Attch_9_FFSP_Certification_Standards.docx

FFSP CERTIFICATION STANDARDS

SERVICE STANDARDS

Volunteer Coordination (N-MIL-VC)

N-MIL-AM 1: MISSION AND SCOPE OF SERVICE

· Operational level program mission

· Description of scope of services offered

· Contracts, MOUs, or service agreements with partnering providers

a. Program director

b. Staff at all levels

c. Community stakeholders

d. Individuals and families

N-MIL-AM 1.01

The operational program mission is responsive to the needs of the customers and guides the administration and delivery of services.

N-MIL-AM 1.02

The scope of services offered:

a. is defined in writing;

b. is adaptable and can respond to changes in the service environment, identified needs, and desired outcomes of customers;

c. when necessary, is secured through written agreement with qualified service providers, community partners, individual practitioners, and consultants; and

d. considers allocation of resources together with available evidence of effective practice.

N-MIL-AM 1.03

The program partners with military and civilian providers and volunteer groups to increase availability of needed services and maximize resource use. Program leadership promotes collaboration and the effective integration of the program’s services with those provided by military and civilian partners to:

a. identify and eliminate duplication of effort;

b. fill gaps in service;

c. ensure ease of access to and successful navigation of the family readiness system; and

d. make improvements to existing services based on results of needs assessments and program evaluations.

N-MIL-AM 2: PROGRAM LEADERSHIP RESPONSIBILITIES AND STRATEGIC PLANNING

· Description of cross-organizational collaboration efforts

· Long-term or strategic plan

· FFSC Site Director job description

· Evidence of regular communication with staff (e.g., staff meeting minutes, memos, trainings, etc.)

a. Program director

b. Staff at all levels

N-MIL-AM 2.01

Program leadership assures the effective delivery of quality services in cooperation with oversight entities, personnel, volunteers, community providers and partners, and other stakeholders. Program leadership promotes a clear understanding and implementation of established values, including expectations for quality service delivery and effectiveness that are expressed through:

a. service delivery practice;

b. human resource practices; and

c. staff training and supervision.

N-MIL-AM 2.02

A system is in place to provide effective management and oversight of program operations.

N-MIL-AM 2.03

Program leadership promotes cross-organizational collaboration to resolve individual, family, and installation community issues that impact military family readiness.

Interpretation: Standard implementation can be demonstrated through active participation on the Family Readiness Coordinating Committee, or a comparable cross-organizational group.

Navy Interpretation: Review of command established Family Readiness Coordinating Committees (FRCC), cross-functional meetings or other quality of life program advisory committee meeting minutes verifies FFSC participation.

N-MIL-AM 2.04

A communication system is in place that:

a. provides all parties with timely information needed to operate effectively; and

b. spells out mutual expectations for all parties.

Interpretation: Parties should include personnel at all levels including program staff, program directors, installation commanding officers, Regional coordinators, and community partners.

N-MIL-AM 2.05

Long-term, strategic program planning involves relevant staff and other stakeholders, and includes:

a. envisioning and setting the program’s direction;

b. a review of the program’s mission, values, and mandates;

c. an assessment of strengths and weaknesses;

d. measurable goals and objectives that flow from its mission and mandated responsibilities; and

e. appropriate strategies for meeting identified goals, including consideration of the program’s continued development and possible need to expand or eliminate services to respond to changing needs among its service population.

Interpretation: The program’s strategic plan will likely flow from the strategic goals set by oversight entities, which should be tailored according to the needs of the local program, service population, and community. Long-term planning should occur approximately every 3 to 5 years but the timeline will vary depending on the timeline set by oversight entities.

Navy Interpretation: Strategic plans are aligned with DoD, Navy, Regional and/or Installation goals.

N-MIL-AM 3: COMMUNITY INVOLVEMENT AND ADVOCACY

· Summary overview or listing of community education, outreach, and advocacy activities

· Methods for soliciting stakeholder feedback

a. Program director

b. Staff at all levels

c. Community stakeholders

d. Individuals and families served

N-MIL-AM 3.01

The program effectively:

a. informs the community of its mission and services;

b. remains informed about the needs of the military community and available resources;

c. advocates for comprehensive and coordinated service delivery within the community; and

d. encourages the elimination of social and economic injustice.

N-MIL-AM 3.02

Program leadership conducts ongoing community outreach and education to:

a. communicate its mission, role, functions, and capacities;

b. provide information about the strengths, needs, and challenges of its customers;

c. build community support and presence and maintain effective partnerships; and

d. elicits feedback as to unmet needs in the military community that can be addressed by the program as its top advocacy priorities.

Interpretation: Community outreach should include command representatives, family readiness unit liaisons, Service members and military families, and civilian service providers. Information about the strengths, needs, and challenges of its customers should include educating the civilian community on the unique needs of military families.

