. You have the right to be provided a treatment professional or a person certified, licensed, or trained to provide that programming who is employed by the LTSR, under contract with the LTSR or who serves as a volunteer, or by any combination thereof.
14. You have the right to have your needs addressed in the manner in which they are to be met, to include but not limited to the following: psychiatric, psychosocial, medical, behavioral, and rehabilitative.
15. You have the right to freedom from treatment discrimination based on race, religion, national origin, gender, or disability. You shall have access to services and programs accommodating your gender.
16. You have the right to freedom from restraints and/or seclusion.
17. You have the right to access to an interdisciplinary treatment team.
18. You have the right to participate in creating your treatment plan.
19. You have the right to at least three well-balanced, nutritious meals daily. Snacks shall also be available.
20. You have the right to a bedroom with the following:
1. Single bed
2. Dresser
3. Lamp
4. Towel hook
5. Window blinds or shades
6. Closet or wardrobe
7. Mirror
8. Bedside table
9. Linens and blankets
10. Bed pillow
Program services will also be made available to persons served with disabilities through the most procedural and economically feasible methods available.
1. The above inherent rights will be reviewed and discussed with the persons served by designated GJR in PA staff member upon admissions.
2. The LTSR Bill of Rights form outlining the inherent rights will be signed by the individual therapist.
3. A copy of the rights will be offered to the persons served with the original filed in the person served record.
REFERENCECODE: PS- 210 - GJRPA
TITLE: Grievances and Complaints Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/29/2021
DATEREVISED: 9/29/2021
PS-210-GJRPA - Grievances and Complaints Policy
Persons served, their families, and other stakeholders have the right to file grievances and/or complaints. The agency has an established process that is shared with those parties.
A complaint can be made informally, verbally or in writing, to share any accusation, allegation, or action that is perceived to be unfair or unjust. A grievance is a more formal complaint and should be submitted in written form.
REFERENCECODE: PS- 210-001 - GJRPA
TITLE: Persons Served Grievance Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-210-001-GJRPA - Persons Served Grievance Procedure
Persons served will be supplied with the following information:
If you are at GJR and you think your rights have been violated, you can talk to someone you feel comfortable will help you. You may file a grievance without being afraid that someone will do something to hurt you. The grievance will not change your treatment goals, your plans for transfer or discharge, or the activities you are scheduled for.
A. Whenever you have a problem with someone, you should always try to talk to the person you have the problem with if you feel comfortable doing so. Talking with the person may solve the problem. If you have earned a natural or logical consequence that you do not think was right you can appropriately disagree after 45 minutes or when it is an appropriate time.
B. If this does not solve the problem or you do not feel comfortable with that person, try talking about the problem with a staff member who works with you who you trust. Sometimes the problem can be solved in this way.
C. If you do not trust anyone in your home or unit to talk to, you can talk to another staff member you know. It could be a Therapist, Nurse, Case Manager, Behavioral Health Technician, Campus Supervisor, or teacher.
D. If this does not solve the problem, you may fill out a grievance form. They are in a folder on the bulletin board in your unit.
E. If you do not feel comfortable talking to staff at all, you can fill out a grievance form at any time and give it to any staff member or put it into a Grievance Drop Box.
F. When you fill out a Grievance form and put it in a Drop Box, it will be given to your Campus Director or Director. That is the person who is the supervisor of the people in your unit or cottage. Drop Boxes can be found in the following places:
1. Program Center
2. Visitation Center
3. Maurice Cohill Academic Center
4. Vocational Center
5. Field House
6. ISU 1
7. ISU 2
8. ISU Gym
9. Secure Detention
10. Pew Counseling Center
11. Wellness Center
12. LTSR Gym
G. You cannot get in trouble or be treated badly for filing a grievance. If this happens, the person who does this will be in serious trouble. If someone does something to you for telling on them, then you need to tell someone else. If you are afraid to, you can put a note in the drop box telling about what happened.
H. If you are afraid that you are not safe, a Campus Director must be told right away so a plan can be made to keep you safe.
1. Your Campus Director will talk to you about the problem. This may happen at Team Meeting or privately in their office.
2. If this does not solve the problem, the next step in the chain of command at GJR in PA is the Vice President of Operations. You can put a form in the drop box asking to meet with the Vice President of Operations. This can only be done if you have already talked to your Campus Director about the problem.
3. If you are not happy with the decision that is made, a meeting will be held with you and the Vice President of Operations, your Campus Director, and your placing agency within ten days. This meeting may include teleconferencing for people not able to travel to GJR in PA.
I. During the grievance process, you may ask your parent or legal guardians to be with you at any of the meetings. You may also send a copy of your grievance form to your placing agency in the mail.
Long Term Structure Residence (LTSR)
LTSR persons served are instructed to address any grievance verbally with Mental Health Technicians and Mental Health Professionals. If this does not sufficiently resolve the concern, persons served are directed to talk to a staff person they know and trust. If they do not feel comfortable talking to any staff, they can file a grievance form at any time, and direct it to a staff person or place in the Grievance Drop Box. This form will be directed to the LTSR Program Director to further address any concerns.
REFERENCECODE: PS- 210-002 - OPMH - GJRPA
TITLE: Outpatient Mental Health Complaint and Grievance Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-210-002-GJRPA - OPMH - Outpatient Mental Health Complaint and Grievance Procedure
A. The Outpatient Mental Health program encourages and supports the rights of persons served to file complaints and grievances without fear of retaliation in the event they believe their rights have been violated.
B. Persons served will be informed of their right to complain or grieve treatment, or other aspects of service, at the time of their admission/intake to the Outpatient Program. Documentation of understanding of this right will be made by having persons served sign the George Junior Republic in PA Grievance Form
C. Persons served will be informed of the treatment plan appeal process as outlined in the Treatment Plan Appeal Policy
D. If persons served choose to file a complaint or grievance associated with outpatient services, they must complete a Grievance Procedure Form and give to the primary therapist. In the event the complaint has been filed against the primary therapist, the form will be given to the Clinical Director.
E. Complaint must be addressed within 48 hours. Outcomes must be documented and entered into the records of persons served. Outcomes of the complaints must also be provided to the Clinical Director or Supervisor, Campus Director, and Vice President of Operations.
F. If complaints cannot be resolved at the primary therapist level, persons served will be scheduled to meet with the Clinical Director or Supervisor within 48 hours of the issuance of grievance responses by therapists. The Clinical Director or Supervisor must attempt to bring complaints to resolution within 48 hours of these meetings whenever possible. Resolution of grievances must be documented in records of persons served, and copies given to the Campus Director and the Vice President of Operations. Along with persons served, outcomes will be reviewed with the primary therapists of the persons served.
G. If complaints cannot be resolved at the Clinical Director or Supervisor level, the person served will be scheduled to meet with the Vice President of Operations within 48 hours of the issuance of the grievance responses by the Clinical Director or Supervisor. The Campus Director/Vice President of Operations will attempt to bring the complaint to resolution within 48 hours of meetings whenever possible. Resolution of the grievances must be documented in the record of persons served. Along with persons served, outcomes will be reviewed with the primary therapists of persons served and the Clinical Supervisor.
17, 2025
H. If the matter cannot be satisfactorily resolved (per persons served) at the Vice President of Operations level, persons served will be referred to appropriate agencies for further action. Depending upon the nature of the grievance, those agencies may include:
Department of Human Services
Bureau of Equal Opportunity Room 521, Health and Welfare Building P. O. Box 2675 Harrisburg, PA 17105
US Department of Health and Human Services Office of Civil Rights Suite 372, Public Ledger Building 150 South Independence Mall West Philadelphia, PA 19106-9111
Appropriate Behavioral Health-MCO:
PA Human Relations Commission
Harrisburg Regional Office Riverfront Office Center 1101 South Front Street, 5th Floor Harrisburg, PA 17104
Bureau of Equal Opportunity Central Regional Office Cameron and Maclay Street Building 56, Patton House, P. O. Box 61260 Harrisburg, PA 17106-1260
1. Community Behavioral Health – Member Services (toll free)
1-888-545-2600
Or write and send to:
CBH
7TH Floor
801 Market Street Philadelphia, PA 19107
ATTN: Quality Review
2. PerformCare formerly Community Behavioral Health Network of PA - Member Services (toll-free) for youth’s county of residence.
a. 1-888-722-8646 Cumberland, Dauphin, Lancaster, Lebanon, and Perry Counties
b. 1-866-773-7891 Bedford and Somerset Counties
c. 1-866-773-7892 Blair County
d. 1-866-773-7917 Franklin and Fulton Counties
e. 1-866-773-7991 Lycoming and Clinton Counties
f. Or write and send to:
CBHNP PO Box 6600
Harrisburg, PA 17112
3. Community Care Behavioral Health Organization – Member Services (toll free) for county of residence of persons served
a. Adams 1-866-738-9849
b. Allegheny 1-800-553-7499
c. Berks 1-866-292-7886
d. Bradford 1-866-878-6046
e. Cameron 1-866-878-6046
f. Carbon 1-866-473-5862
g. Centre 1-866-878-6046
h. Chester 1-866-622-4228
i. Clarion 1-866-878-6046
j. Clearfield 1-866-878-6046
k. Columbia 1-866-878-6046
l. Elk 1-866-878-6046
m. Erie 1-855-224-1777
n. Forest 1-866-878-6046
o. Huntingdon 1-866-878-6046
p. Jefferson 1-866-878-6046
q. Juniata 1-866-878-6046
r. Lackawanna 1-866-668-4696
s. Luzerne 1-866-668-4696
t. McKean 1-866-878-6046
u. Mifflin 1-866-878-6046
v. Monroe 1-866-473-5862
w. Montour 1-866-878-6046
x. Northumberland 1-866-878-6046
y. Pike 1-866-473-5862
z. Potter 1-866-878-6046 aa. Schuylkill 1-866-878-6046 bb. Snyder 1-866878-6046 cc. Sullivan 1-866-878-6046 dd. Susquehanna 1-866-668-4696 ee. Tioga 1-866-878-6046 ff. Union 1-866-878-6046 gg. Warren 1-866-878-6046 hh. Wayne 1-866-878-6046 ii. Wyoming 1-866-668-4696 jj. York 1-866-542-0299 kk. TTY 1877-877-3580 ll. En Espanola 1-866-229-3187
mm. Si Ud necesita la versión en Español, por favor solicite uno a este telefono 1866-229-3187.
Or write and send to:
Community Care Behavioral Health Organization One Chatham Center, Suite 700 112 Washington Place Pittsburgh, PA 15219
Attention: Complaints and Grievances Department
4. Magellan Behavioral Health of PA – To file complaint toll free by phone, use county of residence of persons served as follows:
1. Bucks County: 1-877-769-9784
2. Cambria County: 1-800-424-0485
3. Delaware County: 1-888-207-2911
4. Lehigh County: 1-866-780-3368
5. Montgomery County: 1-877-769-9782
6. Northampton County: 1-866-780-3368
5. Si usted no habla inglés, llame al número que está arriba. Le enviaremos una traducción de este aviso y/o le conseguiremos un intérprete para ayudarle de forma gratuita.
1. Or write and send to: For Lehigh and Northampton counties: Magellan of PA
Attention: Customer Comment Coordinator 1 W. Broad Street Suite 210 Bethlehem, PA 18018 Telephone: 1-866-780-3368
2. Or write and send to: For Bucks, Delaware and Montgomery counties: Magellan Behavioral Health of PA
Attention: Customer Comment Coordinator 105 Terry Drive Suite 103 Newtown, PA 18940-0873
6. Beacon (Value) Behavioral Health of PA
1. Armstrong 877-688-5969
2. Beaver 877-688-5970 3. Butler 877-688-5971
4. Crawford 866-404-4561
5. Fayette 866-404-4561
6. Greene 877-688-5973
7. Indiana 877-688-5969
8. Lawrence 877-688-5975
9. Mercer 866-404-4561
10. Venango 866-404-4561
11. Washington 877-688-5976
12. Westmoreland 877-688-5977 13. TTY 877-615-8502
14. Or write and send to:
Value Behavioral Health of Pennsylvania 520 Pleasant Valley Road Trafford, PA 15085
I. The Compliance Department will review all outpatient complaints and grievances. Recommendations will be made if appropriate and necessary to address the issues resulting in the complaint/grievance being filed. Complaints and grievances will be continuously monitored for trends in order to make necessary changes to the program.
REFERENCECODE: PS- 210-003 - GJRPA
TITLE: Family Grievance Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-210-003-GJRPA - Family Grievance Procedure
Each person served and parent or guardian has the right to lodge grievances without the fear of retaliation. The Family Grievance Procedure of the agency is as follows:
A. If a problem, question, or situation arises regarding the child’s care or treatment, it should be first handled with the child’s Counselor Parent or Behavioral Health Technician.
B. If a problem, question, or situation arises regarding the child’s care or treatment and cannot satisfactorily be resolved with the child’s Counselor Parent or Behavioral Health Technician within 5 working days, it should then be discussed with the child’s Therapist or Residential Manager.
C. If a problem, question, or situation arises regarding the child’s care or treatment and cannot be satisfactorily resolved by the Therapist or Residential Manager within 5 working days, it should then be discussed with the child’s Campus Director. The Campus Director is an administrative staff person and the direct supervisor of the staff working with your child.
D. If a problem, question, or situation arises regarding the child’s care or treatment and cannot be satisfactorily resolved by the Campus Director within 5 working days, it should then be discussed with the Vice President of Operations. The Vice President of Operations is the immediate supervisor for all Campus Directors and treatment staff.
E. If a problem, question, or situation arises regarding the child’s care or treatment and cannot be satisfactorily resolved by the Vice President of Operations within 5 working days, it should then be discussed with the agency’s Chief Executive Officer.
REFERENCECODE: PS- 211 - GJRPA
TITLE: Programmatic Rules Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-211-GJRPA - Programmatic Rules Policy
It is the policy of the agency to provide clear structure and expectations for persons served in order to create a safe environment.
REFERENCECODE: PS- 211-001 - GJRPA
TITLE: Provision of Program Rules/Policies/Procedures to Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-211-001-GJRPA - Provision of Program Rules/Policies/Procedures to Persons Served Procedure
Upon admission, all persons served will be provided with a rule packet that is specific to the program for which they have been admitted. Contained in the rule packet are explanations of agency policies including: family visitation, home passes, phone calls, hygiene, privileges, mail, dress code, school, and medication use.
REFERENCECODE: PS- 211-002 - GJRPA
TITLE: Daily Schedule Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-211-002-GJRPA - Daily Schedule Procedure
A. Each living unit must have a written daily schedule that is available to the persons served.
B. Staff will compile the daily schedules from medical, transportation, therapy, group, activities, and school.
C. Staff will post the daily schedule in the day room area at the start of each day, that it may be clearly visible to persons served each morning.
D. Staff needs to be aware of confidentiality and privacy of the person served, and post with sensitivity.
Long Term Structured Residence (LTSR)
A daily log will be created for each person served, outlining their services provided. Daily activities will be provided to the entire residence in a visible location.
REFERENCECODE: PS- 211-003- GJRPA
TITLE: Regular Residential Meetings Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-211-003-GJRPA - Regular Residential Meetings Procedure
A. Regular meetings to keep persons served informed of the daily operations and programming need to occur throughout the day between staff and persons served.
B. Each morning, at shift change, and at bedtime, a residence meeting should occur.
C. Meeting rules need to be established and reviewed at each meeting and posted.
D. Staff will discuss the daily schedule, unit issues and problems, and plans for the shift.
E. Persons served will also will have check-in, expressing how they are feeling, what their goals are for the day, and who can help to achieve their goals.
