Policies and Procedures Section 4
Complementary Services (COM)
as of April 3, 2025
Contractual agreements may override policies and portions of procedures.
REFERENCECODE: COM- 100 - GJRPA
TITLE: Healthcare Letters of Agreement Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: TBA
COM-100-GJRPA - Healthcare Letters of Agreement Policy
Letters of Agreement (LOA) or Memorandums of Understanding (MOU) will be written, reviewed, and signed with all healthcare providers offering service to persons served, as well as reviewed on an annual basis. These services may include physical health, dental care, pharmacy, laboratory services and optometry.
REFERENCECODE: COM- 100-001 - GJRPA
TITLE: Healthcare Letters of Agreement Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 9/18/2020
DATEREVISED: 9/18/2020
COM-100-001-GJRPA - Healthcare Letters of Agreement Procedure
A. Initial LOA/MOU’s will be written by the administrator defined by the organization as having approval to draft said document.
B. Once drafted, the agreement will be reviewed by both parties.
C. The agreement will be signed and dated by the CEO, appropriate administrator and the agreeing parties
D. Each agreement will be reviewed by all parties on an annual basis.
E. All fully executed agreements will be filed in the standardized format designated by the Executive Administrative Assistant for the Chief Executive Officer.
REFERENCECODE: COM- 101 - GJRPA
TITLE: Medical Record Security Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-101-GJRPA - Medical Record Security Policy
Personal health information for both persons served and employees will be protected at all times in accordance with policy, regulations, and state and federal laws.
REFERENCECODE: COM- 101-001 - GJRPA
TITLE: Medical Record Security Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-101-001-GJRPA - Medical Record Security Procedure
A. Staff members are responsible for the protection of paper and/or electronic medical records.
B. Medical records for persons served may be accessed by designated staff persons and should only be accessed for the purpose of treatment planning, coordination of care or data tracking/management.
C. Security breaches of medical records must be reported to the Director of Health Services and the Risk Officer as soon as possible after the incident.
REFERENCECODE: COM- 102 - GJRPA
TITLE: Notice of Privacy Practices Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-102-GJRPA - Notice of Privacy Practices Policy
To remain in compliance with federal law, all new persons served will be informed of their rights regarding their protected health information. A Notice of Privacy Practices will be given to each person served upon admission.
REFERENCECODE: COM- 102-001 - GJRPA
TITLE: Notice of Privacy Practices Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-102-001-GJRPA - Notice of Privacy Practices Procedure
A. The Notice of Privacy Practices will be provided to the person served upon admission.
B. The admitting nurse will give the copy to the person served and ask them to read the document.
C. If the person served is unable to read the document, the document will be read to them.
D. Persons served may ask questions about the document at any time during their stay.
E. Persons served will sign acknowledgement of receipt by signing the last page of the form.
F. The signature page will be retained as part of the medical file.
G. Copies of the Notice of Privacy Practices are provided to each person served at the time of the initial nursing assessment.
H. Persons served will take the Notice of Privacy Practices with them to their assigned cottage or unit.
REFERENCECODE: COM- 103 - GJRPA
TITLE: Wellness Center Security Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-103-GJRPA - Wellness Center Security Policy
The Wellness Center and the equipment, documentation, and medications will be monitored and secured at all times.
REFERENCECODE: COM- 103-001 - GJRPA
TITLE: Wellness Center Security Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-103-001–GJRPA - Wellness Center Security Procedure
A. Upon hire, staff members working at the Wellness Center will be issued two keys and a fob.
B. During work hours, keys must be secured on their person at all times.
C. Individual staff persons are responsible for the safety of the keys. Any loss of keys must be reported to the supervisory staff of Health Services, relevant Administrative and Maintenance staff immediately.
D. All medications, instruments, sharps, etc., are to be securely locked.
E. The outer doors and interior doors will be locked when the Wellness Center is unattended.
F. All medication will be in locked medication carts or locked cupboards in the Medication Room when not being prepared for medication pass.
G. Persons served are to be closely supervised while in the building.
H. Medical files and other protected health information will be kept out of common areas and waiting areas.
I. Emergency call buttons are located in Health Services and the Psychiatric Suite and should be worn by personnel when providing direct care to persons served
Health Services staff must notify Campus Directors and Supervisors when increased staff supervision is indicated, as in the treatment of persons served from ISU and during assessments of new admissions.
REFERENCECODE: COM- 104 - GJRPA
TITLE: Release of Medical Information Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-104-GJRPA - Release of Medical Information Policy
A valid Release of Information is to be signed when protected health information is to be sent to individuals and/or organizations not covered by Business Associate Agreements and Memorandums of Understanding/Letters of Agreement.
REFERENCECODE: COM- 104-001 - GJRPA
TITLE: Release of Medical Information Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-104-001-GJRPA - Release of Medical Information Procedure
A. In order for a third party to access or be provided medical record/personal health information, a Release of Information form must be completed, then signed and dated.
B. Persons served must be informed what information is requested and by whom.
C. Persons served can refuse to have the information disclosed.
D. If a person served agrees, then the release must be explained to them. The release must be completed, including the name of the person served, date of birth, to whom the information is being sent and why.
E. This consent is not valid for HIV related information.
F. If a person served agrees to the disclosure and are over the age of 14, they may sign and date the release.
G. The release signing must be witnessed, then signed and dated by the witness. Releases are valid for one year unless otherwise noted or indicated.
H. For persons served under 14 years of age, the consent must be signed by a parent or guardian with the exception of a person served residing in the in-patient non-hospital programming. Any person served in the Drug and Alcohol In-patient Non-hospital Rehabilitation Facility may sign their own release regardless of age.
I. A new release must be signed for each request.
J. A blank release should never be signed. Each release should be fully completed before signing.
K. Persons served must be offered a copy of the release. Their acceptance or refusal of a copy is to be documented on the bottom of the form.
L. The release is to be maintained on the permanent medical record. If the original must be sent, a copy is maintained on the record.
M. The above procedure applies as well to any release sent to this organization by another organization/individual requesting information on a persons served Medical Records staff will refuse to honor a release that is incomplete.
REFERENCECODE: COM- 105 - GJRPA
TITLE: Health Services Staffing Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-105-GJRPA – Health Services Staffing Policy
It is the policy of the agency to offer Health Services staffing and response to meet the needs of persons served.
REFERENCECODE: COM- 105-001 - GJRPA
TITLE: Health Services Year Round Staffing Procedure
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 12/12/2024
COM-105-001-GJRPA – Health Services Year Round Staffing Procedure
Health Services will be staffed at all times.
A. The Director of Health Services will prepare a schedule that provides adequate support.
B. Once developed, the schedule will be distributed to the Campus Supervisors and the Director of Business and Clinical Development, and will be posted in Health Services.
C. Any RN/LPN/Med Tech who is unable to work his/her scheduled shift due to illness or personal/family emergency must call Health Services as soon as possible.
D. Upon receipt of the call, the Director of Health Services will be notified and he/she will take steps to locate coverage for the shift. Once coverage is identified, Health Services will be notified.
E. If the Director of Health Services is unavailable, their designee, or the staff person that took the call-off will be responsible for finding coverage.
F. To identify an RN/LPN/Med Tech for coverage:
1. Review the schedule and contact part-time staff members first.
2. Partial shifts or minor schedule adjustments can be made to cover peak medication administration times.
3. Notify the Director of Health Services via voicemail of the coverage arrangement.
4. When no staff member is identified to cover the shift, the staff member who took the call is required to work additional hours and/or provide coverage in order to make certain persons served are appropriately and safely managed.
REFERENCECODE: COM- 105-002 - GJRPA
TITLE: Health Services: Staffing Response to Phone Calls Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-105-002-GJRPA – Health Services: Staffing Response to Phone Calls Procedure
Staff in the cottages and units may call Health Services for general medical information or specific information on a person served. The staff must also call to report emergencies. Health Services staff must answer incoming calls as soon as possible. Outside lines are always available in Health Services for emergency use.
A. All incoming calls to Health Services will be answered as quickly as possible by staff.
B. Unanswered calls will go into voice mail. It is the responsibility of all staff to check for messages and address any voice mail messages as soon as possible.
C. Staff will answer phones and deal with the callers in a professional, courteous manner.
D. Confidentiality will be respected while making/receiving phone calls.
E. There is a telephone in the lobby for the persons served to call their whereabouts.
F. Persons served are not to make personal calls from the lobby or Health Services.
G. Personal calls should be made during break/lunch/dinner time.
H. Personal cell phones must be kept out of the sight of the persons served.
REFERENCECODE: COM- 106 - GJRPA
TITLE: Health and Medical General Services Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-106-GJRPA - Health and Medical General Services Policy
It is the policy of the agency to attend to the healthcare and well-being of persons served as part of overall treatment. The following procedures outline the medical services and processes that support persons served.
REFERENCECODE: COM- 106-001 - GJRPA
TITLE: Health and Medical General Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 12/12/2024
COM-106-001-GJRPA - Health and Medical General Services Procedure
George Junior Republic is responsible for the healthcare and well-being of the persons served in residence. The approach is a holistic one, taking the total needs of the persons served into account. The organization employs professional nurses and contracts with Physician Assistants, Certified Registered Nurse Practitioners, and/or Physicians to provide medical, dental, vision and psychiatric care.
Nursing services are available on campus 24/7.
A. Persons Served Physical Exams
All persons served are seen for an initial health and safety assessment within 24 hours of admission. They are seen by a licensed healthcare provider within 7 days for a complete physical, in accordance with regulatory requirements. Persons served who have physical health complaints or concerns will be seen by a licensed provider the next business day that the contracted healthcare provider is on site. Any follow up information from medical assessments/evaluations will be communicated to the treatment team as necessary.
B. Restriction List
Nursing staff will call all units and homes to notify them of any person served on activity restriction and the reason for the restriction. All direct-care staff members are expected to support and enforce restrictions when supervising the safety and activities of persons served. Nurses will keep direct care staff informed when these restrictions are terminated or changed.
C. Dental Services
A dentist comes to the campus each week. Each person served has an exam and cleaning twice a year.
Other restorative dental work may be done as needed. Persons served with dental pain or acute conditions will be seen at the next available appointment. Health Services staff members are responsible for scheduling the persons served for routine dental care. They will call each unit to communicate when the person served is to come for dental care, as well as any necessary follow up care or instructions.
April 3, 2025
D. Psychiatric Services
GJR employs psychiatric practitioners to attend to the mental health needs of persons served The physician’s schedule is managed by their secretarial support staff.
E. Optometrist Care
Each person served has a vision screening performed by a nurse during the admission interview. If they are having problems with vision, they are scheduled to see the optometrist as soon as possible.
The optometrist comes to GJR every month to provide vision examinations and prescribe eyeglasses if needed. If eyeglasses are prescribed, they are obtained for the person served, who is encouraged to wear them regularly.
F. Laboratory Services
Persons served may have bloodwork completed at the time of admission and periodically thereafter at the discretion of the prescriber. The laboratory technicians come to GJR once per week. The units are called early that day to send the person served to Health Services. Some laboratory tests require a period of fasting (not eating or drinking) for anywhere between 8 and 14 hours. The nurse will notify the house/unit the day before the test is scheduled so that the person served will fast the correct amount of time for valid test results. Persons served who are admitted on psychotropic medications will have laboratory testing performed at intake and periodically thereafter as outlined in the grid shown at the end of this procedure:
G. Medications for Persons Served
The need for psychiatric medication will be assessed by a physician individually with the person served. The order is then written in the medical file of the person served. If the person served is under the age of 14, verbal consent will be obtained to begin the medication, and consent forms will be sent to the parents or guardian. Medication may not be started without consent.
Nurses administer the medications to persons served. When nursing staff are unavailable, only staff who have successfully completed the PA-DPW Medication Administration Training may supervise the self-administration of medications.
At NO time is a person served permitted to carry or store medication until the time of administration. All medication is kept in possession of staff.
At NO time may an employee of GJR administer medication if they have not successfully completed the Medication Administration training.
At NO time may an employee administer a medication unless it has been prescribed or approved for the person served
Routine medications are generally given four times a day: 8AM, noon, 4PM, and 8PM. Sometimes a medication will need to be given at another time. Health Services staff will notify the unit staff if this occurs.
Every precaution is taken to be sure the person served actually swallows the medication, but at times the persons served attempt to steal or “cheek” medication. Report this to Health Services and Campus Director staff immediately. If a pill is found, please take it to Health Services for identification.
H. Medications for Persons Served: Off Campus / Home Passes
During off campus trips, such as court hearings and home visits, every effort must be made to continually provide for the treatment of the person served Make arrangements with the Health Services to coordinate the medications for the person served during these times. Call Health Services or email nurse@gjr.org as soon as you know when the trip is scheduled
Ideally when persons served go home on vacation or home pass, Health Services is to be notified at least one week in advance. Prescriptions will not be mailed to the family with the exception of those persons served traveling by air.
Drivers/staff will secure and bring the medications with them for all home passes. The parents/guardians, who must be 18 years of age and have an I.D. with them, will have to sign that they received the medications, as well as sign for the arrival of the person served. The parents/guardians will still sign for the person served even if he does not have medication.
When a person served is being discharged, a release packet is sent with the person served, which contains copies of important health information and any balance of medications ordered for the person served. The release packet it held by a responsible adult or the driver transporting the person served until they are released to another person’s care. Families and caregivers receive instructions to contact Health Services as soon as possible to arrange prescriptions to be sent to their local pharmacy electronically.
In an effort to provide continual treatment to our persons served, if medication is missed, a staff member will be requested to complete a medication error form, which the ordering physician will review.
Should a person served report side effects or adverse reaction to a medication, the staff member should contact Health Services immediately and document the reported side effects. Any staff person who has questions about medications for a person served are asked to call Health Services/
I. Complaint Times
All persons served have the right to be seen in a timely manner, and to seek medical attention when requested. Persons served with complaints are seen by the nurse during routine medication administration rounds. Encourage persons served to observe these times, however a person served may be seen at any time if staff members feel it is necessary.
J. General Important Points
Persons served should be seen by Health Services staff as soon as possible after a physical restraint, altercations with/between persons served, or when returned from runaway status. Call Health Services to report the incident to a nurse.
Any time a person served is severely injured or ill, it may be necessary to call 911 for transport to the nearest medical facility for urgent/emergency care. Care of the person served is the priority at all times. If the illness or injury is severe, please notify the Vice President of Operations and the Director of Health Services as soon as possible.
K. Long Term Structured Residence
1. Physical Exams – Persons served in the LTSR will be scheduled for initial and routine medical examination, including an initial physical with a local primary healthcare provider upon intake. The initial physical exam will be scheduled to occur within 15 days of admission. Staff from the LTSR program will be responsible for transportation to and from the appointment. Any changes to medications as a result of the exam will be processed by the nurse on duty when the client returns to the program.
2. Potential Emergency Medical Conditions –Potential emergency medical conditions including allergies, asthma, diabetes, etc., will be noted at the top of the Medication List, which is kept in each client folder on the shared drive, and in the front of the Medication Binder kept in the medication storage area. Emergency medications are kept in the first aid cabinet, which all staff have access to.
3. Dental Services - Nursing staff will coordinate dental appointments with Health services for times designated for care of LTSR persons served.
4. Psychiatric Services – Nursing staff will schedule time for evaluations and routine medication checks with the on-site psychiatrist. The psychiatrist is on site weekly. Each person served will be seen weekly for at least 30 minutes.
5. Laboratory Services – Persons served in the LTSR will be transported to the local laboratory for necessary draws. Staff will transport the person served to and from the laboratory.
6. Medications for Persons Served – Only licensed medical staff may pass medications in the LTSR program, unless the client is self-administering medications under a physician’s order. For medications needed while away from campus, the nurse will either prepare
the meds in advance for the client to self-administer at the ordered time, or a licensed staff will accompany the person served on the off-campus trip. All meds will remain secured in the possession of staff until such time as they are administered, or the client is prepared to self-administer.
7. Complaint Times – Clients are encouraged to report health concerns to the on duty nursing staff as they arise for assessment and intervention, if warranted.
Risperidone
*w change in concurrent med known to affect ticyclic metabolism by the liver.
*prior to start with pre-existing heart condition
REFERENCECODE: COM- 106-002 - GJRPA
TITLE: Medication Management: Scope of Services
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-002-GJRPA - Medication Management: Scope of Services
Medications are controlled in a manner designed to prevent harm to persons served.
Medications are administered by licensed staff, or by staff who have successfully completed the PA-DPW Medication Administration Training
GJR-PA provides psychiatric services, including the prescribing of medications under the direction of boardcertified child and adolescent psychiatrists. Person’s served may also be prescribed medications by other licensed practitioners, including contracted physical health, dental, and vision providers, as well as specialist providers from outside of the agency.
Long Term Structured Residence (LTSR)
Only licensed medical staff may pass medications in the LTSR program, unless the client is self-administering medications under a physician’s order.
REFERENCECODE: COM- 106-003 - GJRPA
TITLE: Prescription Drug Monitoring Programs (PMDP) Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-003-GJRPA - Prescription Drug Monitoring Programs (PMDP) Procedure
Prescribers are solely responsible for monitoring of prescription drugs via PMDPs in making prescriptive determinations.
REFERENCECODE: COM- 106-004 - GJRPA
TITLE: Medication Management: Involvement of Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-004-GJRPA - Medication Management: Involvement of Persons Served Procedure
Persons served are recognized as active participants in their care, including in the prescribing and management of medications. Prescribers are in regular consultation with members of the treatment team, family members or other caregivers, and other stakeholders; all of whom are involved in making decisions related to the use of medications. The use of medications is considered an integral part of the individualized plan of the person served.
Persons served, their families, or other involved stakeholders, including primary care physicians, are consulted/screened regarding any/all of the following, in evaluating the ongoing use of or need for medication:
A. Review of past medication use, including
1. Efficacy
2. Side effects
3. Adverse reactions
B. Identification of alcohol, tobacco, and other drug use.
C. Use of over the counter medications.
D. Special dietary needs and restrictions associated with medication use.
E. Necessary laboratory studies, tests, or other monitoring procedures
F. Common medical comorbidities
G. Evaluation of coexisting medical conditions that may be impacted by medication use
Medication therapy is started, only with the documented consent/assent of the person served, and/or a guardian.
Persons served and/or their parents/guardian are also involved in the ongoing reassessment of medications used.
REFERENCECODE: COM- 106-005 - GJRPA
TITLE: Medication Management: Training
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-005-GJRPA - Medication Management Training
All direct service personnel who will be responsible for, or administer medications, receive training as part of their orientation to the agency and at least annually thereafter. Training is intended to provide a general overview of medications most frequently used by persons served in the programs, and provides information regarding the following:
A. The purpose of medications
B. Benefits and risks associated with medication use
C. Contraindications
D. Side Effects
E. Missed doses
F. Potential implications of diet and exercise when using medications
G. Importance of taking medications as prescribed, including, when applicable, the identification of potential obstacles to adherence (timing, frequency, formulation, etc.)
H. The need for laboratory studies, tests or other monitoring procedures.
I. Early signs that medication efficacy is diminishing
J. Signs of non-adherence to prescribed medication therapy
K. Potential drug reactions and interactions, of both prescription and non-prescription medications, including, but not limited to:
a. decreased effect
b. additive effect
L. How to support persons served who self-administer medications (when applicable)
M. How medications are ordered and obtained
N. What to do in the event there are questions or concerns about a medication the person served is taking or has been prescribed.
When prescribed a new medication, or a medication change is ordered, persons served, as well as their family members or responsible stakeholders, are provided with education/training regarding the following:
A. The medication and dosage ordered
B. The anticipated benefits of therapy
C. Possible risks of therapy
D. Potential side effects of the medication
E. Anticipated duration of therapy
F. The importance of taking medications as prescribed
G. The need for laboratory studies or other ongoing monitoring (if applicable)
H. What to do and/or who to contact in the event they have additional questions or concerns regarding medication that has been ordered.
Non-licensed staff who are required to administer medications must successfully pass the PA DPW Medication Administration Training program, and remain in compliance with its requirements.
Long Term Structured Residence (LTSR)
Only licensed medical staff may pass medications in the LTSR program, unless the client is self-administering medications under a physician’s order.
REFERENCECODE: COM- 106-006 - GJRPA
TITLE: Sleep Study Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-006-GJRPA - Sleep Study Procedure
A. Often, a person served is seen by a physician with a complaint of sleep problems. For the physician to accurately diagnose and treat complaints of sleep problems, they may need information regarding the sleep patterns of the person served. A sleep study form will be utilized to assess those persons served with sleep complaints during the sleeping hours.
B. When a person served complains of sleep problems, alert the Evening Security staff to closely monitor the person served for sleeping patterns for the designated days and document it on the form. The form is to be submitted to health Services as soon as it is completed. The physician will utilize the information as a tool in the evaluation of the sleep complaints.
C. If Evening Security notice a person served who is awake often during the night or who has difficulty getting to sleep or staying asleep, the Evening Security staff may initiate this Sleep Form and forward it to the Counselor Parent or Behavioral Health Technicians.
