State of Hawai`i Department of Health Adult Mental Health Division Policy & Procedure Manual Copy Received on June 17, 2010 Compiled on September 20, 2010 Compiled by Poh Sonoda-Burgess Disclaimer: Every intention was made to ensure the awesomeness of this document.However, this is a public service and I make no warranties whatsoever, including warranties as to the accuracy, completeness, current-ness of the document.Use at your own risk/peril, or call AMHD to request the most current version or to check if its accurate. When I requested this document, this is what I was sent. If there are any sections missing (60.700 perhaps) thats because it wasnt sent to me.I received this on June 17, 2010. If you have any questions please contact: Provider Relations Adult Mental Health Division P.O. Box 3378 Honolulu, HI 96813 Phone: (808) 586-4686 Fax: (808) 586-4745 Distribution:Feel free to distribute this document to whomever, whenever.I am not the author, however, since this manual is a non-confidential, governmental record, I assume that this is in the public domain and freely distributable.If I am in error, please let me know: pohaokalani@wccmhc.org.Any errors were unintentional. This PDF is unsecured, text-searchable, bookmarked, printable, and text-copy-able.Cheers! Policy and Procedure Listing (Expand the Bookmarks on the left of your PDF reader to jump to specific P&Ps) 60.100 - General Administration 60.200 - Fiscal Management 60.300 - Personnel 60.400 - Legal 60.500 - Planning 60.600 - Patients 60.800 - Records 60.900 - Appeals 60.100 - General Administration 60.101 - AMHD P&P on P&Ps 60.102 - Policy Numbering 60.103 - Collection of Papers 60.105 - Consumer Sentinel Events and Incidents 60.107 - Directives 60.108 - Disaster Notification 60.200 - Fiscal Management 60.201 - Fiscal Management 60.202 - Use of Petty Cash Funds 60.208 - CMHC Charges [By Rate Schedule] 60.209 - CMHC Charges [By Eligible Clients Who Refuse to Apply for 3d Party Ins.] 60.213 - Use of State-Owned Motor Vehicles 60.300 - Personnel 60.301 - Private Practice, Outside Employment, and Relevant Business Interests 60.302 - Volunteer Services 60.303 - Student Training 60.304 - Standards of Conduct for Employees 60.305 - Human Resources P&P Manual 60.306 - Employee Status - App. for Leave of Absence Processing 60.308 - Motor Vehicle Safety; Reporting of Adverse Driving Record 60.309 - Cultural Diversity 60.310 - Staff Development and Training 60.400 - Legal 60.401 - Informed Consent to Treatment 60.402 - Confidentiality - Fax Transmissions 60.403 - Mandatory Reporting of Dependent Adult Abuse 60.404 - Release of Clinical Information Pursuant to a Subpoena/Duces Tecum 60.405 - Mandatory Reporting of Child Abuse or Neglect 60.406 - Release of Information Pursuant to a Court Order for a Sanity Exam. 60.407 - Release of Confidential Information About Consumers 60.408 - Applicants for Firearm Permits 60.409 - Authorization for Audio or Videotapes, Film or Photos. 60.410 - Protecting 3d Parties from a Consumer's Threats of Violence 60.411 - Designation of Non-Departmental Mental Health Emergency Workers 60.412 - Controlled Substance Registrations 60.414 - Provider Contract Termination and Non-Extension 60.415 - Provider Restriction or Suspension 60.500 - Planning 60.502 - Research Project Proposals 60.503 - Quality Management Program 60.504 - Program Evaluation and Outcomes Management 60.505 - Consumer Satisfaction 60.506 - Assessment of Program Quality for the Consumer 60.510 - Management Information System 60.511 - Accessibility Plan 60.513 - Discharge Oversight for HSH and Other Contracted Inpatient Facilities 60.514 - Community and Inpatient Discharge Coordination from HSH and Other Contracted Inpatient Facilities 60.515 - Role Functions in Support of the State Council and County Service Area Boards 60.516 - Corrective Action Plan 60.517 - Provider Monitoring 60.518 - Provider Certification 60.519 - Emergency Response Assignments 60.520 - AMHD State, County and Service Plans 60.521 - Quality Improvement Teams 60.522 - Committees and Sub-Committees Establishment and Standards 60.523 - Interdisciplinary Exceptional Case Reviews 60.524 - Consumer Protection 60.600 - Patients 60.601 - Eligibility 60.603 - Eligibility Assessment 60.604 - Treatment Plans 60.605 - Court Ordered Required Outpatient Treatment under the Penal code 60.606 - Parole Board Required Outpatient Treatment under the Penal Code 60.607 - Emergency Crisis Intervention Services 60.610 - Advance Directives for Psychiatric Treatment 60.617 - Accessibility and Affirmative Outreach to Promote Recruitment of Persons with Disabilities 60.622 - Patient Referrals from Child and Adolescent Mental Health Division 60.627 - Informed Consent for Psychopharmacologic Treatment 60.628 - Advance Practice Registered Nurses Prescriptive Authority Practice 60.630 - Adult Residential Care Homes 60.638 - Continuity of Care (Transitions) 60.639 - Warm, Welcoming Approach 60.640 - Early, Periodic Screening, Diagnosis and Treatment (EPSDT) 60.641 - Presumptive Eligibility 60.642 - Prison Referral for Eligibility to AMHD Services 60.646 - Hawaii Certified Peer Specialists 60.647 - Dropped Consumers 60.648 - Recovery (Treatment) Planning 60.649 - Consumer Denial of Continued Stay in Inpatient or Residential Programs 60.800 - Records 60.802 - Disclosure of Clinical Information to the Consumer 60.803 - Inquiries from the Office of the Obmudsman 60.804 - Treatment Records 60.812 - Records Retention Policy 60.900 - Appeals 60.903 - Consumer Appeals 60.904 - Multicultural Advisory Committee 60.906 - Consumer Grievances 60.908 - Provider Appeals 60.909 - Consumer Rights 60.910 - Provider Grievances ADULT MENTAL HEALTH DNISION POLICY AND PROCEDURE MANUAL AMHD Administration SUBJECT:AMHD Policy and Procedures on Policies and Procedures REFERENCE: Omnibus Plan for Menta! Health Services in United State of America v. State of Hawaii, eta! .. Civil No. 91-00137 in USDC illawaii) PURPOSE Number:60.101 Effective Date:02/15/92 History:Rev.10/93, 08/98,10/03 Page:I of 6 To establish unifonn guidelines for the development, approval, and review of policies and procedures within the Adult Mental Health Division (AMHD), and to require adherence to policies and procedures appropriately issued. POLICY .The content of AMHD policies and procedures shall confonn toState and/or Federal law; rules, regulations or directives of authorized agencies within the Hawaii state government; the standards and requirements of pertinent