N-MIL-AM 3.03

Program leadership collaborates with the civilian and military community to advocate for issues of mutual concern consistent with the program’s mission, such as:

a. the full implementation of applicable laws and regulations regarding issues concerning the service population; and

b. improved supports and accommodations for persons with special needs.

N-MIL-AM 3.04

The program works in an active partnership with customers and their community to:

a. assist eligible individuals with access to needed services; and

b. reduce barriers to service use.

N-MIL-AM 3.05

The program establishes formal mechanisms to solicit input and feedback from its stakeholders and has a clear process for using this information to better serve its customers and the military community.

Interpretation: Examples of ways to demonstrate standard implementation include, but are not limited to: establishing a stakeholder advisory group; distributing customer satisfaction surveys; conducting town hall meetings; maintaining a suggestion box; or other customer feedback mechanisms.

N-MIL-AM 4: FINANCIAL MANAGEMENT

· Local/Regional SOP related to internal financial control procedures and management

· Sample of procurement forms

· Monthly purchase record and expenditure log

· Fiscal summaries, phasing plans and/or analyses

· Program level operating budget for current fiscal year including budget guidance from oversight entities

· Management Internal Controls (if applicable)

· Credit card reconciliation statements

· Training records for credit card holders/Approving Officials (AO) as applicable

· Purchase card delegation letter/AO appointment letter

· Interview:

a. Program director

b. Staff at all levels

c. Local/Regional Business Officer

· Observe reporting and accounting system

N-MIL-AM 4.01

Positive financial outcomes are achieved through sound financial planning and management practices that accord with applicable military financial management requirements. An internal control includes mechanisms for:

a. review and approval by oversight entities,

b. management or review by more than one person,

c. assurance that directives from oversight entities are carried out;

d. prevention of error, mismanagement or fraud; and

e. safeguarding and verification of assets.

Navy Interpretation: FFSP management confers with installation and Regional management on the program’s finances to ensure all purchases and training requirements are made per current DoD and Navy policy requirements, and Local/Regional procurement regulations and guidance.

Additional Elements to Validate N-MIL-AM 4.01:

Documentation of the most recent approved funding controls and reports indicates FFSP management:

a. Confirms accuracy of budget, obligation and execution of funds.

b. Provides financial planning input to performance measures, Program Objective Memorandum (POM), phasing plans, and mid-year and end of year funding requirements.

N-MIL-AM 4.02

An operating budget:

a. supports the program’s mission and goals;

b. serves as a guide for managing the program’s financial resources; and

c. includes a statement of income and expenditures.

Navy Interpretation: The program provides input into the Local/Regional Appropriated Funds (APF) and Non-Appropriated Funds (NAF) budget and DoD/CNIC reimbursable funding processes.

Additional Elements to Validate N-MIL-AM 4.02:

The procurement file validates that purchases are made using currently approved government processes or established local, Regional, or command operational procedures such as:

a. Government purchase card.

b. DD form 1155, Order for Supplies and Equipment or procedures published by local, Regional, command Activity Purchase Coordinator.

c. SF-182, Authorization, Agreement and Certification of Training if utilized. Refer to procedures published by the local Regional/command travel/budget office.

d. Defense Travel System for all travel for GS employees and government directed training/travel forms for contract personnel.

e. SF 1034, Public Voucher for Purchases and Services other than personal if utilized or locally developed form.

f. DD form 282, Printing Requisition/Order. Refer to local Regional/command DAPS policies.

g. NAVCOMPT form 2275, Order for Work and Services and NAVCOMPT form 2276, Request for Contractual Procurement, if utilized.

N-MIL-AM 4.03

The program regularly evaluates its financial status.

Navy Interpretation: FFSP management monitors the status of execution and obligation rates and has a thorough understanding of current funding status, shortfalls, and subsequent impact. Unfunded, mid-year, and other data-call requirements have been identified and are submitted using the appropriate financial resource tool and business rules.

N-MIL-AM 4.04

For planning purposes, the program director reports to the fiscal authority on the program's finances including:

a. current financial status and any anticipated problems; and

b. financial planning.

N-MIL-AM 4.05

The program implements a financial record keeping system to track how appropriated funds are being used, and ensures the records are kept up-to-date and balanced monthly.

Navy Interpretation: N-MIL-AM 4.05 refers to both appropriated and non-appropriated funds.

Additional Elements to Validate N-MIL-AM 4.05:

A. Review of FFSP installation/region documentation indicates budget log/records/spreadsheets contain:

a. Direct and reimbursable Operating Target (OPTAR) controls.

b. Obligation/Allocation/Job Order reference number and running totals.

c. All obligated versus budgeted expenses.

d. Dates ordered, received, and user name.

e. Recordings of purchase requests and receipts.

B. Documentation verifies credit card statements are reconciled monthly by the credit card holder, approving official, and in accordance with Local/Regional Activity Purchase Coordinator’s internal operation procedures.

