1. Proper hand washing is critical to serving safe food. Wash your hands immediately after using restrooms, handling raw or cooked foods, and after handling chemicals.

2. All kitchen staff to wear proper hair restraints.(Issued by Hillcrest)

3. Gloves to be worn by all cooks when you serve food at all times.. It is also recommended that they be worn while doing prep.

4. Aprons are to be worn at all times and they must be clean.

5. Kitchen staff cannot work with open cuts or wounds. Any injury to the skin must be covered; if on hands, gloves must be worn. Any kitchen staff that have been told they have a Communicable Disease or Illness, ie; E Coli, Salmonella, Shigella or Hepatitis A, can not work until cleared by the Health Department.

6. MSDS sheets must be available and accessible to all staff.

7. Knives are to be under control of cooks at all times, they must be locked in a safe location when not attended.

8. All open containers of food or leftovers must be covered and dated and properly stored.

9. All dry goods that are open must be covered and stored in a container indicating the name of the product.

10. All items stored must be 6” off the floor and 12” from the ceiling.

11. All temperature logs, knife logs, and production sheets must be filled out daily.

12. Doe forms (FP-9) filled out after breakfast and lunch.

13. All assigned cleaning items to be completed according to schedule.

As with any protocol, things may change from time to time. Any changes will be communicated to you.
Revised 11-03-09

1 Objective
To provide the most efficient food service operations to each of the four individual campuses.

2 Food Service Director
Will ensure quality operations are being provided to all four campuses.

3 Program Director (or designee)
Will oversee the day-to-day operations of the food service staff as an integral part of the daily campus functions.

4 Staff-Cooks:
Will be required to report to Program Director, or designee, for daily supervision of duties. Of equal importance, cooks will be expected to adhere to all food service quality standards set forth by the Food Service Director.

5 Food Service Director Responsibilities:
Quality
Schedules
Budget/ordering
Training
Hiring
Sanitation/cleanliness
Menus
Compliance with HEC Personnel Policies,
Discipline (shared responsibility)

6 Line Manager(Program Director or Designee) Responsibilities:
Day to day operations
Daily monitoring
Time cards
Supervision of schedules
Discipline (shared responsibility)

1. PURPOSE AND SCOPE
In the ordinary course of its operations, Hillcrest Educational Centers, Inc. (the “Company”) obtains various forms of personal information pertaining to its employees, students, students’ families, donors, and other individuals. The Company takes seriously its obligation not to engage in or permit the inappropriate use or disclosure of such information. In addition, both federal and state law impose specific requirements relating to certain forms of personal information that could be used to commit “identity theft” or fraud. The Company has adopted this Personal Information Security Program and Policy in accordance with those federal and state law requirements.
Effective immediately, this Personal Information Security Program and Policy applies to all employees of the Company. The Company may amend, revise or update this Program and Policy at any time.