certifying,licensing, and/or accrediting agencies; and official AMHD organizational statementa.The AMHD Chief may obtain opinions from the. Attorney General's office if there is a conflict among different laws, regulations, or directives. Hawaii State Hospital (HSH) policies and procedures shall be consistent with the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Centers for Medicare and Medicaid Services (CMS), state licensing, Federal and State statutes and regulations, and AMHD policies.All policies and procedures for AMHD operated and funded Community Mental Health Centers (CMHC)and AMHD funded Purchase of Service (POS) providers shall confonn to the accreditation requirements of the Comniission on Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation (COA), or the Joint Commission on Accreditation of Healthcare Organizations (JACHO), or the International Center fot Clubhouse Development (ICCD), or other AMHD approved organization, and to AMHD policies. AMHD shall require that it's contracted or monitoring consultants abide by AMHD policies and procedures.Consultants may recommend changes to policies and procedures; however, only AMHD shall decide if new or revised policies and procedures are needed. AMHD shall not implement any policies or procedures that conflict with any provision of the Omnibus Plan for Mental Health Services referenced above. ADULT MENTAL HEALTH DIVISION POLICY AND PROCEDURE MANUALNumber:60.101 AMHD AdministrationPae:20f6 AMHD shall not implement any policy or procedure that conflicts with the terms of the agreements with employee organizations, when-applicable.AMHD policies and procedures are reviewed at least every two (2) years in order to assure continued accuracy and appropriateness. AMHD policies and procedures are expected to change as professional practice standards evolve, and as programs are developed, modified, or discontinued. Staff members of all organizational units of the AMHD are required to follow approved AMHD policies and procedures at all times, Wllessspecifically directed by the AMHD Chief to suspend or disregard any policies and procedures. All contracted Purchase of Service (POS) providers shall be required to contractually agree to abide by the policies and procedures of AMHD, and to develop procedures that assure that applicable AMHD policies and procedures are followed. All AMHD operated and funded CMHCs and AMHD funded POS providers may implement policies and procedures more restrictive than those of the AMHD, but shall not implement policies and procedures less restrictive than those of the AMHD. DEFINITIONS "CMHC System Administration" is defined as all the community mental health centers that are operated by the AMHD. "AMHD funded CMHCs" isdefined as any privately operated Community Mental Health Center that receives funding from the AMHD. "POS providers" is defined as any privately operated program providing mental health services, other than an AMHD funded CMHC, that receives funding from the AMHD. PROCEDURE 1.All policies are issued by the AMHD Chief.Procedures to implement these policies are issued by AMHD, HSH, and the CMHC System Administration. POS-providers shall develop policies and proCedures to assure that AMHD policies and procedures are followed.All AMHD policies and procedures shall be reviewed by the AMHD Medical Director prior to issuance, and shall bear the approval signature of the AMHD Chief or designee.AMHD policies and procedures may be researched and drafted by appropriate clinical or administrative staff members. ADULT MENTAL HEALTH DIVISION POLICY ANDPROCEDURE MANUALNumber:60.101 AMHD AdministrationPe:30f6 2.A method for developing policies and procedures at HSH shall be established by the HSH Administrator, and shall conform to the requirements of JCAHa, CMS, and state licensing. All policies and procedures ofHSH must be approved, dated and signed by the Hospital Administrator, or hislher designee.The Adult Mental Health Division Quality Management Administration (AMHD QMA) shall monitor HSH to assure that HSH complies with AMHD policies and procedures. 3.A method for developing policies and procedures for the CMHC System Administration shall be established by the CMHCSystem Administrator, and conform to the requirements of CARP and state licensing.All policies and procedures of the CMHCs must be approved, dated, and signed by the CMHC System Administrator, or hislher designee.AMHD QMA shall monitor the CMHC System Administration toassure that the CMHC System Administration complies with AMHD policies and procedures. 4.A method fordeveloping policies and procedures at each AMHD fundedCMHC and pas provider shall be established by the respective Executive Directors, and conform to the requirements of AMHD policies and procedures, CARP, and state licensing. All policies and procedures of AMHD funded CMHCs and pas providers must be approved, dated, and signed by their Executive Directors respectively.A.c\1HDQMA shall monitor AMHD fundedCMHCs toassure that each AMHD fundedCMHC and pas provider complies with AMHD policies and procedures. 5.New and expiring AMHD policies and procedures are systematically reviewed as a standing agenda item for AMHD QMA'QMA review will include review of existing policies and procedures, existing AMHD directives, and state and federal requirements.QMA is also responsible for tracking, issuing, disseminating,and assuring implementation of AMHD policies and procedures.AMHD QMA is also responsible for ensuring implementation and consistency with existing and approved written policies and procedures. 6.All AMHD policies and procedures apply unless their application is specifically limited or exempted in writing. 7.Any AMHD staff member may recommend new or revised CMHC System Administration, HSH, or AMHD policies and procedures.Staff members of the. CMHC System Administration or HSH shall review the draft with their respective supervisors before submitting recommendations to or through their program or clinic managers who in turn shall submit recommendations to or through the CMHC Systems Administrator or HSH Administrator respectively to QMA. AMHD administrative staff members may submit recommendations through their supervisor to AMHD QMA. , ADULT MENTAL HEALTH DIVISION POLICY ANDPROCEDURE MANUALNumber:60.101 AMHD AdministrationPae:40f6 8.The QMA Administrator shall review each proposal with the AMHD Medical Director to determine if AMHD policies and procedure are needed and appropriate.if policies and procedures are determined to be warranted, the AMHD Medical Director and the QMA Administrator shall assign the recommended policies and procedures to AMHD staff for deVelopment.After development, the draft policies and procedures shall be returned to the QMA Administrator. 