N-MIL-AM 5: PERFORMANCE AND QUALITY IMPROVEMENT (PQI)

· Local/Regional PQI SOP with a detailed description that outlines the program’s PQI system/process

· Program goals and measurable outcomes, along with a plan or description that addresses how the program plans to achieve these goals and promote these outcomes

· Aggregate analyses results of improvement plans, if applicable

· Sampling of customer feedback and evaluation forms

· Documentation of stakeholder involvement in selection of goals and outcomes

· Facility QA file summary documentation for clinical QA record review for the past year

· Record Audit documentation for non-clinical QA record review for the past year

a. Program director

b. Supervisors, staff at all levels

c. Other relevant stakeholders

N-MIL-AM 5.01

The program develops and implements a system for promoting continuous quality improvement. A culture exists that promotes excellence and continual improvement, and focuses on promoting satisfaction and positive outcomes.

Navy Interpretation: The program has a robust written Quality Assurance (QA) plan which includes procedures for assessing and modifying non-clinical and clinical services and providers.

Additional Elements to Validate N-MIL-AM 5.01:

A. Review of the written QA plan validates the plan includes procedures for assessing and modifying non-clinical and clinical services and providers to include:

a. Records audits and clinical care reviews.

b. Quality Improvement Plans (QIPs) for clinical providers.

c. Supervision/consultation for all service providers.

d. Customer evaluation and feedback.

e. Program observation and evaluation.

f. Data collection/reporting and evaluation.

g. Needs assessments to improve services and short and long term delivery methods.

B. Oversight of the QA policies and procedures is an inherently governmental function. Installation TA’s use the Global Staffing Contract QA plan to assess contract employee performance.

C. The QA plan is reviewed and/or modified at least annually.

D. The QA plan and other documentation, including documentation listed below validates that practice is in accordance with the QA plan and that the FFSP has an effective QA plan.

a. Customer (client and command) surveys

b. Training evaluations

c. Trend analyses and follow up actions

d. Supervision/consultation records

e. Record audits, clinical care reviews and quality improvement plans E. Results of customer feedback, program evaluations, record reviews, and both formal and informal needs assessments are used to evaluate, revise, develop, and improve programs and service delivery methods.

N-MIL-AM 5.02

The program works with relevant stakeholders to set forth desired goals and measurable outcomes that are aligned with its mission and mandate, and merit ongoing monitoring.An interpretation was added to provide clarity

Interpretation: Desired goals and measureable outcomes can relate to any or all of the following: program operations; the quality of programming and services provided; program results; or customer satisfaction and other customer outcomes.

N-MIL-AM 5.03

The program works with key stakeholders, including personnel, customers, oversight entities and the community to analyze data relevant to desired goals and outcomes.

N-MIL-AM 5.04

Quarterly reviews of customer files:

a. evaluate the presence, clarity, quality and continuity of required documents using a uniform tool to ensure consistency; and

b. include a random sample of both open and closed or inactive cases.

Navy Interpretation: Quality Assurance (QA) record reviews are conducted at least quarterly using specified program record review checklists to ensure overall quality in the delivery of programs and services and to ensure that documentation is timely and completed in accordance with requirements. A certification review of clinical and non-clinical record reviews includes some records previously QA’d by the FFSP to demonstrate consistency in conclusions and validate the FFSP’s QA review process.

Additional Elements to Validate N-MIL-AM 5.04:

A. Record reviews are conducted in accordance with requirements for both non-clinical records (Financial Readiness (FR) and New Parent Support and Home Visitation Program (NPSHVP)) and clinical records (Non-Medical Individual and Family Counseling (NMC)/Family Advocacy Program (FAP)) and consists of an administrative review by the FFSC Site Director or supervisor for all records. NMC/FAP Clinical Care Reviews are required for all clinical providers and consists of clinical record reviews by privileged clinical practitioners.

Non-Clinical Record Review: (FR and NPSHVP only)

a. Reviews include, at a minimum, signed Privacy Act and documentation as required by pertinent instructions and local SOP.

b. Demonstrates the FFSC Site Director or supervisor conducts periodic record reviews to ensure all required documentation is present, referrals are appropriate and the record is complete, in addition to ensuring that services provided are of good quality and in compliance with requirements.

c. In fully contracted operations, involvement and oversight of non-clinical QA processes by government representatives is apparent.

NMC/FAP Record Reviews: (Cross-reference N-MIL-TS 4 “Clinical Credentialing Management”)

a. Administrative Records Audit: The FFSC Site Director or supervisor conducts periodic administrative audits to ensure all required documentation is present, complete and timely. Facility QA file summarizes the results of records audit and clinical care review. This summary includes the number of records reviewed, the number of records requiring follow-up action, any negative facility QA trends identified, actions taken to correct negative facility trends, dates all recommended actions were completed and dates of regularly occurring peer consultation/case presentation for Tier II or Tier III providers and review of all records for Tier I providers and clinical interns.

b. NMC/FAP Quality of Care and Record Reviews: The QA plan includes randomly selected quarterly record reviews of ten percent of all open cases and five percent of cases closed per quarter, with a minimum of five cases total per active provider (three open and two closed) and include:

1. Results of both records audits and clinical care reviews and follow-up actions are documented in the FPF.

2. A statement of compliance/negative trends with regard to a particular provider and follow-up actions is also documented in the FPF.