F. Significant check-in information should be included on the daily note.
Long Term Structured Residence (LTSR)
Residential meetings will be provided twice per day, in the morning and evening.
REFERENCECODE: PS- 211-004 - GJRPA
TITLE: Telephone Use by Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 11/28/2022
PS-211-004-GJRPA - Telephone Use by Persons Served Procedure
A. Persons served are permitted to make 2 phone calls per week that last 15 minutes in length.
B. A phone call will not be used as a punishment with a person served. If persons served do not make their call, efforts should be made to give another phone call at a later time at the convenience of staff.
C. Incoming calls should be screened and approved by the treatment team.
D. A person served must be granted permission from staff to use the phone.
E. Staff will document all incoming and outgoing phone calls on the contact sheet.
F. Staff will place the call for persons served. Each unit has a code that is used to place an outgoing call. This code must not be seen by the person served. It is important to make sure the code is entered privately.
G. Outgoing calls can be made only to those individuals who are approved by the treatment team and the caseworker or probation officer of the person served. Out-of-state standards may apply.
H. A list of individuals whom the person served are permitted to call is kept in their file.
I. Safety and security considerations may dictate that a phone conversation of a person served should be monitored. The placing agency will determine this practice. Call monitoring is accomplished by a staff sitting in the room where the call is made for the entire length of the conversation, unless otherwise specified.
J. The placing agency and attorney of the person served will be notified should the person served make a request to speak with them.
GJR Secure Detention
Persons served are permitted to make 3 phone calls per week that last 15 minutes in length.
Long Term Structured Residence (LTSR)
Persons served will be permitted to make two calls per week that last 30 minutes in length.
REFERENCECODE: PS- 211-005 - GJRPA
TITLE: Persons Served Mail Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-211-005-GJRPA - Persons Served Mail Procedure
A. Persons served have the right to send and receive mail unless restricted by order of the court.
B. Mail will not be read by staff.
C. Staff is not to open or read the mail, unless under court order.
D. The person served will open the mail in the presence of the staff person.
E. Persons served cannot earn a negative consequence from staff for anything that comes through the mail. Contraband will be confiscated.
REFERENCECODE: PS- 211-006 - GJRPA
TITLE: Movies and Videos Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-211-006-GJRPA - Movies and Videos Procedure
These procedures have been developed to support staff protecting persons served from being exposed to material which may contribute to their emotional discomfort and difficulties. Emotional states may be influenced by material and stimuli not necessarily considered harmful by the general population.
A. No "R" rated movies. Keep in mind the age and emotional development of the person served in the treatment setting. PG 13 movies or TV shows may not be appropriate. B. No illegally copied movies may be shown to persons served.
C. Persons served at the agency are not permitted to have personal video equipment such as DVD or Blue Ray players, or televisions.
D. Any movies provided by staff must meet the criteria above.
Long Term Structured Residence (LTSR)
“R” rated movies will be permitted within the LTSR, pending approval by staff. Permitted “R” rated movies will not show excessive violence, drug use, sexual activity, or other actions that can negatively impact the recovery of persons served.
REFERENCECODE: PS- 211-007 - GJRPA
TITLE: Music and Games Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-211-007-GJRPA - Music and Games Procedure
A. Persons served at the agency are not permitted to be in possession of or play any video games that are rated “M” (mature).
B. Persons served at the agency are not permitted to bring PlayStation or X Box types of electronic devices to campus.
C. Persons served at the agency are not permitted to have MP3 players unless indicated by the treatment team.
D. Persons served at the agency are not permitted to have devices with wireless capabilities such as a PSP.
E. Persons served at the agency are not permitted to have CD’s, DVD’s, or cassettes.
F. No copied or commercial discs are permitted on campus. If a person served is in possession of a tape or disc, staff will confiscate it, store it securely, and return the item to persons served upon discharge.
G. Persons served are permitted to possess digital music players.
H. Persons served may not wear headphones while operating a mower, bike, or other equipment. Headphones are not permitted in school or at activities.
REFERENCECODE: PS- 211-008 - GJRPA
TITLE: Safety of Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-211-008-GJRPA - Safety of Persons Served Procedure
The agency is committed to maintaining an abuse-free organization. We believe that every person served should feel safe and secure while in our care. An incident report must be completed and submitted to the employee’s supervisor when an allegation of abuse occurs. Every allegation of abuse will be taken seriously. In the event of an allegation of abuse, the agency will cooperate fully with state laws and authorities.
The following behaviors are considered abusive. Persons served and employees are prohibited from engaging in the following behaviors:
A. Hazing
B. Bullying
C. Derogatory name-calling
D. Games of truth or dare
E. Singling out another person served for differential treatment
F. Ridicule or humiliation
G. Sexual innuendo
H. Verbal aggression
I. Physical aggression
REFERENCECODE: PS- 211-009 - GJRPA
TITLE: Religion and Religious Activities Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-211-009-GJRPA - Religion and Religious Activities Procedure
Persons served in placement maintain their personal choice regarding the practice of religion and religious activities. The right to practice religion is addressed in the Chapter 3800.32. (j) regulations regarding child rights. Regulation 32. (j) - a child has a right to practice the religion or faith of choice, or not to practice any religion or faith.
Application: This applies to bona fide religions. A child’s practice of religion may not infringe upon the rights of others in the facility or cause significant disruption or costs to the program. This includes the right to dietary choices (See 163. (b)), grooming practices, or to wear attire that is part of a bona fide religion.
Regulation 163. (b): Dietary alternatives shall be available for a person served who has special health needs, religious beliefs regarding dietary restrictions, or vegetarian preferences.
Differential reinforcement based on participation or non-participation in religious activities is not permitted.
With the above regulations in mind, the following guidelines must be followed:
1) Persons served may not be segregated by location, privileges, activities, living, or sleeping areas based on religious beliefs.
2) Persons served may not be restricted, rewarded, or otherwise treated differentially because they profess a religious belief.
3) Persons served are permitted to wear clothing with religious symbols or significance in the treatment setting but not to school. This includes clothing which pertains to any bona-fide religion.
4) Persons served must be given an opportunity to practice their religion each day. Time to pray, meditate, or read religious material must be provided if a person served requests. This time should be set around other required activities such as school, chores, scheduled activities, and group or individual therapy.
5) In the event that a religious activity occurs during meal time or a requirement of the religious activity precludes eating during certain hours such as occurs during Ramadan, the meals must be held for the person served unless holding a meal would pose a health hazard, and in that event an alternative meal must be provided.
6) Staff must make accommodations for persons served practicing their religion, and give the person served space and time for religious worship without disrupting the treatment setting, schedule, or other persons in the environment.
7) The agency will provide materials to a person served seeking information on a certain religion or belief if the religion is a bona-fide religion.
Persons served should be encouraged to practice their religion without creating an environment of separatism, conflict, or intimidation. Staff must be aware of imposing their own religious beliefs on a person served, and should remain tolerant and neutral when discussing religious issues. Religious beliefs and faith are personal to both you and the persons served within your care.
Long Term Structured Residence (LTSR)
LTSR persons served are afforded religious and dietary accommodation and protection from religious discrimination as outlined in § 5100.53 bill of rights for patients.
REFERENCECODE: PS- 211-010 - GJRPA
TITLE: Bicycle Use Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-211-010-GJRPA - Bicycle Use Procedure
The following policy is in effect for the use of bicycles on campus:
A. Persons served must wear a helmet when riding a bike.
B. Jumping the bike over curbs, speed bumps, and/or other obstacles is not permitted.
C. No person served is permitted to ride a bike to or from activities.
D. No person served is permitted to ride a bike after dark (when the lights come on).
E. No person served is permitted to ride a bike to and from the Wellness Center or school.
F. No person served is permitted to ride a bike across GJR Road or to use a bike while transporting supplies to or from the Service Building.
G. No bikes are to be ridden from October 31 through April 1 of each year.
H. Bicycles should not be ridden in parking areas.
I. Person served will not be permitted to ride “double” on bikes. Only one person served is permitted on a bike at a time.
The staff in each residence are responsible for the enforcement of this procedure.
REFERENCECODE: PS- 211-011 - GJRPA
TITLE: LTSR Off Campus Outings Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 11/9/2023
DATEREVISED: 11/9/2023
PS-211-011-GJRPA – LTSR Off Campus Outings Procedure
A. Throughout the year the Long-Term Structured Residence (LTSR) offers various opportunities for off-campus activities, allowing the person served a chance to be away from campus and demonstrate skills learned through their treatment.
B. For each scheduled outing, treatment staff are responsible for contacting the LTSR Primary Psychiatrist to confirm that the person served is able to participate.
C. Persons served must be involved in treatment for at least 30 days before they are permitted to attend any outings that are off campus.
D. If applicable, the person served’s home county must be notified and grant permission to attend any outings if they are legally remanded to the LTSR.
E. Prior to leaving campus, staff must complete the following:
1. Ensure that staffing is appropriate for ratio of 1 staff to 4 residents on the outing and 1 staff to 4 residents in the unit during the outing.
2. Obtain the Outings Binder which includes the following information for each person served:
a. Person Served Face Sheet including physical description, allergies, and legal commitment status
b. Person Served Medication List
c. Person Served Contact List including emergency contact
d. Person Served Safety Support Plan
e. Policies regarding injury, elopement, campus communication, transport, and emergencies
3. Staff will notify campus Switchboard of outing information and how many persons served will be attending and staying at the LTSR.
REFERENCECODE: PS- 211-012 - GJRPA
TITLE: LTSR Off Campus Outings Medications Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 11/9/2023
DATEREVISED: 11/9/2023
PS-211-012-GJRPA – LTSR Off Campus Outings Medications Procedure
A. LTSR medical staff are expected to provide the same medication management for persons served on days when an outing occurs.
1. Necessary nursing staff and change of scheduling will be considered based on the outing and time of day it occurs to accommodate medication passes.
2. If an outing occurs during time of medication pass, nursing staff must attend the outing to ensure proper distribution. The LTSR unit must utilize available nursing staff or Wellness Center nursing to accommodate persons served not attending the outing.
3. If a person served has a prescribed PRN medication, such as an EpiPen or inhaler, this will go with the resident during the outing.
4. Nursing staff are responsible for handling the scheduled and PRN medications that go on the outing.
REFERENCECODE: PS- 211-013 - GJRPA
TITLE: LTSR Off Campus Outings Crisis and Elopement Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 11/9/2023
DATEREVISED: 11/9/2023
PS-211-013-GJRPA – LTSR Off Campus Outings Crisis and Elopement Procedure
A. There may be times when a person served escalates to behavioral crisis or attempts to elope during an outing. The treatment staff who attend the outing are responsible for de-escalation and response to any crisis that may occur.
B. If a person served is observed to be escalating, staff should utilize one-on-one communication if possible while fellow staff assist to secure the environment.
C. Staff should utilize all methods of de-escalation to prevent a crisis or elopement, including communication of any concerns prior to the scheduled outing, use of persons’ served Safety and Crisis Plans, situational awareness and communication between staff, and use of verbal deescalation strategies.
D. The following actions should be taken prior to and in the event of an off-campus crisis or elopement.
1. Prior to leaving the LTSR, staff must assign themselves to persons served who are attending the outing. This must meet the 1 to 4 staff versus person served ratio.
2. Take a head count of all the other persons served and keep them in your watch.
3. If a person served cannot be located while off-campus, authorities should be notified immediately.
4. Once authorities are aware of the situation, staff will notify the Switchboard at GJR and ask for the staff in this order to report: LTSR Director, Risk Officer.
REFERENCECODE: PS- 212-DA - GJRPA
TITLE: Standards for Inpatient Non-Hospital Activities – Residential Treatment and Rehabilitation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 1/8/2020
DATEREVISED: 9/29/2021
PS-212-DA-GJRPA - Standards for Inpatient Non-Hospital Activities – Residential Treatment and Rehabilitation Policy
It is the policy of this facility to comply with the Standards for Inpatient Non-Hospital Activities –Residential Treatment and Rehabilitation identified by Pennsylvania Department of Drug and Alcohol Programs in Chapter 709.
REFERENCECODE: PS- 213 - GJRPA
TITLE: Personal Appearance, Clothing, and Belongings of Persons Served Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-213-GJRPA - Personal Appearance, Clothing, & Belongings of Persons Served Policy
It is the policy of the agency to implement expectations related to the appearance, clothing, and belongings of persons served in order to maintain a structured environment.
REFERENCECODE: PS- 213-001 - GJRPA
TITLE: Persons Served Clothing and Belongings at Admission/Discharge/Transfer Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-213-001-GJRPA - Persons Served Clothing & Belongings at Admission/Discharge/Transfer Procedure
All persons served must be provided with adequate clothing upon admission to George Junior Republic in PA (GJR in PA). Each person served should have sufficient items in good condition upon admission. Items of clothing in good condition are necessary for each person served. Typically, persons served wear clothes similar to what they would wear, or should wear, in their community. Excessively expensive designer clothing such as jackets, jeans, shoes, etc. should not be brought into placement.
If the person served does not have adequate clothing/shoes or appropriate seasonal wear, the needed items (with sizes) will be provided to the Procurement Director and/or their designee. The request should identify the person served, county of placement, and current residence.
Certain placing agencies/counties will submit clothing vouchers. A purchase voucher, along with an email showing the amount, should be submitted to the Campus Director for disposition-i.e. VPO, Finance, Procurement, etc.
Unit/Campus Home staff will complete a Personal Effects Property Inventory on each person served upon admission, transfer, or discharge. This is completed in the EHR of the person served within 72 hours of admission and within 24 hours prior to transfer or discharge. Upon completion, it is to be signed by the person served as well as the staff who completed the inventory.
The Personal Effects Property Inventory is located in SmartCare EHR.
Long Term Structured Residence (LTSR)
This procedure is observed by the LTSR at admission and discharge. The LTSR Mental Health Technician will complete the Resident Clothing Inventory form during admission and there is provided storage for extra belongings brought to the program by persons served. The LTSR Mental Health Technicians and LTSR Case Manager will assist with identified clothing needs.
REFERENCECODE: PS- 213-002 - GJRPA
TITLE: Persons Served Clothing/Appearance/Hygiene Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-213-002-GJRPA - Persons Served Clothing/Appearance/Hygiene Procedure
Clothing of a person served may be their most important personal possession and an essential part of their health, safety, and welfare. The clothing a person served wears is a part of their personal identity and selfimage.
One of the steps in assisting persons served to become productive members of society is to encourage and teach the person served standards of dress. This is accomplished through educating, monitoring, and role modeling while taking into consideration health, safety, and weather factors.
A high standard of appearance and good hygiene is expected for persons served at George Junior Republic. It must not be assumed that the persons served have mastered these skills. In order for persons served to improve self-image and meet social expectations, the following basic standards will be followed: A. Hygiene:
1. Persons served are expected to shower daily and be odor-free. If engaged in activities, such as sports, they should shower more often.
2. Persons served can shave on an as-needed basis, unless exempted for religious practice or other reasons. Razors and blades will be kept locked up by staff and distributed for the purpose of shaving. Persons served must be monitored while they are shaving.
3. Fingernails should be clean and neatly trimmed.
4. Add all home/units are provided with basic hygiene products. All persons served receive a $10 credit every month which may be used in the campus store for hygiene products.
