Programming Services (PS) - PAC 2026-06-17

Policies and Procedures Programming Services (PS) Preventative Aftercare as of June 17, 2026

Table of Contents PROGRAMMING SERVICES (PS) SECTION 100 - ADMISSIONS ........................................ 4 PS-100-PAC – Admissions Screening and Access to Services Policy ..............................................................................5 PS-100-001-PAC – Limited English Proficiency Procedure ..............................................................................6 PS-100-002-PAC – Admissions Screening and Access to Services Procedure .................................................7 PS-100-003-PAC – MMP Admissions Screening and Access to Services Procedure ........................................9 PS-100-004-PAC - FBMH Admissions Screening and Access to Services Procedure .....................................11 PS-101-PAC – Protected Health Information Policy ....................................................................................................13 PS-101-001-PAC – Protected Health Information Procedure ........................................................................14 PS-101-002-PAC - Disclosure of Information Procedure ...............................................................................15 PS-101-003-PAC – Media Consent Procedure ...............................................................................................18 PS-101-004-PAC – Records Request Procedure ............................................................................................19 PS-101-005-PAC – Breach Notification Procedure ........................................................................................20 PS-102-PAC - Assessment of Clients Policy ..................................................................................................................21 PS-104-PAC - Non-Discrimination of Admissions Policy ..............................................................................................22

PROGRAMMING SERVICES (PS) SECTION 200 – TREATMENT AND INTERVENTION ..... 23 PS-200-PAC - Clinical Treatment Policy .......................................................................................................................24 PS-200-001-PAC – Programming & Client Services Procedure......................................................................25 PS-200-002-PAC – Assessment Procedure ....................................................................................................27 PS-200-003-PAC –Clinical Services Procedure ...............................................................................................29 PS-200-004-PAC – Clinical Services Access Procedure ..................................................................................33 PS-200-005-PAC – Collaboration of Clinical Services Procedure ...................................................................34 PS-200-006-PAC – MMP Psychiatric Consultation Procedure .......................................................................35 PS-200-007-PAC –Mental Health Commitment Process Procedure..............................................................36 PS-204-PAC - Discharge Planning Policy ......................................................................................................................37 PS-204-001-PAC – Continuity of Care and Discharge Planning Procedure....................................................38 PS-205-PAC - Clinical Documentation Policy ...............................................................................................................40 PS-205-001-PAC - Documentation Procedure ...............................................................................................41 PS-205-002-PAC – Individualized Service Plan Procedure .............................................................................43 PS-205-003-PAC – Individualized Service Plan Appeal Procedure.................................................................45 PS-206-PAC – Treatment Coverage Policy ...................................................................................................................46 PS-206-001-PAC – Treatment Coverage Procedures .....................................................................................47 PS-209-PAC - Rights of Persons Served Policy .............................................................................................................48 PS-209-001-PAC – Rights of Persons Served Procedure ................................................................................49 PS-210-PAC - Grievances and Complaints Policy .........................................................................................................51 PS-210-001-PAC - Grievance Procedure ........................................................................................................52 PS-211-PAC Safety Policy .............................................................................................................................................54 PS-211-001-PAC - Safety Procedure ..............................................................................................................55 PS-216-PAC - Sexual Abuse & Harassment Policy ........................................................................................................57 PS-216-001-PAC - Sexual Abuse & Harassment Procedure ...........................................................................58 PS-217-PAC - Safety Plan Policy ...................................................................................................................................59 PS-217-001-PAC – Safety Plan General Guidelines Procedure ......................................................................60 PS-222-PAC – Prohibited Treatment Techniques Policy ................................................................................61 PS-222-001-PAC – Prohibited Treatment Techniques Procedure .................................................................62 PS-224-PAC – Reportable and Recordable Incidents Policy ........................................................................................63

2|Page

June 17, 2026

PS-224-001-PAC – Critical Incidents Procedure.............................................................................................64 PS-224-002-PAC - Critical Incidents of Child Abuse and Neglect Procedure .................................................66 PS-224-003-PAC – Critical Incidents of Seniors and Adults with Disabilities Abuse and Neglect Procedure 68 PS-225-PAC – Suicide Precautions Policy .....................................................................................................................70 PS-225-001-PAC - Suicide Precautions and Response Procedure .................................................................71

Contractual agreements may override policies and portions of procedures.

3|Page

June 17, 2026

PROGRAMMING SERVICES (PS) Section 100 - Admissions

4|Page

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS - 100 - PAC Admissions Screening and Access to Services Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-100-PAC – Admissions Screening and Access to Services Policy It is the policy of Preventative Aftercare, Inc. (PAC) to provide equal opportunity for all clients referred to receive treatment based upon a thorough review and evaluation of current and historical documentation in conjunction with the defined program criteria. The purpose is to determine the suitability of services offered to clients referred. All eligibility decisions are finalized by the identified supervisor/program manager/program director. PAC reserves the right to deny services to clients/families for whom its services are not clinically appropriate or whose needs exceed the capabilities of its programming.

5|Page

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 100-001- PAC Limited English Proficiency Procedure GJR Administrators 03/12/2026 06/17/2026

PS-100-001-PAC – Limited English Proficiency Procedure A. PAC will take responsible steps to ensure that persons with Limited English Proficiency have meaningful access and an equal opportunity to participate in our services.

B. Any client or family member displaying an inability or limited ability to speak, read, write or understand English will be identified as having Limited English Proficiency.

C. Under the guidelines of the Title VI Civil Rights Act of 1964, reasonable accommodations for language requirements of Limited English Proficiency individuals shall be made by providing: 1. Oral language interpretation free of charge 2. Translation of written materials free of charge 3. Notice to individuals with Limited English Proficiency of their right to language assistance and the availability of such assistance free of charge D. PAC will then: 1. Obtain a qualified interpreter 2. Provide written translations of materials and information 3. Provide notice to Limited English Proficiency persons 4. Monitor language needs and implementation E. PAC maintains a relationship with a translation service provider that is available on an as needed basis.

6|Page

June 17, 2026

REFERENCE CODE:

PS- 100-002- PAC Admissions Screening and Access to Services Procedure APPROVED BY: GJR Administrators APPROVED DATE: 03/12/2026 EFFECTIVE DATE: 06/17/2026 TITLE:

PS-100-002-PAC – Admissions Screening and Access to Services Procedure A. Supervisors will be available to all potential referral sources to educate and provide information regarding treatment services and programming.

B. Referrals will be received by the supervisor from contracting counties.

C. Information requested from the referring party is to include referral form with demographic information of the referred to include contact information for the parent or legal guardian, as applicable.

D. For all referrals, including new and re-referrals, current and historical material is reviewed and when applicable, missing or supplemental documentation is requested. When possible, all material is reviewed within 3 business days to accommodate and promote accessibility to services.

E. Referral information will be located in the Electronic Health Record to include the following: 1. All information received and reviewed 2. Documentation of verbal information received in discussion with the referral source 3. Identification of program eligibility or reason for ineligibility a. Once all referral information is reviewed, the supervisor makes determination of admission utilizing the criteria as defined.

1. Eligible Referrals: b. have emotional, social, or behavioral problems c. be of age based on individual county contract (eg., some county contracts limit the ages of clients who can be served) d. approved for services based on county contract (eg., approval from Children, Youth, & Families services, Office of Juvenile Probation, or county school/ school district/school contract) 2. Ineligible Referrals Procedure: a. Any referring source whose person referred is not eligible for treatment at PAC will receive written communication (eg., letter, email) stating ineligibility with the identified reason(s). b. Ineligible referrals will be documented in the electronic health record with the referral form(s), reason(s) for ineligibility, and copy of written communication with referral source reviewing reason for ineligibility. c. When possible, alternative recommendations will be made for referrals who are not eligible for treatment in PAC. 7|Page

June 17, 2026

d. All referrals considered not eligible for services may be re-referred at any time and the procedure for referral will begin again.

8|Page

June 17, 2026

REFERENCE CODE:

PS- 100-003- PAC MMP Admissions Screening and Access to Services Procedure APPROVED BY: GJR Administrators APPROVED DATE: 03/12/2026 EFFECTIVE DATE: 06/17/2026 TITLE:

PS-100-003-PAC – MMP Admissions Screening and Access to Services Procedure A. Mobile Medication Program Manager will be available to all potential referral sources to educate and provide information regarding treatment services and programming.

B. Referrals will be received by the Program Manager from contracting counties and the managed care provider.

C. Information requested from the referring party is to include psychiatric evaluation, current medication list, and Mobile Medication Program (MMP) referral form.

D. For all referrals, including new and re-referrals, current and historical material is reviewed and when applicable, missing or supplemental documentation is requested. When possible, all material is reviewed within 3 business days to accommodate and promote accessibility to services.

E. Referral information will be located in the MMP Electronic Health Record to include the following: 1. All information received and reviewed 2. Documentation of verbal information received in discussion with the referral source 3. Identification of program eligibility or reason for ineligibility F. Once all referral information is reviewed, Program Manager makes determination of admission utilizing the criteria as defined.

1. Eligible Referrals: a. Be at least 18 years of age or older b. Have a primary diagnosis of a serious mental illness. c. Need a community delivered psychiatric medication management services to prevent the need for more intensive levels of care. d. Must meet one of the following criteria i.

Receiving case management or other ambulatory services ii.

Currently admitted or previously admitted to an inpatient placement due to non-adherence or inconsistent adherence to the prescribed medication regimen. iii.

Recently initiated or revived complex medication regimen iv.

Medical diagnosis that requires coordination of physical and behavioral health care, including medication management.

2. Ineligible Referrals Procedure:

9|Page

June 17, 2026

a. Any referring source whose person referred is not eligible for MMP treatment will receive written communication (eg., letter, email) stating ineligibility with the identified reason(s). b. Ineligible referrals will be documented in the electronic health record with the referral form(s), reason(s) for ineligibility, and copy of written communication with referral source reviewing reason for ineligibility. c. When possible, alternative recommendations will be made for referrals who are not eligible for treatment in MMP. d. All referrals considered not eligible for services may be re-referred at any time and the procedure for referral will begin again.

10 | P a g e

June 17, 2026

PS- 100-004- PAC FBMH Admissions Screening and Access to Services Procedure APPROVED BY: GJR Administrators APPROVED DATE: 03/12/2026 EFFECTIVE DATE: 06/17/2026

REFERENCE CODE: TITLE:

PS-100-004-PAC - FBMH Admissions Screening and Access to Services Procedure A. Family Based Mental Health (FBMH) Program Director will be available to all potential referral sources to educate and provide information regarding treatment services and programming.