3. A clinically privileged practitioner reviews case records for each clinical provider to ensure the appropriateness of initial assessment, case notes, safety plans, treatment plans, actions taken, recommendations, referrals, and recommendation for the termination of treatment.

4. Indirect consultations are documented for clinical FFSP Site Directors or supervisors who do not provide direct clinical care services. Indirect consultations are reviewed by other clinical colleagues for validation of quality consultative services.

B. Procedures are in place for a Critical Incident Review Committee (CIRC) investigation and notification to the Designated Privileging Authority (DPA) of alleged clinical provider impairment/misconduct or substandard performance.

C. When QA efforts indicate a recurrent or unremitting negative trend for individual providers facility efforts to rectify the situation are documented. This may include use of a written QIP. The purpose of this is to improve the quality of clinical care, thereby avoiding the possibility of adverse privileging action. The supporting HRO should be consulted.

N-MIL-AM 5.05

The program integrates the findings of external review processes, including certification and monitoring reviews into its PQI process, where appropriate.

Navy Interpretation: External reviews may also include Inspector General (IG) visits and/or Regional QA reviews.

N-MIL-AM 5.06

The program communicates findings and recommendations to key audiences and stakeholders, and makes any needed improvements.

N-MIL-AM 6: ETHICAL PRACTICE

· Policies and procedures for making appropriate referrals

· Priorities for managing wait lists

· Standards of Conduct

· A representative sample of publicly available documents, information, publications, or websites containing program information

· Relevant training curriculum on reporting suspected misconduct

a. Program director

b. Staff at all levels

c. Individuals and families served

d. Community stakeholders

N-MIL-AM 6.01

The program earns and sustains the public trust through honest, truthful, and responsible relationships with its stakeholders; and delivery of services in an honest, ethical, objective manner. Open, transparent operations are promoted by:

a. providing access to clear, timely, and accurate information;

b. setting clear expectations among staff for open and transparent operations; and

c. accurately conveying the identified mission in all communications that contain such a representation.

N-MIL-AM 6.02

Program leadership adheres to the conflict of interest policy and procedures set by oversight entities, ensuring that daily operations and decisions serve the program’s and customers’ best interests, not private interests.

N-MIL-AM 6.03

Staff is trained on and familiar with:

a. the proper, confidential channels for reporting suspected misconduct or questionable practices; and

b. the applicable policies that protect them from employment-related retaliation after coming forward.

N-MIL-AM 6.04

Staff knows and follows the code of ethics of their respective professions.

N-MIL-AM 6.05

When making referrals, the following practices are prohibited:

a. making or accepting payment or other consideration in exchange for referrals;

b. steering or directing referrals based on the difficulty of the case or the cost of serving a particular customer rather than identifying the best service to meet that individual’s or family’s needs; and

c. steering or directing referrals to private practices in which staff, consultants, or the immediate families of staff and consultants are engaged.

N-MIL-AM 6.06

Giving unjustified preference to individuals or families applying for and receiving services is prohibited.

N-MIL-AM 7: RESEARCH PROTECTIONS

· Human subject research policy and procedures

· Informed consent forms

· Mechanisms to review research proposals

N-MIL-AM 7.01

When research is conducted involving the program's customers, the program:

a. ensures that all research is conducted in accordance with applicable legal requirements;

b. has a mechanism to review and approve or deny research proposals;

c. establishes that customers have the right to refuse to participate without penalty;

d. informs customers about the nature and purpose of the research, and any possible risks or discomfort, as applicable;

e. obtains consent forms signed by research participants; and

f. guarantees protection of research participants' identity and confidentiality.

Interpretation: For purposes of N-MIL-AM 7, research does not include internal program evaluation or outcomes research, and educational projects carried out by students and interns as part of their professional training. This standard does not apply to research being conducted by a third party using the program's customers, as the program will have no direct control over how the study is conducted.

Navy Interpretation: To ensure human subject protections, human service research is conducted in accordance with all DoD, federal and ethical guidelines and with prior review, approval and oversight by a DoD, military Institutional Review Board (IRB).

NA Research is never conducted or customer information is only used for research being conducted by third parties.

FFSP CERTIFICATION STANDARDS

ADMINISTRATION AND MANAGEMENT STANDARDS

Administration and Management (N-MIL-AM)

10 DEC 2014

N-MIL-HR 1: WORK ENVIRONMENT

· Discrimination policy

· Harassment policy

· Nepotism policy

· Table of contents for training curricula

Navy Interpretation: Human Resources, Director Civilian Personnel Policy (HR, DCPP) serves as the Command Advisor and spokesperson for all CNIC civilian HR issues providing policy and guidance to FFSP.

