POLICY & PROCEDURE DATABASE

GOVERNMENT OF GUAM GCA/POLICY/EXECUTIVE ORDERS
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
GoG 10GCA CH-82 Mentally Ill Persons Active        
GoG 10GCA CH-82-86107 Advisory Council for Mental Health, Alcohol & Drug Programs & Services Active        
GoG PL33-71 BN115-33 CH-82A Baby Alexya Law Assisted Outpatient Treatment          
GoG 10GCA CH-86 GBHWC (rename DMHSA to GBHWC) 5/6/2013        
GoG 10GCA CH-93 GU System of Care Council for Children w/Serious Emotional Disturbance Active        
GoG 19GCA CH-15 Personal Relations and Prevention & Treatment Active        
GoG Governor EO#2015-09 Social Media Policy for Executive Branch of GoG 5/11/2015       GBHWC Media Relations & Social Media Usage
GoG 4GCA CH-15-P.L.23-105:1 Standard of Conduct For Elected Officers, Appointed Officers, And Public Employees of GoG          
GoG Public Law 31-239 Bill No.116-33 (COR) Act to Amend Public Law 31-239 Authorize GBHWC fully implement fee Schedule 9/1/2015        
GoG Public Law 17-29 Gov't Purchase of Insurance to line, autonomous, and semi-autonomous agencies          
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LEADERSHIP
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD 
GBHWC
Active
       
AD 
MOU GBHWC/UOG
11/1/2015
       
AD 
AD-01
6/8/2017
   
6/5/2017
 
AD 
AD-04
10/20/2017
   
10/20/2018
 
AD 
AD -11
8/30/2013
   
8/30/2017
 
AD 
FORM FAD-11          
AD 
AD-23
1/9/2017
   
1/9/2018
 
AD 
AD-24
1/9/2017
   
1/9/2018
 
AD 
AD-25
1/4/2017
   
1/4/2018
 
AD 
AD-26
1/9/2017
   
1/9/2018
 
AD 
AD-27
4/3/2017
   
4/3/2018
 
AD 
AD-31
6/2/2017
   
6/2/2018
 
AD 
AD-32
1/24/2017
   
1/24/2018
 
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FINANCIAL MANAGEMENT/BILLING SERVICES
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
GoG P.L. 31-239 Sbill No. 506-31 (COR) Public Law 31-239 Fee Schedule
12/6/2012
       
GoG P.L. 31-274 Bill No. 540-31 Public Law 31-274 CASD Fee Schedule
12/26/2012
       
AD-FM   Bureau of Statistics and Plans Subrecipient Monitoring Policies and Procedures          
AD-FM   Line Agency Federal Financial Policies and Procedures          
AD AD-F-01 Corporate Compliance Policy
6/15/2017
   
6/15/2018
 
AD-FM AD-F-02 GBHWC Financial Management
6/15/2017
   
6/15/2018
 
AD-FM AD-F-03 Payroll Services
6/15/2017
   
6/15/2018
 
AD-FM AD-F-04 Accounting Process
6/15/2017
   
6/15/2018
 
AD-FM AD-F-05 Budget Process
6/15/2017
   
6/15/2018
 
AD-FM AD-F-06 Procurement Process
6/16/2017
   
6/16/2018
 
AD-FM AD-F-07 Review of Billing Statements and Claims
9/22/2017
   
9/22/2018
 
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FACILITY & PLANT OPERATIONS
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
GoG Dept/Agency Govt Vehicles-Safety Lights & Use of Govt/Private
2/16/2000
Active      
AD-FO AD-02 Vehicle Usage
6/5/2014
       
AD-FO AD-05 Key Control and Unlockig Offices
9/22/2014
       
AD-HS AD-HS-07 Emergency Preparedness: Utility Failure
6/8/2017
   
6/8/2018
 
AD-FO AD-33 Accessibility Plan
2/8/2017
   
2/8/2018
 
AD-FO Form F-AD-03 Motor Vehicle Trip Ticket          
AD-FO Form F-AD-04 Recall Sheet
7/3/2014
       
AD-FO Form F-AD-07 Key Request Form
9/22/2014
       
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HEALTH & SAFETY
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-HS AD-HS-03 Contraband Policy          
AD-HS GBHWC Emergency Checklist in Preparation for Typhoon          
AD-HS GBHWC Exit Map          
AD-HS GOG Guam Emergency Response Plan
9/1/2003
       