B. Referrals will be received by the Program Director from contracting counties and the managed care (MCO) provider.

C. Information requested from the referring party is to include a referral form and current psychiatric/psychological evaluation (within past 60 days) in which the psychiatrist/psychologist recommends Family Based Mental Health services.

D. For all referrals, including new and re-referrals, current and historical material is reviewed and when applicable, missing or supplemental documentation is requested. When possible, all material is reviewed within 24 business hours to accommodate and promote accessibility to services.

E. Referral information will be located in the Electronic Health Record to include the following: 1. All information received and reviewed 2. Information received in discussion with the referral source 3. Identification of program eligibility or reason for ineligibility F. Once all referral information is reviewed, Program Director makes determination of admission utilizing the criteria as defined.

1. Eligible Referrals: a. Client is under 21 years of age. b. Client has a serious mental illness or emotional disturbance c. Client is determined to be at high risk for out-of-home placement. d. Client requires a step-down to return home following an out-of-home placement. e. Client requires emergency availability of services. f. Client or family is involved with multiple systems g. Client is returning home to their families from a residential setting. h. One adult member of the family agrees to actively participate in the Family Based Mental Health Service. i. At least one parent must have the cognitive ability to learn new skills related to addressing the behavioral health needs of their child that has a serious emotional 11 | P a g e

June 17, 2026

disturbance. j. Client and/or parent/legal guardian will voluntarily consent to treatment. If client is under 14 years of age, the parent or legal guardian will provide written consent. If client is over 14 years of age, he/she will provide written consent to participate in services. However, in the instance of minor refusing to consent, the parent or legal guardian can provide written consent without the consent of minor.

2. Ineligible Referrals Procedure: a. Client is involved in different services, which cannot be conducted in conjunction with Family Based Mental Health Services such as treatment-oriented residential facility, detention center or shelter care. Although, for those clients anticipating discharge, services may be initiated 30 days prior to the date of discharge. b. During client assessment if a need for specialized treatment (i.e., trauma, SUD, etc.) is identified, the clinical determination will be reviewed with the County Mental Health(MH)/Intellectual Disability (ID) and/or MCO for appropriateness to receive specialized treatment in addition to FBMH. c. Client does not have a parent or adult willing to participate in the service.

G. Clients receiving the following ongoing services may continue during treatment with the FB team: 1. Intensive case management 2. Psychiatric partial hospitalization

12 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 101 - PAC Protected Health Information Policy GJR Board of Directors 6/17/2026 6/17/2026

PS-101-PAC – Protected Health Information Policy It is the policy of PAC to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the main Federal law that protects health information.

13 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 101-001- PAC Protected Health Information Procedure GJR Administrators 3/12/2026 6/17/2026

PS-101-001-PAC – Protected Health Information Procedure PAC staff are to adhere to the HIPAA Privacy and Security Rules protecting the privacy and security of individually identifiable health information, including behavioral and mental health, for all current and former clients. This includes protected health information (PHI) in any medium including electronic protected health information (ePHI).

A. The types of information staff should protect and keep secure include: 1. The individual’s past, present, or future physical or mental health condition.

2. The provision of health care to the individual.

3. The past, present, or future payment for the provision of health care to the individual.

4. Individually identifiable health information that identifies the individual including if there is a reasonable basis to believe it can be used to identify the individual.

B. Staff should use the Safe Harbor Method (removing 18 identifiers) for de-identifying client information and encryption for emails that include PHI. C. Client information should be maintained on secure GJR approved electronic devices (phones, computers) and physical security measures such as locks used when transporting client PHI not secured on electronic devices (paper documents).

14 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 101 - 002 - PAC Disclosure of Information Procedure GJR Administrators 3/12/2026 6/17/2026

PS-101-002-PAC - Disclosure of Information Procedure PAC complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the main Federal law that protects health information, by only releasing or disclosing client information under the following procedure: A. Disclosures with written consent 1. All clients are to be provided the “Client Handbook” which includes “Consent for Use/or Disclosure of Health Information to Carry Out Treatment, Payment, and Health Care Operations” and “Notice of Privacy Practices” and reviewed at intake outlining the types of disclosures that may occur as well as limits. After reviewing the Handbook, clients should sign the accompanying Consent form, which will be saved in the electronic health record. Staff should document all unsuccessful attempts to obtain signature(s) on the consent and in the electronic health record.

2. PAC uses a legal release of information form to document client consent to disclose information. PAC does not accept releases from other organizations unless they have been approved by George Junior Republic’s (GJR) Compliance Department.

3. Direct service staff are expected to review and complete releases with clients during intake.

At a minimum, all clients should sign releases of information for the referral source.

Additional releases are to be done throughout the course of services as needed.

4. Each client (such as each child, parent, or person in a family) should have separate releases on file to be valid. State laws vary on the legal age at which a minor may consent to treatment without parental consent. In these situations, a legal minor’s Protected Health Information (PHI) is not allowed to be shared with the parent/guardian without the minor’s consent.

5. For clients refusing to sign certain releases, staff should promptly review the situation and barriers with their supervisor as ongoing participation in services may be contingent on valid consents to treatment and releases on file.

6. If a client is preparing for discharge and anticipates needing records or other items released in the next year, staff may complete new releases with the client to be dated for no more than one year following discharge.

7. The following procedures will be adhered to when disclosing information of clients: a. All consents or releases of information will be in writing and include the following: i.

Name, address, and date of birth for the client ii.

Name of the person, agency, and/or organization receiving information iii.

Specific information to be released iv.

Purpose for disclosure v.

Date and signature of the client vi.

Date and signature of the witness vii.

Date, event, and condition(s) under which the consent will expire 15 | P a g e

June 17, 2026

b. Releases that are not completed in their entirety are not considered valid. c. Subpoenas and court orders may or may not allow PAC staff to release information without a valid release on file. These documents should be reviewed with a supervisor prior to any testimony being offered. d. Under the Minimum Necessary Rule, routine and reoccurring disclosures of PHI should be limited to the minimum information necessary to accomplish the intended purpose even with releases on file. For example, an appointment scheduler only needs the client’s name and phone number, not a diagnosis. e. The Omnibus Rule clarified that the death of an individual does not cause PHI to be unprotected. PHI is protected 50 years after death. f. Court Appointed Special Advocate (CASA) and Guardian Ad Litem (GAL) court orders only pertain to PAC information as it relates to minor children listed in their orders. Because much of the case information contains parent or other adult information, staff should not disclose without first ensuring a valid release is on file or the information shared does not relate to anyone besides the minor child(ren). Reports and case file contents cannot be provided to CASA/GAL by PAC staff. Information may only be released by the GJR Compliance Department. g. Placements (relatives, foster, and others) are often involved in treatment or services and should be considered as clients that would need valid releases if intervention is occurring. Placements are also not entitled to adult client information without valid releases on file. Placements should be communicated with regarding children in their care and any factors related to ensuring the children’s well-being.

B. Disclosures with oral consent 1. Oral consent, or consent given verbally without a written signature, is temporary permission given by a client when written authorization is not able to be done.

2. Two witnesses are required for oral consent. Additionally, documentation of oral consent should be documented in client’s service notes.

3. After oral consent and at the next in person session, PAC staff should obtain a written release and client signature.

C. Informal consent 1. To make disclosures to family and friends involved in the individual’s care or for notification purposes, or to other persons whom the individual identifies, you must obtain informal (or formal written) permission by asking the individual outright, or by determining that the individual did not object in circumstances that clearly gave the individual the opportunity to agree, acquiesce, or object.

2. For example, if a client begins discussing health information while family or friends are present in the family home, referring agency office, court room, etc. this is a “circumstance that clearly gave the individual the opportunity to agree, acquiesce, or object.”

D. Disclosures without consent 1. Disclosures without consent are allowable: a. Pertaining to the immediate threat to health or safety of any individual. Examples may include abuse, neglect, suicidal or homicidal clients. b. To law enforcement if the information is needed to identify or apprehend an escapee or violent criminal. However, not all disclosures to law enforcement are protected under the law and the GJR Compliance Director may need consulted. c. Other examples of disclosures without consent are outlined in the Handbook to be provided and reviewed with all clients at intake.

2. The following procedures will be implemented when consent is not required: 16 | P a g e

June 17, 2026

a. Document the disclosure completely in the record of the client. b. Inform the client of the disclosure, including information disclosed, purpose of disclosure, and to whom it was disclosed, as soon as possible.

17 | P a g e

June 17, 2026

i.

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 101-003 - PAC Media Consent Procedure GJR Administrators 3/12/2026 6/17/2026

PS-101-003-PAC – Media Consent Procedure Prior to a client’s personal information being used on behalf of PAC and shared with the public, permission from the county or other stakeholders per individual contract must be obtained and the GJR Media & Photography Consent Form must be signed by the client/legal guardian and put in the electronic health record of the client. This allows consent for the use of a client’s information for such purposes as the organization’s press releases, newsletters, photography, videos (including voices), recordings, fundraising materials, “broadcasts” or other information dissemination provided on television, radio, computers, phones, social media, blogs, podcasts, mobile devices or apps, the PAC website, other websites or online services, and other existing or future ways to release information.

18 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 101 - 004 - PAC Records Request Procedure GJR Administrators 3/12/2026 6/17/2026

PS-101-004-PAC – Records Request Procedure Any client record requests outside of the referral source are coordinated through the GJR Compliance Department who is responsible for sharing/releasing records on current & prior clients. Additionally, the GJR Compliance Department keeps a log of these disclosures and helps obtain updated releases when needed. Examples of records release may include file subpoena requests, disability file information requests, Court Appointed Special Advocate (CASA)/attorney record requests. PAC staff should follow the outlined procedure when records are requested for release.

A. Staff receive a written notification of a request for release of client records.

B. Staff forward the written request to the GJR Compliance Department and their supervisor for review.

C. If the request is denied, the GJR Compliance Department or supervisor contacts the requestor and advises the records will not be released.

D. If the request is acceptable and approved, the GJR Compliance Department proceeds with the following steps: 1. Checks for a valid release in the client file and works to obtain a release when one is absent.

2. Reviews the client record, redacting any information not applicable, and prepares the content for release.

3. Logs the date, purpose, entity disclosed to, and content released.

19 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 101 - 005 - PAC Breach Notification Procedure GJR Administrators 3/12/2026 6/17/2026

PS-101-005-PAC – Breach Notification Procedure A HIPAA breach is when protected health information has been or is suspected of having been shared without valid release of information or outside the allowable disclosures without consent. Breaches may occur through a variety of situations (accident, staff error, ransomware attack) and should be reported immediately to assist in containment and lessen liability.