9.The QMA Administrator shall meet again with the Medical Director to determine and complete appropriate distribution of the proposed policies and procedures for review and comment.The designated/assigned reviewers shall be AMHD staff whose service area will be affected by the proposed policies and procedures.All draft policies and procedures shall be accompanied by a tracking/log sheet to record timely handling, as assigned, including the author and the person responsible. 10.All written comments on draft policies and procedures shall be returned to the staff member who drafted proposed policies and procedures within ten (10) working days from the date the draft policies and procedures where circulated for review and written comments.The staff member who proposed the draft policies and procedures shall complete the final proposed policies and procedures and submit to the QMA Administrator within five (5) working days from date of assignment.The QMA Administrator shall present thecompleted, proposed policies and procedures to the AMHD Medical Director or hislher officially designated designee for review and recommendation to the Office of Planning and Compliance (OPC) Administrator within five (5) working days from date of receipt. 11.The OPC Administrator shall review the proposed policies and procedures for compliance with the requirements of the Community Plan, consistency with the Statewide Comprehensive Integrated Service Plan, Block Grant Plan, and any other planes) the AMHD may be required todevelop and implement.The OPC Administrator will affirm compliance, or identify the reasons for non-compliance to the AMHD Chief forfinalreview and appropriate action within five(5) working days from date of receipt. 12.As a result ofhislher review the AMHD Chief may determine that the recommended policies and procedures will be implemented first for a pilot period not to exceed six (6) months.During this time the piloted policies and procedures will be reviewed by the QMA Administrator and the AMHD Medical Director, and a recommendation made to the AMHD Chief that the recommended policy and procedures be adopted, modified, or terminated. ADULT MENTAL HEALTH DIVISION POLICY AND PROCEDURE MANUALNumber:60.101 AMHD AdministrationPae:50f6 a.Should the recommendation be made to adopt the pilot policies and procedures, the pilot policies and procedures shall be returned to the staff member who drafted the pilot policies and procedures to be written into formal policies and procedures format within thirty (30) days of assignment. b.Should the recommendation be made to modify the pilot policies and procedures, the AMHD Chief may extend the pilot period for an additional six (6) months after which time the pilot policies and procedures shall be returned to the staff member who drafted the pilot policies and procedures to be written into formal policies and procedures format within thirty (30) days after the end of the six (6) month extension. c.Should the recommendation be made to terminate the pilot policies and procedures, the AMHD Chief shall issue a written notification to the HSH, CMHC System Administration, AMHD funded CMHCs and POS providers of the termination of the pilot policy and procedures and the reason for the termination within five(5) working days after the receipt of the recommendation. 13.The CMHC System Administrator, HSH Administrator, AMHD funded CMHCs and POS provider Executive Directors are responsible forassuring that policies and procedures promulgated by AMHD and by their respective programs are made available toall staff, consumers, and the public upon request, and implemented consistently. 14.The CMHC System Administration, AMHD funded CMHCs, HSH and POS provider policies and procedures manuals must contain a face page that bears the signature of the CMHC Manager and CMHC System Administrator, HSH Administrator, AMHD funded CMHC and POS executive manager or designee, respectively, indicating finalreview,approval, adoption, and issuance of the policies and procedures manual.Such reviews must be conducted every two (2) years. IS.All CMHC System Administration,AMHD fundedCMHCs, HSH, and POS provider staff members shall sign and date acknowledgement of the receipt and review of policies and procedures by number and title, and all staff signed acknowledgements shall be maintained with the policies and procedures manual' at the provider site. ADULT MENTAL HEALTH DIVISION POLICY AND PROCEDURE MANUALNumber:60.101 AMHD AdministrationPae:60f6 16.All AMHD policy manuals must contain a face page that bears the signature of the AMHD Chief, and the Director of Health or hislher designee indicating fmal review, approval, adoption, and issuance of the policies and procedures manual. Such reviews must be conducted every two (2) years.. 17.In an emergency or when prompt action is necessary, the AMHD Chief or hislher designee may issue position statements, instructions or administrative directives; however, an administrative directive that requires policy formulation forfuture guidance shall be assigned to the QMA tobe written into a formal policies and procedures fonnat within ninety (90) days of assignment. 18.In an emergency or when prompt operational guidelines are required to implement an activity which has received the prior approval of the AMHD Chief or hislher designee, a program may issue a Standard Operating Procedure (SOP) to implement operational procedures; however, SOPs that are necessary for continued operation beyond a period of one hundred twenty (120) days shall be written as recommended policies and procedures within ninety (90) days after the 120 day period and submitted to the QMA. 19.All policies and procedures must conform to the approved AMHD fonnat (see attached). 