HAMPSHIRE HOUSE: ACCREDITATION DOCUMENTATION LIST Std. # 1A-01 M
1A-02 M
1A-03
1A-04 M
1A-05 M
1A-06
Check Once Filed
Documentation Sanitation and Housekeeping P&P (re: water supply)
X
Letter certifying potability from Manchester Water Works
X
Website information from Manchester Water Works
X
Sanitation and Housekeeping P&P (re: sanitation and health code compliance)
X
Health Permit for NH Food Bank
X
City of Manchester, NH Ordinance
X
City of Manchester, NH Health Department Letter
X
Commercial Hood and Ventilation System Inspection
x
Weekly Sanitation Checklist/Daily Detail Roster (June, August)
X
Sanitation and Housekeeping P&P (re: program sanitation & safety inspection)
X
Room Search Forms (May & July)
X
Sanitation Report (June, August)
X
Sanitation and Housekeeping P&P (trash & garbage removal and needle coll.)
X
City of Manchester- Trash Removal Section of Website
X
Weekly Sanitation Checklist/Daily Detail Roster (June, August)
X
Room Search Forms (May, July, August)
X
Solid Waste Disposal Contract/Manchester Single-Stream Recycle Pamphlet
X
Waste Management Invoices
X
Sanitation and Housekeeping P&P (re: pest and vermin control)
X
Modern Pest Maintenance Agreement
X
Modern Pest Exterminating Treatment Plan Letter
X
Modern Pest Invoices (May & August)
X
Sanitation and Housekeeping P&P (re: housekeeping and maintenance plan)
X
Weekly Sanitation Checklist/Daily Detail Roster (June, August)
X
Room Search Forms (May & July)
X
RH (House Work Details)
X
1A-07
1A-08
1A-09
1A-10
1A-11
1A-12
1A-13
1A-14
1A-15
Resident Living Environment P&P (re: lighting)
X
Letter from Turner Engineers re: foot candles (adequate lighting)
X
Resident Living Environment P&P (re: ventilation)
X
Letter from Turner Engineers re: ventilation
X
Zoning and Building Code Compliance P&P
X
City of Manchester Inspection Certificate
X
Certificate of Use and Occupancy
X
Resident Living Environment P&P (re: rated bed capacity)
X
City of Manchester Inspection Certificate
X
Certificate of Use and Occupancy
X
Bedcounts (June & August)
X
Sanitation and Housekeeping P&P (re: housekeeping and maintenance plan)
X
Floor plans with janitorial supplies highlighted
X
Resident Living Environment P&P (re: bathroom facilities/showers)
X
Shower ratios (# of beds to # of showers)
X
Floor plans & blank bed sheet
X
Daily Kitchen Temperature Checklist (June & July)
X
Resident Furnishings P&P (re: access to writing and seating space)
X
Photographs of writing and seating areas
X
Resident Living Environment P&P (re: sleeping arrangements)
X
Bedcounts (June & August)
X
RH Page 14: Common areas
X
Floor Plans
X
Resident Furnishings P&P (re: decorations)
X
Intake Process P&P (re: admissions)
X
Resident Handbook (Resident Rooms)
X
1B-01 M
1B-02
1B-03
1B-04
1C-01
1C-01-1
1C-02 M
1C-04 M
1C-05 M
Memo from Assistant Director - re: annual review
X
Photograph of resident room
X
Resident Transportation P&P
X
Memo - re: no vehicle
X
Resident Transportation P&P
X
Memo - re: no vehicle
X
Resident Transportation P&P
X
Memo - re: no vehicle
X
Resident Transportation P&P
X
Memo - re: no vehicle
X
Emergency Plans P&P (re: analysis of emergencies)
X
Memo from Mari and Lyndsey re: stove fire
X
Staff fire safety training (after fire)
X
Emergency Plans P&P (re: analysis of emergencies)
X
Memo from Assistant Director re: no critical incidents at Hampshire House
X
Emergency Plans P&P
X
Memo from Assistant Director re: review of emergency & evacuation plans
X
Floor plans
X
Emergency Evacuation Plans in English and Spanish
X
Emergency Plans P&P (re: staff training)
X
Employee Orientation Checklist
X
Staff Training Roster (1. Emergency Plans) (May)
X
Training Schedule
X
Evacuation Plans (English & Spanish)
X
Emergency Plans P&P (re: dissemination of emerg. Plans)
X
1C-06
1C-07
1C-08 M
1C-09
1C-10 M
Floor plans
X
Copies of Letters containing Emergency Plans sent to NHEMA, Fire, Police
X
Work Stoppage Plans P&P (re: elements of the work stoppage plan)
X
Work Stoppage Plans
X
Memo re: no work stoppage in history of Hampshire House House
X
Staff Training Roster (2. Work Stoppage)
X
Training Schedule
X
Work Stoppage Plans P&P
X
Memo re: no work stoppage in history of Hampshire House House
X
Fire Safety Plans P&P (re: fire inspections)
X
Fire Inspection - Simplex Grinnell Alarm Inspection & Fire Protection Inspection Report
X
Fire Permit
X
Fire Department Commercial Hood and Ventilation System Insp.