N-MIL-HR 1.01

Through the adoption and implementation of human resource policies, the program provides an equitable work environment that is supportive of productivity and diversity. Program leadership adheres to human resource policies prohibiting unlawful discrimination against any person or category of persons and staff are trained on and familiar with the policy.

N-MIL-HR 1.02

Program leadership adheres to human resource policies prohibiting staff from engaging in any form of harassment, as defined by applicable law, and staff are trained on and familiar with the policy.

Interpretation: Types of harassment that are prohibited by law include harassment on the basis of age, gender, sexual orientation, color, race, creed, national origin, ancestry, religious persuasion, marital status, political belief, physical or mental disability, pregnancy, military or veteran status, or retaliation or opposition to any complaint process at the Equal Employment Opportunity Commission (EEOC) or other human rights agency. Training for staff on the harassment policy includes reporting procedures, which should allow staff to bypass any person in the reporting process who is also the alleged harasser.

N-MIL-HR 1.03

Program leadership adheres to human resources policies that:

a. prohibit preferential treatment; and

b. address nepotism with regard to hiring, supervision, and promotion.

N-MIL-HR 2: BACKGROUND CHECKS

a. Program director

· Review:

a. Unofficial employee files

N-MIL-HR 2.01

The program confirms that appropriate, legally permissible, and mandated reviews of state criminal history records and civil child abuse and neglect registries have been conducted for new employees, consultants, independent contractors, volunteers, and student interns who will:

a. provide direct services to, or be alone with, children, the elderly, or other persons determined by the program to be vulnerable or at risk; or

b. work with sensitive or confidential information such as personnel files and customer files.

Navy Interpretation: In accordance with current DoD and Navy policy, management initiates, tracks and documents the status of all required background checks and rechecks.

Additional Elements to Validate N-MIL-HR 2.01:

A. A review of the background check tracking form, documenting the status of background checks for new and existing clinical staff and those routinely working with children under the age of 18 includes:

a. For Government Employees, Criminal History Background Checks shall include:

· State Criminal History Repositories (SCHR) Check for each state the employee has resided in;

· Access National Agency Check and Inquiries (ANACI); and

· When applicable, an Installations Record Check (IRC)

b. For Contract Employees, the Criminal History Background Check shall include:

· State Criminal History Repositories (SCHR) Check for each state the employee has resided in;

· National Agency Check with Inquiries (NACI); and

· When applicable, an Installations Record Check (IRC)

c. For both government and contract employees, a required 5-year re-verification check using the Defense Clearance and Investigations Index (DCII) and IRC is also to be conducted.

B. The tracking form should verify the status of the background checks documenting the date the checks were initiated, the date the results were received and re-verified.

C. Providers awaiting results of background checks comply with restrictions outlined in CNIC Family Readiness program guidance.

N-MIL-HR 3: SATISFACTION AND RETENTION

· Protocols to obtain staff input and provide feedback to staff about their recommendations or suggestions

· Staff grievance policy and procedures

· Training curriculum on staff grievance policy and procedures

· Meeting minutes and/or schedules from regular program and team meetings

· Evidence of improvements made to address identified staff satisfaction concerns

N-MIL-HR 3.01

The program promotes a high level of staff satisfaction and retention. The program promotes open communication and collaboration among disciplines and staff levels by:

a. holding regular program and team meetings; and

b. providing feedback to staff about their suggestions and recommendations.

Interpretation: The program can consider factors that have been associated with staff satisfaction and retention, including: role clarity, recognition of employee contributions, satisfaction with salary and benefits, reasonable workload, autonomy, opportunities for advancement, and career development. The program should also take the opportunity to retain high performing staff by providing support, opportunities, and resources to prepare staff within the program to assume leadership roles.

N-MIL-HR 3.02

The program encourages initiative, creativity, and innovation that supports the program vision and rewards and recognizes the contributions of staff.

N-MIL-HR 3.03

Staff are trained on and familiar with the formal mechanism through which they can express and resolve grievances, which includes:

a. how grievances are filed, to whom, and who will make a final determination;

b. timelines for resolution;

c. how the resolution is documented; and

d. an explanation of any appeal, rights, or recourse.

N-MIL-HR 3.04

Program leadership takes action to identify and address identified staff satisfaction concerns within their program.