The following procedure should be followed when a HIPAA breach is suspected or has occurred: A. Immediately contact the Regional Director who will inform the PAC Director.

B. The PAC Director will notify and keep updated the GJR Risk Director who assists in guidance on difficult situations and must keep a log of all action steps and breaches.

C. The GJR Risk Director will advise based on the scope of the breach on additional notification measures that may need implemented to comply with HIPAA laws.

20 | P a g e

June 17, 2026

REFERENCE CODE:

PS- 102 - PAC Assessment of Clients Policy APPROVED BY: GJR Board of Directors APPROVED DATE: 06/17/2026 EFFECTIVE DATE: 06/17/2026 TITLE:

PS-102-PAC - Assessment of Clients Policy It is the policy of PAC to complete a standard assessment of all clients following admission in order to develop individualized treatment, safety, and transition plans.

21 | P a g e

June 17, 2026

REFERENCE CODE:

PS- 104 - PAC Non-Discrimination of Admissions Policy APPROVED BY: GJR Board of Directors APPROVED DATE: 06/17/2026 EFFECTIVE DATE: 06/17/2026 TITLE:

PS-104-PAC - Non-Discrimination of Admissions Policy It is the policy of George Junior Republic Preventative Aftercare to admit persons served based on admission criteria without regard to race, color, sexual orientation/identity/expression, religious beliefs, national origin, ancestry, or physical disability.

22 | P a g e

June 17, 2026

PROGRAMMING SERVICES (PS) Section 200 – Treatment and Intervention

23 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200 - PAC Clinical Treatment Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-200-PAC - Clinical Treatment Policy It is the policy of PAC to provide clinical services to clients with behavioral and/or mental health issues.

Treatment will not be denied on the basis of age, gender identity, race, religion, ethnic origin, economic status, sexual orientation, identity, or physical disability. Treatment is designed to assist clients and their support systems in addressing behavioral and/or mental health issues, and to support an environment conducive to the overall stabilization of individual functioning.

24 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200-001 - PAC Programming & Client Services Procedure GJR Administrators 3/12/2026 6/17/2026

PS-200-001-PAC – Programming & Client Services Procedure A. Programming in PAC is designed to be: 1. Collaborative: Services are developed with the client, the family/legal guardians (when applicable), and the referring agency. Treatment of PAC clients allows all members of the client’s treatment team to be included.

2. Culturally Competent & Accommodating: Clients maintain their personal choice regarding the practice of their culture within the course of participating in services. Should such practices conflict with law, infringe upon the rights of others, or jeopardize the safety and emotional wellbeing of other individuals, staff will work with the client to resolve the dilemma.

3. Trauma-Informed: The services will be delivered in such a way that the clients/families feel respected, informed, connected, and hopeful regarding their own future. Staff must demonstrate an understanding, through the services provided, of the interrelation between trauma and symptoms of trauma.

4. Evidence-Based: Whenever possible, staff are to use evidence-based, promising practices, and models with fidelity measures to support the highest level of client care and positive outcomes.

5. Ethical: All employees, services, and programs shall comply with their respective ethical codes, to include American Counseling Association Code of Ethics, National Association of Social Workers (NASW) Code of Ethics, and the American Nurses Association Code of Ethics. These respective Code of Ethics are a set of standards that guide professional conduct.

B. When starting services with PAC, clients will be provided with information specific to the program for which they have been referred, including a review of risk factors and expectations of the treatment or services.

C. Discharge planning will begin for all clients at the time of intake and in preparation for discharge from PAC. D. When PAC staff are providing services to clients within their home setting, it is important to show respect to the family within that environment. Additionally, being present in client homes can create an environment where boundaries are blurry, additional safety issues arise, and service delivery is different than an office setting. The following procedures apply to any staff members when servicing clients in their homes: a. Remember, staff are a GUEST in client homes at all times, even if there is a court order for services. Model respect. b. Be on time, consistently. If staff has to be late, call or text the client. c. Stay for the entire length of time staff have informed the client staff plan to work with them. d. Put staff phone(s) on silent or vibrate when working with families; do NOT answer the phone when working with a client unless it is to take a crisis call or handle an emergency. e. Schedule with clients in advance. f. Only cancel home visits due to illness or emergencies, per approval of your supervisor. g. Do NOT use foul language or engage in arguments with clients.

25 | P a g e

June 17, 2026

h. Feedback is best given in the moment. It is essential to be transparent (yet empathetic) when addressing concerns. i. Have an agenda the client has agreed to for each session. The client should know at the end of each session what will be addressed in the next.

26 | P a g e

June 17, 2026

REFERENCE CODE:

PS- 200-002 - PAC Assessment Procedure APPROVED BY: GJR Administrators APPROVED DATE: 3/12/2026 EFFECTIVE DATE: 6/17/2026 TITLE:

PS-200-002-PAC – Assessment Procedure The initial assessment is the document that pulls together the clinical history of the client along with interviews of the client, family and supporting agencies/stakeholders, as indicated. It results in a comprehensive bio-psychosocial summary, which is the foundation for the initial Individualized Service Plan (ISP).

The first meeting with the client will be an assessment and treatment planning session in which PAC staff document the presenting problems and includes the information listed below: A. B. C. D. E. F. G. H.

Identifying information Family composition Educational/vocational history including last school attended Legal history Sexual history Spiritual history and religion of choice Community and social history Medical history and developmental milestones a. For Family Based Mental Health services, the medical history of the child or adolescent shall include a copy of the current physical examination, which conforms to the EPSDT Program periodicity schedule. b. For the MMP, this would include history of medication order, use and efficacy of previously trialed therapies. Side effects, issue obtaining medications, etc.

I. Comprehensive Substance Use (including use of alcohol, tobacco/nicotine, illicit drugs, and prescription/OTC drugs) history and treatment to include all prior treatment, drugs used, age of first use, frequency of use, and date of last use.

J. History of trauma and injuries including emotional trauma and physical injuries K. Prior service and intervention history including mental health and drug and alcohol treatment, placements, and outpatient services for clients and their families L. Mental Status Evaluation (MSE) of the client’s affect, speech, mood, thought content, judgment, insight, attention and concentration, memory, and impulse control M. Strengths which will assist the client in their treatment, discharge, and aftercare planning N. Concerns of the client which must be considered during treatment and discharge planning O. A discussion of the support system of the client P. Presenting problems Q. Barriers to treatment R. Projected discharge plan 27 | P a g e

June 17, 2026

The treatment goals will be developed by PAC staff, clients, family, and other treatment team members.

These goals will be the foundation of the initial treatment plan.

The procedures below shall be followed for assessments and will be included in the client electronic health record: 1. PAC staff must document observations, tests administered, and family & collateral contacts in service notes. The interpretive data from questionnaires/assessments/measures will be included in the Individual Service Plan.

2. All assessment documents required by individual county or program contract.

3. In addition to the formal assessment, ongoing assessment of client need and progress will be documented in session service notes and summarized in the monthly review in the Individualized Service Plan.

4. All assessments must include recommendations regarding services/treatment for the benefit of the client/family.

5. The written assessment must be prepared using the GJR template and be completed within 14 days of the initial intake session.

6. All follow up (e.g., contacts related to the assessment, court testimony, school collaboration, etc.) must be documented.

28 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200-003- GJRPA Clinical Services Procedure GJR Administrators 03/12/2026 06/17/2026

PS-200-003-PAC –Clinical Services Procedure A. Clinical Assignments 1. Supervisors/program manager/program director will receive referrals and review to ensure all required information is present, based on county or program contract. The supervisor/program manager/program director will coordinate with referral sources for missing information. All referral information is to be documented in the electronic health record.

2. The supervisor/program manager/program director will assign clients to PAC staff.

3. Family Based Mental Health (FBMH) services: a. Because of the intense nature of the program, it is expected that services will begin within 24 hours of acceptance in to the program. b. Clients and their families will be assigned to a team upon their admission to FBMH services.

4. Mobile Medication Program (MMP) services: a. Within 24 hours of receiving a completed referral to the Mobile Med program, clients will be assigned to a Mobile Med nurse B. Beginning Treatment 1. PAC staff will initiate first contact with the client/family within 24 business hours of receiving the assignment from their supervisor. a. A minimum of three weekly contacts on different days and different times of day for the first week. b. If no contact within the first week: i.

PAC staff to collaborate with the referral source and confirm contact information on the referral form is correct. ii.

PAC staff to mail cannot reach letter to the client/family with a day/time staff will be at the home to conduct the intake for services. Included in the letter will be the staff person name and number for the client/family to call if the identified day/time does not work for the client/family. c. PAC staff to document all contacts in the client’s electronic health record, to include phone calls to the client/family, phone/emails to the referral source, and letter to the client/family 2. PAC staff will conduct a face-to-face intake with the client/family within 5 business days of initial contact with the client/family.

3. At the initial appointment, the client and PAC staff will a. Discuss informed consent b. Provide client/family with a copy of the “Client Handbook” and review the contents which include: i.

PAC Services ii.

PAC Team 29 | P a g e

June 17, 2026

iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi. xvii. xviii. xix. xx. xxi.

Treatment Team Home Sessions Consistent Attendance Planned and Unplanned Cancellations Inclement Weather Hours of Operation Referral Process Fees/Authorizations Continuing Stay/Discharge Criteria Safety Planning Consent on Mandated Reporting Emergency Medical Plan Client Rights Code of Ethics Grievance Procedure Consent for Recording for the Purpose of Treatment Integrity Consent for Email and Text Messaging Data Collection Consent for Use and/or Disclosure of Health Information to Carry Out Treatment, Payment, and Health Care Operations xxii.

Non-Discrimination Policy xxiii.

Cultural Competency xxiv.

Notice of Privacy Practices c. Complete releases of information d. Complete a comprehensive bio-psychosocial assessment in the electronic health record, highlighting the strengths, needs, abilities, and preferences of the client. e. Discuss goals for treatment planning.

4. For the Family Based Mental Health Services program: a. The initial treatment plan will be reviewed and approved by the program director within 5 days of the initial service 5. Within 30 days of admission, the client/family and PAC staff will review the initial Individualized Service Plan (ISP), to include: a. Clients/family will participate in treatment planning. b. The ISP will be client/family driven and recovery focused. c. Client treatment team members may participate in planning with client consent. d. Client referral information and assessment will be used to identify goals and objectives that may include medical, psychological, social, cultural, behavioral, legal, familial, educational, vocational, and developmental strengths and needs. e. The ISP goals will be statements that show what the client wants to accomplish in treatment. f. The ISP shall also establish specific goals for each family member who is participating in treatment. g. The ISP objectives will be Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART). h. The ISP will be written in a language that the client can understand. i. ISPs will be reviewed and signed by clients (as is age and functionally appropriate) and participating family members.