X
Fire Safety Plans P&P (re: fire evacuation plans)
X
Emergency Plans P&P
X
Floor plans re: emergency route and signs
X
Resident Handbook (Fire Safety)
X
Fire Drills (May & July)
X
Copy of Letter Containing Emergency Plan sent to Manchester Fire Department
X
Staff Training Roster (3. Emergency Plans-Evac./Fire)
X
Training Schedule
X
Fire Safety Plans P&P (re: fire inspections)
X
Manchester Fire Inspection
X
Manchester Fire Permit
X
LRC Fire Safety Inspection of Kitchen Hood & Simplex Inspection
X
RE Lyons Inspections
X
Sprinkler System Inspection Report (Fire Protection Technology)
X
List of all fire equipment (including fire extinguishers and locations)
X
Simplex Fire Alarm Panel Inspection
X
1C-11 M
1C-12 M
1C-13 M
1C-14 M
1C-15 M
1C-16 M
RE Lyons Service Agreement (June 2009)
X
Floor Plans
X
Fire Safety Plans P&P (re: fire inspections)
X
Fire Permit
X
Field Inspection Report - Occupancy Certificate?
?
City of Manchester Inspection Certificate - Fire Inspection?
?
Fire Safety Plans P&P (re: fire prevention and safety & fire prevention serv.)
X
Fire drills (May & July)
X
Attendance rosters for staff training & training materials (PM Manual) in Fire Safety (4. Fire Safety)
X
Memo re: review of fire prevention plan at Hampshire House House
X
Document w/ Name of 1st Responder Station (Fire Station)
X
Fire Safety Plans P&P (re: fire protection services and equipment)
X
RE Lyons Inspections
X
Simplex Grinell Alarm Inspection Report
X
Sprinkler Inspection INVOICE (Fire Protection Technology)
X
Fire Safety Plans P&P (re: fire inspections & protection services and equip.)
X
Fire Inspection
X
LRC Fire Safety Inspection of Kitchen Hood & Simplex Inspection
X
City of Manchester Inspection Certificate
X
RE Lyons Inspections
X
Floor plans re: fire protection equipment
X
Sprinkler System Annual Inspection w/ invoice
X
Fire Safety Plans P&P (re: furnishings)
X
Bob Barker invoices (August 2009) sheets, pillows, pillow cases - missing blanket?
X
Bob Barker Flammability Ratings for pillows and blankets
X
Ecin Mattress Order (no re-orders since)
X
Fire Safety Plans P&P (re: flammable, toxic, and caustic materials)
X
Resident Handbook (cleaning supplies)
X
1C-17 M
1C-18
2A-01
2A-02
2A-03
Memo re: Hampshire House House does not use or store flammables
X
Statement of Work (re: flammables)
X
MSDS Sheets (of alternative items) - (photo of binder, sign out sheet & MSDS)
X
Employee orientation checklists
X
Fire Safety Plans P&P (re: flammable, toxic, and caustic materials)
X
Resident Handbook (prohibited items/Cleaning Supplies )
X
Memo re: Hampshire House House does not use or store toxic materials
X
MSDS Sheets (of alternative items) - (photo of binder, sign out sheet & MSDS)
X
Statement of Work (re: toxic materials)
X
Fire Safety Plans P&P (re: usage of…)
X
Resident Handbook (prohibited items/Cleaning Supplies )
X
Resident Handbook Acknowledgment Forms (June & August)
X
Staff Training Roster (5. Toxic Caustic)
X
Hampshire House Program Monitor How-to-guide (details and chemicals)
X
Training Schedule
X
Resident Accountability P&P (re: facility access and egress)
X
Vendor/Contractor Supervision P&P
X
Visitation P&P (re: monitoring of visits and visitors)
X
Resident Handbook (Resident Accountability)
X
Resident Handbook (Visitors)
X
Structure Sheet highlighting time out, time in, and C.O.D. (June & August)
X
General Log (June & July)
X
Visitation P&P (re: monitoring of visits and visitors)
X
Vendor/Contractor Supervision P&P
X
Resident Handbook (Visitors)
X
General Log documenting a visitor's arrival and departure (May &July)
X
Visitation Request Form (March & June)
X
Visitor Logs (June & July)
X
Staff Availability P&P
X
2A-04
2A-05
Adult Budget Breakdown
X
Staffing Requrements (Admin P&P Manual)
X
Budget Program Staff List (put on checklist: see Director for this confidential document ) cheklist- Note: refer back to general log copies reflecting 24 hour coverage
X
Staff Availability P&P
X
Desk Staff Schedule (May & Aug)
X
Staff Availability P&P
X
Desk Staff Schedule Indicating Gender Breakdown (May & June)
X
2A-06
N/A: Not governed by civil service or unions
2A-07
Intake P&P
X
LSIs & IANs (June & August)
X
Resident Admission Criteria P&P (re: rejections)
X
Rejected Referrals (May & June - None for July or August)
X
Memo - Rejected Referrals
X
Communications P&P (re: general log book)
X
Shift Summaries from general log///Log Notes not Summary (June & August)
X
Weapons P&P
X
Memo re: no instances involving weapons at Hampshire House House
X
RH pages (Prohibited Items/Prohibited Acts)
X
Visitor Request Form
X
Pictures of Gun locker
X
Resident Accountability P&P (re: system for resident accountability)
X
RH Pages (Count & Resident Accountability)
X
Headcounts (June & July)
X
Spot Checks (June & July)
X
Resident Accountability P&P (re: reporting escapes)
X
2A-08
2A-09
2A-10 M
2A-11
2A-12
IAN (escape)
X
General log note
X
Incident Report
X
Memo from A.D. (June & August)
X
2A-13
N/A: No electronic monitoring at Hampshire House
2A-14
N/A: No electronic monitoring at Hampshire House
2A-15
N/A: No electronic monitoring at Hampshire House
2A-16
N/A: No electronic monitoring at Hampshire House
2A-17
N/A: No electronic monitoring at Hampshire House
2B-01 M
Use of Force P&P
X
Memo re: no incidents of use of force at Hampshire House House (rewritten)
X
Use of Force P&P
X
Memo re: no incidents of use of force at Hampshire House House