20.The CMHC System Administration, AMHD funded CMHCs, HSH and POS providers shall have full and immediate access to AMHD policies and procedures at all times.Policies and procedures shall be posted on the AMHDIntranet within two (2) weeks of approval. ATTACHMENT Approved Format forPolicies and Procedures Approved Policy and Procedures for Administrative Directives Date of Review:///. ///// Initials:[L__--Il[L__--'l['-__--'1r ~ ~ _ - , l ATTACHMENT:60.101 APPROVED FORMAT FOR POLICIES AND PROCEDURES ADULT MENTAL HEALTH DIVISION POLICY AND PROCEDURE MANUAL AMHD Administration SUBJECT:D REFERENCE:E Number:A Effective Date:B History:C Page:10fX Recommended: Title:Medical Director, AMHD APPROVED: Title:Chief, AMHDF The approvedformat for policies and procedures is available for use with Word, New Times Roman 12 font.The Adult Mental Health Division Quality Management Administration (AMHD QMA) is responsible for formatting AMHD policy and procedure; however, the template shall be e-mailed to providers upon request. A.The two digit AMHD Division number 60 followed by a period and a three digit number that identifies the specific policy, i.e.60.101, where"60" identifies AMHD Administration, and "101"is the number of a specific policy.. B.The effective date of the policy. C.If the new policy is a revision, enter REV followed by the number of the original policy.If the policy has not been addressed before, enter NEW. D.Title of the policy.Be brief.Try to identify the maiJi idea in the fIrst word. E.Identify the law, standard or rule upon which the policy is based.Be brief, but include the exact reference so that it can be easily traced.If you must include a number of references enter SEE PAGE -- (last page of the policy, above attachments section). ADULT MENTAL HEALTH DIVISION POLICY ANDPROCEDURE MAl'lUALNumber:60.XOOX.NEW AMHD AdrrllnistrationPae:20fX F.Title of AMHD Medical Director for recommendation of acceptance and Title of AMHD Chieffor final review and approval. The body of the document should begin four lines below the last entry on the heading. PURPOSE Ashort statement explaining WHY the policy is being written. POLICY Generally, statements of WHAT is to be done.Should be in narrative form. DEFINITIONS Generally, terms used by the AMHD, or names given by the AMHD toits programs, services and/or organizational segments which are not generally used by non-AMHD programs, services and organizations. PROCEDURE Instructions for HOW, WHO, WHEN, etc., in a sequence or order designed to explain how to carry out a process from beginning to end. ATTACHMENTS Date of Review:ff; _f_f_;ff;....Ll..; Initials:L-l [-1 [-1 L-l [Attachment to AMHDPolicy #60:101 ] I.. ADULTMENTALHEALTHDIVISION POLICYANDPROCEDUREMANUAL AMHDAdministration Number:60.102 EffectiveDate:08/31/92 History:revised10/93 SUBJECT:PolicyNumberingPage:1of2 REFERENCE:(none)

PURPOSE Toestablishuniformcodingofallpoliciesissuedinthe AdultMentalHealthDivision,exceptthoseissuedinHawaiiState Hospital. POLICY AllAdultMentalHealthDivision personnelauthorized toissue policiesshallusetheAdultMentalHealthDivisioncodingsystem toidentifyeachpolicyissued.AllpoliciesissuedbytheAdult MentalHealthDivisionoranysub-divisionthereof,shallbe numbered. PROCEDURE 1.Thefirsttwodigitsofthepolicynumbershallreflectthe organizationalunitfromwhichthepolicyisissued.Thecode numberforeachunitisprovidedinAttachmentA. 2. 3. Example:60.xxxisapolicyissuedinAMHDAdministration. Theorganizationalunitnumbershallbefollowedbyadecimal point. Thenextdigitshallindicatethecategoryintowhichthe policyfalls.Thelistofdigitsandcategoriesisprovided inAttachmentB. Example:60.2xxisafiscalpolicyissuedbyAMHD Administration. I I I 1 i I i \ I , '. I I I I ADULTHEN'l'ALHEALTHDIVISION POLICYANDPROCEDUREMANUAL AMHDAdministration Number:60.102 Page:2of2 4.Thelasttwodigitsareusedtoindicatehowmanypoliciesin thatcategoryhavebeenissuedbythatunit. Example:60.201isthefirstfiscalpolicyissuedbyAMHD Administration;60.211istheeleventh. ATTACHMENTS: A. B. ListingofProgramCodesforPolicyNUmbering CategoryCodesforPolicies AnnualR e ~ i i e w :_..../..1-..../..1__ ; -..../..1_-,-1__ ;_..../..1_-,-1__ ;_--,-1_......1 __ ; Initials: [----][----][----][----] i , j I I I I 30 60 6J. 62 63 64 65 66 67 68 89 ATTACHMENTA LISTINGOFPROGRAMCODESFORPOLICYNUMBERING (XX. xxx) HawaiiStateHospital CentralAdministrativeOffice Central OahuCommunityMentalHealth Center(CMHC) WindwardOahuCMHC LeewardOahuCMHC DiamondHeadCMHC Kalihi-PalamaCMHC MauiCMHC HawaiiCMHC KauaiCMHC CourtsandCorrectionsBranch [Attachmentto] AMHDPolicy#60.102 ATTACHMENTB CATEGORYCODESFORPOLICIES (xx.Xxx) Number 1 2 3 4 5 6... Topic General Administration Fiscal Personnel Training Qualifications Legal Planning QualityManagement ProgramEvaluation Patients Programs Services StandardsofPractice 7(RESERVED) 8Record-keeping Information Reports Communications 9....Rights Ethics o.....(RESERVED) [Attachmentto] AMHDPolicy#60.102 " ADULTMENTALHEALTHDIVISION POLICYANDPROCEDUREMANUAL AMBDAdministration SUBJECT:CollectionofPapers REFERENCE:MentalHealthDivision memorandum- December12,1983 REFERENCE Number:60.103 EffectiveDate:10/15/94 History:ReplacesA-23 Page:1of1 APPROVED: MentalHealthDivisionChiefmemorandum- December12,1983. PURPOSE Toestablishguidelinesonthecollectionofpapersand studiesrelatingtomentalhealthservicesinHawaii. POLICY TheHaHaiiStateHospitalMedicalLibraryshallmaintaina collectionofpublications,papers,andstudies(both publishedandunpublished)regardingmentalhealthinHawaii, theHa."aiiStateHospitalandtheAdultMentalHealth Division. PROCEDURE 1.Acopyofallpapersorstudiesdevelopedwithinthe AdultMentalHealthDivisiononofficialtimeshallbe forwardedtotheHawaiiStateHospitalLibrary. 2.OtherindividualsworkingwithintheAdultMentalHealth Division ondissertations,thesis,or research activities shallbeencouragedtosendacopyofthefinalized documenttotheHawaiiStateHospitalMedicalLibrary. 3.Themedicallibrarianwillsystematicallycategorizeand centralizethelocationofthesedocumentsforreading andresearchpurposes. Attachment:MentalHealthDivisionChiefmemorandum- 12/12/83 AnnualReview: /I_-LI_----'I'-_;_-I-1_--J1,--_; Initials: [----[ ____1[ ____ 1[ __---'_1 .:'R-::::R . .....v-"lOf'.......... . MEMORANDUM TO: FROM: SUBJECT: STATEOFHAWAII CE?ARTMNTOFHEALTH P.o.BOXma HONJl.lJt.U.9&801 December12,1983 CHARLesG..CURX 0' IoIU,LTI'I JOHNF.CiiALMERS.),,1.0. O("VT'"01'..00/.1... .u;:SUEs.I.U,TSUB.l.RJ. DI:questions,pleaseconta.ctme'at 548-5709.Thankyoufo,- ,ourcooperationandassistancein thismatter. atec VALERIEK.AKO Attachment Note:Additionalcopi.,,.uftheseformsmaybeobtainedinthe AdministrativeServices lHNWAIHlt: ....