5. Any unusual hygiene and/or dress problems must be brought to the attention of the Campus Director.
6. All persons served are required to perform hygiene skills each morning prior to leaving the residence.
B. Hair:
1. Persons served hair should be clean and neatly styled at all times.
2. Persons served are not permitted to cut other hair of other persons served. Haircuts are available at the Barber Shop as scheduled by the Program Department
C. Clothing and Grooming for School:
1. Persons served clothing and grooming are to be appropriate. School attire and proper grooming skills are to be observed by all persons served on campus during school hours.
2. Shirts are to be tucked into pants during school. This includes jerseys and long shirts.
3. Belts are to be worn in the belt loops and belts are to be securely fastened at the normal waistline area during school. Any pants without belt loops, such as sweatpants, are not permitted to be worn in school.
4. NO SHORTS ARE PERMITTED IN SCHOOL. Exceptions may be made for summer school by school notification.
5. Shoelaces must be tied and slippers may not be worn in school.
6. Persons served are not permitted to carry extra clothing in school with the exception of vocational school students who may need to carry work clothes to and from their residence for laundry purposes.
7. Shirt jackets and hats must be taken off during school hours.
8. Persons served clothing and grooming are to be approved by staff before attending school every day.
D. General Clothing Rules:
1. All gang-related clothing is to be confiscated immediately; this may include colors, handkerchiefs, and certain clothing styles. Persons served are not permitted to wear bandanas.
2. Persons served are not permitted to wear wave caps outside of the residence.
3. No persons served, regardless of length in placement, are permitted to have free access to their shoes. All shoes are to be stored and locked in a specified closet to prevent theft.
4. Persons served may not wear sleeveless t-shirts or vests without a sleeved shirt.
5. Persons served are not permitted to wear earrings.
6. Persons served are not permitted to go barefoot on campus. Appropriate footwear should be worn at all times. Persons served are not permitted to wear their slippers outside the residence.
7. If a person served is mowing or trimming grass, they must have appropriate footwear, long pants, and safety goggles.
8. Persons served are not permitted to wear clothing with gang, biker, nudity, obscenities, drug and/or tobacco-oriented pictures, any item containing an ethnic or racial slur, or clothing which denotes belonging to any organization which promotes racial or ethnic delineation.
9. Clothing should be neat and fit well.
10. Persons served may dress casually for on-campus activities.
11. Persons served must observe a seasonally appropriate, clean dress code when in the Administration building, Wellness Center, or Resource Center.
12. Persons served going to off campus activities or other meetings such as physician appointments, or visits with family members and others, must be neatly dressed and well groomed.
13. Persons served must wear a collared shirt for court appearances, both virtual and inperson. In addition, they are required to wear dress pants for in-person court appearances.
14. Persons served are not permitted to buy, sell, or trade clothing or other personal possessions.
15. Persons served are not permitted to throw away or destroy clothing without staff permission and parental consent. Any clothing discarded must be noted on the inventory sheet of the person served and submitted to the Admissions Department. If
the person served has thrown away or destroyed George Junior clothing, this must be communicated to BARJ.
16. GJR in PA assumes no responsibility for clothing or other personal possessions of a person served when they abscond. Residential staff must gather and secure possessions as soon as possible after a person served absconds.
17. Staff will monitor clothing of persons served: Inadequate clothing or clothing in poor condition must be brought to the attention of the Campus Director.
18. Persons served are not permitted to write or draw on their clothing.
Long Term Structured Residence (LTSR)
The LTSR follows this procedure with the following observations: Any unusual hygiene or dress concerns should be brought to the attention of the LTSR Program Director. Persons served will have access to their shoes for indoor use. They will be provided shower shoes for bathing.
REFERENCECODE: PS- 213-003 - GJRPA
TITLE: Securing Personal Belongings of Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-213-003-GJRPA - Securing Personal Belongings of Persons Served Procedure
Personal belongings of persons served are important and should be safeguarded as much as possible. It is not recommended to have expensive items, i.e., suede and/or leather coats, or stereo equipment while in placement at George Junior Republic in Pennsylvania. At no time is staff permitted to use, buy, sell, or discard personal property of a person served.
It is the agency's policy to not accept financial responsibility for personal items of a person served beyond basic clothing needs.
Persons served are to be taught to respect, and handle appropriately, both their own property and the property of others. Persons served are not permitted to buy, sell, or trade personal property, either to other persons served or staff.
If the person served has absconded, it is the responsibility of staff to secure the possessions of persons served immediately in a locked storage area. At no time should staff delegate their authority to persons served.
Whenever a person served is absent from the unit for reasons such as absconding, home visit, or long-term court hearing, staff members must gather the possessions of persons served together and secure them in a locked area.
Prior to the discharge of a person served, a staff member should inventory, pack, label, and address the items in cardboard boxes, secure with strapping tape and deliver the boxes to the Warehouse prior to the discharge.
Please follow the guidelines below:
A. Obtain proper shipping boxes from the warehouse.
B. Staff must wear gloves when conducting an inventory of the belongings of persons served.
C. Clothing must be inventoried prior to packing and the inventory placed in the file.
D. Clothing must be neatly folded and packaged.
E. The boxes must be addressed, sealed and taken to the Warehouse for shipping.
F. Staff must inform the Campus Director when boxes are taken to the Warehouse.
G. A copy of the inventory will be shipped with the belongings.
Long-Term Structured Residence (LTSR)
LTSR persons served are expected to take all belongings with them at time of discharge, including clothing and all personal belongings that were brought into the LTSR. If discharge prevents them from taking belongings upon exit, they will be mailed through the Warehouse.
REFERENCECODE: PS- 214 - GJRPA
TITLE: Cleanliness Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-214-GJRPA - Cleanliness Policy
It is the policy of the agency to create clear expectations for persons served related to keeping the environment clean.
REFERENCECODE: PS- 214-001 - GJRPA
TITLE: Chores and Cleanliness – Employee Responsibility Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-214-001-GJRPA - Chores and Cleanliness – Employee Responsibility Procedure
Cleanliness is paramount to the health and wellbeing of each person served and staff member. Keep in mind that each unit is to be maintained to the highest standards of cleanliness and orderliness. This means that each staff member on each shift must work toward maintaining a neat and clean environment. It is the responsibility of the staff to ensure that each person served completes their chore. All steps of the following chores must be completed as stated.
Persons served must have their chores completed by 9:00 AM and 1:00 PM. If the persons served are in school, they must complete chores before leaving for school. Chores must be checked by staff. Staff is responsible for the cleanliness of the home. If the chore is done inadequately, it must be redone. If the person served cannot redo their chore, the staff may assign it to another person served as a volunteer or the staff should complete the chore.
In the Staff secure units, the persons served are not permitted to handle the cleaning products. Staff must apply the chemicals to the area to be cleaned or pour into the buckets. Staff must secure them in a locked storage area immediately so persons served cannot gain access to them. In the Open Campus homes, the persons served must be supervised while using the chemicals. The chemicals must then be locked up.
Completed chores provide BARJ hours for persons served. Employees should document chore hours on the BARJ Time Card Sheet.
Long Term Structured Residence (LTSR)
Each person served will be assigned a daily chore, with the expectation that it will be completed to the best of their ability. Chores are not used for punishment or motivational purposes. There is a designated hour of the day for chores to be completed. Persons served will have supervised access to cleaning products.
REFERENCECODE: PS- 214-002 - GJRPA
TITLE: Bedroom Cleanliness & Guidelines Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-214-002-GJRPA - Bedroom Cleanliness & Guidelines Procedure
It is the agency’s policy that all persons served shall keep their rooms neat and orderly at all times. This teaches the persons served respect for themselves and their belongings, and enhances their self-image. Monitoring the persons served on keeping their rooms clean and neat, and teaching them needed skills is a responsibility of all staff.
The following are guidelines to be used on a daily basis:
A. Beds will be made early in the morning each day. Except for laundry day, each bed is to be made up with two sheets, a pillow with pillowcase, covered by the bedspread (which should be clean). The bedspread is to cover the top sheet and pillow neatly, and be tucked under the front pillow edge. The bedspread should be tucked under the bottom of the mattress and hang smoothly over the sides of the bed.
B. Persons served need not use a pillow for sleeping, but it must be kept in the room at night and used to make the bed each morning. The pillow will transfer with the person served.
C. Persons served must use sheets for sleeping and may use comforters. Once a person served discharges or transfers out of the building, both sheets and comforters will stay in the building and laundered for future use.
D. Persons served are not permitted to sleep during the day unless with staff permission.
E. Bedspreads are not to be removed from the room, except to launder them. They are not to be used for sunbathing or wrapping up in during cold weather. Blankets are to be used for these purposes.
F. Staff members are responsible for monitoring the use of beds and bedding. Persons served found to be misusing and/or abusing these items will be fined the appropriate cost
G. Persons served are expected to have rooms cleaned and straightened before they leave for school in the morning, or within one hour of their wake-up time on non-school days, to include the following:
1. Bed neatly made
2. Furniture dusted and personal items straightened or put away
3. Windows clean and sills dusted
4. Floor clean and vacuumed
5. Clothing put away neatly (not lying around)
6. No food or drink is permitted in youth bedrooms, except water
7. Trash cans emptied
H. A bulletin board is provided in many bedrooms. Personal pictures may be displayed only on the bulletin board and must be in good taste. No sexually suggestive, drug/alcohol-oriented items, or racially or explicitly offensive materials are permitted.
I. No nails, screws, or tape are permitted to be placed in the walls, doors or furniture. Nothing is permitted to be hung from the ceilings.
J. Staff will monitor residents’ electrical items for safety. No exposed wires are permitted.
K. Damage to a room and/or furniture of persons served must be reported to the Campus Director.
Long Term Structured Residence (LTSR)
Persons served are encouraged to make their beds and organize their bedrooms on a daily basis. If there is concern regarding completion of these tasks, it will be brought to the attention of the direct care staff for correction.
Persons served are permitted to sleep in their street clothes.
Persons served are responsible for weekly laundering of their sheets and clothing. Each person served is assigned a laundry day upon admission.
Each bedroom is equipped with the following: A single bed, bed pillow, bed linens and blankets, towels and wash cloths, a chair, bedside table, bedside lamp, towel bar/hook, dresser, mirror, and clothing wardrobe.
REFERENCECODE: PS- 214-003 - GJRPA
TITLE: LTSR Person Served Laundering Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS- 214-003 - GJRPA - LTSR Person Served Laundering Procedure
All persons served will launder their bedding, towels, and clothing on a weekly basis. This teaches the persons served transferrable skills related to independent living and maintaining their clothing and personal belongings. Monitoring the persons served while utilizing laundry machines and teaching them transferrable skills is a responsibility of all staff.
A. Persons served will have one assigned laundry time per week. If they are unable to utilize their assigned time, they will be provided another.
B. Persons served must launder their clothing and bed linens once per week.
C. Persons served are permitted to utilize the laundry machines during unassigned time in the case of an emergency.
D. Persons served will be monitored at all times while in the laundry room by attending staff.
E. There will be laundry detergent and dryer sheets available for persons served. They are permitted to utilize these during their assigned laundry time and while supervised by staff.
F. Persons served will be provided with individual laundry baskets. These items will be marked with the name of each person served.
REFERENCECODE: PS- 215 - GJRPA
TITLE: Prison Rape Elimination Act (PREA) Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-215-GJRPA - Prison Rape Elimination Act (PREA) Policy
As an agency serving persons at risk, it is the policy to assert and enforce the following policy and procedures regarding sexual abuse, assault, and harassment.
REFERENCECODE: PS- 215-001 - GJRPA
TITLE: PREA Definition Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-215-001-GJRPA - PREA Definition Procedure
The Prison Rape Elimination Act was passed in 2003. The law created the National Prison Rape Elimination Commission (NPREC) and charged it with developing standards for the elimination of sexual abuse in confinement. The law required the Department of Justice to review the NPREC standards, make revisions as necessary, and pass the final standards into law. The final rule was published in the Federal Register on June 20, 2012, and became effective on August 20, 2012. The standard requires an agency to establish a zero-tolerance policy for sexual abuse and sexual harassment. The policy also outlines the agency’s approach to preventing, detecting, and responding to such conduct. As a result of this act, George Junior Republic in PA has established the policy based on the PREA standards which all staff and employees will adhere to.
REFERENCECODE: PS- 215-002 - GJRPA
TITLE: PREA Rights Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/17/2025
PS-215-002-GJRPA - PREA Rights Procedure
The following steps must occur within 24-hours of a person served being admitted to George Junior Republic in PA:
1. An intake staff reviews the zero-tolerance requirements of the Prison Rape Elimination Act (PREA), including staff to person served and person served to person served sexual harassment, abuse, and/or sexual assault.
2. Persons served are given written information regarding PREA rights and agency responses.
3. Persons served view a video that further explains PREA rights and protections.
4. Persons served sign the PREA Youth Acknowledgement and Education form.
5. Staff completes the PREA Vulnerability Assessment Instrument to determine if the person served is vulnerable to victimization or has a history of sexually aggressive behavior. This information is used to determine the need for risk-based housing and safety plans.
6. Staff completes the Transgender/Gender-Variant Juvenile Statement of Search if applicable. If applicable and when completed, this form is sent to the PREA Coordinator, PREA Manager, and Campus Director.
Long Term Structured Residence (LTSR)
LTSR candidates will be screened prior to admission for risk of sexual aggression and sexual trauma history for consideration of eligibility and assessment of needs.
REFERENCECODE: PS- 215-003 - GJRPA
TITLE: PREA Considerations Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-215-003-GJRPA - PREA Considerations Procedure
George Junior Republic in PA as an agency providing services to at risk persons asserts and enforces the following procedures regarding sexual abuse, sexual assault, and sexual harassment. To ensure the safety, security, and well-being of persons served and employees, the agency strictly enforces zero tolerance of sexual harassment, abuse, and assault. The policies and procedures of the agency are designed to investigate, pursue, and eliminate threats of sexual abuse, harassment, or intimidation by aggressively investigating and reporting all incidents of sexual misconduct and taking active steps to prevent further occurrences. These policies and procedures apply to all interactions of both employee and persons served whether employee to employee, employee to person served, person served to employee, or person served to person served.
A. Prohibitive behaviors include any and all of the following:
1. Sexual abuse of a person served by another person served or by an employee
2. Remarks suggesting engaging in sexual activities
3. Touching of another individual’s body which would be considered sexual
4. Aggression toward or intimidation of another individual for sexual purposes
5. Statements of sexual suggestion which promise reward or reinforcement for sexual activity
6. Engagement in intimidation for the purpose of sexual activity
7. Rape
8. Forced (unwanted and unsolicited) touching of another person’s genitals
9. Voyeurism by an employee
10. Repeated unwelcome sexual advances, requests for sexual favors, or verbal comments, gestures, or actions of a derogatory or sexual nature
11. Repeated verbal comments or gestures of a sexual nature, including demeaning references to gender, sexually suggestive or derogatory comments about another’s body or clothing, or obscene language or gestures.
B. Sanctions
1. Any staff member who is suspected of sexual abuse, harassment, or rape toward another staff member or person served will be immediately removed from their position.
2. Further employment and permission to be on GJR in PA property will be suspended until the investigation clears the accusation or determines that termination is warranted.
3. Employees who engage in founded incidents of sexual abuse, intimidation, or harassment will be immediately terminated from their employment with the agency.
4. Any incident involving suspicion of sexual abuse, harassment, or rape will be immediately assessed.
C. Investigation and reporting
1. The preliminary investigation will determine whether the alleged act committed by the suspected staff or person served may constitute a criminal offense.