N-MIL-HR 4: HUMAN RESOURCE PRACTICES

· Staff handbook or policies and procedures manual

· Staff utilization documentation (e.g., FFSMIS reporting, Centralized Scheduling and Metrics (CMS) Utilization reports)

· Documentation of staff orientation

· Retired Activities Office (RAO) command appointment letter for Navy sponsored RAO

· Interview:

a. Program director

· Observation of support for RAO

N-MIL-HR 4.01

Human resource practices are equitable and consistently applied. All staff confirm receipt in writing of an up-to-date staff handbook or policies and procedures manual that articulates current:

a. conditions of employment;

b. benefits;

c. rights and responsibilities of employees; and

d. other important employment-related information.Revised interpretation per information technology updates

Interpretation: Policies and procedures that should be provided at the local level as evidence of standard implementation include policies and procedures that address: emergency and safety procedures; equal employment policies; grievance process procedures; performance appraisal system; professional development; standards of conduct; time-off policies; working conditions; and technology/network security and usage policies.

Navy Interpretation: Elements in this standard pertain to GS and NAF personnel. For oversight of contract staff, refer to N-MIL-RPM 6.

N-MIL-HR 4.02

Staff who leave the program voluntarily or due to a Permanent Change of Station have the opportunity to participate in an exit interview.

N-MIL-HR 4.03

If assigned Retired Activities Office (RAO) hosting responsibility, FFSP support services are provided for the Retired Activities Program including access to work spaces, materials and equipment.

Navy Interpretation: If the RAO is located in the FFSC, the RAO has an appointment letter signed by the Commanding Officer.

NA The program is not assigned RAO hosting responsibility.

N-MIL-HR 4.04

FFSC Site Director activates and follows through with personnel actions, and monitoring of workloads and work schedules to avoid excess staffing, overtime, and duplication of function. There are on-going re-engineering efforts to achieve efficiencies while maintaining high quality.

Additional Elements to Validate N-MIL-HR 4.04:

A. Review of personnel action documentation indicates personnel actions are actively managed such as: personnel recruitment, selection, resignation, new positions/reclassification, awards/bonuses, and change in condition of employment.

B. A locally developed tracking form demonstrates follow up on all personnel actions.

C. Review of staff utilization documentation.

N-MIL-HR 5: PERFORMANCE REVIEW

· Performance review templates/forms if applicable

· Performance review procedures

a. Program director

b. Staff at all levels

c. Independent contractors

· Review: Unofficial government employee files to include performance reviews, Individual Development Plan (IDP), and current performance plan

Navy Interpretation: For contract performance review, refer to N-MIL-RPM 6.01 and 6.03.

N-MIL-HR 5.01

The program holds both supervisors and supervised staff accountable for performance and facilitates open, two-way communication as a means to encourage performance improvement. The program has a standardized process for providing every full-time and part-time employee and volunteer with a written performance review at regular intervals that involves the employee or volunteer and the supervisor.

N-MIL-HR 5.02

The performance review process assesses job performance, recognizes accomplishments, provides constructive feedback, and emphasizes self-development and professional growth, in relation to:

a. specific expectations defined in the job description;

b. program-wide expectations for staff;

c. objectives established in the most recent review and objectives for future performance;

d. developmental and professional objectives;

e. recommendations for further training, skill building, and other resources that may contribute to improved job performance; and

f. knowledge and competence related to the characteristics and needs of customers, if applicable.

N-MIL-HR 5.03

The program promotes a work environment that supports active participation by staff in the performance review process.

N-MIL-HR 6: EMPLOYEE FILES

a. Program director

· Review unofficial employee files

N-MIL-HR 6.01

The program maintains employee files for all staff. Employee files are updated regularly, and contain:

a. identifying information and emergency contacts;

b. verification of completed background checks, where applicable;

c. verification of physical examinations, as appropriate;

d. job descriptions;

e. pre-service and in-service training records; and

f. performance reviews and all documentation relating to performance, including disciplinary actions, if applicable.

Interpretation: The program is not required to maintain staff records for short-term or episodic volunteers.

Navy Interpretation: The FFSP maintains unofficial employee files only. The documents listed above are maintained on-site at the local program in the unofficial employee file. The official employee file maintained by Human Resources is not a part of this review.

N-MIL-HR 6.02

Access to employee files is limited to authorized staff on a need-to-know basis.

N-MIL-HR 6.03

Staff may review, add, and correct information contained in their file, in accordance with applicable law.

FFSP CERTIFICATION STANDARDS

Human Resources (N-MIL-HR)

N-MIL-RPM 1: RISK PREVENTION

· Risk prevention and management plan and/or procedures

· Policies and procedures for reporting incidents and accidents that involve the threat of or actual harm, serious injuries, and deaths

· Documentation of risk reviews, that include analyses and evidence of corrective action as needed

· Reports of incidents, accidents and grievances for the previous two quarters

b. Relevant staff

N-MIL-RPM 1.01

The program meets applicable laws, regulations, guidelines, and codes. The program identifies and reduces potential loss and liability by:

a. conducting prevention and risk reduction activities; and

b. monitoring and evaluating risk prevention and management effectiveness.

Interpretation: When necessary, the program consults legal counsel to provide comprehensive information regarding codes, regulations, licensure requirements, employment laws, and general guidance regarding legal compliance.