C. Frequency of Treatment 30 | P a g e

June 17, 2026

D.

E.

F.

G.

1. Clients referred to Intensive, Truancy, Prison Visitation, and Family Based Mental Health programs will receive a minimum of one individual and one family or parent session per week.

2. Clients referred to Mobile Medication program will receive at least one session per week.

3. Clients/families in the Family Based Mental Health program will have a minimum of three contacts per week.

4. Frequency of treatment is detailed in the ISP with minimum requirements based on program/service description along with increased frequency based on clinical assessment and client/family need.

Individual Counseling (clients in Intensive, Truancy, Prison Visitation, and Family Based Mental Health programs) 1. PAC staff will engage clients/families during each session in various modalities (with preference of evidence based or promising treatment) in an effort to work on treatment goals of the client/family. PAC staff will assess each session if the client/family is responding to the therapeutic modality used. If there is limited or no response, PAC staff will make appropriate clinical decisions on continuing the intervention or switching to something new. a. Bachelor’s level Mental Health Workers will review with their supervisor 2. Each time counseling is provided a. An Encounter Form is signed by the client (14 years of age or older) or an adult in the setting where services were provided (home, school) on the day of the service. b. Telehealth phone or telehealth zoom sessions require that the client (14 years of age or older) or adult provide verbal agreement to certify that services were received on the date and at the time indicated on the Encounter Form. c. A service note will be completed within 48 business hours of the service.

Family Counseling or Parenting (clients in Intensive, Truancy, Prison Visitation, and Family Based Mental Health programs) 1. Family counseling or parenting sessions will occur weekly and occur at times most convenience to the family in a manner that promotes family cohesiveness.

2. Family counseling may include any combination of family members participating in treatment, as clinically warranted and based on the ISP goals. a. Bachelor’s level Mental Health Workers will review with their supervisor 3. Each time counseling is provided a. An Encounter Form is signed by the client (14 years of age or older) or an adult in the setting where services were provided (home, school) on the day of the service. b. Telehealth phone or telehealth zoom sessions require that the client (14 years of age or older) or adult provide verbal agreement to certify that services were received on the date and at the time indicated on the Encounter Form. c. A service note will be completed within 48 business hours for every service.

Mobile Med Clients 1. Each time a service is provided a. An Encounter Form is signed by the client on the day of the service. b. Telehealth phone or telehealth zoom sessions require that the client provide verbal agreement to certify that services were received on the date and at the time indicated on the Encounter Form. c. A service note will be completed within 48 business hours for every service.

Continuous Documentation

31 | P a g e

June 17, 2026

1. Every 30 days, PAC staff, the client/family, and, if applicable, other members of the treatment team, will update and review the treatment goals and the progress that the client/family is making on these treatment goals.

2. Changes to the ISP and the reasons for the changes shall be documented in the record of the client as a service note.

3. After a year of treatment, PAC staff and the client/family will reexamine the consent and releases, and resign.

4. Clients who are admitted to treatment prior to the age of 14 years and turn 14 years of age in the course of treatment: a. PAC staff review consent and releases of information with the client b. Have the client sign (or resign) upon turning 14 years of age and becoming legally able to sign H. Treatment Plan Modifications 1. At any time during the treatment, PAC staff and the client/family can make modifications to the treatment goals and objectives. It is important to review regularly to ensure that treatment is reflective of the needs and progress of the client/family.

2. Goals and objectives can be added or deleted at any time that they are no longer deemed appropriate.

I. Clinical Supervision 1. PAC staff will attend individual supervision with their supervisor at least monthly and more frequently as needed (to be determined by the supervisor or by request of the staff person). a. Bachelor’s level MHW staff will attend bi-monthly supervision with their supervisor and more frequently as needed (to be determined by the supervisor or by the request of the staff person). b. FBMH teams will receive team supervision weekly with the program director.

2. Each PAC staff is expected to attend monthly group supervision with their supervisor and team. a. FBMH teams will receive weekly group supervision with the program director.

3. Supervisors will document each supervision including brief review of topics discussed and plan for action by the supervisor or staff. Supervisor logs are signed by supervisors and staff and are available for review by PAC administrators or HR as needed.

4. Supervision is designed to help with cases, provide ongoing support and training, and allow PAC staff to aid other PAC staff with difficult cases.

32 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200-004 - PAC Clinical Services Access Procedure GJR Administrators 03/12/2026 06/17/2026

PS-200-004-PAC – Clinical Services Access Procedure Clients will have access to clinical services as indicated: A. Emergency Situations: In an emergency, utilize 9-1-1 (a response system for Medical, Fire, or Policy Emergencies) to obtain immediate local support, or contact the National Suicide and Crisis Lifeline by dialing 9-8-8 (for behavioral health crises, crisis counseling, and emotional de-escalation). Clients experiencing emergency situations, such as suicidal thoughts, acting to further suicidal thoughts, or experiencing exacerbation of symptoms or new significant psychiatric symptoms, will have access to PAC staff Monday through Friday 8am – 6pm, and are encouraged to reach out to the county mobile crisis after 6pm on weekdays, on weekends, and on holidays.

1. Family Based Mental Health (FBMH) services are available 24-hours, 7-days-a-week to clients/families, which includes the FBMH crisis on-call phone number staffed 24/7 by FBMH clinicians.

B. Acute/Post-Hospital Follow-up care: In the Mobile Med and FBMH programs, a client will be seen by PAC staff within seven (7) days of release from an acute care hospital setting.

C. For FBMH referrals, a rapid response to need is necessary and services should begin within 24 hours of acceptance into the program.

33 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200-005 - PAC Collaboration of Clinical Services Procedure GJR Administrators 03/12/2026 06/17/2026

PS-200-005-PAC – Collaboration of Clinical Services Procedure Services are developed with the client and other members of their treatment team, which may include family/legal guardian(s), other behavioral/mental health providers, schools, pediatrician/primary care physician, and all other agencies involved in the treatment process. PAC staff are responsible for ensuring, with the appropriate written consent, collaboration and coordination with such entities during the treatment and aftercare processes.

A. During the intake process, PAC staff will obtain the names, addresses, and phone numbers of service providers actively involved in the care of the client. Releases of information to permit collaboration will be requested. The release of information will specify the nature of the information to be obtained or released. Releases of information will be stored in the client’s electronic health record.

B. Communications will be documented in the client’s electronic health record, including written and verbal communication.

C. Clients/families have the right at any time during treatment to withdraw their consent for contact between PAC and other identified providers, both medical and non-medical. This should be done in writing by indicating the date/time consent was revoked and witnessed by a PAC staff member.

34 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200-006 - PAC MMP Psychiatric Consultation Procedure GJR Administrators 03/12/2026 06/17/2026

PS-200-006-PAC – MMP Psychiatric Consultation Procedure A. George Junior Republic employs a full time, board certified psychiatrist, available for consultation to PAC staff for the benefit of their clients.

B. The psychiatric consultation of client clinical cases provides for treatment planning and the clinical oversight of the therapeutic process from admission to discharge.

C. Psychiatric Consultation: 1. Ensures the provision of clinical services offered to persons served is based upon their treatment needs by reviewing the client record (as needed) and during consultation 2. Includes consultation with pharmacy services, primary physician, and/or other treatment team members of the client when needed or warranted.

35 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 200-007 - PAC Mental Health Commitment Process Procedure GJR Administrators 03/12/2026 06/17/2026

PS-200-007-PAC –Mental Health Commitment Process Procedure A. Clients who are in need of emergency examination and treatment, pursuant to Section 302 of the Mental Health Procedures Act, will be referred to: 1. their county mobile crisis, and/or 2. local hospital emergency room B. In the event that a client is referred for an emergency evaluation and treatment, PAC staff may consult with the examining physician and assist in the process as needed.

36 | P a g e

June 17, 2026

REFERENCE CODE:

PS- 204 - PAC Discharge Planning Policy APPROVED BY: GJR Board of Directors APPROVED DATE: 06/17/2026 EFFECTIVE DATE: 06/17/2026 TITLE:

PS-204-PAC - Discharge Planning Policy It is the policy of PAC to begin the discharge process upon admission and continue it throughout treatment in order to collaborate with clients/families to identify and implement an effective discharge plan.

37 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 204-001 - PAC Continuity of Care and Discharge Planning Procedure GJR Administrators 03/12/2026 06/17/2026

PS-204-001-PAC – Continuity of Care and Discharge Planning Procedure It is the responsibility of PAC staff, in conjunction with the treatment team, to begin to develop a discharge plan which includes aftercare services recommended to maintain stability and continue with the recovery process. Discharge criteria must include the outcome measures to be achieved for discharge, and will be included in the Assessment, Individualized Service Plan, and all service plan reviews. The aftercare plan includes specific recommendations to maximize continued personal growth and support in the established treatment areas. Discharge planning is an ongoing process, which is documented in the client’s electronic health record. It must be initiated during PAC staff’ first session with a client.

Discharge Planning: Discharge planning will begin upon admission, as it is considered essential to goal development and treatment planning. The clients and their families, if appropriate, will be educated regarding the importance of discharge and aftercare planning throughout participation in treatment. The criteria to be met by the client for successful completion of treatment will begin to be established at the first session. A projected discharge date will also be established at this time. The discharge plan will be reviewed and updated, as necessary, at each treatment plan review meeting.

A. Clients will be considered discharged from treatment upon meeting one of the following criteria: 1. Successful completion of the treatment goals and objectives, as measured by the outcome specified in the treatment plan 2. Upon mutual consent between the client/family and their treatment team which can include transfer to another level of care 3. Based upon the decision of the client/family alone against treatment team 4. Consistent failure of the client/family to comply with treatment recommendations justifying an Administrative Discharge. An administrative discharge can include the need of a client for a higher level of care.

B. Prior to an administrative discharge, PAC staff must notify the referral source, county representative, and/or behavioral health managed care organization (MCO) involved in the treatment of the client.

The following criteria must be met for an involuntary discharge/termination and/or administrative discharge: 1. The client is in need of more restrictive services as determined by their treatment team and it is no longer in their best interest to be served in a community-based setting.

2. The client has failed to adhere to agency policies which place them and/or PAC at risk.

3. A client/family shall be notified in writing of the PAC team decision to terminate their community-based services. This notification will include a reason for their termination.