2. If the act committed raises to the level of criminal behavior it is the responsibility of the responding administrative staff member to contact the Pennsylvania State Police, (PSP) Mercer Barracks, and report the incident for criminal investigation.
3. Record the call to the police by documenting the date, time, and recipient of the call.
4. In addition to notification of alleged criminal acts to the PSP, reports must be made by the administrative staff to the Department of Human Services, Office of Children, Youth and Families and the placing agency. This includes the allegations, status of the investigation, and the personnel investigating.
D. PREA Coordinator and PREA Manager
1. The Risk Officer will serve as the PREA Coordinator.
2. The Compliance and Outcomes Coordinator is the PREA Manager
3. The Vice President of Operations is generally the contact and liaison with the state police, and coordinates investigation activities. This position is responsible to make certain that all persons served are informed the agencies PREA rights and protections.
4. The Staff Development Coordinator will ensure that all employees are trained and competent in the PREA standards and the agency’s procedures regarding PREA.
5. Campus Directors will monitor employees and persons served, and report any violations of the PREA standards to the PREA Coordinator or PREA Manager immediately, or to the Chief Executive Officer in the absence of the PREA Coordinator and Manager.
6. The Director of Health Services will address the immediate medical needs of persons served and employees in the event of a sexual assault. This may involve arranging for examination and referral to an appropriate medical treatment facility.
7. The Human Resources Officer will take personnel action as appropriate and defined within this PREA policy and procedures at the conclusion of any employee investigation.
REFERENCECODE: PS- 215-004 - GJRPA
TITLE: PREA Resident Management and Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-215-004-GJRPA - PREA Resident Management and Services Procedure
A. Supervising Persons Served
1. Campus Directors will regularly inspect the homes and units they are responsible for each week.
2. Given the nature and layout of the campus, Campus Supervisor visits are not announced and staff do not announce visits from administrative staff.
B. Search and Seizure
1. The search and seizure policy of George Junior Republic in PA specifically prohibits cross gender searches and pat downs.
2. Body searches are limited to Campus Supervisors and Secure Detention staff who have been properly trained.
3. Body cavity searches will only be done by medical personnel in an off-site emergency care setting in response to an emergent medical situation.
C. Privacy of Persons Served
1. Persons served will have the right to privacy for the purpose of showering, performing bodily functions, and changing their clothing.
2. All persons, including transgender individuals, are given the same and equal protection of privacy.
3. All bathrooms will be maintained as private and provide for individual use only.
D. Victim Services
1. Any person served who is a victim of sexual harassment or sexual abuse is entitled to physical and mental health services as defined in the treatment section of the Programming Services policy manual.
2. George Junior Republic in PA has developed a memorandum of understanding with AWARE of Mercer County to provide supportive services to victims of sexual abuse.
3. The telephone number and mailing address of AWARE of Mercer County is listed on the PREA information provided during the first 24 hours of admission to each person served.
4. The rights statement assures the confidentiality of communication with AWARE of Mercer County or the therapist of the person served.
E. Immediate Response to Sexual Abuse or Harassment
1. In the event of a sexual assault or rape, the Vice President of Operations will be the immediate administrator in charge of the reporting, investigation, and assignments of the duties of the staff.
2. The Campus Director will immediately ensure the following actions are completed.
a. The direct care employee(s) will immediately ensure the safety of the person served.
b. A staff nurse must be notified immediately of the alleged incident. During sleeping hours, the nurse on call must be notified.
c. Upon notification, the nurse will provide care and determine the extent of any physical harm, and make immediate referrals to the appropriate health care agency if needed. Generally, this requires the nurse to notify Allegheny Health Network, Grove City Medical Center, of the condition of the person served, medical information, insurance information, and the nature of the visit.
d. Persons served who has been sexually assaulted will be offered offsite medical and forensic exams immediately through a local medical center with a Sexual Assault Nurse Examiner (SANE).
e. The nurse will contact local healthcare providers to arrange for examination to ensure the availability of the SANE.
f. Transportation staff will transport the person served to the designated local hospital.
g. All medical assessment, care, and treatment will be provided to the person served free of charge. Medical care will not be withheld for any reason regardless of the victim’s failure to cooperate with the investigation into the incident of sexual assault.
h. GJR in PA and all representatives, employees, and volunteers will comply with and enact any treatment recommended for the victim.
1. Immediately ensure that a nurse examines the medical condition of the person served
2. Arrange transportation of the client to the Grove City Medical Center
3. Immediately secure the scene of the incident by going to the unit and informing the staff of the securing of the scene
4. Notify the Pennsylvania State Police (PSP) 724-662-6162 of the incident, individuals involved and the nature of the allegation of sexual assault or rape
5. Assist and coordinate the investigation with the PSP by providing information regarding any perpetrators, victims and possible witnesses
6. Complete and provide all placing agencies, parents and managed care companies of the allegation of the sexual assault or rape, status of the investigation including the involvement of the PSP and the contact number of the investigating officer
7. Record and file all statements of all individuals i.e. victim, witnesses and perpetrators and develop a file for the filing of all documents created regarding the incident
F. Medical Services
1. George Junior Republic in PA will maintain a memorandum of understanding with the Mercer County rape crisis center, AWARE, for the purposes of providing follow-up care and treatment for victims of sexual assault or rape. George Junior Republic in PA will ensure that any treatment recommendations made by the AWARE are followed in the treatment of the victim. Additionally, George Junior Republic in PA will arrange and facilitate transportation for any treatment sessions scheduled as part of the treatment of the victim.
2. George Junior Republic in PA will offer medical, therapeutic, and psychiatric services to persons served who have been sexually assaulted or raped in any facility other than George Junior Republic upon a victim’s admission. The admission physical will include questions regarding sexual assault or rape, and lead to an assessment of any person served who may have been victimized. Treatment for sexual assault or rape shall be included in the standard of care provided to each person served. Any person served who indicates that they have been sexually assaulted or raped, expresses a complaint of an STD symptom, or requests testing will be processed by the medical department for screening.
G. Search and Seizure
1. As per the search and seizure policy of George Junior Republic in PA, only an off-site emergency care provider may conduct any body cavity searches.
2. Cross gender body and visual searches by staff other than medical staff are forbidden.
3. All persons served, cross gender and intersex included, will be given the opportunity to shower, care for their bodies, and dress in privacy.
4. Female staff working with persons served will have to announce their entry into the bathrooms and bedrooms areas prior to entering the room to give the person served the right to privacy.
REFERENCECODE: PS- 216 - GJRPA
TITLE: Sexual Abuse & Harassment Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-216-GJRPA - Sexual Abuse & Harassment Policy
It is the policy of the agency to investigate, pursue and eliminate any threats of sexual abuse, harassment, or intimidation by aggressively investigating and reporting all incidents of sexual misconduct, and taking active steps to discipline and prevent further incidents.
REFERENCECODE: PS- 216-001 - GJRPA
TITLE: Sexual Abuse & Harassment Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-216-001-GJRPA - Sexual Abuse & Harassment Procedure
To ensure the safety, security, and wellbeing of the persons served and employees, George Junior Republic strictly enforces a zero tolerance of sexual harassment or abuse among the employees and persons served of George Junior Republic.
George Junior Republic’s administrative staff and personnel will make every effort to detect, eliminate, and respond appropriately to reports of sexual abuse or harassment. Responses to allegations of sexual abuse or harassment will be taken seriously, investigated thoroughly, and adjudicated in a timely manner. These policies and procedures apply to all interactions of both staff and persons served whether staff to staff, staff to person served, or person served to person served.
REFERENCECODE: PS- 217 - GJRPA
TITLE: Safety Plan Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-217-GJRPA - Safety Plan Policy
It is the policy of the agency that employees shall create, communicate, review, and update Safety Plans as identified in the following procedures.
REFERENCECODE: PS- 217-001 - GJRPA
TITLE: Safety Plan General Guidelines Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-217-001-GJRPA - Safety Plan General Guidelines Procedure
The licensing regulations of the state of Pennsylvania stipulate that each resident have a written health and safety assessment within 24 hours of admission. If this assessment identifies health and/or safety concerns, then individual safety plans will be developed, implemented, and reviewed. This includes those who have a history of or who have presented a threat to themselves or others or who have engaged in activities which could possibly pose a threat while in the care of George Junior Republic in PA.
According to the regulations, a safety plan is necessary and must be initiated immediately when the following information is present:
A. Known or suspected suicidal gestures
B. Known incidents of aggressive or violent behaviors toward others
C. History of aggression toward self
D. Known history of substance abuse
E. Sexual history or behavior patterns which may place other children at risk In addition to these, nurses may initiate safety plans for the following behaviors:
A. Suicide attempt
B. Assaultive behavior to others
C. Aggression toward self (self-injury)
D. Drug and alcohol history, or acute intoxication or withdrawal
E. History of sexual acting out or behaviors which may place others at risk
F. Asthma
G. Wound care
H. Diabetes
I. Anaphylactic shock (severe allergic reaction)
J. Seizures
K. Concussions
Health Services staff will maintain and review safety plans for areas F-K as identified above.
Safety Plans will be kept in the home in a separate Safety Plan binder which is accessible to all incoming staff who work in the building. Safety Plan binders in all treatment homes are to be kept inside the first aid cabinet, ensuring that all staff, regardless of the location they are working, know where to access the
safety plans. For each Safety Plan, there is a master copy and additional copies for use. Maintain the master copy in the Safety Plan binder and use it to make additional copies.
The Treatment Team must share, file, and review Safety Plans when needed. When the direct care staff initiates a Safety Plan, a copy is sent to Health Services and placed in the Safety Plan binder. The Health Services may initiate Safety Plans for persons served as well, and these must be placed in the binder.
Safety Plans will be reviewed at team meetings in all programs according to the identified timeframe on each plan. It must be signed by the Campus Director, TTC, or Residential Manager in Special Needs Units. Some plans do not need to be reviewed or amended, and some will terminate depending on the nature of the plan. If there is a space for a plan to be reviewed, you must review it on a regular basis.
Long Term Structured Residence (LTSR)
Safety Plans will be reviewed and amended based on necessity and development of the recovery plan of persons served. They must be signed by the LTSR Program Director.
REFERENCECODE: PS- 217-002 - GJRPA
TITLE: Safety Plan Implementation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 1/11/2024
PS-217-002-GJRPA - Safety Plan Implementation Procedure
A. Nurses will do the initial safety interview with a person served when they are first admitted to GJR in PA. If the nurse completing the intake for the person served identifies a specific medical safety concern, a safety plan will be completed that addresses that concern. The person who is responsible for reviewing that safety concern on a regular basis is located on the right side of the safety plan.
1. When nursing completes a form, the original is placed into the Health Services safety plan logbook and copies are emailed to the Residential Manager of the person served. Nursing also calls the school to relay information related to any allergies or diagnoses of asthma.
2. The Residential Manager print the safety plans and communicate the information to staff regarding review of non-medical safety plans. The safety plans are kept in the Safety Plan binder of the residence of the person served.
3. In addition to the actual safety plans, the last page of the nursing interview will also be sent to the unit/campus home and school, as it includes allergies, restrictions, etc.
B. For persons served who are not new, but a new risk has been identified, a safety plan will be initiated.
1. Once a person served is placed in a unit/campus home, their safety plan must be reviewed on a regular basis as specified on the form. This time period will vary based on the severity of the safety concern and is noted on each form. Safety Plan forms must be reviewed at the unit/campus home treatment team meeting and signed by the reviewing staff no less than every 6 months or earlier, as indicated on the form.
2. Every Campus Home/Unit is to keep the current safety plans for their persons served in the Safety Plan binder, which is located in the first aid cabinet. This must be available to every staff member who is responsible for the care of the persons served in that Campus Home/Unit.
Long Term Structured Residence (LTSR)
LTSR Nursing staff and therapists will create safety plan(s) with person served when they are admitted to the program. Each person served will have a safety plan, regardless of their risks.
REFERENCECODE: PS- 218 - GJRPA
TITLE: Supervision Plan Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-218-GJRPA - Supervision Plan Policy
It is the policy of the agency to create, initiate, communicate, and update Supervision Plans as indicated in the following procedures.
REFERENCECODE: PS- 218-001 - GJRPA
TITLE: Supervision Plan Procedures
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-218-001-GJRPA - Supervision Plan Procedures
In the event of an allegation of child abuse, the Vice President of Operations will create a supervision plan for employees named as alleged perpetrators. A supervision plan is designed to ensure the safety of the alleged victim of child abuse. Additionally, it protects the alleged perpetrator from charges of retaliation or threats toward the victim. Supervision plans must be followed and remain in effect until the alleged abuse is investigated and adjudicated. The plan can include any of the following steps:
A. Removal from duty pending the investigation
B. Increased supervision to ensure child safety
C. Transfer to a substantially different area of the organization with different persons served
D. Transfer to a different more closely supervised shift
E. Transfer to different job responsibility that does not include contact with persons served
F. Other appropriate actions as indicated by the circumstances
G. Immediate termination from employment
In the event of an emergency or after hours, a Campus Supervisor may relieve a staff member from duty or transfer the person served to another environment until notification of the incident is provided to a Campus Director and a supervision plan has been established.
The steps taken will be dependent upon the unique circumstances of each allegation.
Long Term Structured Residence (LTSR)
In the event of an abuse allegation, the LTSR Program Director will create supervision plans for employees identified as alleged perpetrators. In the event of an emergency, the Program Director may relieve a staff member from duty until the supervisor plan is in place or an allegation is investigated.
REFERENCECODE: PS- 219 - GJRPA
TITLE: De-escalation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-219-GJRPA - De-escalation Policy
It is the policy of the agency to make attempts to de-escalate persons served before more restrictive procedures are utilized when possible.
REFERENCECODE: PS- 219-001 - GJRPA
TITLE: De-escalation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-219-001-GJRPA - De-escalation Procedure
De-escalation includes nonverbal, para-verbal, and verbal de-escalation techniques. The therapeutic milieu of GJR in PA programs is one in which the rights and dignity of persons served will be respected, and persons served will be placed in the least restrictive environment in order to maximize individual responsibility. Passive physical restraints are used as an atypical and temporary response. These interventions are used in situations with adequate and appropriate justification to protect a person served from causing harm to self or others. Other resources and available techniques that will be considered prior to a restraint will include but not be limited to the following:
A. Providing verbal prompts and reminders
B. Non-verbal interventions (planned ignoring, environmental changes, hand signals)
C. Take the person served aside
D. Offer choices
E. Model coping skills and regulation skills
F. Redirection to another activity to modify or change person’s served focus
G. Increased supervision
H. Active listening
I. Attention to concerns and feelings
J. Reality orientation
K. Educating persons served and families about restraints, including behaviors which trigger the need for a restraint
L. Unobtrusively identifying persons served who are at risk for a restraint so that staff can increase observation and prevention measures
M. Ongoing medication management monitoring
N. Carefully observing persons served group interaction to detect early signs of aggressive behavior and intervening prior to aggression escalating
O. Increasing emphasis on person served/staff interaction, such as staff doing paperwork in areas in which they can closely observe person served
P. Offering person served use of the quiet, comfort, or sensory room
Q. Prevention of counter-aggression by staff by substituting alternative staff as necessary (switching-off or tapping out)
R. Preventative Planned Teaching/Role Play
S. 15-second rule (removing the peer audience)
T. Counseling
Long Term Structured Residence
The use of physical and chemical restraints and seclusion is not permitted in the LTSR.
techniques of de-escalation for persons served will be identified upon admission to the LTSR and will be documented in their Crisis/Safety Plan or Wellness Recovery Action Plan. All staff will work with persons served in identifying appropriate crisis plan options during de-escalation.