X
Use of Force P&P
X
Memo re: no incidents of use of force at Hampshire House House
X
Searches P&P (re: contraband)
X
Resident Handbook (prohibited items)
X
Resident Handbook Acknowledgment Forms (August & June)
X
Searches P&P
X
Resident Handbook (prohibited items & Inspections )
X
Chronological Log of urine specimens (May & July)
X
Alco-sensor logs (March - July)
X
Room search (May & August)
X
Shift Paperwork Bag Searches (May & July)
X
Incident reports for contraband (June & July)
X
Notice of Confiscated Property (June)
X
2B-02
2B-03
2C-01
2C-02
2C-03
2C-04
2C-05
2C-06
2D-01 M
2D-02 M
2D-03 M
3A-01
3A-02
Searches P&P
X
Resident Handbook (prohibited items, rules and sanctions, list of BOP prohibited acts)
X
Incident reports for contraband (June & July)
X
Notice of Confiscated Property (June)
X
Searches P&P
X
memo re: no body cavity searches/ investigations
X
Searches P&P
X
memo re: no body cavity searches/ investigations
X
Searches P&P
X
memo re: no body cavity searches/investigations
X
Control and Use of Keys, Tools, & Equipment P&P
X
Tool Control Plan
X
Tool Inventory
X
Tool sign in/out sheet
X
Control and Use of Keys, Tools, & Equipment P&P
X
Tool Control Plan
X
Tool sign in/out sheet
X
Control and Use of Keys, Tools, & Equipment P&P
X
Resident Key Control Form (April - August)
X
Staff Key Inventory
X
Key Return Form for staff - (memo re: no staff changes within the past year) rewrite
X
Picture of key control box
X
Memo: resident key/bedrooms
X
Resident Rules and Sanctions P&P (re: rule violations)
X
RH (program rules; violations & sanctions; BOP prohibited acts)
X
Resident Rules and Sanctions P&P (annual review)
X
3A-03
3A-04
3A-05
3A-06
3A-07
4A-01 M
RH (program rules; violations & sanctions)
X
Memo re: "I have reviewed the rules and regulations and no updates have been necessary"
X
Resident Rules and Sanctions P&P (re: admissions)
X
RH (program rules; violations & sanctions; BOP prohibited acts)
X
Intake Process P&P (admissions c(2) + c(3)(b))
X
Resident Rules and Sanctions P&P
X
RH (program rules; violations & sanctions; medical services) & Orientation
X
Blue card, RH acknowledgment form, orientation checklist, agreement form all stapled together (June & August)
X
Intake Process P&P (re: translation) ((3)b - admissions)
X
Resident Handbook in Spanish
X
Resident Acknowledgement Sheet
X
Memo from Program Monitor about explaining rules & regs in Spanish
X
Resident Finances P&P
X
Resident Rules and Sanctions P&P
X
RH (subsistence)
X
RH (rules; violations & sanctions & BOP Violations)
X
Employee Handbook (Professional behavior highlighted)
X
Employee checklist with staff integrity and professionalism section highlighted (May, Sept)
X
memo re: no disciplinary action for "unprofessional behaviors"
X
Food Services P&P (re: Dietician Review)
X
Dietician License, Comm. on Dietetic Registration Cert; Safe Serve Cert
X
Letter from RFS re: 5 wk cycle meets dietary requirements for adults
X
Menus
X
RFS Invoices, corresponding menu sheet, & grid for the week (May, Sept)
X
Memo re: HH doesn't serve or prepare food
X
4A-02 M
4A-03
4A-04 M
4A-05
4A-06
4A-07
4A-08
Food Services P&P (re: special diets and meals)
X
Documentation of special medical diets (general log notation of a diabetic resident; structure sheet labels re: special diet, & case note) - email & resident master list (June & July)
X
Agar Supply Kitchen Invoice (shows soy milk order)
X
Food Bank Invoice for Alternative Meals
X
Memo re: HH doesn't serve or prepare food
X
Food Services P&P (re: special diets and meals)
X
Documentation of special medical diets (general log notation of a diabetic resident; structure sheet labels re: special diet, & case note) - email & resident master list only
X
Food Bank Invoice for Alternative Meals
X
Food Services P&P (re: licensing and certification & inspections)
X
Health Permit
X
City of Manchester Inspection Certificate
X
Certificate of Compliance for Kitchen Grease Exhaust (refer to hood)
X
ServSafe Certificates (Multiple Current Staff)
X
Food Services P&P
X
RH (meals)
X
Floor plans with dining areas highlighted
X
Food Service P&P
X
Floor plans with dining areas highlighted
X
Weekly Sanitation Checklist/Daily Detail Roster (June, August)
X
Food Service P&P
X
Floor plans with dining areas highlighted
X
Weekly Sanitation Checklist/Daily Detail Roster (June, August)
X
Daily Kitchen Temperature Checklist (May - July)
X
Food Service P&P
X
Photograph of bathroom closest to kitchen
X
Floor Plans of Location of Bathroom Closest to Kitchen
X
4B-01
4B-02
4B-03
4B-04
4B-05
4C-01 M
4C-02 M
4C-03 M
Personal Hygiene Articles P&P
X
Photograph of hygiene kit
X
Photograph of a resident's personal hygiene items
X
Resident Living Environment P&P (re: washer/dryer)
X
RH (laundry)
X
Resident Laundry sign-up sheets
X
Resident Living Environment P&P
X
RH (Resident Rooms)
X
Photograph of resident room and bathroom (women's & men's bathrooms)
X
Training Roster
X
Resident Furnishings P&P
X
RH (laundry)
X
Photograph of linen closet
X
Resident Room & Property Inspection Property Issued (May-July)
X
Personal Hygiene Articles P&P
X
Photograph of linen closet
X
Photograph of hygiene kit
X
Healthcare Services P&P
X
RH (medical services, prescription medication, grievances)
X
General log notes for ambulance rides (June)
X
Medical Itinerary w/corresponding structure sheets (April)
X
