Like many behavioral healthcare agencies, and particularly those operating multiple, small residential treatment programs for children, Hillcrest chooses to minimize the number of staff to whom clinical responsibilities are accorded in order to maintain simple structures, efficient administrative procedures and close supervision of the treatment of children.

Effective October 27, 2006, Hillcrest authorizes clinical responsibilities for the positions listed below.
Psychiatrist
Pediatrician
Psychologist

The criteria and responsibilities associated with each of these positions are attached as separate documents.

PEER REVIEW PROCEDURES

As noted, Hillcrest chooses to minimize the number of privileged positions in order to maintain simple structures, efficient administrative procedures and close supervision of the treatment of children. Similarly, simple and efficient Peer Review procedures are employed, while insuring the high level of professional competence and work by privileged staff, as well as full compliance with accreditation and regulatory standards.

1. Pediatrician.
Beginning in 2003, Hillcrest will contract for appropriate outside consultation for the minimally biannual review of the Pediatrician.

2. The Psychiatrists are reviewed by a licensed and certified consulting psychiatrists at least every 2 years.

3. The Psychologist is reviewed at least every two years by a licensed and certified Psychologist.

Note: In January 2002, when Hillcrest was reviewing Privileging and Peer Review, the Standards Clarification Unit of the Joint Commission confirmed that it is acceptable for non-privileged supervisees of the same discipline to participate in a peer review of their privileged supervisor’s professional competence in their shared discipline.

Credentialing
This process ensures the competence of licensed independent practitioners. Human Resources performs primary source, or other acceptable verification of the licensure, certification, or registration. Through the interview process, the appropriate supervisor accesses competency, and references are checked by Human Resources. Continued assessment of competency is done through trainings, continued education, supervision and evaluation.

Clinical Responsibilities

The Board of Directors, based on the recommendations of the Executive Vice President and the Senior Management Team, will determine which positions are to be granted HEC privileges. The Licensed Independent Practitioner in these positions will obtain the application for Clinical Responsibilities from Human Resources.

As of March 1,2002 the following positions will be privileged at Hillcrest Educational Centers, Inc.:
1. Psychiatrist
2. Pediatrician
3. Psychologist

The Director of Human Resources will complete the Human Resource Section of the application, will attach the necessary documents, and will submit the application to the appropriate supervisor.

The supervisor will complete the appropriate section and will return to Human Resources, along with a current evaluation.

Human Resources will obtain a peer review for those being reviewed. The packet will be reviewed by the Quality Assurance & Clinical Responsibilities Committee of the Board of Directors for final approval, or for denial of Clinical Responsibilities.

Granting Temporary Clinical Responsibilities

Temporary Clinical Responsibilities may be granted once we have received primary source verification of current licensure to meet the important needs of clients for a limited period of time, not to exceed 6 months.

New LIPs may be granted Temporary Clinical Responsibilities upon primary source verification of licensure, verified education, training and/or experience, meeting expectations for current competence and ability to perform the clinical responsibilities requested.

New LIPs must actively pursue the application process for Clinical Responsibilities during this temporary period, including a complete application, no current or previously successful challenge to licensure or registration, not been subject to involuntary termination of professional or medical staff membership at another organization, when applicable to the discipline, and not been subject to involuntary limitation, reduction, denial, or loss of clinical responsibilities, when applicable to the discipline.

Temporary Clinical Responsibilities may also be given to LIPs who have accepted permanent positions and who will apply for Clinical Responsibilities. For physicians, verification of privileged status at a hospital, primary source verification of licensure and including verification that there are no previous, current or pending successful challenges to licensure or registration, not been subject to involuntary termination of processional or medical staff membership at another organization, when applicable to the discipline, and not been subject to involuntary limitation, reduction, denial, or loss of clinical responsibilities, when applicable to the discipline.

Appealing the Denial of Hillcrest Clinical Responsibilities:

Should the application or reapplication for HEC Clinical Responsibilities be denied at any step in the process, the applicant will be contacted by the Director of Human Resources and will be given written documentation regarding the reason for rejection. The applicant may appeal the decision to deny Clinical Responsibilities in the following manner

Step 1:

The applicant may appeal the decision to deny Clinical Responsibilities to the Executive Vice President. The appeal must be in writing and must include a copy of the application and the letter from the Director of Human Resources, along with any supporting documentation for reversing the original decision. The VP will set up a meeting with the applicant within 2 weeks of receiving the written appeal. The Director of Human Resources will also participate in the meeting. The VP’s written decision on the appeal will be sent to the applicant within 5 working days of the meeting.
 
Step 2:

If the applicant’s appeal is denied by the VP and the applicant wishes to continue the appeal process, the applicant must send a written appeal to the President/CEO within 5 working days of receipt of the decision of the VP. The appeal must include copies of the original application, the letter from the Director of Human Resources, along with supporting documentation for reversing the decision, and a copy of the letter from the VP. The President/CEO will meet with the applicant within 2 weeks of receiving the written appeal and the decision will be communicated in writing within 5 working days of the meeting. Both the VP and Director of Human Resources may be included in the meeting.