If direct care staff work to de-escalate a person served and they are continuing to present immediate danger to themselves or others, appropriate authorities must be called to ensure safety of all within the LTSR.
REFERENCECODE: PS- 219-002 - GJRPA
TITLE: 15 Second Rule Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-219-002-GJRPA - 15 Second Rule Procedure
A. The 15 second rule will be used when one or more persons served is emotionally and/or behaviorally dysregulated in view of other persons served.
B. The persons served not involved in the situation will be asked to go to their bedrooms or other identified area to remove the audience while the staff focus on regulation of their peer.
C. When the phrase "15 second rule" is announced by staff, the persons served are asked to immediately and quickly go to their bedrooms or other identified area until the situation has been diffused, and staff announce they can return and re-engage in prior activities.
D. Staff not involved in the de-escalation process will monitor persons served in their rooms.
E. The person served involved in the incident will be separated and the time out room will be used if necessary and possible.
F. Cooperation with the 15 second rule will be positively reinforced.
Long Term Structured Residence (LTSR)
The 15 Second Rule Procedure is observed at the LTSR as an encouragement
REFERENCECODE: PS- 220 - GJRPA
TITLE: Restrictive Procedures Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-220-GJRPA - Restrictive Procedures Policy
It is the policy of the agency to de-escalate a person served before utilizing a restrictive procedure when at all possible. Additionally, only permitted restrictive procedures may be used in order to preserve the treatment environment.
REFERENCECODE: PS- 220-001 - GJRPA
TITLE: Restrictive Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-220-001-GJRPA - Restrictive Procedure
Person served in care may be dysregulated, impulsive, and physically aggressive. Staff members must recognize that these are responses of persons who are troubled and intervene in a professional and ethical manner. The impact of trauma, past and present, is significant and must be included in planning. Recognizing dysfunctional behavior patterns, mentally and emotionally placing oneself outside of the situation, and intervening therapeutically is the sequential standard that all GJR in PA staff must practice. The goal is nonphysical intervention that allows a person served to develop healthy behavior patterns. The safety and wellbeing of persons served must be the primary concern of staff. It is the duty and responsibility of all GJR in PA employees to preserve the dignity, rights, and respect the well-being of all persons served.
Legal Basis
Title 55 PA. Code, Chapter 3800.201 – 3800.213
Office of Mental Health and Substance Abuse Bulletin Number OMHSAS-02-01
Reference: Department of Public Welfare Special Transmittal issued 1-30-06 entitled “Strategies and Practices to Eliminate Unnecessary Use of Restraint”
In all cases, GJR in PA staff will use non-physical interventions before a physical (manual) safety intervention. The Office of Mental Health and Substance Abuse Services Bulletin (OMHSAS-02-01) issued 48-02 defines the safety intervention as follows:
A manual emergency safety intervention is “a physical, hands-on technique lasting more than one minute (55 PA Code 3800.211) that restricts the movement or function of the child or a portion of a child’s body. A manual restraint does not include a manual assist of any duration for a child during which the child does not physically resist…” The use of manual safety interventions that apply pressure or weight on the youth’s respiratory system is not permitted by regulation (55 PA Code 3800.211).
Additionally, at George Junior Republic in PA, any time that a staff member attempts to secure a person served in a hold and the person served resists, this is treated as and documented as a restraint, even if it the duration is less than one minute.
REFERENCECODE: PS- 220-002 - GJRPA
TITLE: Restrictive Procedures Training and Requirements Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-220-002-GJRPA - Restrictive Procedures Training and Requirements Procedure
A. Restrictive Procedure training and requirements
All direct care staff will receive annual training in non-physical methods of calming and deescalating persons served, as well as employing restraints. Prior to working with any person served, staff will receive training in less restrictive alternatives to the use of restraints. New employees will receive a minimum of 30 hours of training that includes but is not limited to the following:
1. Listening skills
2. Communication skills
3. Relationship building with persons served and families
4. De-escalation techniques
5. Conflict resolution
6. Violence prevention
7. Mental Health
8. Risk assessment
9. Debriefing techniques
10. Possible negative psychological effects of restraints
11. Understanding of how age, gender, sexual orientation, cultural background, history of abuse, or trauma may affect persons served
12. Individual’s response to a physical intervention
13. The proper application of manual restraints appropriate to the age, weight, and diagnoses of the persons served
14. The developmental stages of children/adolescents and their vulnerabilities in determining or assessing physical intervention utilization.
15. How to monitor individuals in a physical intervention
16. Restraint documentation
Prior to working with any person served, staff will receive at least eight hours of physical training on utilization of restraints. Staff will be tested on non-physical and physical techniques for responding to crisis situations. Only staff members that have completed an instructor-certified Safe Crisis Management course may use restraints. A record of staff training hours will be maintained in the Learning Management System and will include the date and length of each course or training session.
Long Term Structured Residence (LTSR)
Prior to working in the LTSR, direct care staff will receive at least nine hours of Safe Crisis Management Adult training, which focuses on topics #1-11 above.
REFERENCECODE: PS- 220-003 - GJRPA
TITLE: Restrictive Procedures Plan Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-220-003-GJRPA - Restrictive Procedures Plan Procedure
Restrictive procedure plan
A. When restrictive procedures will be used with any person served beyond unanticipated use, a restrictive procedure plan will be written and included in the Individual Service Plan. A restrictive procedure plan must be written when any type of restrictive procedure is used four times for the same person served in any consecutive three-month period. (PA code 3800.203)
B. The plan will be developed and revised by the treatment team of the person served under the supervision of the Campus Director and with the participation of the person served, the parent/guardian/agency representative of the person served, and other appropriate professionals and interested persons. The Restrictive Procedure Plan goal will be added from the electronic health record to the treatment plan of the person served.
C. The plan will be reviewed no less than every six months and revised as needed.
D. The plan will be reviewed, approved, signed and dated at least every six months by persons involved in the development, execution, and revision of the plan.
E. The plan will include specific behavior to be addressed, observable signals that occur prior to the behavior, and the suspected cause of the behavior including historical trauma.
F. The plan will include the behavioral outcomes desired and stated in measurable terms.
G. The plan will include the methods for modifying or eliminating the behavior, such as change in the physical and social environment, changes in the routine, use of sensory tools, improving communications, teaching skills, and reinforcing appropriate behaviors of the person served.
H. The plan will include the types of restrictive procedures that may be used and the circumstances under which they may be used.
I. The plan will include the length of the time the restrictive procedure may be utilized.
J. The plan will include the following: health conditions that may be affected by the use of specific restrictive procedures such as heart conditions, respiratory conditions, seizure disorders, history of prior sexual abuse, and physical disabilities.
K. The Treatment Team will be responsible for monitoring and documenting progress with the plan
L. The plan will be implemented as written and may be discontinued when determined to be no longer necessary by the treatment team.
M. Copies of the plan will be kept in the record of the person served and will be readily available in the residence.
REFERENCECODE: PS- 221 - GJRPA
TITLE: Time Out (Exclusion) Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-221-GJRPA - Time Out (Exclusion) Policy
It is the policy of the agency to use Time Out to support a person served in de-escalating behavior according to the following procedures.
REFERENCECODE: PS- 221-001 - GJRPA
TITLE: Time Out (Exclusion) Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-221-001-GJRPA - Time Out (Exclusion) Procedure
A. Exclusion is defined as the removal of a person served from their immediate environment and restricting them alone to a room or area. If a staff member stays in the area with the person served, it is not exclusion.
B. Exclusion may not be used for more than 60 minutes, consecutive or otherwise, within a 2-hour period.
C. Exclusion may not be used for a person served more than 4 times in a 24-hour period.
D. A staff member must observe a person served in exclusion at least every 5 minutes.
E. A room or area used for exclusion shall have the following:
1. At least 40 square feet of indoor space
2. A minimum ceiling height of 7 feet
3. An open door or a window for observation
4. Lighting and ventilation
5. Absence of any item that might injure a person served
Long-Term Structured Residence (LTSR)
Exclusion of persons served is utilized as a de-escalation strategy, and will be encouraged for persons served to implement as a personal strategy relating to their recovery plan.
REFERENCECODE: PS- 222 - GJRPA
TITLE: Prohibited Treatment Techniques Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-222-GJRPA - Prohibited Treatment Techniques Policy
It is the policy of the agency to adhere to the procedures regarding seclusion and pressure points, and to prohibit the use of aversive treatment.
REFERENCECODE: PS- 222-001 - GJRPA
TITLE: Prohibited Treatment Techniques Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-222-001-GJRPA - Prohibited Treatment Techniques Procedure
A. Seclusion, defined as restricting a person served in a locked room and isolating from personal contact, is prohibited. A locked room is a room with any type of door-locking device such as a key lock, spring lock, bolt lock, foot pressure lock, or physically holding the door shut.
B. The use of aversive conditioning, defined as the application of startling, painful, or noxious stimuli, is prohibited.
C. Pressure point techniques, defined as the application of pain for the purpose of achieving compliance, are prohibited.
GJR Secure Detention
A. Seclusion is defined as placing a youth in a locked room. Seclusion does not include lock down during normal sleeping hours and as part of the daily routine. Seclusion will not be used in lieu of adequate programming or staffing.
B. Detention staff must receive authorization by supervisory staff prior to each use of seclusion. This authorization can be either verbal or written. The approval must be documented by staff which will include date, time and name of supervisor approving the use of seclusion.
C. Seclusion may not exceed 4 hours in a 24-hour time frame.
D. Any time a youth is in seclusion staff must observe the youth every 5 minutes. This is to be documented on the appropriate form.
E. The physical needs of the youth must be met promptly when the use of seclusion is implemented.
F. Supervisory staff who is not continually observing the youth in seclusion must check the youth at least every two hours. This is to be documented on the Use of Seclusion form.
G. The use of seclusion may not exceed 8 hours in any 48-hour period without a written court order.
H. Mechanical restraints and seclusion may not be used simultaneously for any youth.
I. The use of any combination of seclusion and mechanical restraints for any youth may not exceed 6 hours in any 48-hour period without a written court order.
Long Term Structured Residence (LTSR)
Seclusion procedures are not permitted at the LTSR as outlined in 55 PA Code 5320.54.
PS-223-GJRPA- Restraint Policy
REFERENCECODE: PS- 223 - GJRPA
TITLE: Restraint Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 4/1/2021
It is the policy of the agency to permit only the use of passive physical restraints according to the procedures.
REFERENCECODE: PS- 223-001 - GJRPA
TITLE: Restraint Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 7/17/2025
PS-223-001-GJRPA - Restraint Procedure
A. George Junior Republic in PA’s core values and beliefs regarding the utilization of restraints include:
1. Elimination of the use of restraints is a shared goal of all employees of George Junior Republic in PA.
2. A restraint is a physical intervention and should be implemented in a manner designed to protect the safety, dignity, and well-being of persons served.
3. A restraint should not be used as a substitute for treatment, as punishment, to address a person served failing to comply with a directive, or for the convenience of staff. Restraints will not be used in lieu of adequate programming or staffing.
4. A restraint should only be used as the last resort in situations where harm may come to the person served or others, and only after appropriate and less restrictive therapeutic interventions have been ineffective.
5. Once a restraint is initiated, it should be as limited in time as possible. The staff must work together with the person served to lessen the duration of the episode.
B. A restraint may only be used when a person served poses imminent risk of harm to self or others. Examples of danger to self and others that may require a restraint include:
1. A disturbance that threatens serious or imminent danger to self or others, such as an assault.
2. Possession of a weapon or object that is being used as weapon and the likelihood of serious or imminent harm to self or others.
C. Examples of events that do not present danger to self or others, and when a restraint should not be used include:
1. Persons served refusing to comply with staff instructions or participate in an activity
2. Persons served swearing at staff or calling staff names, making threatening remarks or looks
3. Persons served destruction of property that does not present a danger to self or others
4. Persons served turning their back to staff or walking away
D. Within 14 days of admission, a person served will have a physical health examination by a licensed physician, physician assistant, or nurse practitioner who will document whether the person served has health or safety restrictions or pre-existing conditions which would preclude the use of all or specific types of physical restraints during care at GJR in PA. The person served
will be re-evaluated at least annually by a licensed medical healthcare provider with a reassessment in writing to determine the presence of any physical restrictions. If a physical condition is identified which restricts use of a restraint, this must be documented in Plan of Care Addendum by medical staff and a Restrictive Procedures Plan created by treatment staff. This addendum is immediately forwarded to the following related to the person served: Campus Director, Therapist/Case Manager/Treatment Team Coordinator, Residential Manager, Behavioral Health Tech, Counselor Parent, and Campus Supervisors. The Treatment Team Coordinator, Therapist/Case Manager/Residential Manager and/or Counselor Parent will ensure all staff are informed of the person’s served medical status.
E. When utilizing a restraint, the following practices will be adhered to in order to ensure the safety and well-being of all involved.
1. The least restrictive technique must be utilized during a restraint event.
2. When applying a restraint, at least two staff trained in the use of manual restrictive procedures should be involved in any intervention to manage the person served when possible. Multiple person restraints are always safer than single person restraints, therefore should be used whenever possible. A third trained staff member who is not involved with applying the restraint should continuously observe the restraint and the emotional condition of the person served, and document the observation at least every ten minutes during the time the restraint is being applied. The staff observing the restraint may order a cessation of the restraint if he/she believes it necessary or advisable to ensure the physical well-being of the person served, or if continuation of the restraint is no longer necessary.
3. As soon as is reasonable and safe, following the initiation of a restraint, staff must notify nursing staff and campus supervisors.
4. No restraint will last more than 10 minutes without a change of position by the intervening staff.
5. Staff must take into consideration any medical conditions or safety plans of the person served. A restraint cannot be utilized on persons served who possess a medical or physical condition where there is reason to believe that such use could endanger their lives or exacerbate the condition, such as a fracture or back injury. At no time shall a staff member apply their weight to any portion of the respiratory system of the person served. Trained staff must take into consideration the history of the person served when making the decision to utilize a restraint.
6. No mechanical devices or items may be used to physically intervene with a person served.
7. Prone restraints are prohibited by Pennsylvania Code.
8. A staff member must contact a Campus Supervisor as soon as possible when a restraint occurs.
9. Nursing staff must be notified as soon as possible following the initiation of a restraint.
10. Within 1 hour of staff having applied a restraint, a face-to-face assessment of the physical well-being of the person served will be documented by a licensed nursing staff. Medical emergencies require that staff call 9-1-1.
F. The initiator of the restraint must complete the restraint incident report in its entirety by the end of the shift.
1. A staff member’s documentation components will be defined by their role in the restraint event (initiator, involved, witness).
2. Staff are to enter their required restraint documentation in the person served record in the electronic health record.
GJR Secure Detention
A. In Secure Detention, the only type of mechanical restraints permitted are handcuffs and leg restraints.
B. The GJR Secure Residential Manager and Director of Secure Programs and Campus Security will approve and authorize use of mechanical restraints, except for those restraints used during transportation, through completion of the Mechanical Restraint document.
C. Use of mechanical restraints, except for those restraints used during transportation, may not exceed two hours without an examination of the youth by an agency nurse and the continued use of mechanical restraints ordered by a physician. After the subsequent 2-hour period ordered by a physician has elapsed, use of mechanical restraints must be discontinued.