N-MIL-RPM 1.02

Program leadership coordinates a process for regularly assessing and responding to potential areas of risk, including:

a. compliance with legal or regulatory requirements;

b. health and safety;

c. human resources practices at the local level;

d. customer rights and confidentiality;

e. fiscal accountability; and

f. conflicts of interest.

Interpretation: Although the program should assess all areas of potential risk at least annually, the assessments do not need to be conducted all together, in one sitting.

N-MIL-RPM 1.03

The program conducts a quarterly review of immediate and ongoing risks that includes a review of incidents, accidents, and grievances related to:

a. service modalities or other program practices that involve risk, as applicable;

b. facility safety issues;

c. situations where a person was determined to be a danger to him or herself or others; and

d. serious injuries and deaths.

N-MIL-RPM 1.04

There is a system in place to report all incidents and accidents that involve the threat of or actual harm, serious injuries, and deaths to oversight entities and all staff are trained on their reporting responsibilities.

N-MIL-RPM 1.05

Individuals qualified by knowledge and experience are responsible for risk prevention and management functions at the local level.

N-MIL-RPM 2: INFORMATION AND TECHNOLOGY MANAGEMENT AND USE

a. Program director

· Observe MIS

N-MIL-RPM 2.01

The information management and technology system supports the program’s operations, planning, and evaluation and allows for:

a. timely access to electronic information;

b. longitudinal reporting and comparison of performance over time; and

c. the use of clear and consistent formats and methods for capturing, tracking, reporting, and disseminating data.

Interpretation: Implementing a controlled document system is one way a program can organize, track, store and ensure the use of the most current version of documents. These systems address, for example, processes for: updating, creating, and deleting documents; notification of changes; identifying documents, i.e., control numbers; and maintaining a master list of documents.

Navy Interpretation: This standard also refers to management and use of Local/Regional systems, e.g., shared drives, team sites, and Local/Regional databases.

N-MIL-RPM 3: SECURITY OF INFORMATION

· Plan or procedure for responding to data interruptions

· Policies and procedures for managing sensitive or privacy act information outside of MIS

· Privacy Act compliant policies and procedures, as applicable

a. Program director

· Observe customer file storage and the MIS

Navy Interpretation: FFSP provides non-medical counseling services. HIPPA regulations do not apply.

N-MIL-RPM 3.01

Electronic and printed information is protected against intentional and unintentional destruction or modification, and unauthorized disclosure or use. The program protects confidential and other sensitive information from theft, unauthorized use or disclosure, damage, or destruction by:

a. limiting access to authorized personnel on a need-to-know basis; and

b. maintaining paper records in a secure location.Revised standard, revised interpretation, and added interpretation regarding information technology updates

Interpretation: The program needs to consider both safety and security when deciding where and how to store and maintain its records. Other important considerations include information taken off-site by staff and online access to the program’s electronic system. The program should develop a system that best fits its needs and circumstances. Secure storage of paper records may include: locked file cabinets; a locked file room with limited access or a gatekeeper system whereby one person or a few people can unlock the file storage area or access the files themselves; or a system using a keypad or keys where only authorized individuals are given the keypad code or copies of the keys. Programs may also consider using fireproof file cabinets; metal file cabinets; a sprinkler system; or not storing records in basements or other areas prone to flooding.

Interpretation: The program may limit access to authorized personnel by: limiting access based on staff role within the program; ensuring the electronic system requires passwords for access to confidential information, requires passwords be regularly changed, locks the user out of the system for incorrect log in attempts, and automatically times out after a period of inactivity; disabling the passwords and access of former employees; and ensuring the system is capable of recording the person accessing confidential information in the system, and records when information is altered or deleted, also known as audit logs.

N-MIL-RPM 3.02

Staff are trained on, and familiar with, protocols for protecting, transmitting, and using confidential, electronic information.Deleted interpretation per information technology updates

N-MIL-RPM 3.03

Customer files are maintained and disposed of in a manner that protects privacy and confidentiality.

Added interpretation per information technology updates Interpretation: Proper disposal of records can include: shredding paper records; clearing electronic files when computers are replaced or reassigned; and destroying electronic media such as flash drives.

Navy Interpretation: N-MIL-RPM 3.03 includes maintaining electronic or paper documents with Personally Identifiable Information (PII) on a local shared drive.

N-MIL-RPM 3.04

The program has policies and procedures that address the risks, benefits, and ongoing processes required to manage web-based technologies and electronic communications.

Interpretation: “Web-based technologies and electronic communications” include, but are not limited to: the program’s own website, email, external websites, blogs, social media and networking sites, wikis, discussion forums, and photo and video sharing sites where the program’s staff may interact with each other or with customers.

Risks associated with the use of web-based technologies and electronic communications may include:

a. unauthorized or prohibited contact between staff and customers;

b. unauthorized or inappropriate use of program logos or trademarks;

c. personal comments or opinions that can be misconstrued as representing the views of the program, or that present the program in a negative light;

d. inadvertent or deliberate disclosure of confidential or proprietary program information; and

e. inadvertent or deliberate disclosure of confidential or protected information about customers.