Step 3:

If the applicant’s appeal is denied by the President/CEO and the applicant wishes to continue the appeal process, the applicant must send a written appeal to the Personnel Committee of the Board of Directors within 5 working days of receipt of the decision of the President/CEO. The appeal must include copies of the original application, the letter from the Director of Human Resources, along with supporting documentation for reversing the decision, and copies of the letters from the VP and the President/CEO. The Committee Chair will schedule a meeting with the applicant within 4 weeks of receiving the written appeal. The Committee’s decision will be communicated to the applicant in writing within 5 working days of the meeting.

The decision of the Personnel Committee of the Board of Directors is final. Every effort will be made at that time to find a position for which the employee is qualified. However, if no position is available, the employee will be expected to resign.

1. Application/resume received in Human Resources. Reviewed for appropriate degree/license/experience.

2. Human Resources sends copy of resume to appropriate supervisor or department head for review. This person also reviews initial paperwork for appropriateness.

3. Candidate is interviewed in HR where application is reviewed, explanation of hiring process is given, and overview of benefits/salary/working conditions is given. Candidate receives copy of job description.

4. Supervisor/department head interviews candidate to determine if candidate has appropriate degree/skills/knowledge for open position. This includes competencies listed in job description.

5. Candidate observes workers at work site and supervisor/department head follows up with question and answer session to determine appropriateness for position.

6. HR discusses candidacy with hiring supervisor and, if an offer is to be extended, proceeds with conducting up to three, but no less than two, reference checks. Degree/license is also verified.

7. Candidate is hired on provisional basis and a Background Record Check is submitted. Signed Job description, reference checks, BRC consent form, photo ID, submittal sheet and drivers license checks are placed in HR file. Copy of BRC adverse results are maintained in a separate locked cabinet in Human Resources. Copy of degree/license is placed in HR file and a second copy is placed in the licensure book.

8. Employee is scheduled for a pre-employment physical/TB appointment prior to Orientation.

9. Employee participates in New Staff Orientation at Administrative Offices.

10. Upon successful completion of New Staff Orientation, employee attends Orientation at campus.

11. Employee receives weekly supervision during the first three months of employment. At the end of the 3 month probationary period, the employee is evaluated and the following can occur:
• continue employment
• extend probationary period for no longer than 3 months
• termination of employment

12. Employee receives supervision on a regular basis and is evaluated after one year of employment and annually thereafter. Documentation of supervision is kept in the campus file. Evaluations are placed in the personnel file located in the Human Resources Department.

13. All employees working at the program sites are required to participate in, and are evaluated on, a minimum of 24 hours of training each year. Training requirements are tracked on a learning management system and records of training are accessed by the supervisor through the report feature in the learning management system.

13. Employees who have certification/licensure are tracked by expiration date as well as by anniversary date to ensure compliance.

Functional Responsibility: Human Resources

Topic: Acquiring and maintaining professional credentials required for each staff’s current position.

Policy: It is the policy of Hillcrest Educational Centers, Inc. to maintain a highly qualified professional staff in all positions. For those positions where it has been determined that the duties of a position require professional licensure or certification, Hillcrest will establish the type and level of licensure needed. Hillcrest will employ staff for professional positions who meet the required license/certification levels, or who will be able to acquire appropriate credentials in a reasonable time frame that is defined and mutually agreed upon in a detailed plan of professional development. The interim status and functions of the non-licensed professional staff will be consistent with his/her profession’s guidelines and the regulations and standards of oversight and licensing agencies.

Purpose: Hillcrest Educational Centers, Inc is committed to the maintaining and recruiting quality and appropriately credentialed staff. This is important to ensure that professional services are being provided by appropriately qualified and credentialed staff, and it is required by our oversight and licensing agencies.

I. Overview of Process:
A. Define and clarify the appropriate professional credentials for each position.
1. Department Head for each department shall review all professional positions within his/her department and confirm that current designated license level and type is appropriate and consistent with agency needs, the duties, responsibilities and autonomy of the position, and established professional standards and relevant regulations.
2. Where license level or type is viewed as inadequate or inappropriate, the Department Head will initiate communications with the respective Program Director and the Director of Human Resources to confirm or revise required credential(s).
B. In each situation where there is a discrepancy between position’s duties/license requirements, resolve the discrepancy by:
1. Establishing a professional development plan to bring the current staff member into compliance with professional standards for the position, or
2. Redefine the position to not require professional licensure by realigning the duties and status and/or increasing or establishing an enhanced supervision structure. Either modification must be determined to be in the best interest or the agency from a service delivery and a cost benefit perspective. Further, any alteration will be within the relevant professional standards and regulations governing the particular practice or function.
C. Changes in license status or position requirements
1. In the event that a staff member’s license status changes for any reason while she/he is in a position that requires that professional license, she/he shall immediately report that change to his/her supervisor who in turn will notify the relevant Program Director and Department Head.
2. Upon realization of the lapse in license the responsible Department Head and Program Director may, at their option and if feasible, temporarily realign the professional duties and/or establish an enhanced supervision structure that provides for a continuum of service provision. Within 30 days of the change in license status, a longer range resolution shall be established in keeping with section “B” paragraph “2”.
D. In the event that it is not possible or reasonable to reconcile the position responsibilities with the individual staff credentials, Hillcrest will endeavor to transfer the affected staff member to another position that is a better match for the staff member.