38 | P a g e

June 17, 2026

C. PAC staff must document in the last formal service note with a client/family the following: 1. A discussion was held regarding the termination of the therapeutic relationship 2. A description of the behavior and attitude of the client upon discharge 3. A review of the treatment goals, objectives, and outcomes related to the client 4. A review of all follow-up appointments with current or referred providers D. An Agency/Program Discharge document will be completed in the client electronic health record at discharge. Copies will be offered to the client/family, county representative, legal representative, and family supports, if applicable.

E. The Agency/Program Discharge document (otherwise known as the discharge summary) must be completed 5 days after discharge. It is essential that the discharge summary be completed within this time frame for the provision of timely discharge information to aftercare providers. Supervisors may request that the discharge summary be reviewed by the supervisor prior to PAC staff signing.

The discharge summary must include the following: 1. Reasons for referral to treatment 2. Initial and final diagnosis or diagnoses, for MMP and FBMH 3. Services offered and provided 4. Summary of treatment progress or lack thereof 5. Medication information & current prescriber(s), for MMP and FBMH 6. Recommendations for aftercare 7. Special needs of the client 8. Status or condition of client upon discharge 9. Medical and psychosocial problems of client 10. Anticipated problems/concerns for future compliance 11. Primary Care Physician if known Aftercare Planning: Approximately one to two months prior to anticipated discharge, the client/family will discuss aftercare planning with PAC staff and other members of the client’s treatment team (per individual PAC program/service description, as applicable. The aftercare planning meeting will be documented in the client’s electronic health record in a service note. The plan will include the services necessary to maximize continued personal growth and support in the established treatment areas. PAC staff will assist the client and their identified supports (i.e. family, friends, other treatment providers, etc.) in the implementation of the plan.

An Aftercare Plan will be included in the Discharge Summary addressing the following: A. All identified remaining problems of the client B. All discharge follow-up appointments C. A crisis plan Aftercare plans will not be required in cases in which the client has left the program prematurely and/or against treatment team recommendation.

39 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 205 - PAC Clinical Documentation Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-205-PAC - Clinical Documentation Policy It is the policy of PAC that all services delivered to clients are documented for placement in the electronic health record of the client by specific, determined timeframes.

40 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 205-001 - PAC Documentation Procedure GJR Administrators 03/12/2026 06/17/2026

PS-205-001-PAC - Documentation Procedure The following will be completed in the electronic health record by the identified time frames: A. Consent Forms and Releases of Information will be completed during the first session held with the client/family in the electronic health record. a. In the event there is no Wi-Fi in the community setting, paper copies will be uploaded to the electronic health record within 48 business hours of the session. b. Consent Form is to be reviewed and signed by clients (as age and functionally appropriate) and parent/legal guardians for minor clients. i. If signature is not obtained, PAC staff will document on the Consent Form and in the Service Note the reason (i.e., client unable to sign due to age, client refused to sign, etc.).

B. Assessment document in the electronic health record will be completed within 14 days of the first session.

C. Individual Service Plans (ISP) 1. Initial will be completed and signed by client and family within 30 days of the first session.

2. FBMH initial treatment plan will be reviewed and approved by the program director within 5 days of the initial service 3. Monthly ISP will be completed and signed by client/family within two weeks of the due date.

D. Service Notes in the electronic health record will be completed within 48 business hours of the session.

E. Encounter Forms in the electronic health record will be completed on the day of service.

1. Paper Encounter Forms (where there is no wi-fi in the community-based setting) will be signed on the day of the service and uploaded to the electronic health record within 48 hours of the session.

F. Case Management Service Notes, which are non-billable, will be completed at a minimum weekly.

G. In identified programs only, Intensive Case Management Service Notes & Travel Service Notes will be completed within 48 hours of the service.

The following documents will be completed as follows: A. Encounter Forms 1. For each type of billable clinical service, PAC staff will indicate the date, start & end time (only exact times will be used and no rounding of times), and type of clinical service on the electronic health record form. a. In the instance there is no wi-fi in the community-based setting where services occurred, a paper Encounter Form may be used. All expectations for documentation apply to paper Encounter Forms.

41 | P a g e

June 17, 2026

B.

C. D.

E.

F.

G.

2. After PAC staff sign the Encounter Form, the service day, times, and type must be certified via a signature on the Encounter Form by the client 14 years of age or older, or an adult in the setting where services were provided (with appropriate Release of Information).

3. A service note will be completed for each billable clinical service on the encounter form with date, times, and type of service matching exactly.

All documentation (i.e., consent, release of information, encounter forms, service notes, ISPs, etc.) will be completed in the electronic health record (EHR), with signature, credentials, and date of signature of the PAC staff.

The EHR contains templates for each service to be utilized by PAC staff in completing clinical documentation.

Service Notes will include the following: 1. Date of Session 2. Start time of session and end time of session (total time of session; rounding is not permitted and must be exact start/end times to match the times on the Encounter Form) 3. Name of the client 4. PAC staff’s full name and credentials 5. Interventions utilized during a session must be documented on the ISP. The ISP must be updated to reflect new interventions to be utilized prior to being implemented.

6. A data section, which addresses information regarding the client, the goals/objectives, and the general content of the session. PAC staff will document the types of interventions utilized or implemented during the session in this section. Specific techniques from the interventions will be provided. a. For MMP (and other PAC programs as relevant), the data section will include a review of any medical conditions and/or laboratory work present/performed which directly impact upon the provision of services.

7. An assessment section, which is the PAC staff’s clinical interpretation, impression and summary of the behavior; mood; interpersonal functioning; and openness of the client/family to the treatment goals being addressed. PAC staff will include objective measurable criteria from the ISP goals/objectives on the progress or lack of progress of the client/family in this section. The response of the client/family to the interventions/techniques will be clearly stated.

8. A plan section, which includes the specific course of action to be taken with the client/family in the future, any task assigned, and how the task assigned and future sessions will address the treatment goals. PAC staff will address the members of the treatment team to be consulted (if appropriate) prior to the next session and the information to be obtained. If during the session the PAC staff and client/family review goals and objectives, this information must be documented in the data section.

Documents in the electronic health record will be signed and dated by PAC staff and by clients/families. Original signatures on electronic health records must be legible – this includes client/family/other adult signatures.

1. In the case of no wi-fi in the community-based setting, the use of paper records is permitted.

Handwritten entries must be legible.

Errors in paper records must have a single line through the material needing to be changed or corrected, the word “error” or “change,” signature with credentials of the staff, and date of the change. No white-out or correction tape may be used in any part of the permanent record.

Critical Incident Reports will be completed and sent to the supervisor and regional director as soon as possible, but no later than within 24 hours of the incident.

42 | P a g e

June 17, 2026

PS- 205-002 - PAC Individualized Service Plan Procedure APPROVED BY: GJR Administrators APPROVED DATE: 03/12/2026 EFFECTIVE DATE: 06/17/2026

REFERENCE CODE: TITLE:

PS-205-002-PAC – Individualized Service Plan Procedure The Individualized Service Plan (ISP) will be developed and updated as follows: A. All plans must be developed based upon the direct input of the client/family and based upon an evaluation of the skill level (strengths, needs, attitudes, and preferences) and assessed baseline performance capacity of the client/family.

B. Goals will be: 1. statements that show what the client wants to accomplish in treatment.

2. established for each family member who is participating in treatment.

C. Objectives will be Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART).

D. Plans will be written in a language that the client can understand.

E. Specific treatment interventions and expected outcome measures must be clearly identified for each goal.

F. The staff position responsible for the implementation of each intervention will be identified on the plan but must reflect input from the client/family and other treatment team members as indicated.

G. Initial ISP will be 1. Created with the client/family and other treatment team members with client/family consent 2. Client/family driven and recovery focused 3. Reviewed and signed by both client (if age and functionally appropriate) and parent/legal guardians within 30 days of the first session 4. Family Based Mental Health Services program initial treatment plan will be reviewed and approved by the program director within 5 days of the first session H. Pertinent information for the formation and development of the plan must include: 1. Referral information 2. Intake with the client/family 3. Input with the family members, legal guardians, caretakers and/or other providers of the client when possible 4. MMP and FBMH to include diagnostic evaluations such as medical, psychiatric, psychological, educational, vocational or other relevant and available assessments 5. Recommendations made by members of the clinical team I. Activities related to the development and review of the ISP must be documented in the Service Note in the electronic health record each time goals are reviewed.

J. PAC staff will maintain the rights of confidentiality and privacy of the client throughout the treatment planning process.

K. The ISP may be reviewed by the client/family and/or PAC staff any time. Should the goals and objectives be deemed inappropriate and/or unnecessary for any reason, goals may be changed, added, or deleted.

43 | P a g e

June 17, 2026

L. Clients (when age and functionally appropriate), parent/legal guardians, participating family members, and PAC staff will sign all ISP updates, additions, and changes. Clients under age 14 years are encouraged to participate in the ISP process as functionally able to do so.

44 | P a g e

June 17, 2026

PS- 205-003 - PAC Individualized Service Plan Appeal Procedure APPROVED BY: GJR Administrators APPROVED DATE: 03/12/2026 EFFECTIVE DATE: 06/17/2026

REFERENCE CODE: TITLE:

PS-205-003-PAC – Individualized Service Plan Appeal Procedure A. Clients will be encouraged to use this process if they believe the Individualized Service Plan (ISP) does not appropriately address identified needs or is not being implemented in an acceptable manner. All rights of clients will be enforced during any appeal process. If formal objections are raised, it is the responsibility of the supervisor/program manager/program director to ensure that the issues are resolved in a timely manner.

B. The clients will be advised to bring their objections, in writing, to a member of their PAC team whenever possible. The “Youth and Family Grievance Procedure” is reviewed with clients/families at the first session and located in the “Client Handbook” provided to clients/families at the first session.

C. The PAC team member who received the grievance will document the concern(s) in the service note.

The PAC staff will attempt to resolve with the client and/or their family within 48 hours. The outcome of the meeting will be documented in the records of the client.

D. If the complaint cannot be resolved with the PAC staff, the client/family will be scheduled to meet with the Supervisor/Program Manager/Program Director within 48 hours of the meeting with the PAC staff. The Supervisor/Program Manager/Program Director must bring the appeal to resolution within 48 hours of the meeting with the client/family whenever possible. The resolution of the appeal must be documented in the medical record and a copy given to the PAC Director. The outcome will be reviewed with the client/family and PAC staff.