REFERENCECODE: COM- 106-007 - GJRPA
TITLE: Use of Psychiatric Medication by Persons Served Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 12/8/2022
COM-106-007-GJRPA - Use of Psychiatric Medication by Persons Served Procedure
A. The need for medication shall be assessed by a psychiatrist in a formal interview with the person served and with input from the Treatment Team.
B. The order will be written into medical notes on the chart of the person served
C. The person served will meet with the psychiatrist for a formal medication check. The psychiatrist will review medication on an as needed basis or if the Treatment Team recommends a medication review.
D. If under age l4, a consent form shall be forwarded to the parents or guardians, who will be notified of possible side effects and other related information.
E. Medication will be dispensed by Health Services.
F. When persons served are traveling home, medication will be sent in an envelope with the driver, who will retain possession of the envelope. The driver will return the envelope to the parent/guardian, who must sign to acknowledge their receipt of the medication.
G. When nursing staff are unavailable to pass medications due to off-campus activities, only staff members who have successfully completed the PA-DPW Medication Administration Training may administer medications, or observe self-administration (if appropriate).
H. Long Term Structured Residence (LTSR)
1. All orders for medication given by the physician will be recorded in the chart of the person served and will be reviewed, renewed and signed at least every 30 days.
Medications and treatments shall only be administered by licensed medical staff or properly trained/certified staff using the 5 rights of medication safety, ensuring the right person is receiving the right med, in the right dose, via the right route, at the right time. Licensed medical staff will check the identity of the individual receiving the medication utilizing two-step verification. The first verification step is to compare the person receiving the medication against a current photo in the medication administration record. The second verification step may be completed by asking another staff person to verify the person’s identity, or if not available, by relying on the medical staff’s knowledge of the individual, if they have passed the medication to the person previously.
REFERENCECODE: COM- 106-008 - GJRPA
TITLE: Obtaining Medications (Ordering, Reordering, & Receiving Medications) Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-106-008-GJRPA - Obtaining Medications (Ordering, Reordering, & Receiving Meds) Procedure
Persons served ordered medications needed to promote desired outcomes while in the program, will have medications obtained on their behalf by the agency via the contracted pharmacy. All medication orders are recorded in the electronic health record.
A. Ordering medications
Upon receipt of an order for medication, nursing staff should review the order for clarity and completeness. If receiving a verbal order, nursing staff should “read back” the order to the prescriber as verification.
Once reviewed, the order should be transmitted to the contracted pharmacy.
B. Reordering Medications
Medications should be ordered in advance of need to ensure availability.
Controlled substances require a new prescription every 30 days, and should be ordered under the process outlined above under “Ordering Medications”, with the exception that verbal orders are not permitted. Electronic transmission of the prescription (e-script) is required prior to processing any order.
C. Receiving Medications
Medications are delivered by the contracted pharmacy via courier at regular intervals and as needed. Upon receipt, nursing staff, or other properly trained staff should verify that all meds ordered, have been received, and that the meds received are correctly labeled.
Medications should then be placed immediately in the medication storage area appropriate to each type of medication received.
D. Returning medications
Medications may require return to the pharmacy for a variety of reasons, including, but not limited to repackaging, relabeling, or destruction.
All medications requiring return to the contracted pharmacy should be stored appropriately for their class and type, until such time as they are placed in the custody of the pharmacy’s courier. Controlled substances cannot normally be returned to the pharmacy.
E. Controlled Substances
Controlled substances are disposed of through Health Services using the drug disposal bottle. Two nurses witness the disposal and sign their initials on the medication disposal log sheet.
Controlled substances are required to be counted at each shift change. All controlled substance counts should be reviewed with one staff from the shift that is ending and another from the shift that is beginning. Staff from both shifts must verify the quantity of controlled medication present prior to signing the controlled substance count sheet.
F. Emergency Access to Pharmaceutical Services
In the event that pharmaceuticals are needed on an emergency basis, the agency maintains a relationship with both the primary pharmacy provider, as well as a local backup pharmacy provider. As a last resort, a person served could be transported to the local emergency for the administration of a medication that was otherwise unavailable.
REFERENCECODE: COM- 106-009 - GJRPA
TITLE: Verification of Medications Brought into the Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-009-GJRPA - Verification of Medications Brought into the Program Procedure
When persons served arrive to the program with medications not filled by the contracted pharmacy, a verification of the medications must be conducted.
Two staff, at least one of whom is a licensed nurse will verify the medication through the use of the pill identifier tool available through www.drugs.com, or through the use of another reference tool or manual. Both staff will verify that the medication received is the same as that indicated on the package label, and/or ordered for the individual if a label is not present. Staff will also verify the amount/quantity of the medication received, proper dosing instructions, and instructions for use, including the method/route of administration. Once the medication has been filled by the contracted pharmacy, the remaining medications received upon arrival will be returned to the family member or stakeholder of the person served, or will be destroyed in accordance with the agency’s medication disposal procedure.
REFERENCECODE: COM- 106-010 - GJRPA
TITLE: Medication: Packaging & Labeling Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-010-GJRPA - Medication: Packaging & Labeling Procedure
Medications are labeled in accordance with facility requirements and state and federal laws. Only a licensed pharmacist may modify or otherwise alter a prescription label.
Each prescription medication label includes (at a minimum):
A. Individual's name.
B. Name of medication, which may include brand, generic, or both.
C. Strength of medication.
D. Dose of medication to be given.
E. Route of administration.
F. Time(s) medication is to be administered.
Labels may also include any/all of the following:
A. Special instructions for use or administration.
B. Quantity dispensed by number or volume.
C. Number of refills.
D. Prescriber's name.
E. Date medication was most recently dispensed/filled. (May also include the date the medication was originally filled).
F. Medication Expiration date.
G. Name, address and telephone number of the dispensing pharmacy.
H. Prescription number.
I. Accessory labels indicating storage or special handling requirements, and class of controlled medication (if applicable).
J. Container number and total number of containers when multiple containers are dispensed for one prescription.
K. Initials of dispensing pharmacist.
Improperly labeled medications should not be accepted for delivery, and should be returned to the supplying pharmacy for corrective labeling. Medication labels should be permanently affixed to the outside of prescription containers.
If an ordered, nonprescription medication cannot be supplied and/or labeled by the pharmacy, then a copy of the physician’s order for same should be attached to, or otherwise kept with the non-labeled product, to be used for verification in the medication administration process.
3, 2025
Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels are returned to the pharmacy for relabeling or destroyed in accordance with medication destruction policy.
Stock medications (if utilized) are kept in the original manufacturer’s container with the expiration date and lot number clearly evident. Products expire on the date listed on the pharmacy label, or on the original container, whichever is earlier. For any questions of expiration, staff should defer to the expiration date printed on the pharmacy label.
Never write on, or alter a pharmacy label in any way. If a medication is to be used differently than indicated on the label, a copy of the physician order with instructions on how to administer the medication must be kept with the medication package. New medication with an updated label should be obtained as soon as possible.
REFERENCECODE: COM- 106-011 - GJRPA
TITLE: Medication: Safe Storage
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-011-GJRPA - Medication: Safe Storage
The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members who have been properly trained to administer or assist in administering medications.
A. The pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers at all times. Transfer of medications from one container to another is done only by a pharmacist. Medications are to be always maintained in their original, labeled containers.
B. Only licensed nursing personnel, pharmacy personnel or staff members who have been properly trained to administer or assist in administering medications are allowed access to medications. Medication and medication supplies are locked or attended by persons with authorized access.
C. Orally administered medications are kept separate from externally used medications.
D. Injectable medications are only to be administered by licensed personnel.
E. Except for those requiring refrigeration, medications intended for internal use are stored in a designated area of the medicine cupboard/cart that is for internal medications only.
F. Medications ordered via different routes (oral, topical, nasal, etc.) and/or of different dosage forms (liquids, solids, etc.) should be stored separately.
G. Medications labeled for persons served should be stored separately from stock medications.
H. Potentially harmful substances (e.g., urine test reagent tablets, household cleaning supplies, disinfectants, insect repellant, etc.) should be stored in a locked area separate from medications.
I. Schedule I medications are not to be stored or utilized within the Agency. Schedule II-III medications may be stored within the Agency under a double locked system. Schedule IV-V medications may be stored within the Agency and are to be securely locked.
J. Medications requiring "refrigeration" are kept in closed and labeled containers, within a locked container in a refrigerator. Alternatively, they may be kept in a locked refrigerator with a thermometer to allow for temperature monitoring. Medications requiring storage "in a cool place" are refrigerated unless otherwise directed on the label.
K. Outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures or a clearly legible and fully intact pharmacy label are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists.
L. Medication storage areas are kept clean, well-lit, and free of clutter.
M. Long Term Structured Residence (LTSR)
1. Only medications which are prescribed for self-administration or that will be administered by an individual appropriately licensed to administer medication is stored in the LTSR.
2. Medications stored in the LTSR are kept in a locked container or medication cart, in a locked roomed, to which persons served do not have unsupervised access.
3. Each prescription medication ordered for a person served is kept in the original prescription container labeled by the dispensing pharmacist for the sole use of the person served
4. Over the counter medications maintained in the facility will bear the original label and name(s) of the persons served for whom the drug is ordered.
REFERENCECODE: COM- 106-012 - GJRPA
TITLE: Medication: Transportation & Delivery Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-012-GJRPA - Medication: Transportation & Delivery Procedure
Medications are to be transported to the units in a secure manner, and should remain in the possession of nursing staff until such time as they are administered.
Medications for use during home pass are prepared in advance and given to the driver until such time as the person served is placed in the care of another adult. Instructions for administration and return of unused medications are also provided to the family member of person or persons responsible for care while away from the facility.
REFERENCECODE: COM- 106-013 - GJRPA
TITLE: Medication: Safe Handling
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-013-GJRPA - Medication: Safe Handling
Medications are to be handled in such a way as to minimize contact between the person preparing the medication for administration and the medication itself. Staff should wash their hands with soap and water prior to preparing medications and in between the preparation of medications for multiple people, so as to prevent cross contamination. For some preparations of medications, including topicals, ointments, gels, creams, patches, etc., gloves must be worn to create a protective barrier.
A record of all ordered medications will be maintained for each person served, including the name and telephone number of each prescribing professional.
REFERENCECODE: COM- 106-014 - GJRPA
TITLE: Administration of Medication (Secured Units Only) Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-014-GJRPA - Administration of Medication (Secured Units Only) Procedure
A. Nursing Responsibilities
1. At the medication times, the nursing staff will administer the medication to the person served through the serving window.
2. The Behavioral Health Technician (BHT) will assist the nurse by monitoring the person served at the window and having others persons served waiting.
3. The BHT will inform the nurse of any person served with complaints or any condition of concern regarding the health of the persons served within the program.
B Additional Considerations
1. At no time may an employee of George Junior Republic administer medication if they have not successfully completed the Medication Administration training.
2. At no time is a person served permitted to carry or store medication until the time of administration.
3. The staff member responsible for the administration of medication must ensure that the medication is administered by the guidelines established in the Administration of Medication Course.
4. If an error occurs in the administration of medication, an error report form must be completed.
5. Should a person served experience side effects or adverse reactions to the medication, the staff member must contact Health Services personnel immediately and document the side effects as per protocol of the Medication Administration standards.
6. If there are any questions regarding this policy or the administration of medications, contact Health Services for clarification or assistance.
REFERENCECODE: COM- 106-015 - GJRPA
TITLE: Medication: Off-Site Use Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-015-GJRPA - Medication: Off-Site Use
When medications are required to be given off site, they will be given by nursing staff or other personnel properly trained and authorized to administer medications, or by a family member or other person responsible for the care of the person served.
Long Term Structured Residence (LTSR)
Only licensed medical staff may pass medications in the LTSR program, unless the client is self-administering medications under a physician’s order. For medications that will be needed while away from campus, the nurse will either prepare the meds in advance for the client to self-administer at the ordered time, or a licensed staff will accompany the person served on the off-campus trip. All meds will remain secured in the possession of staff until such time as they are administered, or the client is prepared to self-administer.
REFERENCECODE: COM- 106-016 - GJRPA
TITLE: Medication: Self-Administration Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-016-GJRPA - Medication: Self-Administration Procedure
Persons served who have been identified by Health Services staff, as being able to self-administer medications, will receive education in the proper administration and monitoring of the specific identified medications.
Nursing staff, or other personnel properly trained and authorized to administer medications, will supervise the person served during the self-administration process to ensure safe and accurate administration.
Documentation in the eMAR will be completed by the staff supervising the self-administration.
Long Term Structured Residence (LTSR)
Persons served who need assistance with medication prescribed by a physician for self-administration will be provided the least assistance necessary, which may include handling medication containers, or taking medication out of its container for the person served. All assistance in self-administration will be provided by a licensed medical staff.
REFERENCECODE: COM- 106-017 - GJRPA
TITLE: Medication: Diversion/Stockpiling Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-017-GJRPA - Medication: Diversion/Stockpiling Procedure
Medication use and ordering is monitored by Health Services staff on an ongoing basis. Administration assignments vary regularly by staff and geography. Medications are maintained in short supply (typically 7 days). Controlled substances are counted each shift by two different staff. Any suspected diversion by staff or persons served is investigated fully, and reported to the appropriate authorities as needed.
The Director of Health Services evaluates the risk for diversion by staff or persons served on an ongoing basis.
If persons served, who receive medications, demonstrate behaviors consistent with stockpiling medications (non-cooperative at times of administration, suspicious behavior, comments to peers, etc.), all steps to identify possible stockpiles, and prevent ongoing occurrences are initiated. These efforts may include, but are not limited to:
A. A search of belongings, person, or quarters
B. Additional, increased supervision during times of administration
C. Verification of medication compliance via laboratory tests and/or chemical screening
REFERENCECODE: COM- 106-018 - GJRPA
TITLE: Documentation of Medication Administration Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-018-GJRPA - Documentation of Medication Administration Procedure
When medications are administered, documentation is placed in the eMAR regarding the following:
A. Time of administration
B. Identification of the person administering the medication, or observing the self-administration
C. Confirmation of the dose being accepted, or documentation of refusal.
Staff should also document and report any observed or reported medication reactions, including information regarding medication sensitivity, allergic or anaphylactic reaction, paradoxical reactions, signs/symptoms of medication toxicity, or other unwanted or side effects to Health Services and the Treatment Team.
REFERENCECODE: COM- 106-019 - GJRPA
TITLE: Medication Emergencies Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-019-GJRPA - Medication Emergencies Procedure
Medication emergencies may include overdose, anaphylactic reaction, medication toxicity, seizure, loss of consciousness, or other medical emergency coinciding with the administration of medication. Staff should immediately contact emergency services (9-1-1) during any medical emergency, stay with the person served, and provide supportive care, including first aid and/or CPR as trained.
If poisoning is suspected, staff should immediately contact emergency personnel (9-1-1), or poison control, as warranted. The numbers for emergency services and for poison control are located on each phone throughout the agency. Persons served are also instructed in accessing emergency services and poison control upon intake.
Following any medication emergency, the Director of Health Services will conduct a review of the incident and provide a report to the administration team of their findings, along with any recommendations for necessary changes to process, procedure or facilities to prevent reoccurrence.
REFERENCECODE: COM- 106-020 - GJRPA
TITLE: Medical Referral to Emergency Room Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 12/12/2024
COM-106-020-GJRPA - Medical Referral to Emergency Room Procedure
In case of an emergency and if immediate medical services are required by persons served, staff members are required to call 911 to be taken to the nearest emergency room.
A. A nurse will be on-site 6am to 10pm to address non-emergent medical concerns/conditions. Between the hours of 10pm and 6am a nurse will be available via on-call.
B. The nurse will record the incident in the medical record of the person served.
C. The incident will be reported as a Reportable Incident (see Policy Reportable Incident)
D. Upon the return of the person served to George Junior Republic in Pennsylvania, the person served will be scheduled to see a licensed practitioner for follow-up at the earliest opportunity.
REFERENCECODE: COM- 106-021 - GJRPA
TITLE: Medication Errors Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-021-GJRPA - Medication Errors Procedure
Medication errors can occur for several reasons, and are defined as “errors” due to the failure of staff to perform one of the procedures necessary to assure that medications are administered safely. The agency keeps a record of all medication errors for administrative purposes. Clinician orders specific to the resolution of an error become part of the clinical record.
The agency defines medication errors as;
Omission - Medication was available but not administered by the time next dose is due. Each medication omitted counts as an error
Wrong Route – Medication was not introduced into the body in the manner that it was prescribed.
Wrong Person – Medication was administered to the incorrect person.
Wrong Time – Medication was not given within 1 hour before or 1 hour after the time it was prescribed.
Wrong Medication – Individual was given medication that was not prescribed to them.
Wrong Dose – Individual was not given the correct dosage as prescribed by the physician.
Wrong Position – Medication was not given per specifications of health care personnel.
Med. Not Available – Human error which results in the medication not being available to administer.
Medication Variables
At times, persons served may not receive medications due to reasons beyond the control of agency staff. In those instances, the “missed dose” is defined as a “variable.” Documentation of medication variables follows the same procedure as medication errors.
Medication “Variables” are defined as follows;
Unavailable Client – For an unforeseen circumstance the person served is not available. (i.e.: An appointment ran over, visit ran over, activity ran over)
Emergency Room Visit – This could be due to physical health or mental health needs during normal medication pass times.
3, 2025
Visit – Medication is not available. This could be due to the medication not returning, or incorrect usage while on visit.
Refusal – Medication is available but the person served refused to take the medication 1 hour prior to or 1 hour following the designated time for administration.
Lack of Consent – Consent for administration of the medication was not obtained from the legally responsible party for a given person served
Miscellaneous- Medication was not available despite all efforts to obtain the medication. (i.e.: a person served admitted to a program without medication on-hand and the staff are unable to obtain the medication in time to avoid the missed dose)
Reporting Errors
All staff have a responsibility to report medication errors to the nursing staff when they are discovered.
Nursing will investigate reports of errors to the degree reasonably necessary to determine their accuracy.
When an error is identified, nursing staff must notify the on-call or treating clinician of the error, and of contributing factors.
The clinician will make recommendations, and/or provide verbal orders for corrective action in an effort to maintain therapeutic benefit (if necessary).
If verbal orders are provided, the nursing staff will read back and then document the verbal orders in the client record.
Nursing staff are expected to make every effort to prevent further errors by reviewing safe practices/procedures with staff and/or identifying the reason for the error and working to resolve the issues that contributed to the error.
Discipline of staff regarding frequent medication errors will be based on the agency’s policy.
The Director of Health Services and/or designated nursing staff will report an error summary monthly to the agency’s Safety Committee.
REFERENCECODE: COM- 106-022 - GJRPA
TITLE: Medication Administration: Biohazards Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-022-GJRPA - Medication Administration: Biohazards Procedure
All biohazardous materials associated with the administration of medications will be managed in accordance with the agency’s Infection & Exposure Control Plans.
REFERENCECODE: COM- 106-023 - GJRPA
TITLE: Abnormal Involuntary Movement Scale (AIMS) Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-023-GJRPA - Abnormal Involuntary Movement Scale (AIMS) Procedure
Persons served who are ordered antipsychotic or neuroleptic medications are assessed at the initiation of therapy and periodically (as deemed medically necessary) thereafter. Reassessment is conducted with the report of symptoms.
REFERENCECODE: COM- 106-024 - GJRPA
TITLE: Availability of Consultation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-024-GJRPA - Availability of Consultation Procedure
An agency psychiatrist, or other qualified professional licensed to prescribe (if needed) is available for consultation on a 24/7 basis.
REFERENCECODE: COM- 106-025 - GJRPA
TITLE: Safe Medication Disposal Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-025-GJRPA - Safe Medication Disposal Procedure
When disposal/destruction of medications is required, the agency follows EPA recommendations regarding the disposal of discontinued, unused, outdated or deteriorated medications. Unused medications are not flushed or disposed of in sinks under any circumstances. The Agency employs the use of RX Destroyer, an activated charcoal based, neutralizing product, for the safe disposal of unused medications, which renders the medications non-retrievable.
A. Sealed containers of the RX Destroyer product should be maintained in each medication storage area for use as needed.
B. Medications requiring destruction should be placed in the bottle, the lid sealed tightly, and the product inverted repeatedly to ensure adequate coverage and even distribution. Once full, the container may be placed in the regular trash.
C. Unless otherwise instructed, all medication requiring destruction is returned to the Health Services Department where it will be:
1. Returned to the contracted pharmacy for disposal
2. If unable to be returned to the pharmacy, disposed of by nursing staff according to the above procedure with two staff present.
D. Sample medications that require destruction will be disposed of similarly.
E. Medications being disposed of via community take back programs (if utilized) are to remain under the supervision of both a licensed nurse and one additional staff during transport, and until such time as they are surrendered.
F. Controlled substances are disposed of as detailed in the procedure on controlled medications in this manual.
G. Long Term Structured Residence (LTSR) This procedure was approved Richard Dodek, RPh on 1/25/21.
REFERENCECODE: COM- 106-026 - GJRPA
TITLE: Return of Unused/Surplus Medications Upon Transition or Discharge Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-026-GJRPA - Return of Unused/Surplus Medications Upon Transition or Discharge Procedure
Upon discharge or transfer to another facility, any ordered medications will be entrusted to a family member or other caregiver with instructions for their ongoing administration and safe use.