AD-HS AD-03 Typhoon Response Plan
7/10/2014
       
AD-HS AD-HS-04 Personal Searches
3/27/2017
   
3/27/2018
 
AD-HS AD-HS-05 Pat Down and Strip Searches Protocol
3/27/2017
   
3/27/2018
 
AD-HS AD-HS-09 Bomb Threat and Suspicious Package
3/17/2017
   
3/27/2018
 
AD-HS AD-HS-10 Active Shooter Response
10/31/2016
   
10/31/2017
 
AD-HS AD-HS-11 Hazardous Materials Management
4/5/2017
  DMHSA Policy# ORG-FO-1-2
4/5/2018
 
AD-HS AD-HS-12 Natural Disaster: Earthquake Response Plan
10/31/2016
   
10/31/2017
 
AD-HS AD-HS-13 Dealing with Disruptive Behavior
6/8/2017
   
6/8/2018
 
AD-HS AD-HS-14 Consumer Transportation
6/2/2007
       
AD-HS CW-02 Dealing with Medical Emergencies
11/7/2016
   
11/7/2017
 
AD-HS CW-07 Standard Infection Control Precautions
1/12/2016
  DMHSA Protocol, Infection Control Protocol    
AD-HS DMHSA #10.09.107 Personal Bag Checks
1/17/2012
       
AD-HS DMHSA Guard Section Manual
8/13/2012
       
AD-HS DMHSA Protocol Fire Saftey Plan Protocol
6/29/2012
       
AD-HS DMHSA Protocol Emergency Exit Routes Protocol
6/29/2012
       
AD-HS DMHSA Protocol General Safety & Consumer Management Protocol
8/17/2012
       
AD-HS DMHSA Protocol Environments of Care Criteria Protocol
8/16/2012
       
AD-HS DMHSA Protocol Consumer Safety Plan Protocol
8/18/2012
       
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HUMAN RESOURCES/PERSONNEL SERVICES & TRAINING/EDUCATION SERVICES
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-HR
AD-HR-08
         
AD-HR
AD-HR-09
         
GoG
4GCA CH-15-P.L.23-105:1
         
AD-HR
             
AD-HR
MOU GBHWC/UOG
1/11/2015
       
AD-HR
AD-HR-01
6/12/2017
6/13/2017
 
6/13/2017
 
AD-HR
AD-HR-02
9/13/2017
   
9/13/2018
 
AD-HR
AD-HR-03
12/14/1992
1/26/2018
 
1/26/2019
 
AD-HR
F-AD-27
8/17/2016
8/17/2017
     
AD-HR
AD-HR 19
9/13/2016
   
9/13/2017
 
AD-HR
AD-18
1/31/2017
   
1/31/2018
 
AD-HR
AD-28
1/27/2017
   
1/27/2018
AD-HR
AD-30
1/31/2017
   
1/31/2018
 
AD
 
Active
       
AD-HR
DMHS 10.01.107
1/30/2012
       
AD-HR
CW- 10
7/18/2016
       
AD-HR
CL-10
3/14/2017
   
3/14/2017
 
AD-HR
CL-46
6/8/2017
       
CL-AP
AD-NU-01
3/27/2017
   
3/27/2018
 
CL-PTB
DMHSA Protocol
         
AD-HR
   
6/1/2017
 
6/1/2018
 
AD-HR
ORG-10-1
5/31/2006
       
AD-HR
ORG-7-3
12/23/1992
       
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QUALITY MANAGEMENT/RISK MANAGEMENT
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-PHARMA AD-PHARMA-01 Medication Use          
AD-RM
AD-20
12/5/2016
   
12/5/2017
 
AD-QM
AD-QM-1
3/27/2017
   
3/27/2018
AD-RM-01 Risk Management Plan
AD-RM
AD-RM-01
3/27/2017
   
3/27/2018
 
AD-RM
AD-RM-02
3/31/2017
12/27/2017
AD-RM-02 revised on 9/7/2017
12/27/2018
 
AD-RM
AD-RM-03
12/27/2017
     
Supersedes Sentinel Event Protocol
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RIGHTS AND RESPONSIBILITY OF CONSUMERS
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-CR
10GCA-CH-2
5/7/2012
       
CL-AP
AD-16
7//18/2016
       
AD-QM
AD-21
4/19/2017
 
Rescission: DMHSA Consumer's Procedure Grievance, made effective 1/8/1991; DMHSA CASD Grievance Protocol, made effective 8/10/2012
4/19/2018
 