E. If the complaint cannot be resolved at the Supervisor/Program Manager/Program Director level, the client/family will be scheduled to meet with the Regional Director within 48 hours following the meeting with the Supervisor/Program Manager/Program Director. The Regional Director must bring the complaint to resolution within 48 hours of the meeting whenever possible. The resolution must be documented in the medical record. The outcome will be reviewed with the client/family, the Supervisor/Program Manager/Program Director, and PAC staff.

F. If the complaint cannot be resolved at the Regional Director level, the client/family will be scheduled to meet with the PAC Director within 48 hours following the meeting with the Regional Director. The PAC Director must bring the complaint to resolution within 48 hours of the meeting whenever possible. The resolution must be documented in the medical record. The outcome will be reviewed with the client/family, Regional Director, Supervisor/Program Manager/Program Director, and PAC staff.

G. If the concerns are still not resolved, the client/family has the right to appeal to the Department of Human Services.

H. If the concerns cannot be resolved and results in termination of treatment, it will be the responsibility of the PAC staff to refer the client/family for alternative treatment.

I. All documentation regarding any level of appeal must become a part of the permanent treatment record of the client.

J. Clients have the right to have individuals of their choice present with them during any level of the appeal.

45 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 206 - PAC Treatment Coverage Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-206-PAC – Treatment Coverage Policy It is the policy of PAC to provide treatment coverage in those instances when a staff will be unable to perform their duties due to vacation, illness, or other approved leave of absence.

46 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 206-001 - PAC Treatment Coverage Procedures GJR Administrators 03/12/2026 06/17/2026

PS-206-001-PAC – Treatment Coverage Procedures In the event that a PAC staff anticipates that they will off work for one week or more for a planned absence, the following actions steps will be taken: A. Staff will follow the policy and procedures for time off in the Human Resources Policy & Procedure manual.

B. PAC programs who work in teams will not be approved for planned absences of team members on the same days without a plan of coverage for each client/family.

C. The PAC staff and supervisor will meet at least two weeks in advance of the planned absence to discuss client/family needs. Clients who require continued services during the staff absence (for example, those who have been in service less than a month, those experiencing clinical acuity, etc.) will receive clinical services from the supervisor or other identified staff. The staff will prepare the client/family at least two weeks before the planned absence including a discussion of what the client/family prefers in terms of coverage and support by the supervisor or another staff. All plans for coverage will be documented in the client’s electronic health record. Clients/families will be given the supervisor name and phone number for use during the scheduled absence.

D. Staff will begin working with clients/families the day that they return to work.

47 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 209 - PAC Rights of Persons Served Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-209-PAC - Rights of Persons Served Policy It is the policy of PAC to communicate and protect the rights of all persons served.

48 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 209-001- PAC Rights of Persons Served Procedure GJR Administrators 03/12/2026 06/17/2026

PS-209-001-PAC – Rights of Persons Served Procedure The following rights of clients/families are reviewed at intake (and throughout treatment as indicated) and provided in writing in the “Client Handbook” to ensure they are followed in all PAC programs and services: A. A Client and their family have the right to be treated with fairness, dignity, and respect.

B. A Client and their family may not be discriminated against because of race, color, religious creed, disability, handicap, ancestry, sexual orientation, national origin, limited English proficiency, age, or sex. These issues have no bearing on the quality of services recommended or provided to you. You have the right not to be deprived of any civil, legal, or human rights due to a mental health/mental intellectual/developmental disability diagnosis.

C. A Client has the right as a minor to not be physically or emotionally abused, mistreated, unreasonably restrained, threatened, harassed, or subject to corporal punishment. You may not be subject to unusual or extreme methods of discipline, which may cause psychological or physical harm to you. It is the policy of PAC to report all allegations of child abuse or neglect to Pennsylvania ChildLine (1-800-932-0313) or Ohio Department of Job and Family Services (855-O-H-CHILD/855-642-4453). It is the policy of PAC to report all allegations of abuse or neglect of seniors or adults with disabilities to Pennsylvania’s Adult Protective Services (Protective Services Hotline 1-800-990-8505) or Ohio’s County Department of Job and Family Services (937-544-2371). Allegations of abuse and/or neglect will be investigated by the state entity receiving the report.

D. A Client has the right to be safe, nurtured, and protected from child abuse and neglect.

E. A Client has the right to grow up in a supportive, stable home.

F. A Client and their family have the right to be informed of the guidelines and expectations of the program.

G. A Client and their family have the right to practice the religion or faith of choice, or not to practice any religion or faith.

H. A Client has the right to appropriate medical, behavioral health, and dental treatment.

I. A Client has the right to rehabilitation and treatment.

J. A Client and their family have the right to an individualized, written treatment plan to be developed after admission.

K. A Client has the right to be free from excessive medication.

L. A Client may not be subjected to unusual or extreme methods of discipline, which may cause psychological or physical harm to the child.

M. A Client and the youth’s family have the right to confidentiality of records and release of this information must be with informed, written consent except as required by legal authority.

N. A Client may not be deprived of specific client or civil rights.

O. A Client’s rights may not be used as reward or sanction.

P. A Client has the right to have the opportunity to work and develop job skills at an appropriate age level which may be reasonably accommodated.

Q. A Client has the right to get life skills training and independent living services as needed.

49 | P a g e

June 17, 2026

R. A Client has the right to receive the agency’s grievance policy and to have the rights, and the grievance policy explained to them in a way that they understand. A Client has the right to lodge a grievance with the facility for an alleged violation of specific client or civil right(s) or a complaint regarding your behavioral health treatment plan without fear of retaliation.

S. A parent/guardian has the right to exercise parental and decision-making authority for their child.

T. A Client has a right not to participate in research projects.

PAC services shall be made available to individuals with disabilities through the most procedural and economically feasible methods possible.

50 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 210 - PAC Grievances and Complaints Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-210-PAC - Grievances and Complaints Policy It is the policy of PAC to allow clients, their families, and other stakeholders to file grievances and/or make complaints.

A complaint can be made informally, either verbally or in writing, to share any allegation of an unfair or unjust action. A grievance is a more formal complaint and should therefore be submitted in written form.

51 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 210-001 - PAC Grievance Procedure GJR Administrators 03/12/2026 06/17/2026

PS-210-001-PAC - Grievance Procedure A. PAC programs encourage and support the rights of clients/families to file complaints and grievances without fear of retaliation in the event they believe their rights have been violated.

B. Clients/families will be informed of their right to complain or grieve treatment, or other aspects of service, at the time of their admission/intake to PAC programs via a review and copy provided of the “Client Handbook” which includes the complaint/grievance process at PAC. Documentation of understanding of this right will be made by having clients/families sign the PAC Consent Form which will be located in the client electronic health record.

C. Clients will be informed of the treatment plan appeal process as outlined in the Individualized Service Plan Appeal Procedure (PS-205-003).

D. If clients/families choose to file a grievance associated with PAC services, they must provide in writing the grievance to the PAC staff or Supervisor/Program Manager/Program Director.

E. Complaints or grievances must be addressed within 48 hours. Outcomes must be documented and entered into the record of the client. Outcomes of complaints or grievances must also be provided to the Regional Director and PAC Director.

F. If the complaint or grievance cannot be resolved at the PAC staff level, the client/family will be scheduled to meet with the Supervisor/Program Manager/Program Director within 48 hours of the issuance of the complaint or grievance response by the PAC staff. The Supervisor/Program Manager/Program Director must attempt to bring complaints or grievances to resolution within 48 hours. Resolution of complaints or grievances must be documented in records of clients, and copies given to PAC staff. Outcomes of the complaints must also be provided to the Regional Director and PAC Director.

G. If the complaint or grievance cannot be resolved at the Supervisor/Program Manager/Program Director level, the client/family will be scheduled to meet with the Regional Director within 48 hours of the issuance of the complaint or grievance response by the Supervisor/Program Manager/Program Director. The Regional Director will attempt to bring complaints or grievances to resolution within 48 hours of meetings whenever possible. Resolution of complaints or grievances must be documented in records of clients. Along with clients, outcomes will be reviewed with the PAC staff of the client and the Supervisor/Program Manager/Program Director. Outcomes of the complaints must also be provided to the PAC Director.

H. If complaints or grievances cannot be resolved at the Regional Director level, the client/family will be scheduled to meet with the PAC Director within 48 hours of the issuance of the complaint or grievance response by the Regional Director. The PAC Director will attempt to bring complaints or grievances to resolution within 48 hours of meetings whenever possible. Resolution of complaints or grievances must be documented in records of clients. Along with clients, outcomes will be reviewed

52 | P a g e

June 17, 2026

I.

J.

with the PAC staff of the client, Supervisor/Program Manager/Program Director, and Regional Director.

If complaints or grievances cannot be resolved at the PAC Director level, the client/family will be scheduled to meet with the George Junior Republic Chief Executive Officer (GJR CEO) within 48 hours of the issuance of the complaint or grievance response by the PAC Director. The GJR CEO will attempt to bring complaints or grievances to resolution within 48 hours of meetings whenever possible. Resolution of complaints or grievances must be documented in records of clients. Along with clients, outcomes will be reviewed with the PAC staff of the client, Supervisor/Program Manager/Program Director, and Regional Director.

If the matter cannot be satisfactorily resolved (per client/family) at the GJR CEO level, clients/families may be referred to appropriate agencies for further action. Depending upon the nature of the grievance, those agencies may include: Department of Human Services Bureau of Equal Opportunity Room 521, Health and Welfare Building P. O. Box 2675 Harrisburg, PA 17105 US Department of Health and Human Services Office of Civil Rights Suite 372, Public Ledger Building 150 South Independence Mall West Philadelphia, PA 19106-9111

PA Human Relations Commission Harrisburg Regional Office Riverfront Office Center 1101 South Front Street, 5th Floor Harrisburg, PA 17104 Bureau of Equal Opportunity Central Regional Office Cameron and Maclay Street Building 56, Patton House, P. O. Box 61260 Harrisburg, PA 17106-1260

Behavioral-Health MCO: Attention Complaint Investigator Carelon Health of Pennsylvania P.O. Box 1840 Cranberry Township, PA 16066-1840 Provider Line: 877-615-8503 Quality Management Department Fax: 855-287-8491 J.

The Compliance/Risk Department will review all PAC services complaints and grievances.

Recommendations will be made if appropriate and necessary to address the issues resulting in the complaint/grievance being filed. Complaints and grievances will be continuously monitored for trends in order to make necessary changes to the program.

K. In the event a grievance against the treatment planning of the program, the original Individualized Service Plan will remain in effect until the disposition of the grievance. In order to protect the interests of all those involved in this process, minutes of each level of attempted conflict resolution are to be kept.