Memo: No ambulance rides since June/none in 3rd quarter
X
Healthcare Services P&P
X
Letters from medical providers (CMC)
X
Memo re: no medical services provided at Hampshire House House
X
Healthcare Services P&P
X
General log notes for ambulance rides (June)
X
4C-04 M
4C-05
4C-06 M
4C-07
4C-08
CPR Cards for HH Staff
X
Healthcare Services P&P (re: training)
X
********Floor plans re: front desk - NEED AED******
X
CPR cards and/or CPR training roster from Maria Alexson (have cards no roster emailed Maria Alexson for roster on 10/15/10)
X
American Red Cross Adult CPR/AED & First Aid curriculum
X
Signs/symptoms of mental illness, mental retardation, chemical dependency staff attendance training roster
X
Signs/symptoms of mental illness, mental retardation, chemical dependency curriculum
X
Training Staff Roster (6. CPR/MI, MR, CD Signs & Symptoms)
X
Training Schedule
X
Healthcare Services P&P (re: first aid equipment)
X
Floor plans (with first aid kit locations highlighted)
X
List of contents in first aid kits
X
Photograph of AED (defibrillator)
X
Healthcare Services P&P
X
Blue card with meidcal/psychiatric social (Dec., Feb., & April)
X
TDAT referral with corresponding appointment sheet (April, August)
X
Medical Quick Sheets (May, May, June), intake form, physical exam,
X
Healthcare Services P&P (re: medical examinations)
X
Blue cards with brookline health stop appointments attached. Dates should be highlighted on both to show exams are scheduled within 14 days of arrival - ACA (SOW requires 5 days) - (April) Blue Card w/ Physical attached (Ma & September)
X
IAN w/ Corresponding Physical in 7 days (May - same as one above)
X
Memo- re: SOW says 5 days
X
Healthcare Services P&P (re: communicable diseases)
X
RH (universal precautions)
X
Memo re: no communicable diseases
X
4C-09
4C-10
4C-11
4C-12
4C-13
4C-14
4C-14-1
Serious and Infectious Diseases P&P
X
Memo re: Hampshire House provides for the management of serious and infectious diseases
X
Hepatitis A and C brochures
X
RH (universal precautions)
X
Serious and Infectious Diseases P&P
X
RH (HIV)
X
Healthcare Services P&P (re: communicable diseases)
X
HIV / Exposure to blood brochures
X
Healthcare Services P&P
X
PRA/Med Itinerary with corresponding structure sheets for dental visits (August)
X
Prescription/Medication Control P&P
X
Healthcare Services P&P
X
Medication adminstration sheets (Cx intaked:June, August)
X
RH (prescription medications)
X
Prescription/Medication Control P&P (re: distribution)
X
Healthcare Services P&P
X
Medication adminstration sheets (Cx intaked:June, August)
X
Medication audits AD
X
Care for Pregnant Residents P&P
X
Itineraries for Medical Services (Memo)
X
Print outs for Planned Parenthood
X
Families in Transitions Brochure
X
N/A re: nursing infants in program Care for Pregnant Residents P&P
X
Families in Transitions Brochure
X
4C-15
4C-16 M
Healthcare Services P&P (re: access)
X
RH (mental health treatment)
X
Structure sheets with appointment sheets for mental health (Sept/)
X
TDAT Referral & Matching appointment reminders (April & August)
X
Suicide Prevention P&P (approved by Terry Burch, CSMA Senior Clinician)
X
RH (suicide prevention)
X
Staff Directory idicating Terry Burch as approved authority
X
Memo re: no suicides
X
Training schedule
X
Training Roster (7. Suicide) Report
X
Suicide training staff attendance rosters
X
Samaritans curriculum (put in brochurs, need power point)
X
4C-17
N/A: No medical services provided at Hampshire House
4C-18
N/A: No medical services provided at Hampshire House
4C-19
N/A: No medical services provided at Hampshire House
4C-20 M
Resident Rights P&P
X
RH (resident rights)
X
Memo re: no residents have participated in medical, pharmaceutical, or cosmetic experiments
X
Emergency contact notification P&P (re: resident illness)
X
Intake Info Form (April & July)
X
4C-21
4C-22
N/A: No medical services provided at Hampshire House
4C-23
N/A: No medical services provided at Hampshire House
4C-24
N/A: No medical services provided at Hampshire House
5A-01
Resident Program Plans P&P (re: IPP)
X
Individual Program Plans (IPP) with corresponding Level of Service Inventory (LSI) - (April, July)
X
Resident Program Plans P&P (re: IPP)
X
5A-02
Treatment Services P&P
X
IPP with corresponding structure sheet showing the IPP being carried out (i.e. find rel. residence) - (April, July)
X
Resident Program Plans P&P (re: plan development)
X
Comprehensive Case Management P&P
X
IPP with blue card stapled (April, July)
X
Resident Program Plans P&P (re: plan changes)
X
Level change requests (June, September)
X
Resident Program Plans P&P
X
Release Preparation P&P
X
LSIs w/ corresponding Closing Summaries (June, Sept)
X
Resident Admission Criteria P&P (re: resident removal or transfer)
X
Closing summaries for removed or transferred residents w/ corresponding IAN (Sept)
X
Resident Program Plans P&P (re: plan development)
X
Intake Process P&P (re: admission)
X
Comprehensive Case Management P&P (re: assignment of case manager)
X
Case notes (2 res. A. apr, june, sept b. aug, sept)
X
Memo re: case manager assignment
X
Arrival/Release Sheet w/ CM assignments(June, Sept)
X
5A-08
TDAT Referrals & Appointment Reminders (April, August)
X
5A-09
Urine Collection P&P (re: test procedure)
X
RH (drug and alcohol tests)
X
U/A lab results: showing chain of custody (May, Sept)
X
memo: no refusals and/or negative results in the past 6 mo.