D. If a mechanical restraint is removed for any purpose other than for movement and reused within 24 hours after the initial use of the restraint, it is considered continuation of the initial restraint. This does not apply to mechanical restraints used during transportation.
E. In the event that mechanical restraints are used, staff are to perform a check at least every 15 minutes for proper fit. This is to be recorded on the Mechanical Restraint Document
F. The physical needs of the youth shall be met promptly when the use of mechanical restraints is implemented.
G. Handcuff and leg restraints shall be removed completely for at least 10 minutes during every 2hours the restraint is used. This is not applicable to restraints during transport.
H. Handcuff and leg restraints shall be checked and observed by a supervisory staff person who is not administering the restraint, at least every 1 hour. This is not applicable to restraints during transport.
I. The use of handcuff and leg restraints may not exceed 4 hours in any 48-hour period without a written court order. This is not applicable to restraints during transport.
Long Term Structured Residence (LTSR)
The use of restraints for behavior management is not permitted at the LTSR as outlined in 55 PA Code 5320.54.
REFERENCECODE: PS- 223-002 - GJRPA
TITLE: Orders for Restraints
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-223-002-GJRPA - Orders for Restraints
Passive physical restraint must be ordered by a physician or designated qualified practitioner who has training and competence in the prevention and management of unsafe behaviors.
As soon as possible following initiation of passive physical restraint, staff are to contact agency nursing via the Health Services Department. Once notified, a licensed nurse will contact the on-call practitioner to obtain an order for the restraint. The order should be entered into the record of the person served as soon as possible, but not more than 2 hours after the initiation of the restraint. The practitioner giving the order for restraint must sign or otherwise validate the order as soon as possible thereafter.
If the on-call practitioner giving the order for restraint is not also the treating practitioner, then the nurse who obtained the order for restraint will also notify the treating practitioner of the restraint as soon as possible thereafter.
An order for restraint may not exceed 1 hour for children and youth under the age of 18, or 4 hours for those over the age of 18.
Persons served must be released at the end of 1 hour. If the situation remains unsafe, passive physical restraint may be reapplied, but would require a new order.
Standing orders for the use of restraint are not permitted.
REFERENCECODE: PS- 223-003 - GJRPA
TITLE: Restraint Observation by Campus Supervisor Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-223-003-GJRPA - Restraint Observation by Campus Supervisor Procedure
A. Given that the primary goal of George Junior Republic in PA is to eliminate the use of restraints, all possible resources are used to support this effort. Campus Supervisors frequently lead crisis responses and as such, are to be alerted to any type of physical intervention. The intent is to assist and support direct care staff in de-escalating person served and offering alternatives to physical intervention.
B. Any time a staff member physically intervenes with a person served, the staff must notify the Campus Supervisor by telephone as soon as safely possible that there is or has been an occurrence or via panic alarm. This policy includes all physical redirections regardless of how long they last or where they occur.
C. The Campus Supervisor will immediately proceed to the site to either assist in or monitor the situation.
D. Note that this applies to any interactions in which staff place hands on a person served to redirect and the person served resists, at all locations on or off campus and includes activities, educational settings, counseling, and all other areas.
REFERENCECODE: PS- 223-004 - GJRPA
TITLE: Evaluation Following Restraint
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-223-004-GJRPA - Evaluation Following Restraint
Within one hour of the initiation of passive physical restraint, a face-to-face evaluation of the involved person served will be provided.
The post-restraint evaluation will include the following:
A. Physical well-being
1. Pulse
2. Respirations
3. Blood Pressure
4. Physical injuries
5. Pain
B. Emotional well-being
1. Is the person served cooperative with assessment?
2. What is their mood?
C. Psychological well-being
1. Is the person served oriented to person, place and time?
2. Is the person served able to recall the events that led up to the incident?
If the person served presents with physical injuries or reports pain as a result of the restraint, immediate medical attention will be provided by the nurse conducting the evaluation. If the injury requires advanced care, transport for further evaluation will be arranged, or emergency services will be contacted.
REFERENCECODE: PS- 223-005 - GJRPA
TITLE: Persons Served De-Briefings Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-223-005-GJRPA - Persons Served De-Briefings Procedure
A. When a restraint occurs, George Junior Republic in PA requires that the person served and staff involved are debriefed in order to attempt to mitigate possible adverse and traumatizing effects for all involved. The treatment team will use the information from the debriefing process to assist in problem analysis to reduce physical intervention with the individual person served and overall organizational reduction of with the goal of elimination of restraints.
B. It is the responsibility of the Residential Manager to document their debriefing of the restraint with both the staff initiating the restraint and the person served If the staff initiating the restraint is the Residential Manager, either the Treatment Team Coordinator or Campus Director will complete the debriefing. The Staff Restraint Debriefing form is located within restraint incident report in the electronic health record. This is accessed through the record of the person served in the electronic health record.
REFERENCECODE: PS- 223-006 - GJRPA
TITLE: Parental Notification and Acknowledgment of Safe Crisis Management, Exclusion, and Time Out Utilization Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-223-006-GJRPA - Parental Notification and Acknowledgment of Safe Crisis Management, Exclusion, and Time Out Utilization Procedure
The person served and family will be educated concerning the use of manual restraints. When possible, the education process will begin prior to admission at the time of the initial interview with the person served and family. Review will occur at the time of the admission. Person served and family education will include:
A. Definition of Time Out
B. Explanation of behaviors that may lead to the use of restraints
C. Explanation of appropriate available alternative responses and behaviors
D. Identification of person served/family participation in treatment which could reduce the use of restraints
E. The parental notification of George Junior Republic in PA’s use of restraints is contained in the Parent/Guardian Information Guide that is sent to the custodial parent of each person served.
F. Parent notification is required any time their child is involved in a restraint. This notification is to be made by a member of the treatment team of the person served within 24 hours of the restraint event. Staff will document all contacts on placing agency and family contact records.
REFERENCECODE: PS- 223-007 - GJRPA
TITLE: Administrative Review of Restraints Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 5/8/2024
PS-223-007-GJRPA - Administrative Review of Restraints Procedure
A. All incidents involving the use of passive physical restraint (or use of mechanical restraint in the secure detention program) will be reviewed by the Campus Director assigned responsibility for the program.
B. Campus Directors will review all completed submitted documentation (incident report, nursing assessment, etc.) and all available video footage of the incident within 72 hours of occurrence. Documentation of the review will be completed using the Restraint Review Form.
C. Upon completion, Campus Directors will submit the Restraint Review Form to the Vice President of Operations for final review and/or approval.
1. Any concerns resulting from the review process will be addressed in consultation with the Campus Director, Human Resources, the involved staff, and the regulatory agency personnel (if warranted). Corrective interventions may include, but are not limited to retraining, disciplinary action, suspension, termination, or reporting of the incident to law enforcement for further investigation.
D. Upon completion of the review, all documentation will be submitted to the Compliance and Outcomes Coordinator.
REFERENCECODE: PS- 224 - GJRPA
TITLE: Reportable and Recordable Incidents Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-224-GJRPA - Reportable and Recordable Incidents Policy
It is the policy of the agency to report and record incidents as identified in the following procedures.
REFERENCECODE: PS- 224-001 - GJRPA
TITLE: Reportable and Recordable Incidents Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-224-001-GJRPA - Reportable and Recordable Incidents Procedure
A. Pennsylvania Title 55, Chapter 3800.16 defines reportable incidents to include the following:
1. “Death of a child;
2. A physical act by a child to commit suicide;
3. An injury, trauma or illness of a child requiring inpatient treatment at a hospital;
4. A serious injury or trauma of a child requiring outpatient treatment at a hospital; not to include minor injuries such as sprains or cuts;
5. A violation of a child’s rights;
6. Intimate contact between children, consensual or otherwise;
7. A child absence from the premises for four hours or more without the approval of staff persons, or for 30 minutes or more without the approval of staff persons if the child may be in immediate jeopardy;
8. Abuse or misuse of a child’s funds;
9. An outbreak of a serious communicable disease as defined in 29 Pa. Code 27.2 (relating to reportable diseases);
10. An incident requiring the services of the fire or police departments; and
11. Any condition which results in closure of a facility.”
B. The Campus Director responsible for persons served involved in the incident or nursing staff, if the event is medical in nature, will complete a written reportable incident report online on the Commonwealth’s Home and Community Services Information System (HCSIS). In-state agencies can then access the information through the statewide database. Out-of-state agencies will receive an email regarding the details of incidents.
C. The Campus Director, nursing staff, or another designee will immediately notify parents and/or, if applicable, guardians or custodians of persons served following a reportable incident relating to a specific person served, unless restricted by applicable confidentiality statutes, regulations, or an individual’s court order.
D. The Vice President of Operations, Campus Director, , or Compliance and Outcomes Coordinator will report to the Department of Human Services Regional Office of Children, Youth, and Families and
the contracting agency within 12 hours, any incident of fire requiring the relocation of persons served and unexpected death of a person served.
E. The Campus Director will initiate an internal investigation of a reportable incident immediately following the report of the incident and will complete the investigation as soon as possible. When a licensing or police investigation is involved, the internal investigation will not take place until the external investigation is complete. The Campus Director or Vice President of Operations will provide the information to the placing agencies following the conclusion of the investigation when required.
F. Copies of reportable incident reports and investigations will be provided to the Vice President of Operations, and the Compliance and Outcomes Coordinator. Reportable incidents will be tracked and trended in order to identify opportunity for performance improvement initiatives.
G. The staff in each home will record of all reportable and recordable events, including but not limited to the following:
1. Suicidal gestures/ideation/threats
2. Incidences of intentionally striking or physically injuring a person served
3. Property damage of more than $500.00
4. Any time staff suspects, witnesses, or obtains a report regarding child abuse
5. Any time a person served is arrested
6. Any time staff needs to document an unusual incident or situation involving a person served or staff member
7. The absence of a person served from the premises without the approval of staff persons that does not meet the definition of a reportable incident in section A of this procedure
8. Injuries, traumas, illnesses or medical events of persons served such as seizures that do not meet the definition of reportable incidents also in section A of this procedure
A GJR in PA Incident Report, found in Documents Published by GJR Administration, Incidents ReportsGJR Forms folder, will be completed by staff prior to ending their shift and placed in the Incident Report box. These reports will be processed the next business day. The original incident reports are forwarded to the responsible Campus Director and copies distributed to designated administrative staff. Once approved, the Campus Director will place the original report in the Records Office mailbox for filing in the permanent record of the person served.
H. Incidents will be tracked, trended, and reviewed and reviewed at least annually by the administrative teams in order to mitigate risk and support quality improvement. In conformance with CARF standards, at least the following broad areas will be monitored for occurrences:
1. Medication errors
2. Use of seclusion (not permitted by PA 55.3800 regulations), except in Secure Detention.
3. Use of restraint
4. Incidents involving injury
5. Communicable disease
6. Infection control
7. Aggression or violence
8. Use and unauthorized possession of weapons
9. Wandering
10. Elopement
11. Vehicle accidents
12. Biohazard accidents
13. Unauthorized use and possession of legal or illegal substances
14. Abuse
15. Neglect
16. Suicide and attempted suicide
17. Sexual assault
18. Overdose
19. Other sentinel events
REFERENCECODE: PS- 224-002 - GJRPA
TITLE: Incident Report Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-224-002-GJRPA - Incident Report Procedure
Documentation of incidents occurring with persons served placed with George Junior Republic in PA is necessary to ensure accurate recording of recordable incident. Tracking and trending supports improved safety and positive outcomes.
A GJR in PA Incident Report, found in Documents Published by GJR Administration, Incidents Reports-GJR Forms folder, is required each and every time the following situations occur:
A. Any time persons served demonstrate suicidal gestures, express suicidal ideation, or threaten suicide (Note that there is a separate suicide report form to use found in Documents Published by GJR Administration, Incidents Reports-GJR Forms folder.)
B. Any incident in which a person served strikes another person served
C. Any time staff suspects, witnesses, or obtains a report regarding child abuse
D. Any time a person served damages property worth more than $500.00
E. Any time a person served absconds or is absent from the premises without the approval of staff
F. Any time a person served acquires an injury, trauma, or severe illness; including any time a person served has a seizure
G. Any time a person served is arrested
H. Any time there is sexual contact between persons served
I. Any time there is a violation of a person’s served rights
J. Any time staff needs to document an unusual incident or situation involving a person served or staff member
All Incident Reports must be completed by the end of the shift.
Incident Reports will be reviewed by the Vice President of Operations, Compliance and Outcomes Coordinator, and Campus Directors in order to track and monitor trends. Trends will be addressed and initiatives developed in order to decrease and prevent future occurrences.
REFERENCECODE: PS- 224-003 -GJRPA
TITLE: LTSR Reportable and Recordable Incidents Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS- 224-003 -GJRPA LTSR Reportable and Recordable Incidents Procedure
A. Pennsylvania Title 55, Chapter 5100 defines reportable incidents to include the following:
1. allegations of abuse
2. allegations of violations of person served rights in the LTSR
3. death of a person served
4. a physical act by a person served to commit suicide
5. an injury, trauma or illness of a person served requiring inpatient treatment at a hospital
6. a serious injury or trauma of a person served requiring outpatient treatment at a hospital, not to include minor injuries such as sprains or cuts
7. nonconsensual intimate contact between persons served
8. a per absence from the premises for four hours or more without the approval of staff persons, or for 30 minutes or more without the approval of staff persons if the person served may be in immediate jeopardy
9. abuse or misuse of person served funds
10. an outbreak of a serious communicable disease
11. an incident requiring the services of the fire or police departments 12. any condition which results in closure of a facility
B. Immediately following a reportable incident, all involved staff will complete the Incident Report Form and send to the LTSR Program Director.
C. The LTSR Director will complete a written reportable incident report to document and allow for GJR in PA investigation. As needed, reports will be made to authorities including PA State Police and PA Department of Human Services.
D. The LTSR Director will immediately notify legal representative, if applicable.
E. The LTSR Director or Risk Officer will report to the Department of Human Services, Southwest Behavioral Health, and the contracting agency within 12 hours of a fire requiring the relocation of person served or unexpected death of a person served.
F. The LTSR Director will initiate an internal investigation of a reportable incident immediately following the report of the incident and will generally complete the investigation as soon as possible. When a licensing or police investigation is involved, the internal investigation will not take place until the external investigation is complete. The LTSR Director or Risk Officer will provide the information to the placing agencies following the conclusion of the investigation when required.
G. Copies of reportable incident reports and investigations will be provided to the LTSR Program Director and Risk Officer. Reportable incidents will be tracked and trended in order to identify opportunity for performance improvement initiatives.
H. LTSR staff will document all reportable and recordable events, including but not limited to the following:
1. suicidal gestures/ideation/threats
2. incidences of intentionally striking or physically injuring a person served
3. property damage of more than $500.00
4. any time staff suspects, witnesses, or obtains a report regarding abuse
5. any time a person served is arrested
6. any time staff needs to document an unusual incident or situation involving a person served or staff member
7. absences of persons served from the premises without the approval of staff persons that does not meet the definition of a reportable incident in paragraph one of this procedure
8. injuries, traumas, illnesses, or medical events such as seizures of persons served that do not meet the definition of reportable incidents also in paragraph one of this procedure
A GJR in PA LTSR Incident Report will be completed by staff prior to ending their shift and placed in the Incident Report box. These reports will be processed the next business day. The original incident reports are forwarded to the LTSR Program Director and copies distributed to designated administrative staff. Once approved, the LTSR Program Director will place the original report in the Records Office mailbox for filing in the permanent record of the person served.