INTRODUCTION
Timely, accurate, and useful information is a prerequisite for monitoring, enhancing and improving the quality of care delivered to HEC students. Efficient and effective service delivery also requires integration of the needs of external entities such as funding and referral resources and State and Federal regulators. At HEC, formal processes addressing both internal and external informational needs exist within the structure of the Senior Management Team, the Department Heads, various ongoing committees, and the general staff. While the Management Team primarily integrates requests from external sources to Department Heads and Committees, the departmental staffs communicate with their managers via regularly scheduled supervision sessions and meetings, periodic focus groups and surveys, and the existence of a culture of open communication. The HEC staff views the information system resources, whether electronic documents, paper report forms, or the structure of meetings, as a dynamic work in progress that can always be improved.
PRIVACY, CONFIDENTIALITY, & SECURITY
The privacy and confidentiality of student records at HEC is protected by one of the nation’s strongest privacy and protection laws, the Family Educational Rights and Privacy Act (FERPA). FERPA regulations provide stringent rules regarding a broad range of records and information that encompasses all paper and electronic documents in an educational environment. All staff members receive specific training regarding the confidential nature of student information during their initial pre-service training and the general staff receive yearly training updates on this subject. Confidentiality of student information is addressed specifically in the Personnel Policies and Procedures in Section 3.8. The HEC Charts Committee, a standing committee with cross campus and interdisciplinary representation, routinely audits existing charts, communicates procedural policies or changes regarding access to the chart, and facilitates any modification to the structural content of the chart. Although the FERPA standard does not require specific security routines regarding electronic documentation, the Information Services Department has embraced the computer security requirements found in the Health Insurance and Portability and Accountability Act (HIPAA) and administers strict security access and disaster recovery procedures. Given that the agency has business partnerships with many other entities who are required to comply with the federal HIPAA standards we have initiated a plan to achieve full compliance with these standards by January 1, 2012. Additionally, the Commonwealth of Massachusetts recently enacted Statute 201 CMR 17 which contains some the most comprehensive privacy standards and expectations in the United States. HEC, in addition to this Information Management Plan, has completed a Personal Information Security Program and Policy document which is currently under review with our legal advisors and will be fully implemented by January 1, 2011. Copies of this document are available from either the Director of Information Services or the Director of Human Resources.
USE & MAINTENANCE OF INFORMATION
The mission of the HEC Information Services Department is to maximize the utility of existing data processing, collection, and communications systems, to expand the existing Information Management System as the needs of the agency change, to maintain, repair, and replace as necessary the hardware components of the system, and finally to train the staff to use the Managed Information System to the highest levels of competency. IS Department personnel are in regular contact with agency staff regarding the efficacy of existing systems and development of new processes. They are involved in agency wide and campus specific Improving Organizational Performance activities and are directly involved in providing aggregate and other data analysis reports to staff. They conduct training to appropriate staff in the assembly of reports that enhance clinical, management, and financial information-based decision-making.
INFORMATION RESOURCES
All HEC professional and supervisory staff have dedicated email accounts and high-speed access to the global Internet. The Training Department uses the network to regularly advertise available conferences and seminars and the departments use the email network to routinely share articles, opinions, and case management tools. Electronic conferencing is used by the Clinical, Education, Quality Assurance, and Admissions Department to rapidly share critical information, share bst practices and collaboratively solve problems. The Management team has adopted an electronic strategy that enables them to meet and share documents and opinions in a virtual environment if necessary. All HEC electronic services, with the exception of finance and human resources data, are centralized, encrypted, and accessible from any workstation in the Hillcrest Network.
STUDENT RECORDS
Student-specific data and information are contained in the students’ Chart. The Chart exists to facilitate client care, treatment, and services, serve as a financial and legal record, support decision analysis, and guide professional and organization performance improvement. All Charts reside in a designated secure area on each HEC campus. Their access is defined by FERPA regulations and additional guidelines generated by the Chart committee. Student Progress Notes are stored electronically and their access is controlled via a regularly maintained role validation access mechanism. Additionally these progress notes are backed up on a daily basis to an offsite location in an encrypted form. Given that our agency is now a part of the New York and Massachusetts SACWIS systems (CONNECTIONS & Family Networks respectively) and anticipates eventual integration with other statewide automated child welfare information systems, the Management team is currently studying the efficacy of moving to an entirely electronic charting system.
EVALUATION & CONCLUSION
The collection and use of information at HEC is evaluated in an ongoing and continuous manner. Given the fluid and rapidly changing technology environment, the IS Department and Business Office find themselves in continuous consultation in an effort to provide the organization with adequate computing resources that remain balanced within organizational needs and resources. While users of the IS system often provide evaluative comments and feedback on a daily basis, more formal evaluation is provided by the campus based Improving Organization Performance committees. Additional evaluation is provided yearly by regularly scheduled, department specific Focus Groups as well as periodic surveys involving the entire community. The Senior Management Team and the Board of Directors formally evaluate the Information Management Plan every three years.
The benefits of information management systems have placed HEC in a position to provide high quality services to students that were unimaginable just ten years ago. Streamlined reporting and communications systems not only enhance services to students and funding agencies but also attract high caliber professional staff that can focus on more specific clinical delivery when reporting chores are lessened by automated systems. Despite our progress in these areas we still see ourselves very much at the beginning of our technology journey. We are fortunate to have made the progress we have and excited as we anticipate the future.