Hillcrest strives for continuous quality improvement and staffing effectiveness. We utilize a variety of measures to insure staff qualifications and competence.

1. Screening applicants for employment: Applicants for all positions are assessed to insure that their qualifications are consistent with and appropriate for the responsibilities of the job for which they are being considered. Prior to hire, applicants are interviewed by a Human Resources Manager of Employment. If successful, the applicant is then interviewed at the campus by a program administrator, and they spend a minimum of 4 hours observing students and program at the campus. During this process the formal position description is carefully reviewed with the applicant. If the candidate appears to be qualified for the position, a background record check (to include CORI and DCF) is conducted, references are checked and degrees are verified.

2. New Staff Orientation: All staff (including full time, part time and on call staff) are required to attend and successfully complete New Staff Orientation prior to assuming their respective duties and responsibilities of their position at Hillcrest Educational Centers. Interns, volunteers and others who work in the program will attend all or portions of New Staff Orientation as determined by the extent of their interactions with students, as well as their respective roles within the agency.

Staff may not be assigned any direct care duties with students until they have participated in and successfully completed all aspects of the New Employee Orientation. Successful completion requires participation in New Staff Orientation in its entirety including being present for all training delivered, completion of all on line orientation coursework, and meeting all competency ratings on written and practical assessments given.

Documentation of successful completion of New Staff Orientation is kept in the staff’s Human Resource File.

3. On-Site Orientation: : Following New Staff Orientation, all staff participates in an On Site Observation lasting the length of a normal workday or normal work shift. This On Site Observation is in addition to pre-employment on site observation that all staff participate in as part of the interview and hiring process. On Site Observation following New Staff Orientation, allows the new staff to observe their work environment after receiving the initial training, giving them an additional opportunity to observe and ask questions now that they have some background, knowledge, and skills and have been oriented to the organization.

4. Supervision: In addition to supervision during their workday, staff, including volunteers and interns, participate in formal supervision meetings during the introductory period, which typically is 90 days, but which can be extended if there are skills or core competencies that need improvement. Frequent formal supervisory meetings continue until staff have shown appropriate levels of competence. The frequency of formal supervision meetings can than decrease based on the evaluation of the supervisor and the type of position. Supervision sheets documenting supervision meetings are kept at the campus.

5. Performance Evaluation: Staff in all positions, including volunteers and interns, are formally evaluated at the end of the introductory period, and at least annually thereafter. Evaluations consist of the measurable assessment of the staff’s ability to perform the activities required by the position they hold and the students with whom they work. The Human Resource Department tracks evaluations to insure they are done in a timely fashion.

6. Continuous assessment of staff competence:
i. Daily Interaction: Supervisors and administrators evaluate verbal and physical skills and competencies on a daily basis and they continuously coach and train staff, volunteers and interns in the most effective methods of working with our students.
ii. Observation: Video from the program’s surveillance cameras are reviewed by supervisors regularly to insure that HEC policies are carried out even when a supervisor is not present. In addition to video review supervisors will observe their staff, volunteers and interns during in the moment interactions with our students as a means of ensuring competency. An educational administrator will be responsible for conducting at least 2 teacher observations in the classroom annually. Any observation of behavior that appears inappropriate or shows less skill than desired is addressed immediately with the staff.
iii. Campus Reports: All significant incidents are reported, reviewed by Campus Administration and entered into a database. The database allows us to seek and identify patterns and trends and can provide information on a vast assortment of fields. Reports can be produced by student name, staff name, building, time of day, day of week and type of incident. These reports are reviewed by the Supervisors, Campus Administration and the Improving Organizational Performance Committee (IOP) for assessment and improvement.
iv. Human Resource Reports: All injuries are tracked by Human Resources in a database that can provide information on the types of injuries, number of injuries, treatment required, name of staff and/or student involved, time of day, day of week, location. Monthly reports and data analyses for the current month are reviewed by campus administration and IOP Committees. Comparisons of current and past months, and between current and past years are also conducted. These reports are reviewed and assessed by the Environment of Care and Senior Management Team for continuous improvement.
v. Outside Consultants: HEC periodically contracts with outside consultants to observe and make recommendations for continuous improvement.
7. Ongoing Training and Development: All staff (including full time, part time, on call, new employees, intern and volunteers) must participate in a minimum of 24 hours of training per year. All staff must be in compliance with all annual federal, state, agency, licensing, and accreditation training requirements. All staff working at program sites must minimally attend one 2 hour training a month offered at each program sites. All staff must complete all ongoing training assigned in the learning management system. All staff at the program sites are required to maintain a First Aid, CPR and AED Certification. All staff at the program sites must attend 12 hours of Therapeutic Crisis Intervention training each year. Six hours must be spent attending and successfully completing the Therapeutic Crisis Intervention Recertification course.

Staff in all departments are also eligible to participate in relevant training, workshops and conferences offered in the state, region, nation and/or on line formats.