Medications for persons served who are transferred to another facility for ongoing care, will be entrusted to an authorized representative of the accepting agency/facility.
REFERENCECODE: COM- 106-027 - GJRPA
TITLE: Pharmacy Consultation/Peer Review
Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-106-027-GJRPA - Pharmacy Consultation/Peer Review
The agency contracts with a pharmacy consultant to provide/conduct peer review of the use of medications for persons served. Reviews are conducted at least annually (typically quarterly) on a representative sample of persons served, for whom prescriptions were provided.
The consulting pharmacist assesses the appropriateness of each medication, as determined by the following:
A. Needs and preferences of the person served (as reported in supporting documentation)
B. The condition for which the medication is prescribed
C. Dosage
D. Need for continued use related to the primary condition being treated
E. Reported efficacy of the medication
And determines whether:
A. The following were identified and, if needed, addressed:
1. Contraindications
2. Side effects
3. Adverse reactions
B. Necessary monitoring protocols were implemented/completed
C. There was simultaneous use of multiple medications, including:
1. Polypharmacy
2. Co-pharmacy
Information from the consulting pharmacist’s review is reported to the Director of Health Services, the prescribing physician, and nursing staff as necessary. It is intended to improve the quality of services provided and summary results are incorporated into the quality and outcomes process though the review of aggregated medication utilization reports.
Long Term Structured Residence (LTSR)
The contracted licensed pharmacist conducts a quarterly review of all drug regimens of persons served, and submits written findings to the program director and prescribing physicians.
Annually, a pharmacist or other licensed medical staff reviews the agency’s medication policies and procedures, including inspection of the medication storage area. A written report of the review, including in service training recommendations, if any, is submitted to the program director.
April 3, 2025
REFERENCECODE: COM- 106-028 - GJRPA
TITLE: Medical Record Abbreviations Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-106-028-GJRPA – Medical Record Abbreviations Procedure
A. Permissible Abbreviations
The following list of medications abbreviations is acceptable for use in the medical record of each person served. If a staff person receives a prescription and is not familiar with an abbreviation/term, they can refer to the following list, verify the abbreviation/term with the prescribing physician, or contact the pharmacy.
Approx. = approximately
B.I.D. = twice a day
B.M.I. – body mass index
BP or B/P = blood pressure
BPM = beats per minute
C = Celsius
cap = capsule
CAT = Computed Axial Tomography
CBC = Complete Blood Count
CMP = Complete Metabolic Panel
COPD = Chronic Obstructive Pulmonary Disease
c/o = complaint(s) of
CPR = Cardiopulmonary resuscitation
CT = Computed Tomography
DOB = Date of Birth
ECG/EKG = electrocardiogram
F = Fahrenheit
GERD = Gastroesophageal reflux disease
gm = gram
gr = grain
gtt = drop
I.M. = intramuscular
I.V. = intravenous
LFT = Liver Function Test
mg = milligram
ml = milliliters
p.r.n. = as necessary, as needed
q = every
q. 1H = every hour
q. 4H = every four hours
Q.I.D. = four times a day
R/O = rule out
Sig = label
Sol = solution
Stat = immediately
tab = tablet
T.I.D. = three times a day
TSH = Thyroid Stimulating Hormone
oz = ounce
B. The following abbreviations are NOT TO BE USED in any manner throughout the Agency. These abbreviations are not to be used in progress notes, doctor's orders, medication lists or in notes as reminders to self of information. All levels of staff are expected to follow this procedure including, but not limited to, contracted providers, licensed staff and all other employees of the Agency.
U (for unit) – Must write "Unit"
IU (for international unit) – Must write "International Unit"
Q.D. or Q.O.D. – Must write "Daily" or "Every Other Day"
Trailing zero (X.0) – Never write zero by itself after a decimal point and always use a zero before a decimal point (Example: 0.05 mg)
MS, MS04, MgSO4 – Must write "Morphine sulfate" or "Magnesium Sulfate"
Abbreviation for microgram – Must write "microgram"
HS – Must write either "Half Strength" or "Hour of Sleep" or “bedtime”
TIW – Must write "three times a week" or "3 times weekly"
SC or SQ – Must write "Sub-Q" or "sub Q" or subcutaneously
D/C – Must write "Discharge"
CC – Must write "ml" or "milliliters"
AS, AD, AU – Must write "left ear", "right ear", or "both ears"
REFERENCECODE: COM- 106-030 - GJRPA
TITLE: Naloxone Procedures
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/3/2022
DATEREVISED: 12/12/2024
COM-106-030-GJRPA - Naloxone Procedures
The agency maintains a supply of Naloxone on campus for administration under the Pennsylvania Standing Order in the event of suspected opioid overdose. Campus Supervisors and nursing staff are trained in the administration of naloxone annually, and maintain supplies in the Health Services Department within the Wellness Center, the Secure Detention Program, the Visitation Center/Check-In Building, and in the Campus Supervisors’ office. Supplies are monitored regularly by the Director of Health Services or their designee for expiration and new supplies ordered from the pharmacy as needed. As part of the agency’s emergency protocols, staff is to contact Campus Supervisors, nursing staff, and/or 9-1-1 depending on the severity of the incident. All responding parties have access to and training in the administration of Naloxone, if needed.
Clients identified as at risk for opioid overdose are provided education regarding Naloxone from the drug and alcohol program staff. Information is also made available for families, caregivers and guardians upon request. The treating physician may, at their discretion, provide individuals who are discharging from the agency with a prescription for Naloxone. This discussion and rationale for providing a Naloxone prescription will be documented in the client medical record.
Individuals residing in residential units may not personally possess any medications due to the risk of unsafe use by themselves and/or their peers.
REFERENCECODE: COM- 107 - GJRPA
TITLE: Physician’s Standing Medical Orders for OTC and Prescription Medications Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-107-GJRPA - Physician’s Standing Medical Orders for OTC and Prescription Medications Policy
Understanding that a physician or advanced practitioner is not always on site, it is the policy of the agency to utilize standing medical orders, which may be followed in the event of a minor illness or injury of a person served as assessed by the nurse and not indicative of emergent care. Standing medical orders will be reviewed by the physician on an annual basis.
REFERENCECODE: COM- 107-001 - GJRPA
TITLE: Physician’s Standing Medical Orders for OTC and Prescription Medications Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 12/8/2022
COM-107-001-GJRPA - Physician’s Standing Medical Orders for OTC and Prescription Meds Procedure
All medications administered to persons served, including over the counter (OTC) medications, require a physician’s order.
OTC or non-prescription medications ordered for specific persons served will be filled through the contracted pharmacy and labeled for individual use of persons served Orders for OTC medications may be instituted at the discretion of the attending nurse.
In consultation with other medical staff at the agency, the contracted physical health provder may designate certain medications as “standing orders” for use on an ongoing, as needed basis, as determined by nursing staff or other personnel properly trained and authorized to administer medications. Standing order medications are ordered at specific doses and intervals for specific, non-emergent conditions, including pain, fever, stomach upset, etc. Only licensed and properly trained/certified staff may administer medications.
Standing medication orders:
A. Claritin (Loratadine) 10mg by mouth – 1 tab as needed at bedtime for signs and symptoms of seasonal allergies, including sneezing and congestion.
B. Benadryl (Diphenhydramine) 25mg by mouth – 1 capsule every 6 hours as needed for itching, rash or hives.
C. Acetaminophen(Tylenol) (max 3000mg in 24 hours)
a. Ages 12 and up; 650mg ( 2 tabs) by mouth every 6 hours as needed for pain or fever above 100F
b. Ages 8-11; 325mg (1 tab) by mouth every 6 hours as needed for pain or fever above 100F
D. Loperamide(Imodium) 2mg tablet- do not give for more than 48 hours.
a. Ages 12 and up; 4mg(2 tabs) by mouth after first loose stool, then 1 tablet with each subsequent loose stool, no more than 4 tablets in 24 hours.
b. Ages 8-11; 2mg (1 tab) by mouth after first loose stool, then 1 tablet with each subsequent loose stool, no more than 3 tablets in 24 hours.
E. Milk of Magnesia 400mg/5ml oral suspension – 30ml by mouth twice daily as needed for not having a bowel movement for 24 hours or for complaints of indigestion, sour stomach and heartburn.
F. Miralax 17gm mixed with 8 oz of water(if Milk of Magnesia was not effective) every 12 hours as needed for constipation for a max of 2 doses if not effective add to doctor line.
G. Triple antibiotic ointment topically to minor wounds as needed every 12 hours
April 3, 2025
H. Hydrocortisone cream topically to itchy, irritated skin as needed every 12 hours
I. A and D ointment topically to dry, cracked or chapped skin as needed every 12 hours
J. Campho-Phenique apply topically to cold sore up to 3 times a day as needed
K. Robafen DM 100mg/5ml give 10ml by mouth( for ages 12 and up only) every 4 hours as needed for cough. If cough persists for 7 days add to doctor line.
L. Selenium Sulfide Shampoo; apply to scalp while showering once daily as needed for dandruff.
M. Stridex pads for mild to moderate acne. Use one pad after washing face in the morning and evening.
N. All routine immunizations will be given according to the American Academy of Pediatrics Recommended Childhood and Adolescence Immunization Schedule, including the yearly seasonal influenza vaccine.
REFERENCECODE: COM- 108 - GJRPA
TITLE: Health Service: Employee Injuries Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-108-GJRPA - Health Services: Employee Injuries Policy
Staff persons injured while on duty may come to the Health Services for assessment, first aid, and referral. The Health Services staff will assist the staff person in starting the Worker’s Compensation procedures.
REFERENCECODE: COM- 108-001 - GJRPA
TITLE: Employee Injuries Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-108-001-GJRPA - Employee Injuries Procedure
Minor Injuries Requiring First Aid:
A. Employees injured on the job who are able to move extremities and show no signs of dizziness or confusion must contact Human Resources to report the injury. Outside of normal work hours, they should contact the Campus Supervisor on duty.
B. The employee may be sent to Health Services to be assessed by the nurse on duty if the injury requires simple first aid.
C. Injured employees are provided the following forms, that must be completed and returned to Human Resources within 24 hours of the injury.
1. First Report of Occupational Injury or Disease
2. Workers’ Compensation Employee Notification (two forms)
3. Medical Records Release Authorization
D. The Occupational Health provider must follow any ongoing medical/care needs.
Life Threatening Emergency/Injury:
A. Dial 911. If calling from a personal cell phone or other non-agency phone, call, or instruct someone else to call/notify campus supervisors of the emergency. If within their unit, staff can also initiate the use of their panic alarm to summon campus supervisors to their location.
B. The staff member is not to be moved under any circumstances
C. If appropriate, provide First Aid and/or CPR until help arrives.
D. Upon arrival of the ambulance, the patient’s care is turned over to the emergency service personnel.
E. The Human Resources Officer must be contacted and the Human Resources Officer/their designee will contact the patient’s family.
REFERENCECODE: COM- 200 - GJRPA
TITLE: Activities and Programming Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-200-GJRPA - Activities and Programming Policy
It is the policy of the agency to provide structured and unstructured activities and programming to persons served in order to support their emotional, mental, physical, and social health.
REFERENCECODE: COM- 200-001 - GJRPA
TITLE: Campus Activities Guidelines Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 10/19/2023
COM-200-001-GJRPA - Campus Activities Guidelines Procedure
A. The 3800 regulations of the Department of Human Services mandates daily activities for persons served in residential facilities. The Program Department is responsible for scheduling daily oncampus activities, as well as various opportunities for off-campus activities. Developmentally appropriate activities and club choices will be provided to all persons served. Activities are designed to teach persons served physical and social interaction skills and alternative avenues for constructive use of leisure time. Persons served may be hesitant to engage in group recreational activities and should be encouraged to become active participants.
B. The Program Department will publish the Daily Activity Sheet in the Activity Share Folder no later than the day before the activity is scheduled. Please check the Activity Share Folder frequently for Program Department updates.
C. Guidelines for the Open Campus Program include:
1. Direct Care staff are required to escort persons served to the scheduled activity, and should arrive no earlier than the scheduled time.
2. When inter-unit activities are schedule, Direct Care staff are expected to remain at the activity and act as coaches.
D. Guidelines for the Special Needs/Diagnostic Programs
1. Behavioral Health Technicians are expected to be active monitors during the activity. Behavioral Health Technicians are expected to:
a. Remain at the scheduled activity for its duration.
b. Refrain from going to other activities.
c. Refrain from cell phone usage during activity.
d. Monitor the persons served and intervene as needed.
E. At times the Program Department may schedule inter-unit activities in the form of tournaments (e.g. basketball, softball, volleyball, etc.).
F. Throughout the year the Program Department offers various clubs, allowing persons served to participate in an activity that interests them. Clubs are both active (e.g. flag-football, hockey) and passive (e.g. book, billiards) to give all persons served an option to participate. Club signups, rosters, and meeting times are published in the Activity Share Folder. Please check the Activity Share Folder often.
1. Due to the nature of clubs, there may be various criteria a potential club member must meet.
2. All criteria will be posted on the club signup sheet.
G. At times inclement weather may result in activity being adjusted or cancelled. The Program Department will notify the unit of any necessary changes, including but not limited to Open Campus Programs receiving transportation to and from activity when lightning or extreme weather is present.
H. If a person served experiences an injury during activity, notify the Health Services Department, who will respond to assess the person served. Do not move the person served prior to assessment. If the injury is severe and/or life threatening, follow the procedures for responding to a medical emergency, including calling 911.
I. Please contact the Program Director for any specific activity concerns not addressed above.
Long Term Structured Residence (LTSR)
Physical activity is not mandated for the LTSR, but one hour of physical activity will be scheduled per day for each person served. The above procedure is observed by the LTSR with the following exceptions:
The programs schedule will be created through the collaboration of the Program Department and LTSR Staff.
LTSR persons served will be transported to and from any activity on the campus.
REFERENCECODE: COM- 200-005 - GJRPA
TITLE: Whereabouts Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-200-005-GJRPA - Whereabouts Procedure
When moving around campus unescorted, persons served are required to make their whereabouts known. Staff members should expect a call from the person served within 15 minutes of departure from the unit. It is the responsibility of the person served to phone the unit and inform staff that they have arrived at their destination and when they are departing for return.
It is the staff’s responsibility to know the length of time required to walk from point A to point B. If persons served do not report to their whereabouts timely, campus supervisors should be contacted to assist in locating the person served immediately.
If a person served is assigned to an activity that requires a roll call, the staff at said activity will take attendance promptly and inform the unit if he is not present. Persons served will still be required to report whereabouts at activities in which roll call is not taken.
REFERENCECODE: COM- 200-006 - GJRPA
TITLE: Off Campus Activities Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-200-006-GJRPA - Off Campus Activities Procedure
A. Throughout the year the Program Department 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.
1. When the opportunity for an off-campus activity arises, Program employees will contact residential units for names of persons served they would recommend for the activity.
2. Persons served will be eligible for off-campus activities based on a number of factors (e.g. safety, behavior, engagement in treatment).
3. Persons served who have not been on an off-campus activity will have priority over persons served that have participated in prior off-campus activities.
4. Once a list of persons served who will be attending the off-campus activity is created, final approval will be granted by a Campus Director through an Off-Campus Activities Approval Form, and the list of persons served participating in the activity will be given to the Switchboard Operator.
a. The Off-Campus Activity Approval Form will include the names of all persons served attending the activity, employees attending and their contact information, and safety measures that will be utilized.
5. Prior to leaving campus, Health Services will be provided a list of the persons served participating in the activity so that they may make arrangements for qualified staff to pass medications while person served are away from campus.
6. Employees will remain with the person served for the entirety of the off-campus activity, providing constant supervision.
a. In the event of an unexpected issue or emergency, employees should contact the agency and/or appropriate emergency services immediately.
B. Employees may have opportunities outside of the Program Department to take persons served to an off-campus activity. If so, they are required to receive written permission from their Campus Director through an Off-Campus Activities Approval Form.
REFERENCECODE: COM- 200-008 - GJRPA
TITLE: Campus Store Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 12/12/2024
COM-200-008-GJRPA - Campus Store Procedure
A. The Campus Store is under the supervision of the Program Department and is located in the Program Center. All residential units will be scheduled to visit the Campus Store on a regular basis.
B. The Campus Store Form and the Store Sheet are distributed to each unit at the beginning of the scheduled store week
C. Counselor Parents/Behavioral Health Technicians are responsible for the following:
1. Staff will document the name of the person served and their monthly allowance on the Campus Store Form.
2. Staff will sign the Store Sheet to ensure the person served has completed it correctly and to answer any questions they may have.
3. Staff must remain in the Campus Store to monitor persons served at all times.
D. The person served is expected to indicate the items they wish to purchase on the Store Sheet prior to the scheduled store day.
E. Program employees will fill the store order for the person served. The person served is to be present so that they can confirm their order has been filled correctly. For persons served who are unable to visit the Campus Store, the Counselor Parents/Behavioral Health Technicians will complete the store sheet on behalf of the person served.
F. If an item is out of stock, the person served will have the opportunity to substitute a similar item.
G. For persons served in the Intensive Supervision Units, Program employees will pick up their completed Store Sheets at the residential unit on their scheduled store day.
1. Program staff will fill the order for persons served.
2. Program staff will deliver the filled store order to the residential unit along with the Store Sheet, allowing the persons served to have a ‘receipt’ of their order.
3. If an item is out of stock, a similar item will be substituted and the Program staff will make note of the substitution on the Store Sheet.
Long Term Structured Residence
LTSR persons served do not utilize the Campus Store.
REFERENCECODE: COM- 200-009 - GJRPA
TITLE: Shoes for Collodi Field House Gym Activity Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-200-009-GJRPA – (REDACTED) Shoes for Collodi Field House Gym Activity Procedure
This procedure was redacted with Administrative approval on 12/12/2024.
Redacted policies and procedures are archived and are available at the request and approval of the Policy and Procedure Committee or designated Administrative Team Member.
REFERENCECODE: COM- 200-011 - GJRPA
TITLE: Haircuts Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-200-011-GJRPA - Haircuts Procedure
A. Haircuts for persons served are scheduled by the Program Department. Each residential unit will be scheduled for the Barbershop once every two months. Haircuts are listed on the monthly Program Department calendar and the Daily Activity Sheet.
1. Haircut dates are subject to Barber availability and may change unexpectedly. If a scheduled haircut date is cancelled, a make-up date will be scheduled on the next available day.
B. Haircuts are performed by the scheduled barber only. Direct Care staff are not permitted to cut the hair of persons served.
C. On the scheduled haircut day, the Program Department will contact the residential unit for the names of persons served who are in need of a haircut. Due to the limited space available in the Barbershop, only persons served in need of a haircut should be included.
D. Persons served will be escorted to and from the Barbershop. A person served should never be sent to the Barbershop without approval from the Program Department.
E. Haircuts for persons served residing in the Intensive Supervision and Secure Detention programs will take place inside the residential unit.
F. Off-campus haircuts are available in emergency situations only. Campus Director approval is required for any person served requiring a haircut outside the agency.
COMPLEMENTARY SERVICES (COM) Section 300 – Visitation (Family and Agency)
REFERENCECODE: COM- 300 - GJRPA
TITLE: Family Visitation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-300-GJRPA - Family Visitation Policy
It is the policy of the agency to encourage parents, guardians, and other relatives who play an impactful role in the lives of persons served to be engaged in their treatment during their placement at GJR through visitation opportunities.
REFERENCECODE: COM- 300-001 - GJRPA
TITLE: Family Visitation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-300-001-GJRPA - Family Visitation Procedure
An important part of George Junior Republic in Pennsylvania's program is supporting youth in placement to receive visits from their family members. These visits serve a two-fold purpose. First, they combat homesickness, and second, they maintain family relationships. The PA Department of Human Services regulations indicate that a person served may not be denied visits from his family on the basis of discipline. George Junior Republic in Pennsylvania has structured campus visits to meet different circumstances.
Exception to these procedures may be granted to meet special circumstances. Permission for these exceptions should be obtained from the Campus Director or other administrative personnel.
George Junior Republic encourages families to visit persons served while in placement. To make the visit as safe and enjoyable as possible, the following procedures must be observed:
A. The agency encourages visitation for the persons served with their families and other approved visitors. Visitation hours are 9:00am to 5:00pm on Saturdays and Sundays. All visitation must be prescheduled. Family members must call 724-458-9330 x2163 to schedule visitation.
B. Only immediate family members are permitted to visit with the person served (e.g. parents, siblings, grandparents, guardians). Extended family members may visit with approval from the placing agency. The legal guardian of the person served will complete a Family Visitation Authorization Form indicating family members they allow to visit. This list is then provided to the Admissions Department and the treatment team.
1. No friends, girlfriends, or boyfriends are permitted to visit the person served.
2. Placing agencies and court orders may prohibit individuals from visiting regardless of the preference of the guardian of the person served.
3. Exceptions to these rules are granted in the case of a court order or placing agency request.
4. If family members have been approved or removed from the Family Visitation Authorization Form, it is the responsibility of the Case/Residential Manager or Treatment Team Coordinator to notify the Admission Department of these changes.