53 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 211 - PAC Safety Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-211-PAC Safety Policy It is the policy of PAC that safety is of the highest priority for the well-being of clients and employees.

54 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 211-001 - PAC Safety Procedure GJR Administrators 03/12/2026 06/17/2026

PS-211-001-PAC - Safety Procedure A. PAC is committed to maintaining an abuse-free organization. We believe that every client should feel safe, secure, and be treated with dignity and respect while enrolled in PAC services. An incident report must be completed and submitted to the employee’s supervisor when an allegation of abuse occurs. Every allegation of abuse will be taken seriously. In the event of an allegation of abuse, PAC will cooperate fully with state laws and authorities.

B.

C.

D.

E.

The following behaviors are considered abusive. Clients/families and employees are prohibited from engaging in the following behaviors: 1. Hazing 2. Bullying 3. Derogatory name-calling 4. Ridicule or humiliation 5. Sexual innuendo 6. Verbal aggression 7. Physical aggression Risk Management: Staff should be aware of how behaviors, words, and boundaries with clients not only relate to ethical codes, but also put the agency at risk. Appropriate affection toward clients can be a way to build trust and show concern. However, if the contact is inappropriate, the client may misread the intent. Staff should take into consideration the age of the client, the client’s history, and how others would perceive displays of affection.

Basic safety protocols: 1. Staff are to have their PAC ID with them at all times.

2. Employees should seek guidance for unclear and unsafe situations by contacting a supervisor or the Regional Director.

3. Safety issues are to be reported immediately to referral sources.

4. For safety issues that are a recordable or reportable event, employees are to follow the Recordable and Reportable Incidents procedure.

Imminent Risk: Staff should call law enforcement and seek to remove themselves as well as others from situations with imminent risk where de-escalation is not possible. Imminent risk is a legal term often defined as an “immediate and impending threat of a person causing substantial physical injury to self or others.” Three acceptable responses to imminent risk include: 1. Run/Escape 2. Hide (if escape is not possible) 3. Fight (as a last resort) Mandated Reporters: Under Pennsylvania and Ohio law, any individual who has reason to believe a child, an adult with disabilities, or an elderly person is a victim of abuse or neglect has the duty to make a report and make a report immediately. PAC staff are mandated reporters and required to follow the reporting law of Pennsylvania and Ohio for suspicions of abuse or neglect.

55 | P a g e

June 17, 2026

F. De-escalation: Clients will be de-escalated in order to maximize individual responsibility and remain safely involved in services. De-escalation includes nonverbal, para-verbal, and verbal de-escalation techniques, including: 1. Providing verbal prompts and reminders 2. Non-verbal interventions (planned ignoring, environmental changes, hand signals) 3. Take the client aside 4. Offer choices 5. Model coping skills and regulation skills 6. Redirection to another activity to modify or change the client’s focus 7. Active listening 8. Attention concerns and feelings 9. Reality orientation G. Environmental 1. Community-based staff will be trained in environmental safety precautions while working in client homes, schools, and the community. Staff may use the safety assessment tool with clients/families in order to minimize the risk for safety concerns and ask screening questions prior to providing in-home services. If staff feel they are in danger of exposure to communicable diseases, parasites, harmful substances, or any other safety concerns arise, staff should report the concern to a supervisor in order for a safety plan to be established, service delivery to be adapted, or in-home services suspended until the risk factor is resolved.

2. Regarding weapons in client home, staff are encouraged to screen and assist clients/families in safely securing all weapons when providing in-home services. Staff are not to keep weapons in their vehicles or transport clients who have weapons on their person.

H. PAC staff are to utilize and follow safety training as provided by supervisors and PAC Safety Modules located in the Relias training record to include: 1. Visit Safety and Security for Home & Site Visits 2. Crisis and Conflict Prevention 3. De-Escalation Strategies 4. Responding to Violent Behavior 5. Sexual Harassment 6. Impaired Clients & Persons 7. Environmental Safety 8. Defensive Driving

56 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 216 - PAC Sexual Abuse & Harassment Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-216-PAC - Sexual Abuse & Harassment Policy It is the policy of PAC to investigate, pursue and eliminate any threats of sexual abuse, harassment, or intimidation by aggressively investigating and reporting all incidents of sexual misconduct, and taking active steps to discipline and prevent further incidents.

57 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 216-001 - PAC Sexual Abuse & Harassment Procedure GJR Administrators 03/12/2026 06/17/2026

PS-216-001-PAC - Sexual Abuse & Harassment Procedure To ensure the safety, security, and wellbeing of clients/families and employees, PAC strictly enforces a zero tolerance of sexual harassment or abuse among the employees and clients/families.

PAC’s administrative personnel will make every effort to detect, eliminate, and respond appropriately to reports of sexual abuse or harassment. Responses to allegations of sexual abuse or harassment will be taken seriously, investigated thoroughly, and adjudicated in a timely manner. These policies and procedures apply to all interactions of both staff and clients/families whether staff to staff or staff to client/family member.

58 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 217 - PAC Safety Plan Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-217-PAC - Safety Plan Policy It is the policy of PAC that employees shall create, communicate, review, and update Safety Plans as identified in the following procedures.

59 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 217-001 - PAC Safety Plan General Guidelines Procedure GJR Administrators 03/12/2026 06/17/2026

PS-217-001-PAC – Safety Plan General Guidelines Procedure Each client will have a written safety assessment completed during intake. All clients/families will participate in the development of a Safety/Crisis Plan located in the client electronic health record during intake that includes the safety concerns identified along with protective factors.

A. A safety plan may include the following safety concerns as clinically warranted: 1. Known or suspected suicidal gestures and/or attempts 2. Known incidents of aggressive or violent behaviors toward others 3. History of aggression toward self (self-injury) 4. Drug and alcohol history 5. Sexual history or behavior patterns which place others at risk (including children or other vulnerable population like the elderly) 6. Anaphylactic shock (severe allergic reaction) 7. Seizures 8. Concussions B. Safety/Crisis Plans will include the following information: 1. Warning Signs of a Safety Concern or a Crisis a. What are the client’s thoughts, feelings, behavior, or moods that indicate that a safety concern or crisis may be developing?

2. Coping Strategies a. What can the client do to make sure that they are personally safe?

3. Support Systems a. Whom does the client contact when they need help?

4. Safety/Crisis Plan Review 5. Date Reviewed, Schedule for Reviewing, Description of Plan Review, Crisis Disposition (if relevant), and Crisis Resolved C. Safety/Crisis Plans must be signed by the client (when developmentally and functionally able), their caregiver (in the instance of a minor), and the assigned staff.

D. Safety/Crisis Plans will be reviewed and amended based on emergence of new safety concerns, additional methods to manage safety risk, following any crisis event, and as specified on the form.

This time period will vary based on the severity of the safety concern.

E. At each session, PAC staff will evaluate the safety of the client/family. Any safety concerns will be documented in the service note and PAC staff will plan for safety with the client/family.

F. Safety Plans are maintained in the client electronic health record and a copy provided to the client/family.

60 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 222 - PAC Prohibited Treatment Techniques Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-222-PAC – Prohibited Treatment Techniques Policy It is the policy of PAC to promote the use of positive interventions, and to prohibit the use of aversive treatment.

61 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 222 -001- PAC Prohibited Treatment Techniques Procedure GJR Administrators 03/12/2026 06/17/2026

PS-222-001-PAC – Prohibited Treatment Techniques Procedure A. Seclusion, defined as restricting a client in a locked room and isolating from personal contact, is prohibited. A locked room is a room with any type of door-locking device such as a key lock, spring lock, bolt lock, foot pressure lock, or physically holding the door shut.

B. The use of aversive conditioning, defined as the application of startling, painful, or noxious stimuli, is prohibited.

C. While clients may choose to use corporal punishment in their parenting practices, GJR staff will not promote or model these techniques as part of their parenting skills teaching.

D. Restraints, or physical intervention, are not an acceptable form of behavior management by staff to clients.

62 | P a g e

June 17, 2026

PS- 224 - PAC Critical Incidents Policy APPROVED BY: GJR Board of Directors APPROVED DATE: 06/17/2026 EFFECTIVE DATE: 06/17/2026

REFERENCE CODE: TITLE:

PS-224-PAC – Reportable and Recordable Incidents Policy It is the policy of PAC to report and record incidents as identified in the following procedures.

63 | P a g e

June 17, 2026

REFERENCE CODE:

PS- 224-001 - PAC Critical Incidents Procedure APPROVED BY: GJR Administrators APPROVED DATE: 03/12/2026 EFFECTIVE DATE: 06/17/2026 TITLE:

PS-224-001-PAC – Critical Incidents Procedure A. Documentation of incidents occurring with clients receiving services with PAC is necessary to ensure accurate recording of recordable incidents. Tracking and trending supports improved safety and positive outcomes.

B. A PAC Critical Incident Report (found in the shared folder “remote-pac” accessible via the Virtual Provider Network (VPN) and in the subfolder “Forms”) is required each and every time the following situations occur: a. Suicidal or homicidal gestures, express suicidal or homicidal ideation with plan or intent, or threaten suicide or homicide b. Any time staff suspects, witnesses, or obtains a report regarding child/senior/disabled adult abuse or neglect c. Client damages PAC property or PAC staff property worth more than $50.00. d. Possession of a deadly weapon and the threat of use of the weapon by a client wherever services are rendered e. Self-Injurious behavior by the client that is potentially life threatening or requires serious medical treatment (urgent/emergent care, such as Emergency Department or Urgent care visit) f. Any time there is police, fire, or EMT called by PAC staff during the provision of services g. Violation of a client’s rights h. Breach of confidentiality i. Death of a client j. An injury, trauma or illness of a client requiring inpatient treatment at a hospital k. A serious injury or trauma of a client requiring outpatient treatment at a hospital not to include minor injuries such as sprains or cuts l. Intimate contact between children, consensual or otherwise or between an adult and child m. A child’s absence from the premises without the approval of staff, referral source, or caregiver n. An outbreak of a serious communicable disease o. Threats to harm others p. Threats to remove a child from the approved caregiver q. Vehicle accidents during which a client is involved with GJR staff r. Seeing, smelling, or suspecting drug use and/or alcohol misuse by a caregiver when the caregiver is responsible for minor children

64 | P a g e

June 17, 2026

C.

D.

E.

F.

G. H.

I.

s. Home environments that could lead to serious injury or death of minor children (if living in the home) or an adult client t. Other safety situations or risk factors that could result in serious injury or death u. Any time staff needs to document an unusual incident or situation involving a client or staff member v. Should staff be involved in a reportable and recordable incident, staff should seek to stabilize the safety of all persons involved first including but not limited to seeking emergency services, law enforcement, or other community services to render immediate aid.