X
MMR results (April - August)
X
IRs for positive UA results & paperwork
X
Resource List and Access to Community Services P&P
X
5A-03
5A-04
5A-05
5A-06
5A-07
5A-10
5A-11
5A-12
5A-13
5A-14
5A-15
5A-16
5A-17
Healthcare Services P&P (re: health education)
X
RH (HIV)
X
Picture med section community resource binder
X
Treatment Services P&P (re: community resources)
X
Resource Directory and Access to Community Services P&P
X
TDAT referrals and corresponding structure sheets (June, July)
X
CMC & Elliot Hospital Letters
X
Resource List and Access to Community Services P&P
X
RH (Resources)
X
Memo
X
Resource List, Manchester Help Directory Book
X
Resource Manual and Access to Community Services P&P (re: content)
X
Housing and Transitional Assistance P&P
X
Housing searches (PRA, structure sheets, etc.) - (June, Sept)
X
Home Furlough Pass Programs P&P
X
Home passes (April, August)
X
Release Preparation P&P (re: closing summary)
X
Closing summaries (June, July)
X
Treatment Services P&P (re: family involvement)
X
Home Furlough P&P (re: pass program/PRA/furloughs)
X
Visitation P&P
X
RH (visitors)
X
Home Passes ( pass request approval & itinerary) - (Apr, Aug)
X
Visitation P&P
X
RH (visitors)
X
Visitor Log Pages (March-June; July - Sept)
X
Banned Visitors email (September, visitor log pages, visitor request form & license picture July)
X
5A-18
5A-18-1
Visitation P&P (re: special visits)
X
General Log & Emails for approved special visits (May, Sept)
X
Emergency Contact Notification P&P Pass Program/PRA/Furloughs P&P (re: types of reintegration activities)
5A-19
5A-19-1
5A-20
5A-21
5A-22
5A-23
X X
Case notes documenting emergency situations (ill family member, funeral request)
X
Resident Communications P&P (re: telephone calls)
X
RH (telephones)
X
Photograph of resident telephones
X
Photograph of TTY phone
X
Telephone contract for resident phones
X
Resident Communications P&P
X
Telephone contract for resident phones
X
Job Search Assistance P&P
X
RH (Employment)
X
Job search itineraries (Apr, Jun, Jul, Sept)
X
Photograph of Job Posting Binder
X
Recreational Opportunities P&P
X
RH (recreation)
X
Photograph of TV
X
Photograph of bookcase
X
Structure sheets for recreation (YMCA etc.) - (May, July)
X
Religious Preferences P&P
X
RH (religious services)
X
Request for religious services and documentation (May, July)
X
Local Places of Worship Resource List
X
Program Meeting Space P&P
X
Visitation P&P
X
Recreational Opportunities P&P
X
Floor plans with recreation areas highlighted
X
RH (recreation)
X
Program Meeting Space P&P
X
Staff offices list with case managers highlighted
X
Floor plans with staff offices highlighted
X
Program Meeting Space P&P
X
Floor plans with TV, visitor room, and classroom highlighted
X
Staff offices list
X
Picture of front of Hampshire House
X
Map with designated counseling services, probation, etc.
X
Resident Rights P&P
X
RH (resident rights)
X
Memo re: no examples of attorney visits at Hampshire House
X
6A-01-1
Memo stating that residents with mental/physical impairments would be submitted to BOP for review
X
6A-02
Resident Rights P&P
X
RH (resident rights)
X
Structure pages w/ Public Library use (May, July)
X
Memo re: access to law library
X
Use of Force P&P
X
RH (resident rights)
X
memo re: no use of force/corporal punishment used
X
Zoning and Building Code Compliance P&P
X
5A-24
5A-25
5A-26
6A-01
6A-03
6A-04
6A-04-1
N/A: Hampshire House House does not receive residents who cannot perform basic life functions
6A-04-2
Zoning & Building Code Compliance P&P
X
6A-05
Resident Rights P&P
X
RH (sexual abuse)
X
RH (resident rights)
X
Resident Communications P&P (re: indigent residents)
X
Resident Finances P&P (re: indigent residents)
X
Example of postage provided to a resident (copy of a letter with postage; Aug, Sept)
X
Bus pass list (October 14)
X
Resident Communications P&P (re: mail)
X
RH (resident conduct)
X
RH (mail)
X
Resident Sign-Off on RH (April, July)
X
Staff Orientation Checklist
X
Resident Communications P&P
X
RH (resident conduct)
X
memo re: opening mail
X
Picture of resident mail
X
Notice of rejected resident mail
X
Resident Communications P&P (re: forwarding first class mail)- revision needed
X
Memo re: mail forwarded for first 30 days, then returned to sender after 30 days
X
Picture of forwarded mail & RTS mail (Aug, Oct)
X
Intake P&P (legal authority)
X
J&C
X
Resident Admission Criteria P&P
X
6A-06
6A-07
6A-08
6A-09
6A-10
6A-11
6A-12
6A-13
6B-01
6B-02
6B-03
6C-01
6C-02
Intake Process P&P (re: admission)
X
Resident Rejection Letter (Rejected Referral June, October)
X
Acceptance Referral Sheets (April, July)
X
Memo re: acceptance procedures
X
Resident Admission Criteria P&P (re: dissemination)
X
Memo re: BOP, US Probation, MA Parole Board, and Suffolk County are aware of Hampshire House House policies on admission
X
Release Preparation P&P (re: release process)
X
RH (release)
X
Relocation Requests w/ corresponding release plan (June, Sept)
X
Equal Access to Programs and Services P&P
X
Resident Admission Criteria P&P
X
RH (resident rights)
X
Memo re: no incidents of discrimination
X
Resident Admission Criteria P&P
X
RH (resident rights)
X
Memo re: no incidents of discrimination
X
Resident Grievance and Appeal Process P&P
X
RH (grievances)
X
Memo re: no grievances
X
BP-8 & Response (July)
X