5. Visitation may be denied if there is not appropriate documentation that an individual has been approved to visit with the person served.
C. No more than four adult family members are permitted to visit at one time. At least one visitor must be over the age of 18. Siblings are to be supervised by a guardian at all times.
3, 2025
1. For visits between siblings under the age of 18 a placing agency representative or other designated individual is required to supervise the visitation.
2. Parents are expected to supervise children they have brought with them. Families will not be allowed to interfere with the structure of the persons served and/or operation of the treatment program.
D. Alcoholic beverages and controlled substances are prohibited.
1. Visitors suspected to be under the influence of drugs and/or alcohol will not be permitted to visit.
2. Alternative arrangements for transportation will be made to ensure safe departure from campus.
E. Weapons are not permitted on the grounds of the agency.
1. Weapons on the property of the agency are prohibited by law. Visitors in possession of a weapon will not be permitted to visit.
F. Smoking in the Visitation Center and all agency buildings is prohibited. Persons served are not permitted to be in possession of a lighter or tobacco products. Providing tobacco to persons served under 21 is prohibited by law.
1. Designated smoking areas are available to visitors.
G. All Visitors are required to:
1. Enter campus via the Irishtown Road entrance.
2. Park in designated parking areas and observe handicap parking designations.
3. Check in at the Visitation Center by providing photo identification and vehicle information.
4. Items brought for the person served (e.g. money, clothing, etc.) must be left with employees of the Visitation Center and may be subjected to a heated decontamination process. A receipt of the items will be provided.
H. Visitation at the Visitation Center:
1. Areas within and around the Visitation Center are available for on-campus visits.
a. Persons served who have not been at the agency for 30 days are required to visit inside the Visitation Center.
b. Visitors/persons served are not permitted to visit inside a vehicle.
c. Visitors/persons served are not permitted to walk around the campus of the agency, and must stay within designated visiting areas.
d. Visitors must be with the person served at all times if visiting outside.
2. Persons served are not permitted to have or participate in the following at the Visitation Center:
a. Pets
b. Haircuts
c. Tobacco, alcohol, controlled substances
d. Utilize cell phones
I. Off-campus visitation
1. Persons served may participate in visitation off grounds. Treatment staff are required to complete a day pass authorization for and acquire the approving signature of the caseworker or juvenile probation officer of the person served.
a. All on campus rules apply while off-campus.
b. Intended destination(s) of the outing are to be indicated in the day pass authorization form and approved by the placing agency.
c. The person served may not visit at a hotel.
d. The person served may not possess or utilize tobacco, alcohol, or controlled substances.
e. The person served may not drive a motorized vehicle.
f. The person served must return to the agency by the time indicated on the day pass authorization form.
2. For persons served who may require a prescribed medication during their off-campus visit, the visitors may sign out the prescribed dose from the Health Services.
3. All items brought back to campus by the persons served or visitors must be returned to Visitation Center employees and are subjected to a heated decontamination process.
4. Exceptions to the off-campus procedures must be approved per a Campus Director and communicated to the Visitation Center.
J. Visitors participating in family therapy at the Pew Counseling Center are first required to check in at the Visitation Center. Families will be transported to the therapy location.
K. If problems arise during visitation, Visitation Center employees will document the problem and supply a report to the Treatment Team of the person served.
L. Visitation records of the person served are documented in the Electronic Health Record and at the Visitation Center.
M. Hygiene/Food Items During Visitation for Open Campus, Drug & Alcohol, Diagnostic, Special Needs, and Special Needs RTF Programs:
1. Families may provide their child with both hygiene products and food/snack products during visitation.
2. Hygiene products must be in their original and sealed packaging. Products that contain alcohol and/or CBD are not permitted. Aerosol products are not permitted.
3. Food/snack products that require refrigeration and/or need cooked are not permitted.
REFERENCECODE: COM- 301 - GJRPA
TITLE: Home Visit Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-301-GJRPA - Home Visit Policy
It is the policy of the agency to support the family relationships of our persons served through periodic, goaloriented therapeutic home visitations according to the established procedures.
REFERENCECODE: COM- 301-001 - GJRPA
TITLE: Home Visit Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 10/19/2023
COM-301-001-GJRPA - Home Visit Procedure
Weekend and vacation visits by persons served in placement at George Junior Republic in Pennsylvania are an integral component of the program and serve several purposes.
A. Home visits may:
1. Provide attainable goals for the person served
2. Improve family relationships
3. Provide the person served with familial contacts
4. Permit the person served a short-term time frame to practice the skills they have learned at George Junior while at home
5. Provide the treatment staff with current information on how a person served handles a less structured environment.
B. Eligibility Requirements for home pass unless there is a Court Order or special agency Request:
1. Persons served are not permitted to go to their home or community without permission from their agency representative.
2. The treatment staff must make any request for home visit arrangements in writing to the Transportation Department and contact the placing agency and family of the person served concerning the visit. It is important to speak to the placing agency and parents directly.
3. Emergency home visits may be granted if there is a death or serious illness in the family of the person served. Arrangements for these types of visits must be made through the Campus Director and Transportation Department
4. When the person served returns to campus from a home visit, their luggage and personal belongings are to be deposited in a central area for inspection indicating that the person served has checked-in officially. Agency Staff will take any money brought back from a home visit and ensure that it is placed in the student account. A receipt will be issued to the person served. The staff at the unit will inspect luggage and belongings for contraband. Male staff will complete the check in process keeping in mind PREA standards
5. For additional procedures related to a home pass, please reference the Off-Campus Transportation information in the Complementary Services section.
A. Home Visit Expectations
1. Positive behaviors are expected during travel time between George Junior Republic in PA and home. Positive behaviors are expected to be displayed at home during the visit.
2. Persons served are expected to return to campus on time and by the arrangements stated on their tickets and passes. The staff needs to review all details to catch any errors before the person served departs. Persons served are not permitted to change travel arrangements without the permission of the Transportation Department.
3. If any problems occur during the home visit, the guardian of the person served is instructed to call George Junior Republic immediately, collect if necessary, advising George Junior Republic of the situation. The phone number is on the Home Note. The Switchboard answers 24-hours per day.
4. Persons served must adhere to school dress code standards when they leave for a home pass. Check each person served prior to his departure from the unit that he is properly dressed and has appropriate luggage. Persons served are not permitted to carry luggage in plastic bags.
Long Term Structured Residence (LTSR)
LTSR persons served are not permitted to use home passes. They may receive community visitation through a court order.
REFERENCE CODE: COM- 301-002 - GJRPA
TITLE: Home Visit Rules Procedure
APPROVED BY: GJR Administrators
DATE APPROVED: 8/3/2020
DATE REVISED: 10/19/2023
COM-301-002-GJRPA - Home Visit Rules Procedure
Home Visit expectations must be reviewed with the person served by their Case Manager/Residential Manager, and signed by the person served prior to their departure for a home visit.
Persons served are expected to abide by the condition set forth by probation officer, caseworkers, and their families/guardians. To ensure the success of the home visit, clear communication must take place between the treatment team and the family/person served. Persons served should have goals for home visits to include practicing of newly learned life and social skills.
A. If they have any questions, call 724-458-9330. A Supervisor or Campus Director can help them. They can also call their Campus Home/Unit.
REFERENCECODE: COM- 301-003 - GJRPA
TITLE: Home Visit Luggage Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-301-003-GJRPA - Home Visit Luggage Procedure
New persons served are issued a home pass bag upon admission to GJR. Once a person served has been issued a bag, it is their assigned bag for the remainder of his time at George Junior Republic. When a bag has been assigned to a person served, their name is to be put on the bag and that bag becomes theirs to use for all home visits and only for home visits. When a person served is discharged from George Junior Republic, they may keep their assigned bag if they choose to do so. If a person served is transferred to another cottage or unit, their assigned bag is to go with them
The bags are to be given to persons served in time for them to be packed just prior to leaving for a home visit. Everything that a person served takes home must fit into this one bag. Each person served also needs to be instructed that they can only bring this one bag back with them from the home visit. When the bags are delivered to their respective units following the home pass return, it is the responsibility of staff to thoroughly search each bag.
At no time is a person served to be given back a bag that has not been searched. After the bag has been searched, then and only then, can a person served remove his belongings from his bag and put them away. Once the bag has been emptied, it is to be secured in a locked closet by staff. Person served are not to have access to these bags for any reason between home visits.
REFERENCECODE: COM- 301-004 - GJRPA
TITLE: Home Visit Check-in Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-301-004-GJRPA – Home Visit Check-in Procedure
When persons served return from home visit, the following procedures are to be followed:
A. Drivers will call the Switchboard 30 minutes prior to returning to campus.
B. Persons served are to be taken to the Visitation Center upon returning to campus.
1. Any family/guardian/placing agency returns are to be directed to the Visitation Center.
2. Family/guardian/placing agency returns should never be permitted to drop a person served or any belongings off directly to the residential unit.
C. Once a person served exits the agency vehicle they will take all of their belongings into the Visitation Center with them.
D. Persons served are only permitted to return with one agency provided bag. Nothing is to be tied onto/hanging off of the bag. No coats or shoes are permitted to be hanging off of the bag.
1. Persons served are issued one home visit bag upon their admission to the agency
E. Any cell phones or other electronics devices not permitted in the residential unit will be given to the Campus Director for safekeeping with documentation
F. All money will be returned to the account of the person served, who will receive a receipt for the amount deposited.
G. Unused medication/inhalers will be collected and returned to Health Services
H. The drivers will search the vehicle and report any concerns. Persons served will be returned to the residential unit in a vehicle different than they were returned to campus in.
I. All items brought on to campus will be subjected to a heated decontamination process
1. Persons served will have the opportunity to turn in contraband. If contraband is disclosed or found, it will be given to the Campus Director with proper documentation. The items will then be delivered to the residential unit.
2. When bags are delivered to the residence of the person served following the decontamination process, staff must thoroughly search the bag and update the inventory sheet based on the contents of the bag. Home visit bags will not be searched at the Visitation Center.
3. Please advise persons served to keep one set of clothing at the residential unit, as they may not receive their home visit bag until the following day.
J. Inform persons served going on a home visit of these procedures and encourage them to take home only the basic items they need for the home visit.
REFERENCECODE: COM- 301-005 - GJRPA
TITLE: Home Visit Authorization Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/8/2022
COM-301-005-GJRPA - Home Visit Authorization Procedure
The Home Pass Authorization Form and Home Pass Assessment Form were developed by the Pennsylvania Juvenile Court Judges Commission for all Pennsylvania delinquent persons served earning a home pass while in placement.
The Home Pass Authorization Form must be completed by the residential facility and returned to the Probation Officer/Caseworker of the person served no less than 10 days prior to the beginning of the proposed home pass.
Sections I - IV must be completed by staff responsible for the person served and returned to the Transportation Department immediately. There must be four goals/responsibilities of the child outlined Under the travel schedule, the left column dates are departure dates and the right column dates are return dates. The Mode of Transportation section must specifically include who is transporting, e.g: parent/guardian/agency/GJR transport.
Section V is completed by the Probation Officer/Caseworker responsible for the person served. Once Section V is completed, it is to be returned to the Transportation Department as follows: The section can be faxed; printed then signed, scanned and then emailed; printed then signed and photographed then emailed; or forward the email so that the Home Pass Request and Approval attachments are not dropped and include an email stating they approve of the home visit from date to date.
Notification of approval for the person served to go on home pass will be made by the Transportation Department as per approval of the Probation Officer indicated in Section V of the report.
The forms are submitted primarily by the Case Manager via email. The Transportation Department must be copied on the submitting email to the placing agency. Should the Case Manager receive the Home Pass approval directly from the placing agency, they must immediately forward it to the Transportation Department.
REFERENCECODE: COM- 301-006 - GJRPA
TITLE: Home Visit Assessment Documentation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/8/2022
COM-301-006-GJRPA - Home Visit Assessment Documentation Procedure
The Home Pass Assessment Form was developed by the Juvenile Court Judges Commission for Pennsylvania persons served to help residential treatment facilities document the home pass goals and assess the degree to which each of the goals was achieved. This form needs to be completed by the Case Manager after the arrival of their person served from his home pass. The responsibilities of the Case Manager are as follows:
A. Meet with the person served prior to his home pass to establish the goals to be achieved during the home pass.
B. Complete the background information required in Section I and list each of the goals established for the home pass in Section II of the Home Pass Assessment Form.
C. The Case Manager must instruct the person served to share the Home Pass Assessment Form containing his established goals with his parent(s)/guardian(s) immediately upon arriving home.
D. Treatment Staff are required to make at least one documented call to the person served/family during the home visit on the Therapeutic Home Pass/Family Time Document form. Immediately following the home pass, staff will meet with the person served to determine their perspective regarding the extent to which each of the established goals were achieved during the home pass.
E. Contact the parent(s)/guardian(s) of the person served immediately following the home pass to obtain their perspective regarding the extent to which each of the established goals were achieved during the home pass.
F. Provide staff’s assessment of the extent to which each of the established goals was met by the person served during their home pass. Any additional comments/problem areas must be listed in Section III of the Home Pass Assessment Form. The Case Manager must then sign and date the Home Pass Assessment Form in Section IV.
G. After completion of the Home Pass Assessment Form by the appropriate staff member(s), the form must be forwarded to the file room within four days of the return from the home pass.
H. All youth Home Notes must be filed in the file of the person served.
I. Campus Home/Unit staff or Case Manager must call the Probation Officer of the person served within 7 days of the return of the person served from the home pass.
REFERENCECODE: COM- 302 - GJRPA
TITLE: Decontamination Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-302-GJRPA - Decontamination Policy
It is the policy of George Junior Republic to maintain the safety and security of the person served. In accordance, all items brought into the program by/for the persons served are subject to a heated decontamination process before being sent to a residential home.
REFERENCECODE: COM- 302-001 - GJRPA
TITLE: Decontamination Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/8/2022
COM-302-001-GJRPA - Decontamination Procedure
General Procedures
A. All items placed in the decontamination room are to be labeled with the name and residential unit (if known) of the person served.
1. If the person served has more than one bag, box, etc., each one should include their name and residential unit.
B. Program/Visitation staff will begin the decontamination process by:
1. Turning the power of the heating element on and,
2. Setting the temperature of the heating element to 135°F
C. Once the temperature of the decontamination room reaches 135°F, any item being decontaminated must remain in the heating process for one hour.
D. Once all items are finished, the decontamination processes is ended by:
1. Lowering the temperature of the heating element to standard room temperature and allowing a five-minute cool down period before turning the power to the heating element off.
E. Items will be searched and returned to the residential unit.
Items Brought by New Persons Served
A. All items brought into George Junior Republic by new persons served will be subjected to a heated decontamination process before being sent to the residential unit of the person served.
B. Immediately after returning the new person served to the Wellness Center, Drivers are to bring any belongings that came with the new person served to the Visitation/Check In Center.
1. Drivers are to label ALL bags, boxes, etc. with the name of the new person served, or communicate the name of the person served to the on-duty Program staff.
C. If the person served arrives to campus after all Program staff are gone for the day (9pm), or if the new person served is transported by a agency/county worker, Campus Supervisors will be responsible for transporting all belongings that came with the new person served to the Visitation/Check In Center.
1. When so, it is the responsibility of the Campus Supervisors to label ALL bags, boxes, etc. with the name of the new person served and the residential unit of the person served (if known).
D. Items will be placed in the decontamination room by Program staff until they meet the decontamination process requirements.
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E. Once the decontamination process is complete, items will be returned to the residential unit of the person served in a timely manner.
F. The direct care staff in the residential unit will search the items and add them to the property inventory of the person served.
1. Any item that the person served is prohibited from possessing will be locked in their personal belongings in the residential unit or will be given to the Campus Director who oversees the residential unit, along with proper documentation (e.g. the Chain of Custody form).
Items Brought by Visitors
A. All items brought for the person served that will be returning to the residential unit after a family visit must be left with staff at the Visitation Center so that it can go through the decontamination process.
B. Visitation Center staff will label the items with the name and residential unit of the person served.
1. Any item prohibited from returning to the residential unit of the person served will: a.Be given back to the visitor and asked to not be brought back to campus; or b.Be given to the Campus Director who oversees the residential unit the person served resides in, along with proper documentation (e.g. the Chain of Custody form).
2. Any item that Visitation staff deem may be damaged by the decontamination process will be removed, labeled, and individually inspected (e.g. food/snacks, hygiene products, electronics, etc.)
C. Items will be placed in the decontamination room by Visitation staff until they meet the decontamination process requirements.
D. Once the decontamination process is complete, items will be returned to the residential unit of the person served in a timely manner.
E. The direct care staff in the residential unit will add all new items to the property inventory of the person served.
Items Brought by Agency Workers
A. All items brought for the person served that will be returning to the residential unit after a Caseworker/Agency visit must go through the decontamination process.
B. Agency workers will label the items with the name and residential unit of the person served.
C. An agency worker will have a Campus Driver deliver the items to the Visitation/Check In Center.
D. Items will be placed in the decontamination room by Visitation staff until they meet the decontamination process requirements.
E. Items completed with the decontamination process will be returned to the residential unit of the person served in a timely manner.
F. The direct care staff in the residential unit will search and add all new items to the property inventory of the person served.
Items Brought Back from Home Pass
A. All items brought back from a therapeutic home visit by the person served must go through the decontamination process before being returned to the residential unit.
B. When the person served begins the home pass check in procedure, a Program staff will take their belongings and make sure all items are labeled with the name and residential unit of the person served.
1. If the person served returns from home pass after all Program staff have left for the day (9pm) this will become the responsibility of the Campus Supervisors.
2. The staff performing the check in procedure will confirm with the person served that there are no medical supplies/inhalers in the belongings; if these items exist, the person served will be asked to remove them from their belongings and the staff will transport them to Health Services.
C. Items will be placed in the decontamination room by Program staff until they meet the decontamination process requirements.
D. After items have been decontaminated, a safety and security check will be completed by Program staff.
E. Any item deemed as contraband or is otherwise not permitted in the residential unit will be given to the Campus Director who oversees the residential unit, along with proper documentation (e.g. the Chain of Custody form).
F. The direct care staff in the residential unit will update the property inventory of the person served.
REFERENCECODE: COM- 400 - GJRPA
TITLE: Person Served and Family Collaboration in Decision-Making Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 4/1/2021
DATEREVISED: 8/6/2020
COM-400-GJRPA - Person Served and Family Collaboration in Decision-Making Policy
It is the policy of the agency to recognize that the collaboration with persons served and families is vital to the treatment and subsequent reunification of the youth. Persons served and families are seen as experts, and, as such, are partners with the treatment staff in the formulation of treatment plans and goals. Additionally, services offered, as well as services that may be facilitated by an outside entity, are shared with the person served and family.
REFERENCECODE: COM- 400-001 - GJRPA
TITLE: Person Served and Family Collaboration in Decision-Making Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-400-001-GJRPA - Person Served and Family Collaboration in Decision-Making Procedure
Persons served and families are seen as experts and will collaborate with the treatment team in the formulation of treatment planning and goal development. Service delivery, along with services offered by outside entities, are communicated with the person served and family.
A. During the pre-placement interview, the admissions staff will communicate and discuss all services offered.
B. Upon admission of a person served, the family receives the following:
1. Parent/Guardian Information Guide
2. Introductory phone call with treatment team contact and phone numbers
C. A person served progress and collaboration with the treatment team is the PRIMARY goal of these contacts.
D. In most cases, these referrals are mandated by a court order or the placing agency.
E. The person served and family will be involved and notified by the treatment team of the court order and the rationale for any change in level of care will be communicated.
REFERENCECODE: COM- 401 - GJRPA
TITLE: Campus Advisory Council Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-401-GJRPA – Campus Advisory Council Policy
It is the policy of the agency to focus on inclusion and collaboration with persons served, with the goal of improving the quality of care across the organization.
REFERENCECODE: COM- 401-001 - GJRPA
TITLE: Campus Advisory Council Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-401-001-GJRPA – Campus Advisory Council Procedure
A. The Campus Advisory Council will seek to represent the persons served.
1. Nomination forms of persons served will be accepted throughout the year.
2. In order to seek representation from across campus, staff will engage campus wide nominations from Direct Care Staff, Treatment Team Coordinators, Campus Directors, and/or GJR staff from other departments.
3. All persons served from across campus will be eligible.
4. All person served will have the opportunity to recommend a peer that may be a strong candidate for the council Nomination forms will be submitted to the Development Office by their Direct Care Staff, Treatment Team Coordinators, Campus Directors, and/or GJR staff from other departments.
5. GJR staff will review the nominations and interview persons served for open positions as they become available. New candidates will be presented to the Campus Advisory Council for approval.
6. GJR staff has final authority on the selection of Campus Advisory Council members.
7. Campus Advisory Council members will be provided with an opportunity for an orientation session before their first meeting.