-STATEOFHAWAII DEPARnIENTOFA=OUNTlNGI ANDGENERAl.SERVICES ,.o.ItOX'" HOHOI.IA.U.HAWAII",1HU. June .20,1989 COMPTROLLER'SMEMORANDUMNO.1989-16 TO: HeadsofDepartmentsandAgencies ATTN:RiskManagementCoordinators FROM,RusselNagata,Comptroller. SUBJECT,ClaimsforLossofStateProperty JIIUSSllS.NAGATA --LossesanddamagestoStateproperty,includingthose initscustodyand costlyanddisruptive. TheydeprivetheStateoftheuseofthepropertyandcause disruptionsof-servicestothepublic.TheStateRiskManagement RevolvingFund(SRMRF)wascreatedundertheRiskManagement Programtominimizethesedisruptionsbymakingfunds topay.forthese andrestoreservicesassoonas Inadditiontopropertyloss,SRMRFwillfinance automobileno-fault,andtortclarmsupto$10,000.The followingtablesummarizestheexposuresfinancedbySRMRF, INCIDENT Auto Fireto.Other Casualties Theft Tort BodilyInjury/ PropertyDamage Bldg.'"Content Equipment Money Equipment BodilyInjury/ Prope.rtyDamage COVERAGE SELF-INSUREDEXCESS No-Fault $250,000* Value $10,000* Value $10,000* Insurance lnsur.ance Insur.anc:. *P"rhicid.mt Comptroller'sMemorandum1999-16 Page2 ,june20,1999 ProceduresforreportingandfilingofAutoandTort clalmshavebeencoveredunderComptroller'smemorandumsentitled "StateAutoFleetLiabilityInsuranceProgram"dated,june1,1999 and"TortClaimsAgainsttheState"datedOctober1,1998, respectively.Proceduresforreporting.andfilingofclaimsfor propertylossordamagearecoveredunderthismemorandumand sh.alltakeeffectonJul y1,1989. ForalossordamageofStateproperty,including propertyinitscare,custodyorcontrol,resultingfromtheft, fireandothercasualties,tobefinancedbySRMRF,acl.aimmust befiledwiththeRisk Program.Aclaimismadeby submittingacompletedFormRMP-OOl,LOSSORDAMAGEOFSTATE PROPERTY.Pleaserefertotheattachedform. Thisformisusedtoreportallpropertylossesor damages,exceptlossesordamagesresultingfromaccidents.--(Automobileaccidentsaretob ..reportedontheACORD AutomobileLossNotice.)Part1is.to preparedbythe employeeorthesupervisoroftheemployeewhodiscoveredthe lostordamagedproperty.Parts2and3aretobepreparedby theimmediatesupervisorhavingauthorityorcontroloverthe lostordamagedproperty.Theformshouldbereviewedand5i.gned bythedepartmentalriskmanagementcoordinatorbeforefilingit withtheRiskManagementProgram. Otherformsor-informationmayberequestedtoassist inlosscontrolandintheinvestigationandsettlementofthe claim. Theclaimant'sdepartmentwillbenotifiedthatthe claimhasbeenreviewedandthereplacementDrrestorationofthe propertywillbefinancedby-SRMRF.Fundscaneitherbe transferredtoth ..departmentbyjournalvoucherordirect paymentcanbemadetothevendor.Itwillbetheresponsibility ofthedepartmenttofollow procurementproceduresunder thelaw. Ifyoushould Mr.JohnTakamune,Risk Attachment pleasecont.act ,at548-3214. Report . (RMuse) DEPARTMENT UNIT/SCHOOL STATEOFHAWAI I LOSSORDAMAGEREPORTOFSTATEPROPERTY (RiskHanageeent) 1.TYPEOFlOSSCII,Th.flFire/A"onhruldi ..Ston Olh.u__ __ (SpICily) C.DATEINCIDENTDISCOVERED___,..;.. ____ TIllE_____ Jp 3.omINCIDENTOCCURRED_________TIllE_____ /p \.HOWWASLOSSDISCOVERED_________________________ S.WHODISCOVEREDLOSS______________ TITLE-:-_-'-________ b.WHOISRESPONSIBLEFORPROPERTY___________ TITLE .___________ 7.MOUNTOFlOSS!.ol ____ ATTACijACOPYOFTHEDETAILINVENTORYOFPROPERTYREPORTOROTHERDOCUnENTSAHDINDICATETHEITE"STHAT AREINVOLYEDINTHELOSS.INADOfTIOH,INDICATENEITTOEACHITEnTHEBUILDINGANDROOn'NU"BERWHERETHE PROPERTYWASLOCATED,IFAPPLICABLE.NOTE:THISITE".nUSTBECO"PLIEDWITHINORDERTOVERIFYEIISTENCE OFTHEPROPERlY. 8.IFCRInESUSFECTED, i.WHEREENTRY"ADE'nAHHER_,-,--:--:-:---,-:-_--,-;-_ (building;lndroo.I)'.ind.o/d.or/l.uv" It.) b.SECURITYTYPEOFSYSTEM'fin/bur, lir 'pitrol,.tt.)'oind"/g.I.lihnllighh,.Ic.) c.INCIDENTREPllRTEDTOlOCAl.POLICE,NAIIE-:-:-= _________________ BADGENUnBER_________-,-_______ STATUm_________=:-_______ DATE_________ TIllE________ 9.OTHERPERTINENTIHfORnATION. I CERTIFYTHATTHEABovEISTRUEANDCORRECTTOTHEBESTOFnyKNOWLEDGEANDBElIEF. 5lgnolu" Originilto,DAGSJRisinonage.en! Dal. F.reRIlP-GOI PulIof3 , ReportNo. (RMuse> STATEOFHAWAII SUPERVISOR'SLOSSOR.DArlAGEREPORTOFSTATEPROPERTY (RiskManagRMent) 1 Se.er.1Descriptio.ofProplrlyLoslorD lq.d, 1 1 1 1 1 BuildingindRoo.No.____________ S,_::--,.--lotll 1------------------------------------------------------------1 A 1 I.Whiticl.,fiilurt10iclind/orcondilionsconlribultd.o.1dirtclly10Ih.10.sl 1 H , 1 A , 1 L 1 1 Y 1 1 51J 1 I1 2.Whllir.IhlblsicorfundiaenlilrelsonstorIh.Ixistlnc.ofIhe .. &clsindlorcondilionl! J 1 S 1 ----------------------------------------------------, 11 ----------------------------------------------_--_1 .1, -----------------------____ ----' J, 1 ,EVAlUA TlOH,1 ,, ,lo .. SeverityPolenliil,Probibl.Recurr.nceRilel, ,1 ,_, _, Kijor_I_, Serious_I_, Kin"_, _, Frtgulnl_, _, Oceisi.nil_, _, Rire, ,---------------------------------------------------, ,P ,WhilIcli.nhi'or.ill beI"tntopre,"nlrecurrenct?Lisl.11.cli.n.insequencel1 1 R'1._________________________________ , ,E ,I. ,Y 1E.I 1 Ell 1 H 13.I ,T ,I 1 II\.I I0JI IH,_I I1 6ived.t.ofi.aldi.l.Ictiontlktn.Sivedll he.iclioncoapilled.I IIlandiilt Action1., _____ Z.3. _____ \.,_____I 1IActionCoapleld1.Z.3. _____ 4._____I __ ' I lnvestiqiledby:I Rtvi ldbYII 1II I__-:-________---:-,--_-:,.---,- II ISupI"isorDilePhoneNo.--=R"'is"7t-:ft:-I-'"-p-.-e-:nl"'C=-.-or-:d"'i'-I"'Io-r- Dlt.PhoneNo.I NOTE,INORDERTORECEIVEREI"BURSEHENT,PARTS1,2 &!!R3 KUSTBECOIlPlETED. Driqi.I'tOIDAGS/Risk"".Ig nl For.RftP-oG1 Plrl2 of3 Ac:tion STATEOFHAWAII SUPERVISOR'SLOSSORDAI'IAGEREPORTOFSTATEPROPERTY LISTOFPREVENTIVEACTIONSNOTx/'lPL.El'1ENTED ANDREASONS (Risk PROPERTY No.--------------------- REASON----------------------------OriginaltOIDAGS/RiskManagementFormRMP-OOl Part3of3 stateofHawaii DEPARTMENTOFHEALTH Honolulu . ADMINISTRATIVESERVICES MEMORANDUMNO.88-28 June2.1988 OFFICE To:DivisionandBranchChiefs,StaffOfficers; andDistrictHealthOfficers From:Chief,AdministrativeServicesOffice Subject:stateAutoFleetLiabilityProgram- Update AttachedforyourinformationisStatecomptroller's MemorandumdatedJune1,1988,describingandupdatingthe presentautofleetliabilityinsuranceprogram. Highlightsoftheprogramchangesareincludedinthd memorandum. Yourattentionisespeciallyrequestedonthepolicy andprocedure(pg.3-4)governingrentedcars.Enclosedforyou:,. useisaComptroller'smemorandumtoautomobilerentingcompanies explaining State'spolicyregardingcollisiondamagewaiver (COW)coveragewhenusingcarrentalcompaniesinthisState. Employeesshouldinformtherentalagenciespriortorentingthe vehiclethattheState,notthedriver,willbeliablefor collisiondamage.Employeesshouldnotpatronizeagencieswhich refusetoacceptthiscondition. Newno-faultidentificationcardswillbeprovided aftertheapplicationforFY1989isapproved;andthismustbe keptintheDepartment'sStatecarsandleasedvehiclescovered bythispolicy. Pleasegivethismemorandumwidedisseminationamong yourstaffandifthereareanyquestions,pleasecallCalvin Kunihisaatx5995,ormeatx5709.