REFERENCECODE: PS- 225 - GJRPA
TITLE: Suicide Precautions Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-225-GJRPA - Suicide Precautions Policy
It is the policy of the agency to address suicidal ideations and threats with a comprehensive approach in which staff education and training lead to awareness and prevention. At-risk thinking and/or behaviors are assessed, and appropriate actions are immediately provided in order to address and ensure the safety of persons served in these circumstances.
REFERENCECODE: PS- 225-001 - GJRPA
TITLE: Suicide Precautions Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-225-001-GJRPA - Suicide Precautions Procedure
George Junior Republic in PA provides a continuum of comprehensive residential services for troubled persons served and their families. The first and foremost concern of the organization is the safety of each youth committed to our care. As such, the policy and procedures regarding suicide precautions are to be followed regarding persons served without deviation. Administrative staff are responsible for oversight of suicide watch procedures. Failure to follow all the requirements will result in immediate disciplinary action, up to and including termination of employment if deemed warranted.
A. Staff members are to be familiar with Common Warning Signs/Indications of Suicide:
1. Talking about suicide or death
2. Making statements about feeling hopeless, helpless, or worthless
3. Deepening depression
4. Preoccupation with death
5. Taking unnecessary risks or exhibiting self-destructive behavior
6. Seeking to isolate oneself
7. Out of character behavior – changes in eating, sleeping or exercising patterns
8. Loss of interest in the things cared about previously
9. Making arrangements; putting affairs in order
10. Giving away possessions
11. Impulsivity
12. Prior suicide attempt(s)
B. Staff also need to be aware of Risk Factors that can increase the possibility of suicidal ideation:
1. A history of suicidal ideation or attempts
2. Family or loved ones who have committed suicide
3. Substance abuse history
4. Parental history of violence, substance abuse or divorce
5. History of abuse, neglect or molestation
6. Sexual identity and gender issues
7. Learning disability or disabilities
8. Depression including use of prescription antidepressant
9. Youth who isolate from peer relationships
10. Low self-esteem
11. Serious academic problems
12. Perfectionist personalities
13. Genetic predisposition – close family member with a history of suicide
C. The following behaviors require a person served to be placed on Suicide Watch:
1. Demonstration of a suicidal gesture that is life threatening such as placing or tying a rope-like item around the neck.
2. Engaging in self-injurious/self-mutilating behavior; for example, cutting a wrist with a sharp object such as a piece of sharp plastic or metal. Tattooing is not considered to be a suicidal gesture.
3. Making a statement or statements of wanting to die even if done so in anger, frustration or defiance.
4. Writing or art work that indicates or depicts a desire to die or end one’s life.
5. Expressing desire to join a deceased loved one.
D. Supervision procedures for Suicide Watch:
1. Any staff who has reason to believe that a person served is suicidal or wants to injure himself will immediately initiate Suicide Watch. The behaviors listed above are to be utilized as guidelines only and are not to be considered all-inclusive.
2. The person served must be in visual sight of staff AT ALL TIMES during waking hours. There are no exceptions. Staff will provide continuous visual supervision of the person served during waking hours and maintain 5-minute supervision during sleeping hours until a physician discontinues the Suicide Watch.
3. When supervision of the person served changes from staff member to staff member, the person taking over supervision must be told that they are now the person responsible for the person served on suicide watch. This must occur even if it is for a short period of time such as a bathroom break.
4. Staff must visually supervise the person served while showering or using the restroom via open door.
5. The person served will be accompanied by staff when going into his bedroom to retrieve any personal items.
6. Staff will conduct a thorough search of the bedroom of the person served for potentially harmful items including contraband. This search will be repeated prior to the person served returning to the room unsupervised
7. The person served will remain within arm’s length of staff during transport to and from any building. Staff will maintain constant visual supervision in all settings.
8. The person served will remain on Suicide Watch until it is discontinued by an order from the Psychiatrist following a face-to-face assessment. Staff must continue
constant and direct visual monitoring of the person served during awake hours until such time as the Psychiatrist discontinues Suicide Watch.
General Residential
A. Staff will request immediate assistance from a Campus Supervisor.
B. The person served must remain in the line of sight of staff at ALL times throughout the entirety of the suicide watch.
C. Staff will notify the Wellness Center immediately.
D. All ligature items (shoe laces, belts, hoodie strings, etc.) are to be removed from the possessions and bedroom of the person served.
E. Staff will complete the Suicide Watch report and email this report to the Suicide Watch email group.
F. Plans will be made for an additional staff member to be assigned to the cottage for one to one supervision purposes through the Campus Supervisors. Counselor Parents and the staff assigned to assist must alternate the provision of 1:1 supervision of this person served every hour. G. Persons served are not to return to bedroom without direct visual supervision.
G. Staff must be immediately outside the bathroom, with the door ajar, whenever a person served is in the bathroom for any reason.
H. A cot will be delivered to the cottage and is to be placed in the corner of the living room area, where the person served will sleep under the direct supervision of a Behavioral Health Technician assigned to the cottage.
I. Persons served will remain on suicide watch under these procedures until removed from watch by the Psychiatrist. The psychiatrist will meet with the person served as soon as it can be arranged. In many cases, this will be the next day.
J. During the course of the Suicide Watch, staff must complete the Suicide Watch Form. This form is to be placed in the file of the person served at the conclusion of the watch. This form requires that staff document the location of the person served every fifteen minutes.
Special Needs, Diagnostic, Therapeutic Residence for Adolescent Complex Cases. and Intensive Supervision Units:
A. Persons served will remain under continuous visual supervision during waking hours.
B. Staff will not permit home visits or visits out of the unit during Suicide Watch. Visits may take place under staff supervision.
C. A person served on Suicide Watch will sleep in room 1, the first bedroom closest to the Day Room. One staff member i.e. a Behavioral Health Technician is required to station themselves outside the bedroom door and monitor the person served during sleeping hours. The monitoring assignment shall switch at least every hour.
D. In the instance that more than one person served in one unit are on Suicide Watch at the same time, the second person served will be placed in the bedroom adjoining or opposite bedrooms.
The Behavioral Health Technician, Clinical Aide, or Evening Security Worker shall be stationed between the two rooms and visually monitor each of the persons served every five minutes. Reporting Procedures for Suicide Watch A. Initial Reporting:
1. The staff member observing any signs or indications of suicidal ideations and threats or self-injurious behavior will contact Health Services, Treatment Team Coordinator, Campus Director and Campus Supervisor as soon as feasible. Health Services will immediately contact a Psychiatrist and will use the Suicide Watch Report received from the staff member initiating the Suicide Watch to provide details. The report to the Psychiatrist will include data substantiating the decision to place the person served on Suicide Watch including the affect and mood of the person served; if the person served has any injury as a result of a suicide attempt; historical data regarding prior Suicide Watches; existence of a Suicide Safety Plan or prior psychiatric hospitalizations. A Psychiatrist will evaluate the person served on the next working day or the same day if possible.
2. Between the hours of 10:00 PM and 6:00 AM, staff will immediately notify the Campus Supervisor who will then place a call to the on-call nurse. The Campus Supervisor will leave voice mail messages on the office phones of the Campus Director of the person served, Psychiatrist, Vice President of Operations, and Health Services Director
3. The Treatment Team Coordinator, Case Manager, or Campus Director will notify the parents/guardians and placing agency in a time sensitive manner.
4. If the person served is injured due to a suicide attempt/gesture the Campus Supervisor will notify a nurse at Health Services. Based on the injury the nurse on call may need to directly examine the person served or direct the Campus Supervisor to transport the person served to Allegheny Health Network Grove City. The nurse on call or the nurse at Health Services will immediately contact the Campus Director, Vice President of Operations, Health Services Director, and Psychiatrist.
B. Ongoing Reporting Procedures for Special Needs, Diagnostic, and Intensive Supervision Units:
1. Nursing staff will complete a brief face-to-face check on the status of persons served on Suicide Watch at least one time per day. Nurses will closely monitor persons served taking medication to prevent the possibility of overdose by accumulating medication not swallowed. The attending Nurse will write a note in the in the Medication Administration Record system to serve as an alert for the Nurse to assess the person served and document findings.
2. If a person served on Suicide Watch leaves the unit for any reason, staff will inform all auxiliary and support staff who will have contact with or be responsible for supervising the person served including but not limited to Transportation Staff, Admissions Staff and Clinical Staff, that the person served is presently on Suicide Watch.
3. Persons served will attend group therapy while on Suicide Watch and will remain constantly visually supervised, including during transport to and from group. Staff from the
unit of the person served will directly inform both Transportation staff and the Group Therapist regarding the Suicide Watch.
4. Staff will report the Suicide Watch status of persons served to each incoming staff at shift change.
5. Campus Supervisors will observe each person served placed on Suicide Watch one time per shift. The Campus Supervisor will speak with the person served if they are awake and inquire about their status, review the daily Suicide Supervision Form for completion, and sign off on this form in the Administrative Review section.
6. Campus Directors will also meet with persons served on Suicide Watch when in any building with a person served on Suicide Watch. They will document this visit in the Administrative Review section of the form.
Documentation Procedures for Suicide Watch
A. Initial Documentation
1. Upon initiating a suicide watch, the staff member initiating the watch must notify Health Services immediately by calling Ext: 2410.
2. The staff member placing the person served on Suicide Watch will complete and email the Suicide Watch Report form to suicidewatch@gjr.org. The suicide watch form is located in Documents Published by GJR. Documents Published is an icon on your computer screen which will open when you double click the icon.
3. Staff will complete and distribute the Safety Plan for Suicide as soon as possible and within 24 hours of the person served being placed on Suicide Watch in the following circumstances:
a. For any person served being admitted to George Junior Republic in PA with a history of previous suicidal ideation, gestures or attempts.
b. For any person served being placed on Suicide Watch while in placement at George Junior Republic in PA.
3. If a physical gesture of suicide or injury occurs, Health Services will complete and submit a Reportable Incident Report
4. Special Needs, Diagnostic, and Intensive Supervision staff will identify the person served on Suicide Watch with a daily entry in the log book. Entries will be documented each shift until the suicide watch is ended by the Psychiatrist. Staff will also verbally communicate this information to other staff providing care for the person served and provide status updates especially at shift or staff changes.
B. Ongoing Documentation for Special Needs, Diagnostic, and Intensive Supervision Units
1. The staff placing the person served on Suicide Watch will initiate use of the Suicide Watch Supervision Form immediately.
2. Each shift, day, and afternoon, will provide Life-Space Counseling to the person served and document the session on the Suicide Watch Supervision Form. In addition to LifeSpace Counseling, the following information must be recorded on the form:
a. Any suicidal comments, ideation or gestures
b. Observations about the feelings, mood, or thoughts of persons served
c. If the person served complies with their medication regime, if applicable
d. The daily routines of persons served related to eating, sleeping, and participation in activities
e. Behavioral Health Technicians 1 will document how the person served slept during the overnight hours
3. When working, the Treatment Team Coordinator will review the Suicide Watch Supervision Form and sign off, and provide the person served with additional intervention as clinically appropriate.
4. If a suicide watch has been initiated, the Treatment Team Coordinator or Therapist/Case Manager must conduct an individual therapy session with the person served the same day or the day of returning to work if the watch was initiated during the Treatment Team Coordinator’s absence. This therapy session will specifically address the suicidal ideation, threat, or attempt and shall be documented as such in the therapy note in the electronic health record.
5. Behavioral Health Technicians will initiate use of the Positive Coping Skills during the first 24 hours of Suicide Watch.
6. All documents except the log book must be placed in the permanent file of the person served at the administration building upon the discontinuation of the watch.
REFERENCECODE: PS- 225-002 - GJRPA
TITLE: LTSR Suicide Precautions and Response Procedure
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS- 225-002 - GJRPA – LTSR Suicide Precautions and Response Procedure
George Junior Republic provides a continuum of comprehensive residential services for persons served and their families. The first and foremost concern of the organization is the safety of each person served committed to our care. As such, the policy and procedures regarding persons served suicide precautions are to be followed without deviation. Administrative staff are responsible for oversight of suicide watch procedures. Failure to follow all the requirements will result in immediate disciplinary action, up to and including termination of employment if deemed warranted.
A. Staff members are to be familiar with Common Warning Signs/Indications of Self Harm/Suicide:
1. Talking about suicide or death
2. Making statements about feeling hopeless, helpless, or worthless
3. Deepening depression
4. Preoccupation with death
5. Taking unnecessary risks or exhibiting self-destructive behavior
6. Seeking to isolate oneself
7. Out of character behavior – changes in eating, sleeping or exercising patterns
8. Loss of interest in the things cared about previously
9. Making arrangements; putting affairs in order
10. Giving away possessions
11. Impulsivity
12. Prior suicide attempt(s)
13. High-risk materials missing from bedroom, bathrooms, or common areas (e.g. lamp chord, shower curtain, knives, pencils/pens, etc.)
B. Staff also need to be aware of Risk Factors that can increase the possibility of suicidal ideation:
1. A history of suicidal ideation or attempts
2. Family or loved ones who have committed suicide
3. Substance abuse history
4. Parental history of violence, substance abuse or divorce
5. History of abuse, neglect or molestation
6. Sexual identity and gender issues
7. Learning disability or disabilities
8. Depression including use of prescription antidepressant
9. Persons served who isolate from peer relationships
10. Low self-esteem
11. Serious academic problems
12. Perfectionist personalities
13. Genetic predisposition – close family member with a history of suicide
C. The following behaviors require a person served to be assessed utilizing the C-SSRS (ColumbiaSuicide Severity Rating Scale):
1. Demonstration of a suicidal gesture that is life threatening such as placing or tying a rope-like item around the neck.
2. Engaging in self-injurious/self-mutilating behavior; for example, cutting a wrist with a sharp object such as a piece of sharp plastic or metal. Tattooing is not considered to be a suicidal gesture.
3. Making a statement or statements of wanting to die even if done so in anger, frustration, or defiance.
4. Writing or art work that indicates or depicts a desire to die or end one’s life.
5. Expressing desire to join a deceased loved one.
Persons served exhibiting any above features will be assessed using the C-SSRS. If they are determined to not show risk for suicide, their statements and/or behaviors will be documented and addressed by the clinical treatment team, and the person served will be checked on daily for mental/behavioral health progression.
Once a person served is assessed using the C-SSRS and is determined to be suicidal, the following steps will be taken for implementing Suicide Watch:
D. Supervision procedures for Suicide Watch:
1. Any staff who has reason to believe that a person served is suicidal or wants to injure himself will immediately initiate Suicide Watch. The behaviors listed above are to be utilized as guidelines only and are not to be considered all-inclusive.