B. The Campus Advisory Council will have the flexibility to respond to challenges that arise.
1. The Campus Advisory Council will meet formally on a monthly basis.
2. Subgroup or work sessions may be called on a more frequent basis, as needed.
3. Meeting notes will be kept and distributed as necessary
4. All recommendations by the Campus Advisory Council will be documented and assessed for implementation viability.
C. The Campus Advisory Council will be visible across campus.
1. Information about the Campus Advisory Council will be distributed to each cottage or unit across campus.
a. Posters, flyers, etc. will assist us in our goal to maintain awareness.
b. Mailings, surveys and/or other communication forms will be utilized to gain input from persons served, per diem
2. A Campus Advisory Council representative will formally present to the campus directors quarterly.
3. A Campus Advisory Council representative will support staff education initiatives, as defined by the Staff Development department
D. The Campus Advisory Council will seek to keep all available positions filled at all times.
1. Seven persons served will be selected to serve on the Campus Advisory Council.
2. As discharges occur, a new council member will be selected based on prior nominations received
3. As openings become available, positions will be filled.
4. Persons served may serve on the Campus Advisory Council for a period of one school year (July 1 – June 30). Continued participation may occur on a case by case basis.
5. Persons served may be removed from the Campus Advisory Council under the following circumstances:
a. Lack of interest
b. Misconduct
c. If a current safety plan exists for the person served that would preclude them from participation due to reasons of safety or security.
d. At the discretion of the GJR Staff, Treatment Team Coordinator or Campus Director
E. The Campus Advisory Council seeks to promote the voice of the persons served and support quality improvement initiatives defined by the Risk Officer to include:
1. mechanisms to increase cross-campus communication with persons served,
2. developing and disseminating satisfaction surveys for persons served,
3. person served perspective on campus policies and procedure
4. mechanisms to increase person served participation in individual and group therapy sessions.
REFERENCECODE: COM- 402 - GJRPA
TITLE: Parent Advisory Committee Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-402-GJRPA - Parent Advisory Committee Policy
George Junior Republic in Pennsylvania will establish and maintain a Parent Advisory Committee that will help guide, drive and support the mission and vision of our organization. The focus will be on the parent/guardian experience and fostering success while their family member receives services throughout their time at George Junior Republic in Pennsylvania.
REFERENCECODE: COM- 402-001 - GJRPA
TITLE: Parent Advisory Committee Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-402-001-GJRPA - Parent Advisory Committee Procedure
A. The Parent Advisory Committee will seek to represent the persons served.
1. The Advancement Coordinator will engage staff members in the recruitment of potential committee members.
2. Initial candidates for the Parent Advisory Committee will be selected from a pool of applicants (representative of the persons served).
3. Parent(s)/Guardians will be considered, regardless of their proximity to campus.
4. The Advancement Coordinator will be responsible for making certain parent/guardian representatives are reflective of diverse communities, races/ethnic backgrounds, and socio-economic status.
5. Selected committee members must attend an Orientation meeting.
B. The Parent Advisory Committee will have the flexibility to respond to challenges that arise.
1. The Parent Advisory Committee will meet formally on a monthly basis.
2. The Advancement Coordinator will practice due diligence in scheduling all meetings to reduce barriers related to participation. Due to the distance from campus, parents have the option to participate via phone or video conferencing.
3. Subgroup or work sessions may be called on a more frequent basis, as needed.
C. The Parent Advisory Committee will be recognized as serving in an advisory capacity.
1. External marketing will take place to inform parents of this committee.
2. An introductory letter highlighting the role of the Parent Advisory Committee will be mailed out with the first ISP report. This will include information on how to get involved with this committee.
3. Mailings, surveys and other forms of information gathering will be utilized.
D. A designated Parent Advisory Committee will participate in the training of staff on systems based challenges, as needed.
1. The Advancement Coordinator will work with the Coordinator of Staff Development to define training needs.
2. The training will be provided via pre-recorded video.
3. The parent will sign off on all applicable waiver documents prior to being videotaped.
E. The Parent Advisory Committee will provide feedback to the Campus Directors and/or Leadership Team on a quarterly basis.
1. Meeting notes will be distributed to the Vice President of Operations and the Risk Officer after each meeting.
2. All recommendations will be documented and assessed for implementation/viability.
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F. The Parent Advisory Committee will seek to keep all available positions filled. The following methods can be utilized for the replacement of representatives serving on the Parent Advisory Committee:
1. Parents showing leadership potential and a willingness to serve, will fill out an application and submit it to the Advancement Coordinator.
2. A pool of candidates will be maintained at all times by the Advancement Coordinator.
3. As openings become available, positions will be filled.
4. Parents may serve on the board for a term of one year, or longer, as needed/based on request.
G. Parents may be removed from the Parent Advisory Committee under the following circumstances:
a. Lack of interest
b. Breach of confidentiality
c. At the discretion of the Advancement Coordinator.
H. The Parent Advisory Committee seeks to promote the voice of the parents/guardians of the persons served and support quality improvement initiatives defined by the Risk Officer, to include:
1. Communicating organizational updates to parents, guardians, and families.
2. Parent/Guardian perspective of the admissions process
3. Development and dissemination of family satisfaction surveys.
COMPLEMENTARY SERVICES (COM) Section 500 – Wellness Program and Food Service
REFERENCECODE: COM- 500 - GJRPA
TITLE: Child Nutrition Program and Food Services Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-500-GJRPA - Child Nutrition Program and Food Services Policy
It is the policy of the agency to create an environment that provides healthy and safe meals which meet the nutritional guidelines established by the United States Department of Agriculture and the Pennsylvania Department of Education.
REFERENCECODE: COM- 500-001 - GJRPA
TITLE: Wellness Program Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-500-001-GJRPA - Wellness Program Procedure
George Junior Republic in Pennsylvania has the responsibility to remediate the social, moral and legal challenges of the persons served entrusted in our care. Maintaining a healthy lifestyle is especially pertinent when working with high-risk persons served. George Junior Republic will make every effort to educate the persons served of our program in a safe environment, minimizing environmental risk, and establishing a lifestyle that promotes wellness through nutrition, exercise, and other recreational activities.
The present and future health, safety, and well-being of the persons served of George Junior Republic in Pennsylvania are the focus of the Wellness Program. As such, this program will focus on the following:
A. Each residential unit and all common buildings and activity areas will provide a safe and healthy environment for the persons served and staff.
B. All persons served will be informed regarding proper nutrition and exercise as a means to establish and maintain personal health.
C. Each unit will focus on quality meals, exercise and safety.
D. George Junior Republic’s administration, in conjunction with the contracted Food Service Management Company, Grove City Area School District, Program Department, athletics, and Health Services, will provide for the healthy nutrition, education and physical health of each individual person served
To ensure the proper health and well-being of each person served, George Junior Republic in Pennsylvania will provide each individual with the following:
A. Quality, well-balanced meals that meet the standards of the Child Nutrition program.
B. A minimum of six hours per week of physical activity in which each person served will perform active physical exercise to promote the health and conditioning of each person served.
C. Information and input into the development of menus, food items and preparation of the meals served to them.
Process:
The Child Nutrition Director (Procurement Director), along with the administrative staff and the contracted Food Service Management Company will ensure that the Wellness Program is implemented, monitored, and amended as needed.
Through the scheduling of activities, George Junior Republic in Pennsylvania will ensure that each person served receives the opportunity to participate in a minimum of six hours of events per week. Events will provide times for physical activity.
Guidelines
Wellness Committee
The Child Nutrition Director will appoint a Wellness Committee comprised of the following:
A. Food Service Management Company General Manager
B. Child Nutrition Director (Procurement Director)
C. A Student Representative
D. Development Office Representative
E. Director of Health Services
F. Direct-Care Staff
G. Principal
H. Program Department
The Wellness Committee will serve as an advisory committee regarding health and safety. The Child Nutrition Director will be responsible for facilitating meetings multiple times a year. Wellness Committee members will serve in an advisory capacity regarding health and safety and will develop a policy which will be presented to the Chief Executive Officer, Vice President of Operations and to the George Junior Republic School Principal for approval.
The Wellness Committee will make recommendations and report findings, as needed, to the Chief Executive Officer.
Nutrition
Academic performance and life quality are impacted by proper nutrition. As defined by the Child Nutrition Program, a healthy diet supports physical growth, the ability to learn, and social and psychological well-being.
George Junior Republic in Pennsylvania will offer meals that meet the guidelines of the Child Nutrition Program. The Food Service Management Company will develop menus that conform to the Child Nutrition Program and will be entered and approved in the Primero Edge system. These menus will include the ingredients and the food value of each item. The Food Service Management Company General Manager is responsible for the oversight of meal quality and the safe preparation and the Child Nutrition Director is responsible for the delivery of meals to the students.
There are no competitive foods available for students during the school day. Competitive foods include a la carte, vending machines, school stores, food fundraising, and classroom parties. The organization does not participate in the Smart Snacks program.
George Junior Republic in Pennsylvania is a Residential Corrections Care Institution and for this reason, no marketing or advertising of foods and beverages occurs on campus.
Health Education and Life Skills
Healthy eating habits and physical activity will be taught to the persons served both through example, the teaching of life skills and based on educational programming provided to students by the Grove City Area School District.
George Junior Republic in Pennsylvania staff will be trained in safe food handling and proper nutrition. Training will be conducted through scheduled meetings and through the Relias online learning system. Staff training will also include education on disease prevention and control, blood borne pathogens and food safety.
Physical Education and Activity
The Program Department will ensure each person served is provided with a minimum of 6 hours of activity time each week through our scheduling of daily activities. These activities include the following:
A. Basketball
B. Swimming
C. Weight Lifting
D. Jogging
E. Baseball or Softball
F. Volleyball
G. Soccer
H. Various other physical activities
George Junior Republic in Pennsylvania operates intermural sports and activities in the following areas:
A. Weight Lifting
B. Intramural Flag Football
C. Intramural Softball
D. Golf Club
E. Intramural Basketball
These activities will encourage participation and the development of physical exercise into the daily routine. Each person served will be encouraged to develop their skills and knowledge of a healthy lifestyle.
Each activity will provide for at least a minimum amount of physical conditioning or exercise.
Each person served will be provided with a variety of activities and events in which to participate.
Healthy and Safe Environment
All residential, common buildings and facilities will be monitored to provide each person served with a safe and healthy environment.
George Junior Republic in Pennsylvania will maintain a Safety Committee which inspects each unit twice a year and yearly by an outside agency.
The medical, childcare, security, food preparation, human resource, administration and staff training departments of George Junior Republic in Pennsylvania will be represented on the safety committee. Findings of the safety committee will be presented to the Chief Executive Officer and Facility Manager.
All buildings will be maintained at the highest level possible and exceed the requirements of the Department of Human Services, Labor and Industry and the Office of Mental Health and Substance Abuse Services.
George Junior Republic in Pennsylvania is a drug free facility.
Through training, monitoring and supervision, George Junior Republic in Pennsylvania will maintain a safe and harassment free environment for both staff and person served.
Social and Emotional Well Being
Through the hiring of Masters level therapists each person served shall be provided with individual and group therapy where their concerns, issues and problems are heard. Person served will be encouraged to express themselves in a socially appropriate manner. Persons served will be encouraged to learn tolerance, emotional regulation and relationship building skills.
In addition, each person served meets with one of two child and adolescent psychiatrists.
Health
All person served generally receive a physical assessment by a pediatrician or mid-level practitioner within 72 hours of admission, not to exceed 15 days. The services offered within this department are as follows:
A. A complete physical exam by a pediatrician upon admission and each year thereafter
B. A complete dental exam and follow-up visits every six months
C. An eye screening by an optometrist upon admission with a follow-up screening if needed
D. Updates of immunizations as needed by a registered nurse
E. Hearing screening
F. Medication management and education
G. Diabetes education and disease management as needed
All person served admitted to George Junior Republic in Pennsylvania will receive a physical. A physician or mid-level medical practitioner is available daily for ongoing ailments and treatment.
George Junior Republic in Pennsylvania will maintain referral agreement with local clinics, hospitals, and treatment centers to ensure quality of inpatient care.
Admissions and annual health screens include the Body Mass Index to identify persons served who are over or under weight. Nursing staff will assist the food preparation staff in establishing diets that are healthy and
appropriate for persons served who are either over or under weight. Additional special diets, consultations and monitoring will be scheduled for any person served with special dietary considerations such as food sensitivities or allergies.
Family and School Partnerships
Families will be informed of any medical or health concerns regarding their child Parents will be encouraged to promote a healthy lifestyle for their child and support the efforts of George Junior Republic in Pennsylvania.
George Junior Republic in Pennsylvania will coordinate with Grove City Area School District in the monitoring of the physical needs of the person served The nursing staff will identify and communicate any special needs of persons served to school personnel.
Wellness Policy Updates and Communication
On an annual basis, the Wellness Policy will be reviewed by members of the Wellness Committee. All updates/changes will be presented to the Chief Executive Officer, Vice President of Operations, George Junior Republic’s Principal and the Child Nutrition Director for review and signature approval. Once approved, the Wellness Policy will be posted on the George Junior Republic website and in each building where food service occurs.
The Parent/Guardian Information Guide highlights the location of the Wellness Policy under the heading of Child Nutrition Program. The guide is disseminated to all parents/guardians when their child is placed at George Junior Republic in Pennsylvania.
On an annual basis, the Child Nutrition Director meets with members of the Campus Advisory Council to update the group on any changes to the policy and Child Nutrition program. The Campus Advisory Council is made up of persons served in the program from across the organization.
Every year the organization completes an assessment of services and child nutrition. The assessment is provided to persons served and changes to the Child Nutrition program are a direct result of the surveys outcomes. Wellness Policy changes will be documented, printed and placed at the Visitation Center for parent/guardian review.
Nutrition Promotion
Each unit and cottage has posters highlighting healthy eating habits and messaging promoting a healthy lifestyle. Posters are updated at least annually and hung with Child Nutrition program signage (i.e. menus, Justice for All, and meal components).
Goals:
A. To provide persons served with healthy and nutritious meals following the guidelines of the Child Nutrition program.
B. Educate persons served on the Child Nutrition program regulations pertaining to healthy meals.
C. Non-National School Lunch Program meals/snacks will include healthy food choices.
D. On an annual basis, all persons served will be provided the opportunity to complete a food survey.
E. Prior to the beginning of each school year, the organization’s Wellness Policy will be reviewed against the Pennsylvania School Board Association Wellness Policy (example).
F. Progress made in attaining the goals of the Wellness Policy will be sent to everyone in the organization and reviewed yearly to make sure progress is made towards the goals set forth.
Staff Wellness
Staff members may use the recreational facilities with prior approval and have the opportunity to participate annually in other organization wide events. Through partnerships with local gym facilities, employees have the option of joining one of many local gyms and receiving a discounted membership based on their employment at George Junior Republic (i.e. IXL and YMCA). A comprehensive listing of employee benefits is outlined in the Employee Handbook.
On a monthly basis all staff members receive information on living a healthy lifestyle. The Live Well, Work Well newsletters are posted to the organizations Intranet portal.
Responsible Parties
The Wellness Committee is responsible for the review of the Wellness Policy and making recommendations to changes in the policy and programming. The Child Nutrition Director serves as the lead administrator for the program. The following administrators are responsible for approval of the policy:
A. Chief Executive Officer
B. Vice President of Operations
C. George Junior Republic School Principal
D. Child Nutrition Director
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activities in any program or activity conducted or funded by the USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
A. Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410
B. Fax: (202) 690-7442; or
C. E-mail: program.intake@usda.gov
This institution is an equal opportunity provider.
REFERENCECODE: COM- 500-002 - GJRPA
TITLE: Child Nutrition Program and Food Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-500-002-GJRPA - Child Nutrition Program and Food Services Procedure
According to the United States Department of Agriculture and the Pennsylvania Department of Education requirements, all meals are planned, reviewed, and established based on the recommendations of the contracted Food Service Management Company (FSMC) and George Junior Republic in Pennsylvania.
Food should never be withheld from persons served or used as a tool for punishment. This is good standard of practice and a requirement by our licensing agency. Withheld food or food used as punishment could be construed as a tool for abuse. Restricting food is not a prudent plan for growing adolescents
A. Food Service Trainings
The Child Nutrition Program mandates staff members participate in training on an annual basis. George Junior Republic staff members will receive training related to the Child Nutrition Program in person and via training(s) uploaded into the Relias platform. All training hours will be recorded in Relias and into Premiero Edge Teamwork.
B. Civil Rights
On an annual basis, all staff members working as part of the Child Nutrition Program are mandated to attend a Civil Rights Training. The training will include the following components:
1. Assurances
2. Public Notification Systems
3. Nondiscrimination Statement
4. “Justice for All” signage
5. Complaint and Discrimination Procedures
6. Racial and Ethnic Data Collection
7. Limited English Proficiency (LEP)
8. Disability Discrimination
9. Conflict Resolution
10. Communication with parents or guardians of persons served, including Civil Rights and Direct Certification.
C. Milk and Bread Purchases and Procurement and Distribution
The Procurement Director is responsible for securing safe and healthy food for persons served outside of what is procured by the Food Service Management Company (FSMC).
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Annually, milk and bread purchases will be procured outside of the food procured by the contracted FSMC. This selection will be based on George Junior Republic in Pennsylvania Procurement Policies. The Procurement Director is responsible for the oversight of milk and bread contracts.
Milk and bread deliveries will take place from the warehouse and be transported to all cottages and units per a weekly schedule. It is the responsibility of the staff working in the cottages and units to make certain the milk is placed in the refrigerator and the bread is available during meal service.
The refrigerator temperature must be taken at 7:00 a.m. each morning and at 4:00 p.m. each day and written on the Breakfast and Dinner Production Record. Milk must be rotated and dated upon receipt.
D. Government Food
The Purchasing Agent is responsible for working with the FSMC in determining the government food items to be selected. Government food products will be those items on the menu that can easily be replaced.
E. Peanut Butter and Jelly
Peanut butter and jelly will be delivered by the warehouse to all units and cottages on a weekly basis. These items will be secured through the government food program or through a competitive pricing process.
F. Food Service Management Company
George Junior Republic selects and contracts the FSMC through a competitive bidding process. Contracts with George Junior Republic in Pennsylvania may last a total of five years depending on several factors. Each year of the five-year period the contract is able to be renewed. For the purposes of the Child Nutrition Program, a year is defined as July 1 – June 30 and directly relates to an operating school year.
G. Menu
The menu is designed by the FSMC and is written in English and Spanish. All staff members have the opportunity to contact the Central Kitchen, x4590, or the Director of the Child Nutrition Program if they have questions or concerns about the menu. The menu is a fiveweek cycle menu and will be posted in each Cottage and Unit.
All staff members assigned to food service operations must follow the menu for all meals and snacks. Menu items for breakfast and lunch are calculated for nutritional content to make certain they meet the dietary needs of the persons served. Recipes for all menu items and specific nutritional values are entered into Primiero Edge and approved for nutritional content.
The menu may be altered based on various factors. Due to the process surrounding menu changes, all menu changes must be approved by state authorities prior to being disseminated to staff and persons served across campus.
H. Food Distribution
The distribution of items on the menu will be primarily delivered by the warehouse transportation workers. These workers will be assigned various routes based on unit/cottage location. Bread and buns will be delivered with meals from the Central Kitchen when required for the specific meal. Staff members must be aware of menu items and the inclusion or exclusion of bread from each meal.
I. Receiving Food
Staff must be aware of the importance of food borne illness and food safety and must make certain food is held at the appropriate temperature(s).
According to Serve Safe Guidelines:
a. Milk must be received at 45 degrees or lower. The milk must be cooled to 41 degrees within four hours.
b. Hot food must be received at a temperature of 135 degrees or higher.
c. Liquids should be rejected if they have leaks, the packaging is damaged or it has stains related to spillage.
d. Peanut butter, jelly, milk and bread (if not used on the day it is delivered) must be correctly labeled with month, day, and year. Labeled date must reflect the date received. Food held over for persons served should also be dated and marked by name and easily identified by staff.
J. Snacks
Snacks are mandatory as part of the Bureau of Human Services Licensing (BHSL) guidelines. The menu lists three meals and one snack each day. The snack is not an individual meal; it is only a snack.
K. Serving Schedule
George Junior Republic in Pennsylvania participates in the Pennsylvania Department of Educations (PDE) Child Nutrition Program seven days per week for breakfast and lunch.
State regulations hold staff members accountable for serving food on the menu and at designated times each day. No more than six hours should elapse between breakfast and lunch on the same day and no more than fifteen hours should elapse between the evening meal and breakfast on the following morning.
School breakfast and lunch times are seven days a week in a 365-day period. As noted, the menus rotate every five weeks and must be followed exactly as written.
a. Breakfast must be served by 9 a.m. every day.
b. Lunch must be served between 11 a.m. and 1 p.m. every day.
c. The breakfast and lunch requirement applies seven days a week, including weekends and holidays.
L. Permissible Substitution List
When a person served presents with a religious belief or health condition requiring a physician’s order that prohibits them from safely/consciously eating what is on the menu, a substitution must be provided. If a person served does not like what is on the menu for lunch or dinner, a peanut butter and jelly sandwich can be provided as a substitution.