PM: STUDENT INJURIES DURING RESTRAINTS
Data submission: Data for campus submitted to the IS Director by the 15th day of each following month.
Quarterly Reporting Schedule: By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Student Injuries measure.

PM: STAFF INJURIES DURING RESTRAINTS
Data submission: The Assistant Director of Human Resources manages Staff Injury data and reports the data to the IS Director by the 15th of each month.
Quarterly Reporting Schedule: By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Staff Injuries measure.

PM: PHYSICAL INTERVENTIONS
Data submission: Data for campus submitted to the IS Director by the 15th day of each following month.
Quarterly Reporting Schedule: By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Physical Intervention measure.

PM: MEDICATION ERRORS
Data submission: The data/Med Tracking form is submitted to the IS Director within 7 working days after the end of each month.
Quarterly Reporting Schedule: By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Medication Error measure.

PM: STUDENT PERCEPTION OF CARE SURVEY (SPC)
Data submission: All sub and total scores are submitted to the IS Director within the first two weeks of the end of each month.
Quarterly Reporting Schedule: By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Student Perception of Care measure.

INSTRUMENT/DOCUMENT
The Student Perception of Care Survey developed by HEC.

MEASURE
Average “cluster scores” for each of 7 subsection: Environment of Care; School/Education; Medical/Dental; Staff; Treatment; Program, plus an average of the total ratings for survey. Scores above reported by campus and in aggregate form for the agency.

The PM consists of the averaged scores themselves (cluster scores and survey total score; campus + agency), and the differences between (+/-) the current quarter and those of the last quarter and the previous year.

ADMINISTRATION CYCLE
New Students
Only students who have been at a Hillcrest campus for more than 90 days will participate in the SPC. Students will participate in the SPC on each anniversary of their admission to HEC.

During Placement
The SPC is administered by the program’s designated staff member once each year on the anniversary of the student’s admissions to HEC. The SPC will eventually be scored (sub scores and total) by computer.

As Discharge Approaches
If the student nearing discharge has had the SPC during the past 6 months, the SPC will not be administered again. If the student nearing discharge has not had the SPC during the past 6 months, the student will participate in the SPC within 15 – 30 days of the projected discharge date.

Regarding ITU students, only students who have been at the ITU for more than 90 days should participate in the SPC. If the annual anniversary of the student’s admission to HEC will not occur prior to the student’s scheduled discharge/transfer from the ITU, the SPC should be administered to the student as discharge approaches, as described above.

ADMINISTRATION & DATA MANAGEMENT
The SPC is administered by the program’s designated staff member. It will eventually be computer scored. The designated campus person reports all sub and total scores to the IS Director within the first two weeks of the end of each month. (As noted below, the campus IOP Committee monitors instrument administration and CPM data reporting.)

The IS Director maintains the reported data and computes the campus and agency data for quarterly and annual reporting.

PERFORMANCE MEASURE REPORTING
By the 20th day of the following each quarter, the IS Director issues a quarterly report on the Student Perception of Care Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.
The IS Director provides interpretation of the quarterly data.

In addition to the sub, total and comparative scores, the analysis of both quarterly and annual data will include: N/total #; mean; median; frequency ranges (frequency w/in each segment in the range); mode (the +/- score that shows up most often).

PM OVERSIGHT
Because the numbers of SPC administered vary each month, depending on the number of students whose admission anniversaries occur and their length of placement at that time, the campus IOP Committee is responsible for overseeing the CS Performance Measure.