Resident Rules and Sanctions P&P (minor infractions)
X
RH (rules; violations and sanctions)
X
Incident reports for minor infractions (April & July)
X
Resident Rules and Sanctions P&P
X
RH (rules; violations and sanctions)
X
Incident reports for major infractions (April)
X
6C-03
Resident Rules and Sanctions P&P
X
RH (rules; violations and sanctions)
X
Incident reports (April, July)
X
Needs to be highlighted
FBOP SOW (discipline)
X
6C-04
Resident Rules and Sanctions P&P (re: progressive discipline)
X
RH (rules; violations and sanctions)
X
Incident reports showing progressive discipline (i.e. 20 hours extra duty to 40 hours extra duty) - need examples that show multiple violations
X
Progressive Discipline Sanctions - HH Discipline records for 2nd & 3rd qtr for 2 individual residents to match above incident reports
X
Resident Finances P&P
X
RH (subsistence)
X
Examples of child support, appearance in family court, or other examples of restitution etc. (payment & court doc 2nd qtr; payments 3rd qtr)
X
Orientation to Supervision Manual US Probation (section II: Restitution)
X
Resident Finances P&P (re: monthyl budgets)
X
Examples of child support, appearance in family court, or other examples of restitution etc. (payment & court doc 2nd qtr; payments 3rd qtr)
X
Orientation to Supervision Manual US Probation (section II: Restitution)
X
Legal Entity & By-Law Requirements P&P *(Admin. P&P: Policy 200.00)
X
Articles of Organization
X
CRJ Annual Report (2007)
X
501 C3 Application (tax-exempt status)
X
6D-01
6D-02
7A-01
7A-02
N/A: CRJ is not a sole proprietor
7A-03
Fiscal Agency Audits & Reports P&P *(Fiscal P&P: Policy 400.02)
X
Reporting Requirements P&P *(Admin. P&P: Policy 211.00)
X
990 Form (extenstions)
X
Tax Returns (extensions)
X
Legal Entity & By-Law Requirements P&P *(Admin. P&P: Policy 200.00)
X
***7A-04
7A-05
7B-01
7B-02 M
7B-03
7B-04
7B-05
7B-06
7B-07
CRJ By-Laws
X
Zoning and Building Compliance P&P
X
Use of Occupancy
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Resume from Director of Hampshire House
X
Job description for Hampshire House Director
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Certifications of Lisa's CPR/FA
X
Employee Handbook (Prof. Staff & Staff Classifications)
X
Volunteers and Citizen Involvement P&P *(Admin. P&P: Policy 700.00)
X
Memo re: there are no volunteers providing professional services
X
Volunteer Handbook
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Employee Handbook (training section)
X
Hampshire House job descriptions
X
CRJ Hiring Process
X
Selection and Interview Process
X
Examples of Tuition Reimbursement
X
Any examples of employees receiving credit for prior training (Erik CPR)
X
Employee Handbook (Criminal and background checks)
X
CRJ Hiring Process
X
CRJ 3 month performance review (blank?)
X
CRJ performance appraisal: self-evaluation (blank?)
X
CRJ performance appraisal: program monitor (blank?)
X
CRJ performance appraisal: supervisory staff (blank?)
X
CRJ performance appraisal: professional staff (blank?)
X
Operations Manual P&P *(Admin. P&P: Policy 110.00)
X
Employee orientation checklist (May, August)
X
7B-08
Operations Manual P&P *(Admin. P&P: Policy 110.00)
X
7B-09
Operations Manual P&P *(Admin. P&P: Policy 110.00)
X
7B-10
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Training Schedule
X
Director Human Resources Resume
X
Training Roster
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
ACA training requirements
X
BOP training requirements (found in the SOW)
X
Training Schedule
X
Annual Training Needs Assessment
X
CRJ performance appraisal: self-evaluation (blank?)
X
CRJ performance appraisal: supervisory staff (blank?)
X
CRJ performance appraisal: professional staff (blank?)
X
Job Analysis Questionnaire
X
CRJ Management Development Individual Planning
X
Training and Development Assessment Tool Guide
X
Training Roster
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Training Evaluation Forms (completed examples, May, Sept)
X
Maria Alexson's Train the Trainer Certificate
X
Training Roster
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Samaritans Brochure (to show that the training utilizes community resources)
X
Servsafe Invoices (to show that the training utilizes community resources)
X
E-Academy website page
X
Training Roster
X
7B-11
7B-12
7B-13
7B-14
7B-15
7B-16
7B-17
7B-17-1
7B-18
7B-19
7C-01
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Employee Orientation Checklist (May, August)
X
Staff Training Schedule
X
Staff Training Roster/Report (8)
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Staff Training Schedule
X
Staff Training Roster/Report (9)
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Training Roster
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Staff Training Schedule
X
Staff Training Roster/Report (10)
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Staff Training Schedule
X
Staff Training Roster/Report (11)
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Contract Staff Orientation Checklist
X
Staff Training Schedule
X
Staff Training Roster/Report (12)
X
Expense Reimbursement P&P *(Fiscal P&P: Policy 400.12)
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Employee Handbook (Professional Development; Tuition Reimbursement; Tuition Remission; E-Academy)
X
Examples of Tuition Reimbursement (Matt C.)