VALERIEAKO Att ( ....WAIH!E ... -IIIUSSEL$.H"",,1'.t. Co-TtQ,.\fA KNKI'fA8U STATEOFHAWAII DEPARTMENTOFA=OUNTING ANDGENERAL.SEF!VICES 1:001 ....... 1'. TO: ATTENTION: SUBJECT: , P.O ..ax11' HONO\.VLU.KAWAU""10001,, June1,1988 HeadsofDepartmentsandRiskManagementCoordinators stateAutoFleetLiabilityInsuranceProgram-Update TheenclosedsummaryoftheState LiabilityInsuranceProgramhasbeenupdated. changesare-shownbelow: AutoFleet High I'i gh ts 1:Theterm"self-insured"hasbeenremovedfromthe excessinsurancehasbeen toprotecttheState,againstlosses. 2.Thelimitsoftheno-faultbenefitshave beenupdated.Nocoverageisprovidedfor uninsuredandunder insuredmotorists. 3.Theself-insuredretentionispresentlyat $1,000,000peroccurrence. 4.Excessautoinsuranceof$4,000,000per occurrencehasbeenpurchasedtocover catastrophiclossesovertheself-it'5ured retention. 5.willcontinuetoserveastheadjuster. 6.No-faultbenefitforlossofearnings (disability)isavailableasasupplementto Workers'Compensationdisabilitybenefit. Thecurrentmemorandumtotheautomobilerental regardingCollisionDamageWaiver(CDW)isalso ene: 1 osed forrenewalasaself-insurerhasbeen madeforthe Year1988-89.Assoonastheapplicationis approved,newno-faultidentificationwillbedistributed. HeadsofDepartmentsandJune1,1988 Page2 Iflir.John Takamune,Risk STATEOFHAWAII RISKMANAGEMENT AUTOINSURANCEPROGRAM (AProgramofContinuingCoverage) TheStateself-insuresitsautomobileno-faultcoverage. insuranc:emaybepurcha,.",dtoprotec:'ti tsel fagain,.t c:atastrophiclosses."No-Fault"referstoinjuriesresulting froman.utoaccident. Thebasic:no-faultpolicyc:ontainsupto$15,000 perpersonforinjuries,residualbodilyliabilityof$35,000 perperson,andpropertydamageliabilityof$25,000foreach occurrence.ThereisnocoverageToruninsuredmotoristnoris providedforunder insured Theaggregatelimitofself-insuredretentionis$1,000,000 peroccurrenC4i. Coverageabovethe retention,upto$4,000,000 isprovidedunderthe"excessautomobile insurancepolicy_ Automobilescovered: Stateautomobilesandmobileequioment. EmployeeownedcarswhileonauthorizedStatebusiness. Coverageislimitedtoexcessoveremployee'sperson.l autoinsuranCRpolicy. Leased,hired,rented,non-ownedcarswhenauthorized bytheStateandoperatedunderthenameoftheState. UnlessautoshavebeendeSignatedforphysicaldamage c:overagBbythedepartmentsandapprovedbytheRiskManagement Officer,physic.ld.mageisnotacovered1055.Noemployee ownedc:ariscoveredforphysical underthisprogram. Driverdefined; Stateemployee,legislator, ofboards,c:ommissions, orcouncils,volunteer,studentdriveror.nyother authorizedindividuallic:ensedtooperateanautomobile c:overedunderthispolicy. ClaimsAdministrator(TnroughJun.30,1990r: NameandTelephone NumberofIndivi-dualtocontact: Premiumcharge: AleKsisRiskManagement,Inc. 1221KapiolaniBlvd.,Suite901 Honolulu,Hawaii Mr.LarryBusto (808)531-2011or (808)Eachspecialfundedprogramwillbeassessed,aprorata shareoftnetotalannualcostbasedontotalamount ofexpectedself-insuredlossesincludingadministrative feesoverthenumberofautomobilescoveredbythe program.Theproratasnareforgeneralfundedprograms andtnepremiumfortneeKceS5insurancepolicywillbe absorbedbytneRiskManagementProgram. In ofanthe andhis/hersupervisoror tneRiskManagementCoordinatorshouldbeguidedbytnefollowing procedures: I.- DRIVINGASTATEAUTO(including'le.sedautowherethelease agreementrequiresStatetoinsureauto): 'AccidentsonOAHU: Notifythe Ifanyareinjured,seetoitthattheyreceive propermedicalattention.Drivershouldreportany injury,deathormajorpropertydamagetohis/her supervisororriskmanagementcoordinatoratonceby phoneifpossible.Thesupervisororriskmanagement coordinatormustimmediatelyreporttheaccidentby phonetoAleKsis. Discusstheaccidentonlywithyoursupervisoror State'srepresentative(AleKsis)andthepolice.No admissionoffaultorresponsibilityshouldbemade. DrivershouldusetneReportofAccidentCardfound inthedriver'scompartmenttofilloutthedetails ofthe,accidentatthesceneandgiveittohis/her supervisororriskmanagementcoordinatorimmediately afterthe Writtenreportmustfollowwithinfive(5)working daysusingstandardaccidentform(Acord-Automobile Loss Thereportistobesent to Alexsis.Retainacopyforyour 2 StAteemployeesusingDAGSMotorPoolvehiclesare requestedtofollowSection17"AccidentReports"of DAGSCentralMotorPoolRulesandRegulationsin reportingaccidentsinsteadoftheprocedureoutlined above. AccidentsanNEIGHBORISLANDS: Notifythepolice, Ifanyareinjured,seethattheyreceiveproper medicalattention. Discusstheaccidentonlywithyoursupervisoror State'srepresentative(Alexsis)andthepolice.No admissionoffaultorresponsibilityshouldbemade. shouldusetheReportofAccidentCardfound inthedriver'scompartmenttofillautthedetails oftheacC identa tthesceneandsubm{tittohi s/h.r risk ccordin.torimmediat.ly aftertheaccident. MinorAccidents.Forminoraccidentswithoutinjury, thesupervisororriskmanagementcoordinatormust submitth@ accidentform(Acord-Automobile Notice)directlytoAlexsiswithinfive(5) workingdays.Retainacopyforyourrecord. MajorAccidents.Forallmajoraccidents(especially