Staff must be mindful of potential food allergies. A food allergy is an adverse reaction to a food protein by the immune system. Common foods allergies include milk, eggs, peanuts, tree nuts, fish, crustacean shellfish, soy and wheat. Information regarding food allergies of the person served will be entered into the Electronic Health Record by Health Services staff. A report on food allergies will be electronically sent to the Central Kitchen. The Central Kitchen will be responsible for providing food options to persons served that meet their dietary restriction. A chart listing all allergies or dietary restrictions of persons served will be sent in the grey bin during each food distribution. It is the responsibility of the staff members to make certain they only provide food identified and designated for the specific persons served
It is important for staff members to recognize and understand the difference between food allergies and food intolerances. A food intolerance is an abnormal physiological response to eating. These symptoms are often confused with food allergies.
M. Staff and Meals
Staff members are permitted to eat meals delivered by the FSMC as long as there is enough food to serve all persons served first. Therefore, it is appropriate that the persons served be served their meals before staff.
If staff elect not to eat the meal prepared by the FSMC, staff members are encouraged to eat food purchased outside of George Junior Republic in Pennsylvania or brought from home out of view of the persons served. Containers and dishes must be washed by the staff using them and put away.
If staff members bring food in from the outside and place these food items in the refrigerator, they must have a staff name on the outside of the packaging and a date before being placed in the refrigerator. Any food item left in the refrigerator over 24 hours or not marked with a date and name will be discarded. If a staff member spills something in the refrigerator or freezer, the staff must clean up the spill.
Kitchens are to be used for food service only. All staff members entering the kitchen must comply with kitchen health and safety standards.
Direct Care staff are eligible to eat FSMC meals while with the persons served
N. Health Inspection
George Junior Republic in Pennsylvania, as a participant in the Child Nutrition Program, is required to have two health inspections each year. The Child Nutrition Director will contact the Health Inspector each September and January requesting a health inspection take place. Based on George Junior Republic’s designation as a RCCI, the health inspector will be accompanied on campus by the Child Nutrition Director or designee. Based on the results of the inspection, George Junior Republic in Pennsylvania will make corrections to meet the guidelines established by the Pennsylvania Department of Agriculture.
Requests for an on-site health inspection will be kept on file in the office of the Child Nutrition Director. If the health inspector is unable to conduct an inspection, the Child Nutrition Director will request documentation of this discussion and the information regarding his/her inability to complete the inspection will be kept on file.
REFERENCECODE: COM- 500-003 - GJRPA
TITLE: LTSR In-House Kitchen Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-500-003-GJRPA – LTSR In-House Kitchen Procedure
Persons served will be assigned activities in the LTSR kitchen to provide instruction and skill-building opportunities for cooking, baking, dishwashing, and general understanding of kitchen supplies and appliances. Access to the in-house kitchen will provide opportunities to learn and improve life skills and increase independence.
Procedures for the in-house kitchen are as follows:
1. The kitchen will be locked at all times and will only be unlocked by LTSR staff.
2. Persons served are permitted to utilize the kitchen under staff supervision during structured activities.
3. All knives will be locked in the kitchen. Any use of knives or high-risk utensils will be supervised by staff. Any person served on Suicide Watch will not have access to high-risk utensils.
4. Kitchen specific chores will be assigned to persons served. These will include the following:
a. Sweeping and mopping
b. Sanitizing all surfaces
c. Assisting with set up of meals
d. Sanitizing serving and eating utensils following all meals
e. Clean kitchen bathroom
REFERENCECODE: COM – 500 - 004 - GJRPA
TITLE: Food Service Bid Protest Procedures
APPROVEDBY: GJR Administrators
DATEAPPROVED: 4/21/2022
DATEREVISED: 4/21/2022
1. Who may file the protest:
a. Any bidder or prospective bidder who is aggrieved in connection with an Invitation for Bid (IFB) or Request for Proposal (RFP) from George Junior Republic in Pennsylvania or the award of a contract obtained through such a process may file a protest. A bidder is a person or organization that submits a bid in response to the IFB/RFP. A prospective bidder is one who has not submitted a bid. Protests relating to the cancellation of IFBs and RFPs and protests relating to the rejection of all bids are not permitted.
2. Time for filing a protest:
a. If a prospective bidder submits a protest, it must be filed within five business days after the prospective bidder knew or should have known of the facts giving rise to the protest. In no event may a prospective bidder be allowed to submit a protest after bid opening time.
b. If a bidder files a protest, the protest must be filed within five business days after the protesting bidder knew or should have known of the facts giving rise to the protest. Once the bid opening has occurred, the bidder has five business days to file a protest. The date of filing is the date of receipt of the protest by the Food Service Director.
3. Form of protest:
a. All bid protests must be in writing and filed with the Food Service Director at George Junior Republic in Pennsylvania, 233 George Junior Road, Grove City, PA, 16127.
b. The protest must state all grounds upon which the protesting party asserts that the solicitation or award was improper. Issues not raised by the protesting party in the protest are deemed waived and may not be raised on appeal.
c. The protesting party may submit with the protest any documents or information deemed relevant.
4. Notice of protest:
a. If the award has been made, the Food Service Director shall notify the successful bidder or contractor of the protest. If the protest is received before the award and substantial issues are raised by the protest, all bidders who appear to have a substantial and reasonable prospect of winning the award shall be notified and may file their agreement/disagreement with the Food Service Director within three days after receipt of notice of the protest.
5. Stay of Procurement:
a. The Food Service Director shall immediately decide whether, upon receipt of the protest, the solicitation or award should be stayed, if the protest is timely received after the reward, or the performance of the contract should be suspended. If it is deemed that the protest has merit, the Food Service Director shall not proceed further with the bid process or award of the contract and shall suspend performance under the contract if awarded unless the award of the contract without delay is necessary to protect the substantial interests of George Junior Republic in Pennsylvania.
6. Determination Procedures:
a. Within five days of receipt of the protest, the Food Service Director shall submit to the protesting party a response to the protest. The protesting party then has five days to file a response.
b. The Food Service Director shall review and decide the merits of the protest based on all documentation and information, including the initial protest, subsequent responses, and any additional documentation provided. The Food Service Director may, in their sole discretion, conduct a hearing.
c. If the protest occurred prior to the bid opening date, the Food Service Director shall decide on the merits of the protest within a reasonable time period and, if necessary, reschedule the bid award accordingly. If the protest occurred subsequent to the bid opening, the Food Service Director shall decide on the merits of the protest prior to the final vote of the award by the George Junior Republic in Pennsylvania Board of Directors.
d. Within five days of making a decision, the Food Service Director shall notify all affected parties in writing of their determination. The determination shall state the reason for the decision. If the determination is a denial of the protest, the Food Service Director shall inform the protesting party of its right to file an action in the Commonwealth Court within fifteen days of the determination mailing date.
REFERENCECODE: COM- 501 - GJRPA
TITLE: Hazard Analysis and Critical Control Point (HACCP) Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-501-GJRPA - Hazard Analysis and Critical Control Point (HACCP) Policy
It is the policy of the agency to adhere to HACCP standards, which address corrective actions, monitoring procedures, verification procedures, and record keeping procedures related to food safety.
REFERENCECODE: COM- 501-001 - GJRPA
TITLE: Hazard Analysis and Critical Control Point (HACCP) Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM- 501-001-GJRPA - Hazard Analysis and Critical Control Point (HACCP) Procedure
George Junior Republic in Pennsylvania, through its participation in the Child Nutrition Program, is required to follow the HAACP policies and procedures.
A. Because food will be made at a Central Kitchen many of the HACCP requirements will only be required of Central Kitchen employees. These include the following:
1. Cleaning and sanitizing food contact surfaces
2. Controlling for time and temperature during food preparation
3. Cooking food to the appropriate internal temperatures
4. Date marking food items and maintaining the labeling of food
5. Monitoring hot and cold food temperatures
6. Personal hygiene
7. Receiving deliveries
8. Serving food
9. Storing and using chemicals
10. Calibrating and using thermometers
11. Washing fruits and vegetables
12. Washing hands
13. Using appropriate temperature log for food items and for the monitoring of the on-site refrigerators and freezers
14. It is important to note, all recipes entered into Primero Edge identify associated critical control points.
15. A HACCP manual is located in the office of the Metz General Manager. The HACCP manual will be reviewed on an annual basis.
B. Staff must be aware of the Food Process Categories and the importance of understanding these processes as related to food safety.
1. No Cook: Food kept cold from preparation through serving.
2. Same Day Service: Prepared hot and served the same day.
3. Complex: Prepared hot and served cooled, or possibly reheated. This food is high risk for food borne illnesses if not handled as required.
4. George Junior Republic’s menu is No Cook and Same Day Service.
C. The School Lunch Monitor will make monthly food safety checks, to include:
1. Thermometer
Thermometers are provided to every building serving meals by the warehouse. Staff serving the meals are responsible for calibrating the thermometer. If staff are unaware of how to calibrate the thermometer or need a new thermometer they need to contact the warehouse. Sanitizing wipes will be sent to each unit/cottage each day and at each meal service. It is the responsibility of the staff to wipe the thermometer with the sanitizing wipe in between taking the temperature of each food item.
Food thermometers should be used to take the temperature of all hot lunch and dinner meals. Thus, staff members should take the following action steps:
a. Food thermometers should be used to temp all hot lunch and dinner meals.
b. Thermometers need to be wiped with the sanitizing wipe. Staff must make certain no food particles remain on the stem of the thermometer to prevent cross contamination.
c. After cleaning the thermometer and after all food temperatures are taken the thermometer must be stored in a sanitary place in the kitchen
2. Food Temperatures
As noted, HACCP guidelines must be followed and food temperatures must be taken and recorded at every meal and when food is received.
The following guidelines must be followed:
a. Hot foods must be held at 135 degrees until served.
b All cold items must be cooled down to 40 degrees or below before serving.
c. Temperatures of hot and cold foods must be recorded prior to meal service.
d Food items such as bread, chips, pretzels and fresh fruit does not need to have a recorded temperature and should be recorded as N/A.
e All food and drink items must be listed on the specified Production Record.
3. Corrective Action – Temperature
Corrective action refers to the action taken from the initial temperature taken of food to the serving temperature of food.
Cooked temperature does not refer to the temperature of the stove or oven. It refers to the temperature of food items while cooking. This temperature determines if the food has reached the correct temperature and what corrective action is needed.
Corrective Action means: Correcting an action if food has not reached the appropriate temperature.
If a corrective action is needed, staff must call the Central Kitchen immediately, x4590. No leftovers are to be served to persons served unless plate is held and dated. All leftovers must be discarded within 24 hours.
4. Signage
Each unit/cottage must have various posters and signs hanging in the building and available for review by the persons served at any time. Signage would include Offer vs. Serve information, photos of reimbursable breakfast and lunch meals, Justice for All posters, the menu in English and Spanish and information from Metz.
REFERENCECODE: COM- 502 - GJRPA
TITLE: Child Nutrition Program Documentation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-502-GJRPA - Child Nutrition Program Documentation Policy
It is the policy of the agency to adhere to all applicable Child Nutrition Program Documentation procedures.
REFERENCECODE: COM- 502-001 - GJRPA
TITLE: Child Nutrition Program Documentation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-502-001-GJRPA - Child Nutrition Program Documentation Procedure
The Child Nutrition Program provides funding that make it possible for schools to offer nutritious breakfast and lunch to students each day. As a participant in this program, George Junior Republic in Pennsylvania receives federal funds for each breakfast and lunch served, provided that the meals meet nutritional guidelines established by the United States Department of Agriculture.
A. Production Sheet/Meal Plan
Each unit/cottage will receive a packet with each meal detailing the menu and serving amounts for Breakfast, Lunch, Dinner and Snack each day. The Meal Count Sheet must be filled out for Breakfast and Lunch meals.
The Production Sheet must be thoroughly and accurately completed in order for George Junior Republic in Pennsylvania to receive reimbursement.
Total Youth: This is the total number of persons served on the roster, not the total number of beds. Do not include persons served not currently in the unit.
Reimbursable Portions Served: This is the total number of persons served who are served.
Record the number of milk that is served with first portions (Offer vs. Serve requirement).
Metz Fills out the Production record Daily for Breakfast and Lunch for the National School Lunch program.
Persons served may have a second serving of food and specified staff may have one or two servings of food. These food items are to be recorded as non-reimbursable.
B. Religion and Special Dietary Needs
During Ramadan, food held for persons served cannot be counted on the meal count and production sheets. In these instances, meals are to be consumed before 7:00 a.m. and after 1:00 p.m.
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Plates of food saved for persons served must be covered with plastic, marked the name of the person served and the date and time the meal was held. Food should not be held in the refrigerator overnight.
C. Emergency Procedures
If a person served is admitted after the Central Kitchen closes, Campus Supervisors have access to boxed lunches that are made to accommodate such situations.
D. Wellness Policy
On an annual basis, George Junior Republic in Pennsylvania will review and update Wellness Policies and Procedures (see Wellness Policy).
E. Reimbursable Meals for the Child Nutrition Program are breakfast and lunch.
Metz is responsible for developing the menus based on the guidelines established by the USDA and the Child Nutrition Program and recommendations by George Junior Republic in Pennsylvania and persons served.
Meals must be counted at the point of service in the food service operation where it is determined a free meal, meeting the USDA meal guidelines, has been served to a person served.
It is not acceptable to count the number of eligible persons served; rather persons served must be counted as they receive their breakfast and lunch meal.
Daily meal counts for breakfast and lunch by eligible persons served must be claimed for each unit and cottage and returned to the Central Kitchen the following day in the bin.
On-site monitoring will occur on a regular basis across campus.
F. Offer Versus Serve
Offer Versus Serve (OVS) is a concept that applies to menu planning and the meal service. OVS allows persons served to decline some of the food offered in a reimbursable lunch or breakfast. The goals of OVS are to reduce food waste and to permit persons served to choose the foods they want to eat.
George Junior Republic in Pennsylvania staff involved in the Child Nutrition Program will be
required to participate in initial and annual OVS training. The training will outline and highlight the components of OVS and what constitutes a reimbursable meal. Staff members must complete the initial and annual OVS training or they will be ineligible to work in the Child Nutrition Program.
Staff members will also be given the OVS Guidance for the National School Lunch Program and the School Breakfast Program developed by the Food and Nutrition Service of the United States Department of Agriculture. George Junior Republic in Pennsylvania will make certain the updated Guidance is used when educating staff on OVS.
The Child Nutrition Director is responsible for the oversight of OVS.
George Junior Republic in Pennsylvania
Staff Responsibilities for Food Service Management ATTACHMENT A
BREAKFAST (7:00 a.m. – 9:00 a.m.)
1. Breakfast will be delivered daily with dinner delivery in grey tote.
2. Review and record the temperature on the thermometer in the refrigerator at 7:00 a.m. on the Production Record.
3. Offer breakfast to each person served and appropriate drink. If fruit is on the menu, offer to persons served.
AFTER BREAKFAST (9:15 a.m. – 11:15 a.m.)
1. Cambro, red tote (for dirty dishes) and a grey tote (clean dishes and meal supplies) will be dropped off for lunch.
2. Cambro, red tote and blue tote from previous evening’s dinner will be picked up.
3. Meal Count sheets from previous day (for Breakfast, Lunch and Dinner) must be in the grey breakfast tote and ready for pick-up.
LUNCH (11:15 a.m. -1:00 p.m.)
1. Hot foods must be checked for appropriate temperature and must be recorded on the Production Record.
2. After lunch, grey tote, red tote and the cambro should be ready for pick up.
AFTER LUNCH (2:30 p.m. – 4:30 p.m.)
1. Dinner cambro and will be dropped off with a red tote (for dirty dishes) and a blue tote (containing clean dishes, meal supplies, evening snack, breakfast, Production Records for following day).
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2. Review and record the temperature on the thermometer in the refrigerator at 4:00 p.m. on the Production Record.
DINNER (4:30 p.m. – 5:30 p.m.)
1. Hot foods must be checked for appropriate temperature and recorded on Production Record.
2. Blue tote, red tote (with dirty dishes) and the cambro should be ready for pick-up.
EVENING SNACK (7:00 p.m. – 9:00 p.m.)
1. Staff must serve each persons served one snack item.
REFERENCECODE: COM- 503-DA - GJRPA
TITLE: D & A Rehab. Program Dietetic Services Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 4/1/2021
DATEREVISED: 9/25/2019
COM-503-DA-GJRPA – D & A Rehab. Program Dietetic Services 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 (a) regarding all dietetic services.
REFERENCECODE: COM- 504 - GJRPA
TITLE: Child Nutrition Program Procurement Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: Pending Board of Directors Final Approval
DATEREVISED: 4/3/2025
COM-504-GJRPA – Child Nutrition Program Procurement Policy
It is the policy of the agency that all procurements will adhere to free and open competition. Documentation of procurement will be maintained for a minimum of three years.
REFERENCECODE: COM- 504-001 - GJRPA
TITLE: Child Nutrition Program Procurement Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 4/3/2025
DATEREVISED: 4/3/2025
COM-504-001-GJRPA – Child Nutrition Program Procurement Procedure
George Junior Republic in Pennsylvania will purchase goods, products and/or services for use in the Child Nutrition Program in compliance with 2 CFR, Chapter 1 and 2, 7 CFR Part 3016.36, 3019.44 and State Law, using the procedures as outlined below.
The primary purpose of this procurement plan and the associated procedures is to ensure that open and free competition exists to the maximum extent possible. The procurement process will not restrict or eliminate competition. A review of the plan will be conducted annually.
It is the responsibility of the Procurement Director/Food Service Director to document the quantities to be purchased and to track the usage of said purchases.
A. Informal Purchase Procedures: This method will apply to purchases of goods, products, and/or services when the aggregate dollar amount is less than $150,000. Quotes from more than one qualified vendor/contractor will be acquired.
1. All vendors will receive the same information.
2. Each vendor will be contacted and given an opportunity to provide a price quote on the same specifications.
3. The Procurement Director/Food Service Director will be responsible for contacting potential vendors/contractors when price quotes are required.
4. The price quotes will remain confidential until the actual purchase has been made.
5. Quotes will be awarded by the Food Service Director.
6. Quotes will be awarded to the lowest and best quote based on price, quality, and serviceability.
7. The Procurement Director/Food Service Director will be responsible for documentation of records to show vendor selection, reasons for selection, names of vendors contacted, price quotes from each vendor, and written specifications.
8. The Procurement Director/Food Service Director will be responsible for documenting that the specified product is received.
9. Any time an accepted item is not available, the Procurement Director/Food Service Director will select the acceptable alternate and document the reason for accepting the alternate. This documentation will be kept on file.
10. Bids will be awarded based on price, quality, and delivery.
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11. The Procurement Director/Food Service Director is required to sign documentation, confirming a review and the approval of the purchase of the goods, products or services.
12. The Procurement Director/Food Service Director are the Sponsor’s authorized purchasers.
B. Micro Purchase Procedures: This method applies to purchasing supplies or services when the aggregate dollar amount does not exceed $3,000. These purchases may be awarded without soliciting competitive quotes if the entity considers the price reasonable.
1. The Procurement Director/Food Service Director will be responsible for contacting potential vendors.
2. The Procurement Director/Food Service Director will be responsible for documenting the purchase, the vendor's name, price, and written specifications.
3. The Procurement Director/Food Service Director will be responsible for documentation that the actual product was received.
4. The Procurement Director/Food Service Director is required to sign documentation, confirming a review and the approval of the purchase of goods, products and/or services.
C. Formal Purchase Procedures: This method applies to purchases of supplies or services when the aggregate cost amount is more than $150,000. The formal procurement method requires an Invitation for Bid or a Request for Proposal.
1. The Procurement Director/Food Service Director is the Sponsor's authorized purchaser.
2. An announcement of the Invitation for Bid or Request for Proposal will be placed on the George Junior Republic website to publicize the intent of the Child Nutrition Program Sponsor to purchase the needed items. The advertisement for the bids or proposals will run for four weeks.
3. An advertisement is required for all purchases over the district’s simplified acquisition threshold of the actual amount of the CNP Sponsor’s simplified acquisition threshold. The announcement will contain a general description of items to be purchased, the deadline for submission of sealed IFB’s or RFP’s, and the address where complete specifications and other procurement documents may be obtained.
4. Each vendor will be given the opportunity to bid on the same specifications.
5. The Food Service Director will perform a cost or price analysis concerning every procurement action in excess of the Pennsylvania school code requirements or federal Simplified Acquisition Threshold.