X
Blank Tuition Reimbursement Form
X
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Employee Orientation Checklist (May, August)
X
7C-02
7D-01
7D-02
7D-03
7D-04
7D-05
7D-06
7D-07
Staff Training and Development P&P *(Admin. P&P: Policy 500.15)
X
Drug Free Work Place P&P
X
Goals and Objectives P&P *(Admin. P&P: Policy 210.10)
X
Hampshire House Annual Goals
X
Goals and Objectives P&P *(Admin. P&P: Policy 210.10)
X
Management Audit in a Residential Facility P&P *(Admin. P&P: Policy 275.00)
X
Annual BOP self-monitoring from Susan Jenness Phillips
X
S&QA Adult Survey Results, Jan '10
X
Organizational Chart & Description P&P *(Admin. P&P: Policy 220.00)
X
CRJ Organizational Chart
X
Hampshire House Organizational Chart
X
Volunteer and Citizen Involvement P&P *(Admin. P&P: Policy 700.00)
X
CRJ Organizational Chart
X
Hampshire House Organizational Chart
X
Use of Electronic Equipment & Information P&P *(Admin. P&P: Policy 800.01)
X
Annual and Monthly Report P&P *(Admin. P&P: Policy 270.00)
X
Photograph of resident files
X
Hampshire House Monthly Management Reports (April - September)
X
Research Ethics P&P *(Admin. P&P: Policy 600.10)
X
Public and Community Relations P&P *(Admin. P&P: Policy 260.00)
X
Copy of letter containing emergency plans to Manchester Police Department
X
CRJ Annual Report (2007)- on checklist: refer to 7A-01
X
CJI Publication entitled, "Promoting Public Safety Through Successful Community Transitions"
X
CJI list of publications
X
Intake Process P&P (enumerated)
X
Hampshire House Blue Cards w/ additional information found on the Medical Intake (June, October)
X
7D-08
Case Records P&P
X
Confidentiality and Release of Information P&P *(Admin. P&P: Policy 370.05)
X
Case Record Management in Residential Programs P&P *(Admin. P&P: Policy 370.00)
X
Use of Electronic Equipment & Information P&P *(Admin. P&P: Policy 800.01)
X
Information Storage and Retrieval P&P *(Admin. P&P: Policy 370.03)
X
Release of information
X
Employee Orientation Checklist (May, August)
X
Case Records P&P
X
Case Record Management in Residential Programs P&P *(Admin. P&P: Policy 370.00)
X
Case Records P&P
X
Case Record Management in Residential Programs P&P *(Admin. P&P: Policy 370.00)
X
Closing summaries for transferred residents
X
Case Records P&P
X
Case Record Management in Residential Programs P&P *(Admin. P&P: Policy 370.00)
X
Memo re: resident access to case records
X
7D-12
Research Ethics P&P *(Admin. P&P: Policy 600.10)
X
7D-13
Resident Property Control P&P
X
Resident Handbook (Prohibited Items)
X
Resident Property Control P&P
X
Confiscated Property Form (Oct.) & Holding $$ Form 2nd qtr
X
Emergency Contact Notification P&P
X
Memo re: no deaths at Hampshire House House
X
Fiscal Budgets P&P *(Fiscal P&P: Policy 400.01)
X
Program Director Job Description
X
***7D-09
7D-10
7D-11
7D-14
7D-15
7D-16
Emails re: budget process
X
Fiscal "Fiscal" P&P *(Fiscal P&P: Policy 400.04)
X
Fiscal Client and/or Staff Financial Transactions P&P *(Fiscal P&P: Policy 400.05)
X
Finance Client Funds P&P *(Fiscal P&P: Policy 400.06)
X
Fiscal Insurance P&P *(Fiscal P&P: Policy 400.03)
X
Expense Reimbursement P&P *(Fiscal P&P: Policy 400.12)
X
Resident Finances P&P
X
Expense Reimbursement Examples
X
Fiscal Budget P&P *(Fiscal P&P: Policy 400.01)
X
Adult Budget
X
Hampshire House House Budget
X
CRJ's analysis of the budget presented to the Board of Directors
X
Board of Director's Meeting Minutes
X
7D-19
Fiscal Budget P&P *(Fiscal P&P: Policy 400.01)
X
7D-20
Fiscal Budget P&P *(Fiscal P&P: Policy 400.01)
X
FMRs
X
General Ledger
X
Hampshire House House Budget
X
Fiscal Client and/or Staff Financial Transactions P&P *(Fiscal P&P: Policy 400.05)
X
Resident Finances P&P
X
Photograph of safe in 213 (where money orders are stored)
X
Fiscal "Fiscal" P&P *(Fiscal P&P: Policy 400.04)
X
FMRs
X
Independent Auditor's Report- see Financial Audit Report from 7D-24
X
Surplus/Deficit Report
X
Fiscal Agency Audits & Reports P&P *(Fiscal P&P: Policy 400.02)
X
FMRs
X
7D-17
7D-18
7D-21
7D-22
7D-23
7D-24
7D-25
7D-26
7D-27
7D-28
Surplus/Deficit Report
X
Fiscal Agency Audits & Reports P&P *(Fiscal P&P: Policy 400.02)
X
FMRs
X
Fiscal "Fiscal" P&P *(Fiscal P&P: Policy 400.04)
X
Fiscal Fixed Assets and Capitalization Index P&P *(Fiscal P&P: Policy 400.07)
X
Inventory P&P *(Fiscal P&P: Policy 400.08)
X
Hampshire House House Inventory
X
Inventory card
X