N-MIL-RPM 3.05

The program is prepared for the interruption of data and limits disruption to its operations and service delivery by:

a. following procedures for responding to data interruptions and resuming operations;

b. notifying staff of procedures for data interruption;

c. maintaining contact information for all staff;

d. following procedures for alternate methods of communication with staff and stakeholders during periods of disruption.

N-MIL-RPM 3.06

The program ensures its electronic system for managing protected customer information:

a. operates in compliance with all applicable regulations; and

b. limits access to information in accordance with customer privacy preferences and confidentiality rules.Added standard per information technology updates

Interpretation: Additional consideration should be given to information specific to mental health treatment, substance use treatment, genetic information, and HIV/AIDS status, as these information types are governed by additional confidentiality and disclosure rules and regulations.

N-MIL-RPM 4: CUSTOMER FILES

a. Direct service and supervisory staff

b. Program director

c. Individual or families served

d. Review customer files or cross-reference applicable FFSMIS, Navy Family Accountability and Assessment System (NFAAS) and Defense Sexual Assault Incident Database (DSAID) Record Checklist Review

N-MIL-RPM 4.01

The program maintains a customer file for each individual or family. Customer files contain sufficient, accurate information to:

a. identify the client;

b. support decisions about interventions or services; and

c. document the delivery of services.

Interpretation: Individuals looking for one time information and referral or who attend an occasional educational session may not need a full customer file opened. However, the program should have procedures in place for documenting service utilization and any customer requiring on-going contact or follow-up should have a record on file that meets the standards in this section.

Navy Interpretation: Customer files are limited to those maintained in FFSMIS, NFAAS or DSAID.

N-MIL-RPM 4.02

Customer files comply with all legal requirements and contain information necessary to provide services, such as:

a. demographic and contact information;

b. the reason for requesting or being referred for services;

c. up-to-date assessments, including risk assessment findings;

d. the service plan, including mutually developed goals and objectives;

e. copies of all signed consent forms, including signed Privacy Act statement, and records of disclosures;

f. signed Customer Rights and Responsibilities for ongoing services;

g. a description of services provided directly or by referral;

h. routine documentation of ongoing services, including case contacts and case activity notes;

i. Victim Preference Reporting Form, when applicable;

j. case extension request approval for counseling, when applicable;

k. documentation of referrals and follow-ups;

l. documentation of routine supervisory review;

m. aftercare or transition plan;

n. Child/Spouse Abuse Incident Report, when applicable;

o. recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and

p. a closing summary entered within 30 days of termination of service.Added interpretation per information technology updates

Navy Interpretation: Cross-reference summary results of certification record reviews to assess compliance with this standard.

N-MIL-RPM 4.03

Customer file entries are made by authorized personnel only, and are:

a. specific, factual, relevant, and legible;

b. kept up to date;

c. completed, signed, and dated by the person who provided the service; and

d. signed and dated by supervisors, where appropriate.Revised interpretation per information technology updates

Interpretation: Electronic signatures should include a verification of the signer’s identity, such a unique user password.

N-MIL-RPM 4.04

Progress notes comply with legal requirements, and are entered:

a. at least quarterly; or

b. more frequently as required by law or regulation for individuals receiving protective services or frequent or intensive counseling or treatment.

N-MIL-RPM 4.05

Customers may add a statement to their files, and:

a. any response by personnel is added with the customer's knowledge; and

b. the customer is given the opportunity to review and comment on such additions.

N-MIL-RPM 4.06

At case closing, or when a case becomes inactive, customer files are reviewed and unsummarized notes, personal observations, and impressions are expunged.

Navy Interpretation: Records are maintained and expunged in accordance with the System of Records Notice.

N-MIL-RPM 5: ACCESS TO CUSTOMER FILES

· Interview:

a. Program director

b. Supervisors, Direct service staff

c. Individuals or families served

N-MIL-RPM 5.01

Access to customer files is limited, consistent with legal requirements. Access to confidential customer files meets legal requirements, and is limited to:

a. the customer or, as appropriate, a parent or legal guardian;

b. personnel authorized to access specific information on a “need-to-know” basis;

c. others who are permitted access;

d. former customers;

e. requests for records of deceased customers; and

f. auditors, contractors, and licensing or accrediting personnel consistent with the program’s confidentiality policy.

Interpretation: Customer files should not be left in public areas such as on carts in hallways, on desks, or in non-secured areas. When not being used by authorized staff, files should be returned to a secure area.

Navy Interpretation: FFSP demonstrates that customer record keeping procedures and practices are in place for the confidential preparation and controlled access, maintenance, storage, temporary removal, destruction and/or deletion of files, and management of customer records.

Additional Elements to Validate…