6. The IFB or RFP will clearly define the purchase conditions. The following will be included in the document:
a. Contract period
b. CNP Sponsor is responsible for all contracts awarded.
c. Date, time, and location of bid opening.
d. Notification of selected bid
e. Delivery schedule
f. How bidder will be evaluated
g. Benefits to which the CNP will be entitled if the contractor cannot or will not perform as required
h. Statement to include and involve minority and small businesses
i. Provision requiring compliance with the EEO for all contracts over $10,000
j. Bid protest procedures
k. Provision for access by authorized representatives of the CNP Sponsor, State Agency, or USDA to any books, documents, or papers, and contractor records pertinent to the negotiated contract.
l. Method of shipment or delivery upon contract
m. Signed Certificate of Lobbying for contracts over $100,000
n. Specifications will be prepared and provided to potential vendors desiring to submit an IFB or RFP for the products or services requested. Vendors will be selected using the Sponsor’s procedures, such as:
a. Do the vendor’s products meet the required specifications?
b. Does the vendor’s delivery meet the scheduled Sponsors’ needs?
c. Any other criteria important to the procurement of the specific good/service.
o. Questions by potential vendors must be addressed with the Procurement Director/Food Service Director
p. The Procurement Director/Food Service Director are responsible for ensuring compliance with Federal and State laws and the policies of the Sponsor agency.
q. The following criteria will be used in awarding contracts as a result of bids.
i. Price
ii. Quality
iii. Service
r. A weighted evaluation of all bids will be conducted. Price alone is not the primary reason for the award but remains a key consideration when the contract is awarded.
s. A contract will be awarded to a bidder whose proposal is responsive to the invitation and best meets the needs of the CNP Sponsor, price, and other considered factors as outlined above.
t. The Procurement Director and Food Service Director will be responsible for documenting that the actual product specification has been received and reviewed.
u. Any time an accepted item is not available, the Procurement Director/Food Service Director will select the acceptable alternate. The contractor will be responsible for informing the Procurement Director/Food Service Director that the item is not available and the Food Service Director must approve, in advance, the receipt of the alternate product to be received. Compliance must be maintained with the Buy American provision.
v. The Procurement Director/Food service Director will be required to maintain all documentation of the procurement process.
7. Code of Conduct: The CNP Sponsor will maintain and ensure the Code of Conduct is followed by employees engaged in the award and administration of the CNP contracts.
8. George Junior Republic in Pennsylvania and its designated employees or representatives will not solicit gifts, travel packages, or other incentives from prospective vendors.
9. Penalties for violation of the Code of Conduct will result in the following actions:
a. Verbal Warning
b. Written Warning
c. Suspension
d. Termination
COMPLEMENTARY SERVICES (COM) Section 600 – Transportation Department
REFERENCECODE: COM- 600 - GJRPA
TITLE: Transportation Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/29/2021
DATEREVISED: 9/29/2021
COM-600-GJRPA - Transportation Policy
It is the policy of the agency to provide secure transportation to persons served by qualified employees, adhering to the identified policies and procedures.
REFERENCECODE: COM- 600-001 - GJRPA
TITLE: Transport Requirements Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 10/19/2023
COM-600-001-GJRPA - Transport Requirements Procedure
All drivers are considered to be George Junior Republic staff members. All drivers will be assigned to and expected to work in both On and Off Campus driving capacities. Additional duties, other than transportation, may be assigned by your Supervisor based on the needs of the agency.
George Junior Republic persons served may only be transported in George Junior Republic vehicles. Additionally, the persons served may be transported in school/charter buses approved through the Program Office or the Transportation Department. At no time may a staff member contract, agree or give permission for an outside company or agency to transport a George Junior Republic person served. All transportation by an independent company outside George Junior Republic must be approved by a Campus Director or Vice President of Operations.
All off campus transportation requires at least two staff members, unless approved by a Campus Director, Vice President of Operations, Procurement Director, or Director of Transportation. There must be at least one staff member supervising the transportation of the person served in addition to the driver for up to 8 persons served. In practice, this means that the driver cannot be counted in the staff-to-person served ratio for supervision. The driver’s duty is that of a driver and the second staff member’s duty is to supervise the person served during transport. Once at their destination both staff are responsible for supervising the person served
When staff are transporting person served or operating a company vehicle, staff are expected to obey all speed limits, traffic laws and parking regulations. If staff violates any of the above, and receives a citation, that staff will be expected to pay any fines, charges, and processing fees assigned for the violation. This policy applies to the wearing of seatbelts, which is a state law and must be obeyed by all staff and persons served. George Junior Republic vehicles are equipped with GPS tracking systems which will notify the George Junior Republic Director of Transportation of the location, speed of travel, and route taken to and from the assigned destination.
At all times, persons served should be dressed appropriately for the transport and destination. Please refer to the dress code for specific details on dress, but keep in mind that dress and presentation is a reflection on George Junior Republic and you as a staff member. If a person served is not dressed appropriately, staff needs to have them go back into their cottage/unit to change his clothing prior to departing and inform the Campus Director of this issue as soon as possible. When departing during the night, staff can contact a Campus Supervisor via the Switchboard Operator and request an attire check for court or other formal trip
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locations if necessary or instructed. If a direct care staff attends the trip, it is their responsibility to ensure the person served is dressed appropriately.
At no time may a staff member who does not possess a valid driver’s license operate a George Junior Republic vehicle or any other vehicle used for the transport of persons served. Additionally, at no time may an individual without a valid driver’s license operate a vehicle (personal or company) on the grounds of George Junior Republic.
Staff members under the age of 21 are not permitted to transport persons served in any vehicle. At no time may an employee under the age of 18 operate a company vehicle or a personal vehicle for George Junior Republic.
Transportation is divided and defined into two main categories; on and off campus trips. On campus transportation, including, but not limited to: to and from the Wellness Center, Administration Building, Pew Counseling Center, and Academic Center are provided by the Transportation Department, campus supervisors, or home or unit staff. Off campus transportation such as hearings, medical appointments, home visits, admissions, and discharge is provided by the Transportation Department unless otherwise indicated by the Treatment Team Drivers may be scheduled for a combination of both on campus and off campus transports/tasks depending on the needs of the agency and the persons served.
At times, employees other than drivers may need to transport a person off campus for the above purposes. The same rules apply to any staff member conducting the transport of a person served. A daily transportation sheet is issued listing these trips, the drivers assigned, and the departure time. It is the responsibility of the staff members in the cottage/unit of the person served to have them ready to depart, dressed properly, and inform the drivers of any special considerations or circumstances of which they are aware. It is the responsibility of the driver to secure any medications needed for the persons served for the duration of the trip. Medications are to be locked in the glove box or console at all times when not being administered.
Often, trips will be scheduled which include a driver from the Transportation Department, and child care or clinical staff. In this case, the child care and clinical staff are expected to assist in the driving of the vehicle as needed. Only staff who have a valid driver’s license and who are permitted to operate agency vehicles should be assigned to assist with trips.
Each driver and supervisor on the campus is in contact with the various departments and switchboard via radio and can be dispatched to transport a person served. The drivers and/or Campus Supervisor are available for transportation purposes. In the event of a crisis, the Campus Supervisor is expected to intervene and provide transportation for the person served.
Long-Term Structured Residence (LTSR)
The LTSR has a designated vehicle for transport of persons served, which is parked at the LTSR. LTSR staff will transport persons served to all off-campus and on-campus activities. GJR in PA drivers will transport upon the request of the LTSR staff through the Director of Transportation
REFERENCECODE: COM- 600-002 - GJRPA
TITLE: Consent for Transportation Services Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/8/2022
COM-600-002-GJRPA - Consent for Transportation Services Procedure
A. Parents, guardians, or legal representatives are given information regarding transportation processes in the Parent/Guardian Information Guide. They then sign that they have received this information.
B. Consent will include transportation for admission, medical appointments, court hearings, off campus activities, home passes, school field trips, and discharge.
REFERENCECODE: COM-600-003 - GJRPA
TITLE: Transportation: On-Campus Trips Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-600-003-GJRPA - Transportation: On-Campus Trips Procedure
The following procedures are in effect regarding transportation of persons served:
A. It is the driver’s responsibility to operate the vehicle safely.
B. Appropriate Attire
1. Persons served must wear appropriate footwear during all transports.
2. Persons served must wear coats if the weather is inclement.
3. The Cottage/Unit staff is responsible for ensuring the person served is wearing shoes and dressed appropriately for the weather.
4. Drivers are to report any issues with the persons served transport dress code to the Director of Transportation.
C. School Unit Shuttles
1. Staff and persons served will load onto the bus at the scheduled time and driver will transport to the designated entrance.
2. Staff and persons served will exit the bus and enter the building where their class is located.
3. Driver should transport the persons served and staff back to the unit at the designated time.
4. If there are any behavior problems or concerns on the bus, Drivers will inform both the staff in the home or unit and the Director of Transportation. If there is a major issue, the Driver will stop the bus and radio for a Campus Supervisor.
D. Groups
1. Group Therapy Transports
1. Staff will pick up group sheet at the Pew Counseling Center. Pew Counseling Center staff will call the units in advance of the group to confirm persons served attendance.
2. Drivers will start picking up persons served at least 15 minutes prior to start time of group.
3. Unit staff should have persons served ready.
4. It is the driver’s responsibility to drive the vehicle safely.
5. In the event that a bus, rather than a van, is necessary for transport, the additional staff member in the vehicle is responsible for supervising and maintaining safe behavior from persons served on the bus. Staff rider (non-
3, 2025
driver) should position themselves on the bus in such a way as to allow for supervision of persons served and to respond to an issue if it occurs.
6. The group will be dropped off at the group location.
7. Staff from the unit will communicate to the group worker if a person served is not in attendance and why.
8. When picking up groups, drivers will return to the designated group door to be let in.
9. Drivers will observe the activity sheet to see if any of the persons served are to be at an activity and drop off at activity. Persons served are to be escorted in and activity staff is to be made aware of who they are receiving.
10. When dropping off at the unit after a group, persons served must be walked into the unit when a confirmed staff cannot be visualized at the door.
11. If there are any behavior problems or concerns on the van/bus, Drivers will inform both the staff in the cottage and the Director of Transportation. If there is a major issue, the Driver will stop the van/bus and radio for a Campus Supervisor.
E. ISU Transport
The following procedures will be in effect when transporting persons served outside the Intensive Supervision Units. These procedures apply to trips or escorts on and off campus. The staffing will be provided by ISU or the Campus Supervisor. Drivers will only be responsible for transportation and cannot act as security staff.
1. Persons served from the Intensive Supervision units must be transported in a secured vehicle.
2. On Campus transports should include one driver and one ISU staff. ISU staff does not need to ride behind the cage unless two drivers are involved in the transport. Drivers are never permitted to ride in the cage with persons served.
3. Off Campus transportation for court should include one driver, one clinical staff, and one ISU/security staff. ISU/security staff will ride behind the cage.
4. Off Campus transportation for medical trips should include two drivers and one ISU/security staff. ISU/security staff will ride behind the cage.
5. Certain circumstances may require individualized procedures at the time of the trip and may be determined by the Campus Director, Vice President of Operations, or the Director of Transportation.
6. For medical appointments, security escorts must accompany the person served into the facility and stay with them throughout the wait.
8. At least one escort must accompany the person served into the physician’s exam room or office and remain with them the entire time. For hospital visits such as radiology or surgical procedures, one staff must accompany the person served as far as the hospital will permit.
9. At no time may a person served be left under the supervision of a non-security escort except when otherwise approved by the Campus Director or the Vice President of Operations. This includes both campus and off-campus trips.
F. Suicide Watch/Security Transports:
1. Suicide watch transports should refer to PS-225-001-GJRPA
2. TRACC and ISU programs must typically provide a security staff for transportation. Under certain circumstances, a Campus Supervisor can provide the transport, or a Campus Director, Vice President of Operations, or the Director of Transportation can give permission to transport without security staff on an individual basis.
REFERENCECODE: COM- 600-004 - GJRPA
TITLE: Transportation: Off Campus Trips Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-600-004-GJRPA - Transportation: Off Campus Trips Procedure
A. The Transportation Sheet contains important information regarding trips, drivers are to pay close attention to any medical concerns, security issues, any included instructions, and pertinent information.
B. Drivers and unit staff dress appropriately.
C. Persons served must be supervised at all times by a George Junior Republic staff.
D. Medications are picked up from the Health Services from 6AM – 10PM and from the Switchboard from 10PM – 6AM. Only staff with a current Medication Administration certification may administer medications. It is the Driver’s responsibility to transport and administer medications in the prescribed manner at the prescribed time. Secure prescription medication until transferred into the custody of another responsible adult or administer to the person served during the trip when applicable.
E. Only drive thru or take out/pick up meals are permitted when transporting person(s) served; Drivers may dine-in when travelling over meal times when no person(s) served are present in the van. Dine-in stops are only permitted as long as it will not interfere with any set schedule times and the stop may not be longer than 30 minutes. Drivers may not travel off route for any reason, i.e. a particular eatery or other establishment, scenic route, personal business, etc.
F. No stops should be made until trip is at least 30 miles outside of the county of residence of the person served expect during an emergency or unforeseen circumstance. State and county maps can be located in the van for reference. If you are unsure of a home or placing county and need to confirm the information, contact the Director of Transportation.
G. If restroom break is needed, only one person served is permitted out of the vehicle at a time. One driver will remain with vehicle if more than one person served is on the trip.
H. Person served must be escorted to unit/cottage door upon return to campus to ensure staff is in the building, unless staff comes to the door.
I. Employees may not take a person served off campus without the permission of a Campus Director.
J. Persons served must be fully supervised any time they are off campus. This means that the person served must remain within the sight of the staff.
K. Any person served in placement for less than 30 days is not permitted off campus without Treatment Team authorization.
L. At no time is a staff member permitted to transport or authorize any person served or group of persons served for an event which includes swimming, boating, or fishing. The only time persons
served are permitted to swim is on campus under the supervision of a certified lifeguard. The lifeguard cannot be counted in the supervision ratio.
M. There must be two staff accompanying a person served off campus at all times unless written approval states otherwise. If it is necessary to take a person served off campus, staff must arrange for a second staff and a company vehicle for the transport.
N. Types of Off-Campus Trips:
1. Court
a. The Director of Transportation is to be contacted if trip is going to be late for any court hearing as soon as possible so appropriate parties can be notified. In the event the Director of Transportation cannot be reached, notify the Procurement Director.
b. Any time a person served is going off campus it is the responsibility of the driver to obtain their medication through the Health Services from 6AM – 10PM or the Administration Building Switchboard from 10PM – 6AM
c. If asked to testify, drivers must state that they are not qualified to provide information regarding persons served
d. If a person served has been discharged or given a home pass from a court hearing, the person served will remain in staff custody until staff receive notification of discharge/home pass from one of the following: Probation Officer, Children and Youth Worker, Judge, Admissions Department, GJR Liaison, Clinical Staff or Treatment team member actively attending the trip, Campus Director, or the Director of Transportation; Drivers must then immediately verbally notify one of the following in this order: (1) the Director of Transportation, (2) Admissions, and (3) Health Services, of the hearing outcome.
2. Home Pass
a. Medications are picked up at the Health Services along with HP Signature Sheet. All persons served should be signed for by a parent or guardian regardless if they receive medication or not.
b. If the trip leaves prior to 6am, medications will be at the switchboard.
c. Drivers are to check the trip sheet. If it states Need Approval next to the name of the person served, then they are not yet approved for the home visit. Once the Need Approval indicator has been crossed out at the Switchboard, the person served is approved for the visit. Contact the Director of Transportation if it is not crossed out for instructions.
d. Contact the Director of Transportation immediately with a new arrival time if the trip is going to be late for any home visit Pickup or Drop off.
e. Any person served who fails to show for a home pass pick-up should be verbally reported in this order to (1) the Director of Transportation, (2) the Procurement Director, or (3) Campus Supervisor via Switchboard dispatch.
f. Transportation Department is to be notified with any no shows.
3. Picking up new persons served
a. The Admissions Department or Liaisons will notify the Director of Transportation of any scheduled new persons served pickup.
b. All new persons served will be picked up in a caged vehicle. Drivers must not leave campus without a caged vehicle.
c. Admissions/Liaisons will notify transportation of any safety concerns regarding the persons served.
d. Admissions/Liaisons will notify transportation of the Location of the pickup.
e. All picks up are required to occur in a secure location.
f. Call the Switchboard once the new person served is secured in the vehicle. The Switchboard Operator will email the Admissions Department to notify them of the confirmed pick up.
4. Medical Appointments
Health Services will notify the Transportation Department of any scheduled off campus medical appointments. The time of departure is scheduled each day on the trip sheet.
a. Drivers are to check in with the Health Services support staff for any paperwork, x-rays, medications, etc.
b. Staff are to make sure they receive written follow-up orders from the physician. (If not provided to staff, they are to ask).
c. The transport driver may not sign consent for any treatment or testing to be done. All requests should be forwarded to the George Junior Republic Health Services Department
d. Once staff arrive at the office or appointment site, they are not leave the person served unattended. Staff must escort person served into the office unless the physician, nurse or person served request otherwise. Should staff be asked not to attend the appointment, remain outside of the door.
e. All paperwork is to be returned to Health Services immediately upon return from the appointment. If Health Services is closed, paperwork should be placed in the Health Services mailbox at the Switchboard.
f. Any person served returning from a hospitalization, Emergency Room trip, or same day surgery must be taken directly to Health Services immediately upon return unless the return time is between the hours of 10PM and 6AM
g. Nurses on duty will transcribe all follow-up orders written by the consulting physician and notify the unit staff of any new orders or information regarding the outcome of the appointment.
REFERENCECODE: COM- 600-005 - GJRPA
TITLE: Transportation: Smoking/Vaping in Agency Vehicles Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-600-005-GJRPA - Transportation: Smoking/Vaping in Agency Vehicles Procedure
At no time is staff, persons served, or visitors permitted to smoke/vape in a company vehicle. See George Junior Republic employee procedures for further details.
REFERENCECODE: COM- 601 - GJRPA
TITLE: Transportation Employment and Requirements Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-601-GJRPA - Transportation Employment and Requirements Policy
It is the policy of the agency to establish employment and training requirements for drivers.
REFERENCECODE: COM- 601-001 - GJRPA
TITLE: Employment Requirements for Drivers Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-601-001-GJRPA - Employment Requirements for Drivers Procedure
A. Driver must meet all George Junior Republic employment qualifications to include the Pennsylvania Department of Transportation requirement and having a valid driver’s license Human Resources is responsible for confirming a valid driver’s license.
B. If charged with any violation that would result in the loss of a driver’s license, drivers must immediately report this to the Director of Transportation and Human Resources.
C. Driver must possess and maintain a satisfactory driving record.
D. Driver will submit to fingerprinting for a criminal background check.
E. Drivers must pass a physical and drug screen and be able to perform the duties of the job description.
REFERENCECODE: COM- 601-002 - GJRPA
TITLE: Driver Training Requirements Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-002-GJRPA - Driver Training Requirements Procedure
George Junior Republic Transportation Staff will be required to complete the standard George Junior Republic trainings and also any scheduled Transportation Department trainings including but not limited to:
A. George Junior Republic Annual Complementary Services Transportation policies and procedures review
B. Annual Driver Evaluation
1. Evaluations will be completed by the Director of Transportation.
2. Each driver is required to pass an actual driving evaluation with a score of 80% or better
3. If a driver obtains less than an 80% they will be required to be evaluated again on their next scheduled trip.
At any time, staff may be asked to complete refresher trainings or individually designed trainings to ensure safety. Any failure to do so could result in disciplinary actions.
REFERENCECODE: COM- 601-004 - GJRPA
TITLE: Vehicle Use/Scheduling Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-004-GJRPA - Vehicle Use/Scheduling Procedure
George Junior Republic in PA maintains a fleet of vehicles for use in transporting persons served To use a vehicle, the following procedures must be followed:
A. Prior to the use of company vehicles, each employee’s driver’s license must be presented to the Human Resource Department.
B. Vehicles, once authorized, must be signed out and returned. Monday through Friday from 8AM to 4PM, the vehicle can be obtained from the Auto Shop. Before 8AM and after 4PM on weekdays and throughout the weekends, vehicles will be signed out through the Switchboard.
C. Personal vehicles may not be used to transport persons served off campus.
D. Staff must keep the vehicle neat and clean, including emptying the vehicle of all trash and checking the vehicle to make sure no items have been forgotten prior to parking and locking the vehicle.
E. Any emergency transportation on the weekends or at night must be approved by the Campus Director and/or Campus Supervisor on duty. All non-emergency trips will be scheduled through the Transportation Department.
F. Before leaving the vehicle, staff must make sure vehicles are checked for belongings and properly locked.
REFERENCECODE: COM- 601-005 - GJRPA
TITLE: Transportation Expenses Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-005-GJRPA - Transportation Expenses Procedure
A. If transportation is arranged through the Transportation Department, a credit card allotment will be assigned for meals and will be issued to the driver prior to the trip. The credit card allotment does not include gas expense. Gas can be purchased with the credit card when necessary and upon return from the trip. Additionally, cash may be assigned to trips as needed.
1. Trips leaving prior to 8am will pick up their funds from the supervisor at the Switchboard.
2. Trips leaving after 8am will pick up their funds from the Finance Department.
3. Weekend trips will pick up their funds from the Campus Supervisor at the Switchboard.
B. These funds are to only be used for meal, tolls, parking and gas. If assigned an EZ Pass this should be used for tolls. Snacks and excessive drink purchases are not permitted.
C. Meal allotments are guidelines for maximum purchase per person and are predetermined by the agency.
1. This allotment includes drink and tip.
2. Over-spending will be at the expense of the staff responsible.
3. Allotment is per person. Should one person spend less than the allotted amount, another person may not add and use the difference for another person.
4. All receipts are to be submitted prior to the end of the shift.
D. If assigned an EZ Pass:
1. It is picked up in the same place that staff get the keys for the assigned vehicle (Auto Shop 8:00am-4:30pm, Switchboard 4:30pm-8:00am and on weekends).