The IOP insures that 1) the tests are being administered and administered according to the schedule required by HEC procedures; 2) the CPM data is reported to the IS Director and reported according to the schedule required by HEC procedures.

INSTRUMENT/DOCUMENT

Medication Errors, including Omissions, are documented on the Nursing Occurrence Form.

MEASURE

The following medication errors are tracked:

• wrong medications (a medication not prescribed by a physician).
• wrong dosages (for medication prescribed by a physician, a dosage not prescribed by a physician is administered; higher or lower than prescribed).
• omissions/missed medications (medications prescribed by a physician but not administered).[1]

Data is tracked for the month and the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

One Nurse at each campus is designated to manage Med Error data. He/she tallies the data from the Nursing Occurrence Forms, enters the data on the computerized Med Tracking form, and send the data/Med Tracking form to the IS Director within 7 working days after the end of each month.

PERFORMANCE MEASURE REPORTING

By the 20^th day of the first month following each quarter, the IS Director issues a quarterly report on the Med Error Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The Program Manager provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Medication Error Performance Measure.

The IOP insures that 1) Med Errors are being documented and the associated data is being managed according to HEC procedures; 2) the Med Error data is reported to the IS Director and reported according to the schedule required by HEC procedures.

[1] Omissions do NOT include instances during which student refuse medication. These are classified as “Refusals”.

INSTRUMENT/DOCUMENT

Physical Interventions are documented on Physical Intervention Report forms.

MEASURE

The number of Restraints, Extended Restraints, and Total Restraints for the month and the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

One person at each campus is designated to manage PI data. He/she reports the data to the IS Director by the 15^th of each month.

PERFORMANCE MEASURE REPORTING

By the 20^th day of the first month following each quarter, the IS Director issues a quarterly report on the Physical Intervention Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The Program Manager provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Physical Intervention Performance Measure.The IOP insures that 1) PIs are being documented and the associated data is being managed according to HEC procedures; 2) the PI data is reported to the IS Director and reported according to the schedule required by HEC procedures.

INSTRUMENT/DOCUMENT

Staff injuries during restraints are documented on Accident Report & Treatment form (ART form), with a copy of the Incident Report form attached.

MEASURE

Included in this PM are all staff injuries:

• that occur during restraints;
• and for which ART forms are completed.

The number of staff injuries that occur during restraints for the month and the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

The person designated at the campus sends copies of all ART forms (with copies of Incident Report forms attached, for in juries that occur during restraints) to the Assistant Director of Human Resources. The Assistant Director of Human Resources manages Staff Injury data and reports the data to the IS Director by the 15^th of each month.

PERFORMANCE MEASURE REPORTING

By the 20^th day of the first month following each quarter, the IS Director issues a quarterly report on the Staff Injuries Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The Program Manager provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Staff Injury Performance Measure.

The IOP insures that 1) the injuries are being documented and the associated data is being managed according to HEC procedures; 2) the PM data is reported to the IS Director and reported according to the schedule required by HEC procedures.

INSTRUMENT/DOCUMENT

Student injuries during restraints are documented on Incident Report, Physical Incident Report forms and the Incidents All Sites Database.

MEASURE

The number of student injuries that occur during restraints, for the month and for the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

The Nursing Dept. notes any student injury and the severity of injury on the Incident Report or Physical Intervention report form. A specific person at the campus is designated to tally and enter such data. He/she reports the data for campus to the IS Director by the 15^th day of each following month.

PERFORMANCE MEASURE REPORTING

By the 20^th day of the first month following each quarter, the IS Director issues a quarterly report on the Student Injuries Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The IS Director provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Student Injury Performance Measure.

The IOP insures that 1) the injuries are being documented and the associated data is being managed according to HEC procedures; 2) the PM data is reported to the IS Director and reported according to the schedule required by HEC procedures.