CL-AP
CL-NU-36
1/31/2017
   
1/31/2018
 
CL-AP
CL-40
10/27/2016
   
10/27/2017
 
AD-HS
DMHSA Protocol
8/15/2012
       
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MEDICATION MANAGEMENT
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-MM AD-PHARMA-01 Medication Use          
AD-MM MC-01 Consumers Receiving Medication Clinic Services 07-08-14        
AD-MM DMHSA Protocol Current Medication Protocol 08-17-12        
AD-MM DMHSA Protocol Consent to Psychotropic Medication Protocol 08-17-12        
AD-MM DMHSA Protocol Monitoring Medication Protocol 08-18-12        
AD-MM DMHSA Protocol Psychotropic Medication Protocol 08-17-12        
AD-MM DMHSA FORM Medication Administration Record 06-26-09        
AD-MM DMHSA 40.01.111 Precautionary Measures for Medication Administration 09-09-09        
AD-MM DMHSA PP Monitoring Effects of Medication 06-26-09        
AD-MM DMHSA PP Medication Errors no date noted        
AD-MM DMHSA 40.01.110 Proper & safe Storage of Controlled Substances 09-09-09        
AD-MM DMHSA PP Medication Stock 06-24-09        
AD-MM DMHSA PP Consumer's own Medication 06-24-06        
AD-MM DMHSA PP Medication Order Specified Time Intervals 06-24-09        
AD-MM DMHSA PP Discharge Medication and Instruction 06-26-09        
AD-MM DMHSA PP Telephone, Verbal and Written Medication Orders 06-24-09        
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RECORDS OF CARE/MEDICAL RECORDS
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-MR GoG Records Retention & Disposition Schedule 09-15-88        
AD-MR AD-MR-01 Clinical Peer Review and Medical Records Review 04-19-17        
AD-MR ADMR-02 Medical Records Completion and Deficiency Notice 11-28-17     11-28-18  
AD-MR ADMR-05 Storage of Closed Consumer Medical Records 12-12-17     12-12-18  
AD-MR MR-04 Mechanisms to Authenticate Entries in the Medical Record 08-11-13        
AD-MR MR-06 Color Coding Medical Record Filing 08-11-13        
AD-MR MR-10 Documenting Telephone Communications in the Medical Record 08-11-13        
AD-MR MR-14 Legibility of Medical Record Documentation 08-11-13        
AD-MR MR-17 Entries in the Medical Records 08-11-13        
AD-MR CL-39 Clinical Documentation 03-01-16        
AD-MR DMHSA Protocol Accounting for Disclosure of PHI protocol 06-18-12        
AD-MR DMHSA Protocol Afterhours Checking In & Out Chart Protocol 05-18-12        
AD-MR DMHSA Protocol Alternative Communication of PHI Protocol 06-13-12        
AD-MR DMHSA Protocol Amendment of PHI Protocol 06-13-12        
AD-MR DMHSA Protocol Checking In & Out Chart Protocol 05-18-12        
AD-MR DMHSA Protocol Closing Consumer Record Protocol 05-09-12        
AD-MR DMHSA Protocol Clinical Records Closure Protocol CASD 08-10-12        
AD-MR DMHSA Protocol Confidentiality of Psychotherapy Notes 06-20-12        
AD-MR DMHSA Protocol Emailing Protected Health Information Protocol 06-05-12        
AD-MR DMHSA Protocol Safeguarding and Storing PHI Protocol 06-05-12        
CL-CASD DMHSA Protocol CASD Storage of Clinical Records Protocol 08-10-12        
AD-MR DMHSA Protocol Transporting of PHI within Facility and by Motor Vehicle 06-06-12        
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NON VIOLENT PRACTICES
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
CL-NU AD-08 Seclusion and Restraint Plan          
CL-NU AD-07 Seclusion and Restraint 7/10/2014        
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INFORMATION TECHNOLOGY/MANAGEMENT INFORMATION SYSTEM
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Division/Unit Policy No. Policy Title Effective Date Reviewed Date Rescinded/Revised Policy(s)/ Dept/Div Policy Next Review Due Date Related Policies
AD-MIS AD-MIS-1 Technology and Systems Plan 3/14/2017     3/14/2018  
AD-MIS AD-MIS-2 Password Management Policy 6/2/2017     6/2/2018  
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