2. The staff will assess person served utilizing the C-SSRS and if they are determined to be suicidal, the following steps will occur:
a.The person served must be in visual sight of staff AT ALL TIMES during waking hours. There are no exceptions. Staff will provide continuous visual supervision of the person served during waking hours and maintain 5-minute supervision during sleeping hours until a physician discontinues the Suicide Watch.
b.Staff will conduct a thorough search of the bedroom of the person served for
potentially harmful items including contraband. This includes but is not limited to chemicals or cleaning supplies of any kind; food and/or drinks; electric shavers; scissors; tools; glass or ceramic bottles, plates, mirrors; fishing equipment; metal scraps, pieces, plates or wires; toys with small parts that could result in choking; sewing supplies, pins, safety pins, needles, scissors, seam rippers; glue or correction fluid of any kind; medication of any kind; push pins, tacks or sharp objects; extra sheets; weapons; alcohol and drugs; lighters, matches and flammable substances; paint and aerosol containers. This search will be repeated prior to the person served returning to the room unsupervised
c. Personal belongings or bedroom items imposing risk for self-harm will be removed and if possible, replaced with non-risk items.
d.When supervision of the person served changes from staff member to staff member, the person taking over supervision must be told that they are now the person responsible for the person served on suicide watch. This must occur even if it is for a short period of time such as a bathroom break.
e.Belts, shoes, and shoes strings will be taken.
f. Appropriate staff must visually supervise the person served while showering or using the restroom via open door.
g.The person served will be accompanied by staff when going into their bedroom to retrieve any personal items.
h.The person served will remain within arm’s length of staff during transport to and from any building. Staff will maintain constant visual supervision in all settings.
i. Overnight, the Mental Health Technicians will rotate constant watch for the person served with bedroom open door policy implemented.
j. The person served will remain on Suicide Watch until it is discontinued by an order from the Psychiatrist following a face-to-face assessment. Staff must continue constant and direct visual monitoring of the person served during awake hours until such time as the Psychiatrist discontinues Suicide Watch.
E. Reporting Procedures for Suicide Watch
1. Initial Reporting:
a. The staff member observing any signs or indications of suicidal ideations and threats or self-injurious behavior will contact the LTSR Nurse, Mental Health Professional, and LTSR Director as soon as feasible. The LTSR Nurse will immediately contact a Psychiatrist and will use the Suicide Watch Report received from the staff member initiating the Suicide Watch to provide details. The report to the Psychiatrist will include data substantiating the decision to place the person served on Suicide Watch including the C-SSRS assessment results; if the person served has any injury as a result of a suicide attempt; historical data regarding prior Suicide Watches, existence of a Suicide Safety Plan or prior psychiatric
hospitalizations. A Psychiatrist will evaluate the person served on the next working day or the same day if possible.
b. The LTSR Director will be notified 24 hours, 7 days a week. There will be an on-site nurse. The on-site nurse will leave voicemail messages on the office phones of the Psychiatrist and Risk Officer.
c. The LTSR Director will notify the legal representative and placing agency in a time sensitive manner.
d. If the person served is injured due to a suicide attempt/gesture, the LTSR Nurse will be notified who then can directly examine the person served or transport the person served to Allegheny Health Network Grove City Health Services.
2. Ongoing Reporting Procedures
a. Nursing staff will complete a brief face-to-face check on the status of persons served on Suicide Watch at least one time per day. Nurses will closely monitor persons served taking medication to prevent the possibility of overdose by accumulating medication not swallowed. The attending Nurse will write a note in the in the Medication Administration Record system to serve as an alert for the Nurse to assess the persons served and document findings.
b. If a person served on Suicide Watch leaves the unit for any reason, staff will inform all auxiliary and support staff who will have contact with or be responsible for supervising the person served including but not limited to Recreation Supervisors, Transportation Staff, Admissions Staff and Clinical Staff, that the person served is presently on Suicide Watch.
c. Persons served will attend group therapy while on Suicide Watch and will remain constantly visually supervised.
d. Staff will report the Suicide Watch status of persons served evening staff each night at shift change.
e. Mental Health Professionals will observe each person served placed on Suicide Watch one time per shift. The Mental Health Professionals will speak with the person served if they are awake and inquire about their status, review the daily Suicide Supervision Form for completion, and sign off on this form in the Administrative Review section.
f. The LTSR Director also meet with each person served on Suicide Watch once each day, assess safety and the completion of the Suicide Supervision Form. They will document this visit in the Administrative Review section of the form.
F. Documentation Procedures for Suicide Watch
1. Initial Documentation
a. Upon initiating a suicide watch, the staff member initiating the watch must notify LTSR Nursing staff.
b. The staff member placing the person served on Suicide Watch will initiate the LTSR Suicide Watch Report form for the resident file.
c. Staff will complete and distribute the Safety Plan for Suicide as soon as possible and within 24 hours of the person served being placed on Suicide Watch in the following circumstances:
i. For any person served being admitted to George Junior Republic with a history of previous suicidal ideation, gestures or attempts.
ii. For any person served being placed on Suicide Watch while in placement at George Junior Republic.
d. If a physical gesture of suicide or injury occurs, Health Services will complete and submit a Reportable Incident Report. The LTSR staff will identify the person served on Suicide Watch with a daily entry in the log book. Entries will be documented each shift until the suicide watch is ended by the Psychiatrist. Staff will also verbally communicate this information to other staff providing care for the person served and provide status updates especially at shift or staff changes.
2. Ongoing Documentation
a. The staff placing the person served on Suicide Watch will initiate use of the Suicide Watch Supervision Form immediately.
b. The following information must be recorded on the form:
i. Any suicidal comments, ideation or gestures
ii. Observations about the person’s served feelings, mood or thoughts
iii. If the person served complies with his medication regime, if applicable iv. The person’s served daily routines of eating, sleeping and participation in activities
v. Mental Health Technicians will document how the person served slept during the overnight hours
c. When working, the Mental Health Professional will review the Suicide Watch Supervision Form and sign off, and provide the person served with additional intervention as clinically appropriate.
d. If a suicide watch has been initiated, the Mental Health Professional must conduct
an individual therapy session with the person served the same day or the day of returning to work. This therapy session will specifically address the suicidal ideation, threat, or attempt and shall be documented as such in the therapy note in the electronic health record.
e. Mental Health Technicians will initiate the use of the Positive Coping Skills during the first 24 hours of Suicide Watch
f. All documents except the log book must be placed in the permanent file of the person served at the administration building upon the discontinuation of the watch.
REFERENCECODE: PS- 226 - GJRPA
TITLE: Absconding Prevention Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
PS-226-GJRPA - Absconding Prevention Policy
It is the policy of the agency to employ the following procedures related to persons served absconding from the treatment environment.
REFERENCECODE: PS- 226-001 - GJRPA
TITLE: Abscond Watch Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-226-001-GJRPA - Abscond Watch Procedure
A. The staff person who first becomes aware of an abscond attempt/risk will immediately initiate Abscond Watch for any persons served who display behaviors or statements of threatening to run away.
B. Staff will provide continual, visual supervision. Persons served must be in sight of staff at all times with the exception of when they are in their bedroom and using the restroom.
C. Staff will search the rooms of persons served for contraband or any evidence related to an abscond attempt. This requires prior approval from the Campus Director or Campus Supervisor.
D. Persons served will remain on Abscond Watch until it is discontinued by the treatment team. Staff must maintain direct visual contact of the persons served at all times until they are taken off of Abscond Watch.
E. Staff will not permit home visits or out-of-unit visits during Abscond Watch.
F. Staff will permit persons served to be in all areas of the unit with continual visual supervision by staff at all times. In Special Needs, the courtyard and back hallway are only permitted when a staff member is directly with persons served and visually supervising them during Abscond Watch.
G. Persons served on abscond watch must be within arm’s reach of staff during transport in and out of the unit. Persons served WILL be expected to attend group therapy. Notify drivers and group therapist of abscond watch.
H. Behavioral Health Technicians will help to monitor the exits of the Program Center at all times.
I. Regardless of security status, all persons served must wear their shoes when leaving the unit. This includes all Special Needs Units, and ISU for all transportation on and off the GJR campus.
J. The unit alarms must be activated at all times and all exits are to be monitored by staff at all times.
K. The door between the dayroom and the back hallway to the Treatment Team Coordinator’s office must be closed any time the TTC is not in the office (units with applicable floor plan only). The door is not to be locked due to fire safety regulations.
L. Staff will inform support staff of Abscond Watches when out of the building. This includes but is not limited to Transportation, Admissions, and clinical staff.
M. Staff will relay information to Evening Security Workers regarding persons served on Abscond Watch.
N. The staff member making the assessment for safety will initiate the use of the Suicide/Abscond Watch form as soon as possible.
O. Staff will continue to record the details of the Abscond Watch on the Daily Log Entries for each day that the persons served are on Abscond Watch.
REFERENCECODE: PS- 226-002 - GJRPA
TITLE: Absconding from Campus Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-226-002-GJRPA - Absconding from Campus Procedure
Staff Responsibilities
A. Notify the Switchboard immediately if persons served cannot be located in a period of 10 minutes and initiate the Abscond Watch Procedure as indicated in the previous procedure.
1. Give physical description and clothing worn by persons served and any precipitating circumstances that may have caused persons served to abscond to the Switchboard.
B. Do not leave other persons served unattended in the unit or home to go to help look for the absconder. In the units, no less than two direct care staff must always remain on duty at all times.
1. Other persons served are not permitted to accompany staff to look for an absconder.
2. Persons served are not permitted to supervise other persons served at any time. C. Count the persons served in the residence.
D. Talk to other persons served to elicit any helpful information about the persons served who absconded.
E. If the persons served are found, notify the Switchboard immediately.
F. Inform Health Services so that the persons served may be assessed by the nursing staff.
G. The Campus Director, Residential Manager, Treatment Team Coordinator or Case Manager is responsible for contacting the families and the placing agencies of persons served.
Switchboard Responsibilities
A. Upon receiving a report that a youth has absconded, the switchboard employee will:
1. Send an absconder notification with Face Card to the AWOL distribution list.
2. Initiate the Absconder Report, including immediate notification of both local and PA State Police, Campus Director and Administration.
Campus Supervisor Responsibilities
A. Upon receiving a report that a youth has absconded, the Campus Supervisor will:
1. Access security cameras to gather any pertinent information such as location youth was last seen and/or direction that the youth took.
2. Coordinate search using any available staff.
3. Ensure that all staff assisting in the search are adhering to agency procedures while in the community.
4. Maintain communication with other staff assisting in search.
5. Maintain communication with local and PA State Police.
6. Document constant visual supervision using the sight and sound check form until person served has been seen by Health Services.
Long Term Structured Residence (LTSR)
Once direct-care staff is made aware of a person served absconding, they will notify the Switchboard immediately to inform campus supervisors. Staff are not permitted to search for the absconder and should focus on immediate security and safety of other persons served. Once the Switchboard is notified, staff should notify the county representative and local authorities to file a report. Once the absconder is found, staff must notify the switchboard immediately.
REFERENCECODE: PS- 226-003 - GJRPA
TITLE: Absconding While Off-Campus Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/8/2021
DATEREVISED: 2/9/2021
PS-226-003-GJRPA - Absconding While Off-Campus Procedure
A. Take a head count all of the other persons served and keep them in your watch.
B. Call the Switchboard at the facility and ask for the following supervisors in this order: Campus Director(s) of the home or unit in which the persons served live, Campus Director on duty, the Vice President of Operations, Admissions, and Campus Supervisor. Staff must inform the Switchboard Operator that they will be searching, and obtain a vehicle and radio prior to leaving to search.
C. Staff at the scene are responsible for calling the local police to report the incident. They may share the physical and clothing descriptions of the persons served, the circumstances of the disappearance, and their hometowns if known. The local police will provide instructions or dismiss staff members after filing a report.
Long Term Structured Residence (LTSR)
Once direct-care staff is made aware of a person served absconding while off-campus, authorities should be notified immediately. They may share the physical and clothing descriptions of the persons served, the circumstances of the disappearance, and their hometowns if known. The local police will provide instructions or dismiss staff members after filing a report. Once authorities are aware of the situation, staff will notify the Switchboard at GJR and ask for the staff in this order to report: LTSR Director, Risk Officer.
REFERENCECODE: PS- 226-004 - GJRPA
TITLE: Searching for Absconders Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
PS-226-004-GJRPA - Searching for Absconders Procedure
The following procedures apply to any staff member searching for persons served who have absconded. The first consideration in searching for an absconder is always the SAFETY of persons served, staff members and the general public.
A. At no time will a staff member search for absconders alone.
B. Staff should obtain a vehicle and radio prior to leaving to search for absconders.
C. The search will be coordinated and conducted by the administrative person on duty. If no administrator is available, then the Campus Supervisor will coordinate and conduct the search.
D. All staff members must obey all laws during searches. This includes obeying all traffic regulations.
The property and rights of those in the community must be observed. Employees of George Junior Republic in PA do not have the right to invade, trespass, or enter private or public property without the permission of the owner.
E. While searching for absconders, staff must always be aware of safety. Staff must safely remove their vehicles from any roadway when stopping.
F. Staff must safely park vehicles and take keys before leaving the vehicle to search. Car keys must always be secured on the driver’s person.
G. At no time is a staff member permitted to pursue, chase, or attempt to block persons served who are in motorized vehicles.
H. Staff members must always interact appropriately with the public without creating undo confusion, public incidents, or soliciting the assistance of the public in the search and apprehension of absconders.
I. Staff members must be aware that the local police and general public may be monitoring the radio. At no time may staff of George Junior Republic in PA use profanity, disclose confidential information regarding an absconder, or divulge information over the radio that is sensitive in
nature. If communication with the local and state police becomes necessary, administrative personnel or the Campus Supervisor will initiate or respond to contact with local authorities.
J. Do not divulge information to the public that would violate the confidentiality policies of the agency. This includes information regarding the treatment plans, family information, reasons for placement, or personal information regarding persons served which would normally be held in confidence.
K. When persons served are apprehended, staff must maintain professionalism and uphold the rights of persons served.
L. Persons served who are apprehended must be searched prior to placement in vehicles for transport back to the campus.
M. If persons served are unruly and uncooperative, then staff members must summon other staff to assist in safely transporting the persons served back to the agency. Police officers may also escort the person served back to campus.
N. Persons served who abscond may be homesick and/or frightened, and staff should interact in a calm and reassuring manner to de-escalate the situation.
O. Staff members must return vehicles, keys and radios immediately upon returning from searching for absconders.
REFERENCECODE: PS- 227-DA - GJRPA
TITLE: D&A Client Aftercare Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 4/1/2021
DATEREVISED: 8/6/2020
PS-227-DA-GJRPA – Drug and Alcohol Client Aftercare Policy
It is the policy that the Inpatient Non-Hospital Drug and Alcohol Rehabilitation Facility comply with 28 Pa Code Section V Chapter 709.54 (b) (d) in developing a client aftercare policy, and providing access and communication about outreach services.
REFERENCECODE: PS- 227-001-DA - GJRPA
TITLE: Client Aftercare in the Drug and Alcohol Inpatient Non-Hospital Rehabilitation Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 7/17/2025
PS-227-001-DA-GJRPA - Client Aftercare in the D & A Rehab. Program Procedure
The following procedures will be followed to complete a client aftercare plan:
1. The Drug and Alcohol Case Manager, or designee, will work directly with the Client, client discharge resource and placing agency to complete a personalized aftercare plan.
2. The Aftercare plan will identify the discharge resource by providing the name, address, telephone number and relationship to the client.
3. The aftercare plan will identify the continued treatment appointments for addiction, mental health, family therapy, and medication management as it applies individually to the client.
4. The aftercare plan will identify the plan for educational needs and identify the school the client will return to for academic attendance.
5. The aftercare plan will identify any barriers to compliance and all necessary outreach services needed to support the client and family with reintegration into the home and community.
PS-228-GJRPA – Fine Arts Policy
REFERENCECODE: PS- 228 - GJRPA
TITLE: Fine Arts Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 6/29/2022
DATEREVISED: 6/29/2022
It is the policy of George Junior Republic to utilize the fine arts as an instrument for the advancement of therapy, community, education, and promotion.