wherebodilyinjuryordeathisincurred)the supervisororriskmanagementcoordinatormustcall AleKsisbyphoneaCompletedautomobilelossnotice mustfollowby withinfive(5)workingdays.On adviswtheoper.torontheAlexsis answeringserviceoftheaccidentandleaveyourandphonenumber. II.DRIVINGEMPLOYEE'SCAR: providedunderthisprogramislimitedtoe.cess overemploy.e's autoinsurancepolicy.Employe.should beguidedbyhis/h.rinsurer'sinstructionsforreportingan accidentaHoweverminorthe seem,anreportshouldalsobefiledwithAlexsisinaccordancewiththe procedureoutlinedinItemI,III" DRIVINGARENTEDCAR: underlimitedsituationasdescribedbelow,the St.tepolicydoesnotpermitemployeestopurchase collisiond.m.gewaivercoverage(CDW)norpersonal accidentinsurance.Therent.lagencyshouldbeinformed 3 priortorentingthevehiclesthatthe notthe employee(driver),willbeliableforcol11s10ndamages. Acceptanceofthisconditionmustbeacknowledgedbythe rentalagencypriortoexecutionoftheagreement. 'itl;11k7'Idnotpatronize..genc:ie.whic:hr.fus.to acelfPt'.c:anq it ion . Allrent .. l..greementsshouldn ..theSt.. teofH....aiias therenter.Thisisdonebysigningtheagreementas follows. STATEOFHAWAII,(.mploy signatur.), Eachrentalagencyhasitsownprocedu......fo ....reportingan accident.Regardlessoffault,theemployeewillbegiven anestimatedlossstatement.Instructth ..agencytobill theactualcostofthedamage'tothefollowingaddressof Alexsis(ac:ollecttelephonecallisautho ....izedtobemade ifconfirmationis.... equired): AlexsisRiskManagement,Inc:. 1221KapiolaniBlvd.,Suite901. Honolulu, .. aii96814 (F'hone:(808)531-2011) ReportoftheaccidentmustbesenttoAlexsisusingth .. Acord-AutomobileLo Not ice .Al .. "s i 5.... i11payforthe lossandwill'conductitso .... ninvestigationoftheaccident todeterminefaultorliability.Itisthereforevital thatallinformationoftheaccidentoerecordedas accuratelyaspossible. Purchaseofcollisiondamagewaiver(CDW)ispermitted underthefollowingsituations: . drivingoutsidetheStateofHawaii; conditionforrentingacarwherefinancialterms.re advantageous; paym.ntisfullyreimbursabletotheStat .. ; paymentiscoveredbyfundsotherthanStatefunds. IV.OTHERS: Wheneveritisdeterminedthattheotherpartyisatfault, itistheresponsibilityofthedepartmentoragencytosee thattheotherparty' 5insurancecomp .. nypaysfor.the damagedStateproperty.Acopyofthedamagereportand amountoflossshouldbesenttotheRi.skM.. nagementStaff. Workers'CompensationwillbeprovidedtoStateemployees whenwork-relatedinjuriesaresustainedinanautomobile 4 i, accident.No-faultbenefitsmaysupplementWorkers' Com-p.ns.tionbenefitsinwhereinjuryresultsin 10s5ofearnings. AllaccidentsaretobereportedtoonAcord-Auto-mobileLossNoticeforms. No-FaultIdentificationCardandReportofAccidentCard mustbekeptinallcoveredStateandLeasedAutomobiles. FormsareavailableattheRiskManagementStaff,DAGS. Informationcontainedhereinisintendedtoguidelines withrespecttotheadministrationoftheSt':eAutoFleet LiabilityProgram.TheStateNo-FaultLaw, administration contract,excessautoinsuranceandWorkers!Lawshallbethegoverningdocument$fromwhichcoverages, exclusionsandothermatterswillbeinterpreted. s JOHNW,t,IKlE ....-STATEOFHAWAII OEPARTMENTOFA=OUNTINGI ANOGENERAl..Se,;VlCES P.O.,. It. HONOLULU.MAW ..'"'1)001 t, TO:AUTQMOBILERENTALCOMPANIES(HAWA"II) S.NAQ,lT.&

/ IC!NIC'l'oM.ll'Utyco... .. TheStateofHawaiiinconauctingitsbusinessauthorizesits employeesandagentstorentautomobilesthroughouttheState. TheStateofHawaiiwishestoremindallautomobilerentalcompanies thatit hasenteredintoanagreementwithAlexsisRiskManagement, Inc.,tohandleallno-faultclaimsandcollisiondamagesforauto-mobileaccidentsinvolvingStateemployeesandagentswhilethey areonStatebusiness.Coverageforrentedautomobilesis includedinthisagreement.Consequently,'Stateemployeesand. agentshavebeeninstructednot-topurchaseyourcollisiondamage waiver(CDW)coverage,includingpersonalaccidentinsurance. Intheeventofanaccident,wehaveinstructedouremployeesagentsto' immediatelyreportthedetailstoAlexsis.Alexsis',oIiL.' notifyyourcompanyandarrangeforasettlement.Youc:ayalso reporttheincidenttoAlexsisbycalling(808)531-2011or544-1397, orfileaclaimwiththeirHonoluluOfficeat1221Kapio1ani Blvd.,Suite901,Honolulu,Hawaii96814 . Furthermore,it isrequestedthatyouremployeesmakenodemands forup-frontpaymentforcollisiondamages.Allclaimsagainstthe Statearetobehandled.throughAlexsis. Iamsure thereare notifymy thatthisarrangement anyquestions,please staffat548-3214. willbemutallybeneficial.If to\\e,boveaddressor 1\\!..1-cc:RiskManagementCoordinators AlexsisRiskManagement '" '\,, RUSELG.A Comptroller To, STATEOFHAWAII 'EPARTMENTOFHEAJ..TH P.o..axU7J HOHOLUW.KAWAUMI01 ADKIHISTRATIVE IIEKORANDUIIHO. . InI'9Db.DIAM FU OFFICESERVICES ,.,__October14.1988 DivisionandBranchStaandDistrict