Staff will then notify their supervisor and then the staff or the staff’s supervisor will immediately notify the referring agency, parents and/or, if applicable, guardians or custodians of the client following a reportable incident unless restricted by applicable confidentiality statutes, regulations, or an individual’s court order.

Staff members should record reportable incidents on PAC’s Critical Incident Form and ensure a copy is sent to their supervisor for review within 24 hours of the incident’s occurrence. A follow up email to the referring agency will also be sent summarizing the incident, which will be documented in the client’s electronic health record.

The supervisor will review the incident form adding any additional information prior to sending to the Safety Committee Chairperson, Regional Director and PAC Director within 24 hours of receiving from the employee. Should additional steps be needed, the Regional Director and/or PAC Director will follow up including but not limited to consulting George Junior Republic’s Risk Director.

The Safety Committee Chairperson, PAC Director, or GJR’s Risk Director will initiate an internal investigation of a reportable incident should the incident suggest any issues on the part of GJR staff immediately following the report of the incident and will complete the investigation as soon as possible. When a licensing or police investigation is involved, the internal investigation will not take place until the external investigation is complete. The Safety Committee Chairperson, PAC Director, or GJR’s Risk Director will provide the information to the placing agencies following the conclusion of the investigation when required.

Incidents will be logged and sent to the safety committee for review. Reportable incidents will be tracked and trended in order to identify opportunity for performance improvement initiatives.

Incident Reports will be reviewed by the Safety Committee Chair, PAC Director, Risk & Compliance, and supervisors in order to track and monitor trends. Trends will be addressed and initiatives developed in order to decrease and prevent future occurrences.

For MMP and FBMH, Serious Reportable Events (SREs) that require a Carelon Reportable Event Form are described on the Carelon website at www.pa.carelon.com/providers/provider-manual/4notifying-carelon-of-reportable-events/. Program Manager/Program Director, MMP staff, and FBMH staff will follow the procedures on the Carelon website for reporting, and document in the client electronic health record.

65 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 224-002 -PAC Critical Incidents of Child Abuse and Neglect Procedure GJR Administrators 03/12/2026 06/17/2026

PS-224-002-PAC - Critical Incidents of Child Abuse and Neglect Procedure All mandated reporters of PAC are required to immediately report to the proper authorities any suspected abuse or neglect of a child. PAC will follow all state and federal laws regarding child abuse to include the following: A. The Pennsylvania Child Protective Services Law (23 Pa.C.S. Chapter 63) can be found at https://www.pa.gov/agencies/dhs/resources/keep-kids-safe/about-keep-kids-safe/cps-laws B. The Ohio Revised Code Section 2151.031 defining child abuse can be found at https://codes.ohio.gov/ohio-revised-code/section-2151.031 C. The Trafficking Victims Protection Act of 2000 defining sex trafficking and labor trafficking can be found at https://humantraffickinghotline.org/en/human-trafficking/federal-law The process for reporting child abuse and neglect at PAC: A. A mandated reporter is responsible to make the report when they suspect a child is a victim of abuse.

B. Nothing requires a child to come before the mandated reporter in order to make a report.

C. All mandated reporters in Pennsylvania must make an immediate and direct report of suspected child abuse to Child Line.

1. The report can be submitted in two ways: a. www.compass.state.pa.us/cwis i.

When a mandated reporter makes a report electronically via the internet, they must use their own account established with Child Welfare Information Solution (CWIS). User names and passwords that staff obtained when applying for clearances using the CWIS system are used when filing an electronic child abuse report b. Childline: 1-800-932-0313 i.

If an oral report was made to ChildLine, a report of suspected child abuse (CY 47) must also be completed and forwarded to the county children and youth agency within 48 hours after making the report. This form can be obtained at www.KeepKidsSafe. pa.gov or from the children and youth agency. If a report is made electronically, no CY-47 is required to be completed.

D. The Ohio Department of Job and Family Services has launched 855-O-H-CHILD (855-642-4453), an automated telephone directory that will link callers directly to a child welfare or law enforcement office in their county.

E. After making the report of suspicion of child abuse, mandated reporters are required to immediately thereafter notify their supervisor and complete a Critical Incident Report. a. Staff will send the Incident Report to their supervisor within 24 hours of witnessing or learning of a suspicion of abuse or neglect. b. Supervisors will review the Critical Incident Report and send to Regional Director and PAC Director.

66 | P a g e

June 17, 2026

F. Staff will notify the referral source and document in the client’s electronic health record that they were informed.

G. Staff will notify the managed care organization, if appropriate, and electronically submit a completed Reportable Event Form. Staff will document completion of same in the client’s electronic health record.

H. Staff will notify the parents/guardian, if they are not the alleged perpetrators. Staff will document this notification in the client’s electronic health record.

67 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 224-003 -PAC Critical Incidents of Seniors and Adults with Disabilities Abuse and Neglect Procedure GJR Administrators 03/12/2026 06/17/2026

PS-224-003-PAC – Critical Incidents of Seniors and Adults with Disabilities Abuse and Neglect Procedure All mandated reporters of PAC are required to immediately report to the proper authorities any suspected abuse or neglect of seniors or adults with disabilities. PAC will follow the state and federal laws regarding child abuse to include the following: A. In Pennsylvania, the Adult Protective Services Act for reporting abuse of seniors or adults with disabilities can be found at https://www.pa.gov/agencies/dhs/report-abuse/adult-protective-services B. In Ohio, the Adult Protective Services law for reporting abuse of seniors can be found at https://codes.ohio.gov/ohio-administrative-code/rule-5101:2-20-12 The process for reporting senior abuse or adult with disabilities abuse is: A. Abuse of Adults with Disabilities Reporting Helpline 1. Staff who suspect that an adult who has a physical or mental disability is the victim of abuse, neglect, exploitation, or abandonment should call the statewide protective services hotline. a. Pennsylvania Protective Services Hotline: 1-800-490-8505 b. Ohio Adult Protective Services Hotline: 855-644-6277 (855-OHIO-APS) 2. For Pennsylvania, in addition to reporting to the Protective Services Hotline, staff must make an oral report to the Pennsylvania Department of Human Services/Adult Protective Services Division (by calling the mandatory abuse reporting line at 717-265-7887 and selecting option #3) and local law enforcement only for suspected abuse or neglect involving sexual abuse, serious injury, serious bodily injury or if a death is suspicious. a. Within 48 hours of making the oral report to the hotline, staff will fax the Act 70 Mandatory Abuse Report to 484-434-1590 or email the report to Liberty Healthcare (the Pennsylvania contracted provider of protective services) at: mandatoryron@libertyhealth.com. i.

The mandatory reporting form found on the Department’s website at www.dhs.pa.gov under Report Abuse>Adult Protective Services. b. Within 48 hours of making the oral report to law enforcement (only for suspected abuse or neglect involving sexual abuse, serious injury, serious bodily injury or if a death is suspicious), staff will send the Act 70 Mandatory Abuse Report to law enforcement.

B. After making the report to the Protective Services Hotline, staff will immediately notify their supervisor and complete a PAC Critical Incident Report.

1. Staff will send the PAC Critical Incident Report to their supervisor within 24 hours of witnessing or learning of a suspicion of abuse or neglect.

68 | P a g e

June 17, 2026

2. Supervisor will review the Critical Incident Report and send to the Safety Committee Chairperson, Regional Director, and PAC Director.

C. Staff will notify the referral source and document in the client’s electronic health record that they were informed.

D. Staff will notify the managed care organization, if appropriate, and electronically submit a completed Reportable Event Form. Staff will also document in the client’s electronic health record.

E. As appropriate, staff will notify the family or caretakers of the client, if they are not the alleged perpetrators. Staff will document this notification in the client’s electronic health record.

69 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 225 - PAC Suicide Precautions Policy GJR Board of Directors 06/17/2026 06/17/2026

PS-225-PAC – Suicide Precautions Policy It is the policy of PAC to address suicidal ideations and threats with a comprehensive approach in which staff education and training lead to awareness and prevention. At-risk thinking and/or behaviors are assessed, and appropriate actions are immediately provided in order to address and ensure the safety of clients in these circumstances.

70 | P a g e

June 17, 2026

REFERENCE CODE: TITLE: APPROVED BY: APPROVED DATE: EFFECTIVE DATE:

PS- 225-001 - PAC Suicide Precautions and Response Procedure GJR Administrators 03/12/2026 06/17/2026

PS-225-001-PAC - Suicide Precautions and Response Procedure PAC provides community-based services for clients/families. The first and foremost concern of PAC is the safety of each client. As such, the policy and procedures regarding client suicide precautions are to be followed without deviation.

A. Staff members are to be familiar with common warning signs or indications of self-harm/suicide as well as risk factors that can increase the possibility of suicidal ideation, which may be found at https://www.samhsa.gov/mental-health/suicidal-behavior B. Should risk factors or warning signs be identified, staff will further assess the client utilizing the C-SSRS (Columbia - Suicide Severity Rating Scale): C. If the client is determined to be actively suicidal or if the client is injured due to a suicide attempt/gesture, staff should assist getting the client medical care by calling 9-1-1, requesting officers trained in mental health, as well as an ambulance to transport the client safely.

1. Staff will notify their supervisor immediately.

2. If they need emergency room service or hospitalization (either medical or psychiatric), the hospital will follow their policy with regard to contacting a psychiatrist/MH delegate to examine issues of voluntary/involuntary admission processes.

D. Staff will complete a PAC Critical Incident Report (CIR).

1. Staff will send the Incident Report to their supervisor within 24 hours of the incident.

2. Supervisors will review the CIR and send to the Safety Committee Chairperson, Regional Director, and PAC Director.

E. Staff will notify the referral source and document in the client’s electronic health record that they were informed.

F. MMP & FBMH Staff will notify the managed care organization, if appropriate, and electronically submit a completed Reportable Event Form. Staff will also document as such in the client’s electronic health record.

G. Staff will notify the parents/guardian, if they are not the alleged perpetrators. Staff will document this notification in the client’s electronic health record.

H. The Safety/Crisis Plan will be reviewed and updated following significant events related to self-harm, suicidal ideation, and/or suicidal gestures. A copy will be provided to the client/family. The Safety/Crisis Plan will be located in the client electronic health record. All safety crisis plans should include references to both 9-1-1 and 9-8-8 as emergency care options.

71 | P a g e

June 17, 2026