Budged P&P *(Fiscal P&P: Policy 400.01)
X
Budget P&P
X
Adult Budget Breakdown
X
RFS Invoices (2 May, 2 Sept)
X
FMRs
X
Fiscal "Fiscal" P&P *(Fiscal P&P: Policy 400.04)
X
Fiscal Budgets P&P *(Fiscal P&P: Policy 400.01)
X
Adult Budget Breakdown
X
Hampshire House House Budget
X
Vacancy Request Process
X
Vacant position request form
X
CRJ internal job inquiry form
X
CRJ Hiring Process
X
Employment Legal Status: I-9 (checklists: refer to personnel files)
X
Fiscal Insurance P&P *(Fiscal P&P: Policy 400.03)
X
Summary of Insurance
X
7D-29
N/A: There is no commissary or canteen
7D-30
Fiscal Client and/or Staff Financial Transactions P&P *(Fiscal P&P: Policy 400.05)
X
Receipt of Resident Travel Funds
X
7D-31
7D-32
7D-33
7D-34
7D-35
7D-36
7D-37
7E-01
7E-02
Resident Fees and Ability to Pay P&P
X
Fiscal "Fiscal" P&P *(Fiscal P&P: Policy 400.04)
X
Resident Finances P&P
X
Fiscal Client and/or Staff Financial Transactions P&P *(Fiscal P&P: Policy 400.05)
X
RH (Subsistence)
X
SOW (Subsistence)
X
Resident Finances P&P
X
Fiscal Client and/or Staff Financial Transactions P&P *(Fiscal P&P: Policy 400.05)
X
Examples of Resident Subsistence (both employed and unemployed residents)
X
BOP Invoices
X
Board of Director's Meeting P&P *(Admin. P&P: Policy 250.00)
X
Communication P&P *(Admin. P&P: Policy 380.00)
X
Communication P&P *(Admin. P&P: Policy 380.00)
X
Hampshire House House staff meeting minutes
X
Hampshire House House staff attendance roster for staff meetings
X
Communication P&P *(Admin. P&P: Policy 380.00)
X
Any internal memo that shows client/staff communications
X
Program Meeting Space P&P
X
Floor plans with staff offices highlighted
X
Employee Handbook (re: grievances)
X
memo: no grievances
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Floor plans with elevator and ramp highlighted - need memo
X
memo: no ne construction - grandfathered into previous building codes
X
7E-03
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
7E-04
CRJ Sexual Harassment Policy
X
Employee Handbook (sexual harassment)
X
Employee orientation checklist
X
Training Roster
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Employee Handbook (Equal Employment Opportunity)
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Employee Handbook (Equal Employment Opportunity)
X
Organizational Chart & Description P&P *(Admin. P&P: Policy 220.00)
X
Legal Assistance P&P *(Admin. P&P: Policy 280.00)
X
Operations Manual P&P *(Admin. P&P: Policy 110.00)
X
Itemized Employee Handbook (numbered so that it corresponds to standard items)
X
CRJ Organizational Chart
X
Hampshire House House organizational chart
X
Staffing Requirements P&P *(Admin. P&P: Policy 500.05)
X
Hampshire House House Job Descriptions
X
Employee Handbook (re: compensation)
X
CRJ Equity Chart Description
X
Employee Handbook (re: Progressive Discipline)
X
Employment at Will States
X
7E-11
Employee Handbook (re: Access to personnel records)
X
7E-12
Employee Handbook (re: Access to personnel records)
X
7E-05
7E-06
***7E-07
7E-08
7E-09
7E-10
7E-13
Employee Handbook (re: Political Activity)
X
7F-01
Public and Community Relations P&P *(Admin. P&P: Policy 260.00)
X
7F-02
Public and Community Relations P&P *(Admin. P&P: Policy 260.00)
X
Memo re: media access
X
Public and Community Relations P&P *(Admin. P&P: Policy 260.00)
X
Memo re: media access
X
Public and Community Relations P&P *(Admin. P&P: Policy 260.00)
X
Research Ethics P&P *(Admin. P&P: Policy 600.10)
X
CJI Publication entitled, "Promoting Public Safety Through Successful Community Transitions"
X
Advisory Board P&P (re: meeting schedule) *(Admin. P&P: Policy 251.00)
X
Advisory Board Agenda
X
Advisory Board Minutes
X
7F-03
7F-04
7F-05
7F-06
N/A: The Bureau of Prisons notifies the victims of crime
7F-07
Public and Community Relations P&P *(Admin. P&P: Policy 260.00)
X
Advisory Board Agenda
X
Advisory Board Minutes
X
Rodman Ride Brochure
X
Volunteer and Citizen Involvement P&P *(Admin. P&P: Policy 700.00)
X
Memo re: there are no volunteers providing professional services
X
Volunteer and Citizen Involvement P&P *(Admin. P&P: Policy 700.00)
X
Memo re: there are no volunteers providing professional services
X
Volunteer and Citizen Involvement P&P *(Admin. P&P: Policy 700.00)
X
Memo re: there are no volunteers providing professional services
X
7F-08
7F-09
7F-10
***Individual bulleted items must be identified and labeled
Final Version