2. It is not to be mounted in any of the vehicles as they must be returned after each trip.
REFERENCECODE: COM- 601-006 - GJRPA
TITLE: Vehicle Operation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-006-GJRPA - Vehicle Operation Procedure
A. Pre-Operation
1. Staff are to inspect the vehicle for damage or trash. If a vehicle is found to be damaged or not clean, it is reported to the Director of Transportation as soon as possible.
2. Persons served being transported to the Wellness Center, group or other campus locations are not permitted to take pens, pencils or other writing instruments. Staff will secure writing instruments carried by persons served and alert the staff in the home.
3. Seating and mirrors are checked for adjustment.
4. Gauges and gasoline level are to be checked.
5. Passengers are to be loaded from the back to the front.
6. Assure all passengers have fastened their seat belts.
7. Cargo or suitcases must be stored in the back of the vehicle.
8. The driver must secure their seat belts.
B. During Operation
1. Staff members are not permitted to operate a vehicle for more than eight hours without at least a one hour break.
2. Speed limits both on and off campus must be obeyed.
3. Traffic laws as established by the state must be obeyed
4. The second staff member is to act as a ground guide when backing up the vehicle.
5. Mirrors are to be used when backing up.
6. Both hands must be on the steering wheel while driving.
7. Gauges are to checked periodically while driving.
8. A vehicle is never to be left unattended while running or unlocked.
9. All persons in the vehicle must keep their seat belts on at all times.
10. Do not back up vehicles on campus unless there is no other option. Circle around campus for your next destination instead of backing up. Do not pull in to cottage/unit parking areas in order to avoid backing out.
C. After Operation
1. The vehicle is to be inspected for trash, making sure staff remove all items.
2. Any damage or mechanical concerns is to be reported to the Director of Transportation If the Director of Transportation and the auto shop are unavailable, email the auto shop and copy the Director of Transportation.
3. Gas tank is to be filled if below ¾ tank.
4. Staff should return keys to instructed location or the Switchboard if no instructions were provided; Drivers should return keys to the Auto Shop when opened, or the lock box in the loading dock when closed.
REFERENCECODE: COM- 601-007 - GJRPA
TITLE: Cell Phone Use During Transportation Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-007-GJRPA - Cell Phone Use During Transportation Procedure
GJR has a ZERO TOLERANCE for cell phone or mobile device usage of any kind while staff are driving company vehicles. If there are trip updates, the Transportation Department will leave a voicemail and attempt to call the driving partner. Staff should not answer. It is suggested that staff check their voicemails upon arrival at the destination. Another option is to have the staff riding as the passenger answer calls for the driver.
A. Safety on trips is the #1 concern and priority.
1. Drivers are never permitted to use a phone while driving; the only exception being if staff are using the GPS function, if required to do so
2. Calls must be handed to the passenger to answer or voicemail must be used.
3. No Bluetooth use while driving.
4. No texting while driving.
5. Staff are encouraged to report any failure to comply with this rule.
REFERENCECODE: COM- 601-008 - GJRPA
TITLE: Transportation Scheduling Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-601-008-GJRPA -Transportation Scheduling Procedure
A. Monthly schedule calendars must be submitted to Director of Transportation no later than the 25th of every month for the following month
1. If adjustments must be made to schedules, notification to the Director of Transportation is required 48 hours in advance.
2. Vacations must be discussed with the Director of Transportation in advance for approval. Consideration will be taken by seniority
B. Protocol to follow when calling off:
1. When calling off, drivers must call off to the Director of Transportation or Procurement Director. If neither can be reached, contact the Switchboard and notify the operator or Campus Supervisor. Leaving a message is not an acceptable method of calling off; Staff must always speak with a person associated with the call off process.
2. Failure to follow the procedure will result in disciplinary action.
REFERENCECODE: COM- 601-009 - GJRPA
TITLE: Transportation: Incident Reports Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-009-GJRPA - Transportation: Incident Reports Procedure
Staff must write incident reports for accidents, medical emergencies, persons served absconding and any unusual situation. The report must be as detailed as possible and contain who, what, where, when, and how information. It must be turned in prior to the end of the shift on which it occurred.
Staff must be interviewed by the Transportation Department following any of these incidents:
A. Auto accidents
1. In the event that an accident occurs, on or off campus, involving a George Junior Republic vehicle, an Accident Report must be completed immediately or as soon as possible if the staff member is injured. Accident Reports are located in the binder or glove box of every GJR vehicle. Follow the Accident Report Checklist along with any directives by the Director of Transportation or Procurement Director to insure all information and steps have been completed.
2. Do not admit fault in any accident.
3. Reports are turned in to the Director of Transportation mailbox upon return to campus and by the end of the shift.
4. Verbally report the accident to the Director of Transportation or the Procurement Director during non-business hours.
5. All staff and persons served involved in an off-campus accident of any type must be evaluated and cleared by the closest emergency room prior to any further transportation.
B. Absconding
1. When a person served absconds during a trip, call 911 and file a police report.
2. Provide a verbal report to either the Director of Transportation, Admissions Department, or Procurement Director (in this order of availability) as soon as possible.
3. Complete an Incident Report and submit it to the Director of Transportation or, if after hours, the mail folder in the loading dock for drivers, or mailbox at the Switchboard for staff who are not drivers.
C. Medical emergencies
1. Contact the GJR Health Services Department for any medical emergencies involving persons served and the Director of Transportation or Human Resources for any emergencies involving staff.
2. For accidents occurring on campus with no obvious injuries, contact Health Services.
3. Contact Human Resources, Campus Director, and the Director of Transportation to inform everyone to contact the appropriate entities.
4. Complete an Incident Report upon return to campus or as soon as possible if injured. Incident Reports are located in the van, Transportation Office, or at the Switchboard.
5. Turn the reports in to Health Services, Director of Transportation, and Campus Director of any persons served involved.
REFERENCECODE: COM- 601-010 - GJRPA
TITLE: Transportation Employee Dress Code Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-601-010-GJRPA - Transportation Employee Dress Code Procedure
A business casual dress code must be followed by all Transportation Department employees:
A. George Junior Republic identification badges must be kept on one’s person while working.
B. Shorts are not permitted.
C. Good personal hygiene and appearance are expected.
D. See Human Resources dress code for further information regarding dress code.
REFERENCECODE: COM- 601-011 - GJRPA
TITLE: Transportation: Radio Etiquette Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-601-011-GJRPA - Transportation: Radio Etiquette Procedure
Staff using radios must be professional at all times:
A. Professionalism:
1. Do not discuss personal information.
2. Do not use profanity.
3. Speak in a professional manner at all times.
B. Be brief:
1. Be precise and to the point.
2. Avoid unnecessary talk of irrelevant information.
3. Communicate information that is necessary and relevant.
C. Be clear:
1. When speaking on the air, enunciate each word and be specific with detail.
2. Be concise but communicate all necessary information.
D. Be secure:
1. Do not transmit confidential information such as the names of persons served.
2. Frequencies are shared so others can hear radio conversations.
REFERENCECODE: COM- 602 - GJRPA
TITLE: Transportation Medication Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-602-GJRPA - Transportation Medication Policy
It is the policy of the agency to secure medications during transport and administer them according to applicable procedures.
REFERENCECODE: COM- 602-001 - GJRPA
TITLE: Transportation: Obtaining Medications Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 12/12/2024
COM-602-001-GJRPA - Transportation: Obtaining Medications Procedure
A. Any time a person served is going off campus, it is the responsibility of the driver to obtain the medication of the person served through Health Services.
B. Health Services will issue the medication to the driver escorting the person served, and the drivers will administer the medication to the person served as per the guidelines of the medication administration standards. Any staff who has not taken the Medication Administration training may not administer medications to persons served.
C. Any trip leaving prior to 6am will have medications at the switchboard for the person served.
D. Drivers must obtain signature of adult for medications for any person served going on a home pass.
E. Adult signatures must be obtained for any person served going on a home visit or a day pass, regardless of whether or not they take medication.
COMPLEMENTARY SERVICES (COM) Section 700 – Balanced and Restorative Justice (BARJ)
REFERENCECODE: COM- 700 - GJRPA
TITLE: Balanced and Restorative Justice (BARJ) Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-700-GJRPA - Balanced and Restorative Justice (BARJ) Policy
It is the policy of the agency to utilize the Balanced and Restorative Justice program, as outlined in the following procedures, to hold persons served accountable for their actions, develop adaptive competencies, and promote public safety.
REFERENCECODE: COM- 700-001 - GJRPA
TITLE: BARJ Definition Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 2/4/2021
DATEREVISED: 2/9/2021
COM-700-001-GJRPA - BARJ Procedures
The Balanced and Restorative Justice (BARJ) response to crime is a balanced approach, giving equal consideration to the victims, offenders and the community. The main principle of BARJ is that crime is a harm, not just to the state, but also to victims and the community. Crime creates an injury to the victims and the community in which it occurs. This balanced approach provides the victim and community an opportunity to hold the offender accountable, and to help decide how to repair the harm that was created by the offender.
The balanced approach has three main goals. First, to hold the offenders accountable to the victims and the harm they caused. Second, to have the offender leave the system more competent to function within the community than when he/she entered the system. Third, to promote public safety by the involvement of the community. The community should be responsible for the well-being of its members and should allow the offender to repair the harm and make reparations.
A. Employee Training related to BARJ
1. New employees will receive training on the BARJ program during their first week of employment during initial training. The BARJ Coordinator and/or designee, and the Outpatient Services Director will complete training.
2. The training will consist of the following:
a. History of BARJ in Pennsylvania
b. BARJ principles (Accountability, Community Protection and Competency Development)
c. Definition of restitution, community service and fines
d. Victim Awareness curriculum and groups
e. Mandated five hours of community service for delinquent persons served
f. BARJ community-based projects
g. Completing BARJ Timecard sheets
B. Time Distribution Report/Time Card Documentation
1. A BARJ Time Distribution Report (timecard sheet) must be completed for each qualifying person served.
2. The form must be accurately completed to reflect the total number of community service hours completed per week for each eligible person served. GJR requires each person served complete five hours of community service each week.
3. Completed timecards must be submitted to the BARJ Coordinator every Wednesday by 5:00 p.m. for the previous week (Monday – Sunday).
4. Once reviewed and calculated, the BARJ Coordinator or designee is responsible for submitting the time card sheet to finance every Tuesday by 5:00 p.m.
5. Finance reviews the document and sends checks to placing agencies once a month for each participating person served.
C. Electronic Health Record Documentation
1. The BARJ Coordinator updates the BARJ section of the Electronic Health Record on a daily basis; including community service hours, restitution, court fees/fines, and GJR fines.
2. Residential Managers and Therapists update the competency development and community protection sections of BARJ questionnaire in the Electronic Health Record when completing an ISP report.
3. The BARJ Coordinator completes the accountability section of the BARJ questionnaire.
4. BARJ related information is to be included in every ISP Review and court report. This includes community service hours worked, restitution earned, fines paid and competency development.
5. BARJ information in the Electronic Health Record can be found by ‘clicking’ on the BARJ tab at top of the menu. Items that can be accessed for every person served includes the Client Questionnaire, Summary, Required Services, Fines, Campus-specific Fines, Restitution, and Community Service hours.
D. Persons Served Referral to BARJ
1. The BARJ Coordinator tracks all Community Service, Restitution and Court Fines on a daily basis. This is tracked through court orders received and from placing agencies.
2. Based on hours and money owed, the BARJ Coordinator assigns each eligible person served to various on campus and off campus work details.
3. The Campus Director will approve any fines the person served accrues during residency at GJR in PA. For example, fines may be charged to the persons served for destruction of property or other similar acts. In this example, the BARJ Coordinator must be notified and will provide the Electronic Health Record documentation to Finance.
4. All BARJ persons served will participate in Victim Awareness group where BARJ principles are discussed.
5. Treatment staff may refer persons served to the BARJ Coordinator for work details. Assignments given will be based on the level of functioning, all factors documented on Risk Assessments, and progress in the program. Assignments may include unit/cottage, on-campus or off campus projects.
E. Role of Finance department
1. Assess all restitution funds and community service hours worked.
2. Mails checks to placing agencies on a monthly basis.
3. Persons served who have earned their GED or who have graduated are only individuals who may be discharged with funds in their account. In these instances, the finance department sends check to the person served upon his discharge.
F. Communicating with Parents/Guardians
1. Residential Managers and Case Managers discuss BARJ related information with parents/guardians during monthly phone calls and family contact sessions.
2. Parents/guardians are updated on restitution paid and community service hours worked during the monthly phone calls or based on request.
G. BARJ Persons Served Supervision
1. BARJ staff supervise persons served assigned to BARJ.
2. Staff concerns regarding supervision or safety risks will be communicated to the BARJ Coordinator.
3. Persons served utilizing equipment will receive safety education prior to utilizing the equipment.
4. Equipment will not be used without the use of appropriate safety equipment.
H. BARJ Chores
1. At the beginning of every week, a list will be distributed to each home/unit listing the name of the person served owing restitution, fines and/or community service.
2. Chores will be paid through the BARJ program with money for restitution and fines, or hours for community service. They are to be done for BARJ and not for points. If more than one person served in the home is included in this category, the chores may be equally divided among all eligible participants. It is the responsibility of staff to document the amount of time the person served spends doing these chores and to turn the time sheets into the BARJ Coordinator. If no BARJ participants in the home, the chores may be assigned to other persons served.
3. Chores include:
a. Snow Removal: This includes shoveling the walks that lead to all of the doors of the building, shoveling parking areas, and salting sidewalks and parking area (if needed).
b. Landscaping: This includes removing debris (tree limbs, litter and leafs) from lawn and sidewalks, watering flowering plants and shrubs around cottage/unit, weeding flower beds and area around shrubs, mowing the lawn weekly and remove grass clippings as needed, trimming shrubs in the spring before spreading mulch, spreading mulch around cottage and shrubs, and raking leaves so they are ready for roadside pick-up.
Memorial Café: This includes cleaning/sanitizing the tables, sweeping floors, removing debris from restrooms, wiping down the restroom sink, and taking out the trash.
Long Term Structured Residence (LTSR)
The LTSR does not utilize BARJ services.
REFERENCECODE: COM- 700-002 - GJRPA
TITLE: Persons Served Right to Compensation for BARJ Work Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-700-002-GJRPA - Persons Served Right to Compensation for BARJ Work Procedure
Persons served are to be compensated for work performed under the BARJ program, except under the following conditions:
Personal housekeeping tasks related directly to the personal space and possessions of the person served.
Shared responsibilities for regular household chores among a small group of persons served.
Employees of George Junior Republic are not permitted to compensate a person served via the Motivational System or other privileges related to their treatment and residency within George Junior Republic. In addition, a person served may not be hired out for the purpose of an employee earning or collecting a profit on their employment.
Persons served are permitted to work within the BARJ and Community Service Programs for the purpose of fulfilling their obligation to the placing agency and for the provision of victim restitution. Persons served assigned to the BARJ program will be paid minimum wage and the funds earned will be forwarded to the appropriate agency for the purposes of restitution and victim compensation.
Persons served owing community service, fines and restitution activities must complete these activities through the BARJ program while in GJR in PA
REFERENCECODE: COM- 800 - GJRPA
TITLE: Education Policy
APPROVEDBY: GJR Board of Directors
DATEAPPROVED: 9/25/2019
DATEREVISED: 9/25/2019
COM-800-GJRPA - Education Policy
It is the policy of the agency to work cooperatively with the identified education providers to ensure that all persons served are provided with an appropriate education plan to address their individual needs in the least restrictive setting feasible.
REFERENCECODE: COM- 800-001 - GJRPA
TITLE: Supervision of Persons Served to and from School and Lunch Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-800-001-GJRPA - Supervision of Persons Served to and from School and Lunch
A. Guidelines:
1. Staff must escort persons served to and from school, providing supervision throughout the walk.
2. Staff and persons served will leave the home in a group at the designated time in order to arrive to the school shortly before the start time.
3. Persons served are responsible for bringing the following: library books and homework/assignments.
4. Staff must support persons served in following the dress code, as indicated in the school handbook. Appropriate winter wear must be worn in colder months.
5. Each group will walk uniformly and together as a group at a safe social distance, using appropriate communication skills.
6. Groups will stay separated with one staff in the front of the group and one staff in the rear.
7. Groups may cross roads only at the crosswalks.
8. Staff and persons served must be sure to look both ways before crossing at the crosswalks.
9. Groups will stay on the sidewalks and crosswalks unless otherwise instructed.
B. Attendance and dismissal times:
1. Persons served will arrive at school no earlier than 8:10 AM and no later than 8:12 AM. Students should not return to the school from lunch more than 5 minutes prior to the scheduled start of their next class.
2. Persons served are to enter and exit the school using the door assigned by school personnel.
3. Persons served attending the Career and Technical Center must be escorted to the crosswalk across the road from the Career and Technical Center. Staff do not need to escort persons served across George Junior Road.
4. Staff must ensure that all the persons served in their group enter the Academic Center, or the Career and Technical Center.
5. When escorting the person served from school, staff will meet their students at the designated area outside the library entrance.
6. Staff must account for all persons served
C. Transitioning to and from Lunch
1. Units Attending the Academic Center (in Memorial Cafe):
i. Persons served must report to their assigned room during lunch and learn.
ii. Staff will escort persons served across the street to the cafeteria in a uniform group.
iii. Each group will keep communication and socialization within their own group.
iv. Staff and persons served will look both ways before crossing the street.
v. Each group will report to their assigned lunch room.
vi. Persons served will follow staff instructions regarding the serving of the meal and clean-up of the lunch room.
vii. The group will follow the above procedures when returning to school.
D. Returning from the Vocational School:
1. It is mandatory that after crossing George Junior Road at the crosswalk, a person served should immediately turn right and use the sidewalk in front of Diagnostic I.
2. Staff are to advise the person served that they are not to cut across the AD Parking Lot or use the sidewalk behind Diagnostic I.
3. Persons served are to proceed left on Republic Street to go the Academic Center to await staff escort back to their respective building.
4. When staff members are escorting their group to school in the morning and after lunch, they do not have to follow this route to the Career and Technical Center.
REFERENCECODE: COM- 800-002 - GJRPA
TITLE: School Attendance Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-800-002-GJRPA - School Attendance Procedure
All persons served are required to be in school every day. Persons served will not be excused from school except for the following reasons: medical appointments, emergency leave off campus, team meetings, court hearings or any conflicts due to religious beliefs. Staff must call the school if a person served will not be in attendance.
The School has an Attendance Secretary at extension 3704. The Secretary should be contacted regarding any attendance issue (i.e., team meetings, teleconferences, student absentees, students late to school, , etc.) The Secretary should be contacted about attendance issues at school without exception. The Attendance Secretary at the Vocational School can be reached at ext. 3900.
The inability of a person served to attend school due to illness will be determined by a nurse on duty. A person served whose illness does not incapacitate them may do school work in their room. .
If a person served is emotionally upset and/or has had a behavioral problem prior to leaving for school and staff feel that it will interfere with the educational process, staff are permitted to hold the person served back from school. It is the staff’s responsibility to notify the school before the time that the person served would be expected to arrive for class. The Campus Director of the person served also needs to be notified in this case.
A person served who misses school due to illness will be restricted from activities for the remainder of the day.
Staff must notify Health Services of the illness.
REFERENCECODE: COM- 800-003 - GJRPA
TITLE: Prohibited Items in School Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 8/3/2020
COM-800-003-GJRPA - Prohibited Items in School Procedure
Problems arise when persons served bring articles which are hazardous to the safety of others or interfere in some way with school procedures. Such items, if brought to school, will be confiscated and will be returned to their residence upon request. The following items are not permitted at SCHOOL:
A. Radios, tape recorders, CD/DVD players, MP3 players, any entertainment devices, cell phones, pagers, two-way radios or other communication devices.
B. CDs, DVDs and computer discs
C. Trading Cards
D. All food items including seeds and gum
E. Dice, playing cards, balls or any types of games
F. Toothpicks
G. All bags including paper bags, plastic bags, book bags, etc.
H. Magazines that are not educational in nature
I. Money
J. Non-essential clothing
K. All other items deemed prohibited by the school
REFERENCECODE: COM- 800-004 - GJRPA
TITLE: Being Prepared for School Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-800-004-GJRPA - Being Prepared for School Procedure
All persons served must be prepared for school when they leave their residence. Within units that do not attend school at the Maurice J. Cohill Academic Center, persons served must be prepared when they enter the classroom in the morning.
A. Persons served must be dressed properly and have all necessary items for school.
B. Persons served are to bring only educationally necessary materials to school such as text books, notebooks, and assignments.
C. Persons served must go directly to their class.
REFERENCECODE: COM- 800-005 - GJRPA
TITLE: Student School Card Procedure
APPROVEDBY: GJR Administrators
DATEAPPROVED: 8/3/2020
DATEREVISED: 10/19/2023
COM-800-005-GJRPA - Student School Card Procedure
The school card is a system to provide teachers with a tool to communicate student behavior and grades to the staff at their cottage/unit of residence. The person served is responsible for the school card.
If the person served loses the school card, they can obtain a replacement card at school.
The person served is responsible to have the school card signed by their teacher. Teachers are not permitted to sign cards after the person served leaves the classroom.