TORTCL.AIMSAGAINSTTHESTATE,andIHCIOEf{T/ACC.IOHT REPORT A.oOctob.r1,1988,'lh.h b ..n .utho.... i.z..d- tor....prope-rty-dg ..or .. and injur/ th..St.t. upto Th.r.ior.,this aupwrc.dA50"'-0Ho.76-17(dat.dHayASOK.-.oNo ..86-29(d.t... dKay29,1986),andASOtloNo ..88-27 (dat.dKay26,1988). Theatt.cb.d..ro.theO.partnto Accountingandontort andthestandard 2or_xoranr.port b. by pro9ra._inth.O.parta.ntofH lth The orD9- orInjury(ForMAO be- -a.ntdir.ct.iybyt.b.cl.i.ant..toOAGS.t.'lh ...addre-ss shownonth.or . Wh.nOftth. R.port(For. R"L-001),prQ9ra ar.r.qut.dto an andone copy the R.porttoth. withint.n(10)workingdaysoxth. cccurr.no..r.vi.v,th.originalvillb.orward.dto th.RisklIanag ___ ntatDAOS. Ith.r..r. anyqu tiona,pl.... contact.. 5709.ThankyouxQrandist.no. int.hi. P. s. .t2t:r Adei.tiona.!copioth.....or ....ayb ..obtain_inth. Ad",in:Lst.r".t.iveo 01'1'j,ce-. , J .tOHNWAlKIE --.. STATEOFHAWAII DEPARTMENTOFA=OUNTlNC; ANDCOENERALSERVICES lit.O.&OJ:11' HONOUILU.KAWAUtNlo-ottt October1,1988 COMPTROLLER'SMEMORANDUMNO.88-34 TOIHeadsofDepartmentandAgencies ATTENTION:RiskManagementCoordinatQrs FROM.RusselNagata,Comptroller SUBJECT:TortClaimsAgainsttheState The,",urposeof memorandumistonot; fyall departmentsand.lgenc iesthattheAttorneyGeneralhasauthor ized theComptrollertoresolveproperty. damageorlossandpersonal injuryclaimsagainsttheStateuptoSI0,000. LegalReference:Act266,SLH1988,permitsthe AttorneyGeneraltoreferclaimsarisingunderChapter662-11to theComptrollerforresolution. Discussion:Themajorityofclaimshandledbythe AttorneyGeneralstaffinvolvepersonalinjuryandproperty damageorlossofamountslessthan510,000.Betterutilization oftimeandeffortwillberealizedwhentheseclaimsarehandled byclaimadjustersratherthanattorneys.Moretimewillbe availabletothe stafftodealwithmuchbiggercases. Losspreventionmeasureswillbeenhancedasthecasual ofthelosscanb.analyzedandtreatedbytheRiskManagement StaffoftheDepartmentofAccountingandGeneralServices . Inordertoutilizethemostefficientmethod availableforadjustingclaims,Ale"sisRiskManagement,Inc. hasbeencontractedtoprovideclaimsadjustingservices. Procedure:EffectiveOctober1,1988,alltort Statefiled withyourdepartmentoragency shallbeforwardedtotheDepartmentofAccountingandGeneral Services,RiskManagementStafflocatedintheKalanimoku Building,RoomIllB.Theclaimantwillreceiveawritten acknowledgementoftheclaimandbeinformedthatan investigationwillbeconducted. HeadsofDepartmentOctober1,1988 Page2 AllclaimswillbeanalyzedbytheRiskManagement toidentifyproblemsandimprovelossactivities. Theclaimswillbesenttotheclaimsadjuster,AleKsis,for resolution.AleKsiswill aninvestigationofthe whichmayinvolveyourdepartmentorYourfullcoopera-tionandintheirinvestigationisrequested. Basedupontheirinvestigationandevaluation,theywilleither denytheclaimorpaymentoftheclaim. Ifpaymentis ,theAttorneyGeneralwill 'reviewthesettlement forapproval.Ifthe 'settlementisapproved,paymentwillbemade.Ifasettlementis notapprovedorcannotbe theclaimwillbedeniedor referredtotheAttorneyGeneralforfurtheraction. StandardForms(Attached): ClaimforDamageorInjury(FormAG1986-08231), Inorderforaclaimtobeaccepted,theclaimant mustbeinstructedtocompletetheformin withthe outlinedinthe form. b)Incident/AccidentReport(FormRML-OOl): TheprimarypurposeforcompletingtheIncident/ Reportisforlosscontrol.'Thisrepor.t thefirstnoticeofanincident/accident. Promptreportingisinordertocol'lect theyareavailableandfreshinthe mind. Thisform(Parts1&2)istobepreparedbythe emp loyeewhomaybecontactedbyphone,let'ter, orinpersonregardinganThisform(Parts3&4)istobepreparedbythe immediatesupervisorhavingauthorityorcontrol over,theincident/accident. OtherForms:Otherformsorinformationmaybe requestedto.ssistinlossandinthe investigationandsettlementofaclaim. , . He&dsofDepartmentandAgencies October1,1988 P&ge3 Ifyoushouldhaveanyquestions,pleasecontact Mr.30hnTakamune,RiskManagement.Officer,at548-3214. Your tortclaimswill Attachments cooperationinthisnewprocedure bo U, ~ ~ ~ ~ ~ RUSSELNAG, Comptroll'r forhandling .' 1I0nctTOCLAlIIAIIT Inorduthatyourclai ..for""'"gelmayncelveprop'!r consideration, 'rpuIIIUStsupplylheinforlllat.ioncalledforon theclai.for...All.oterialfactaahouldbe.tat.edonthis form,asitwillbethebasi.offurtheract.ionuponyour claim. readlheinstructionsbelowcarefullybeforethe formisprepared. IIIStRUCTIOllS Claim.forpropertydamage,lossordestruetion,Orfor personalinjury,IIIUSt.besignedbytheowneroftheproperty orbytheinjuredorbypatent,Inth'!caseofa minor.Ifthatpersoncannot.itil"becauseofdeath,. disability,oeotheeacceptabletotheStateof"awlii, thentheduly agentorother1e9alrepresentative filetheelaimIndmustproyideevidence tiafactoryto theStateoftheiraut.horltyloact.. !heamountclaimedshouldbesupportedasfollows: (a)Forpersonalinjuryordeath,theclaimantmust submit"writtenreportbytheattandinqphYsiCian,the and ofinjurY,thenatureandextentof the .. ofpermanent disabl lity,if any,t;,e prognosis,Indtheperiodofhospitalization,or incapacitation.TheclaimantorphysicianmustattaehItemized bill.formedical,hospital,orburialexpense.actually incurred.. (b)Fordan,ag_topropertywhichha.beenorcanbe economicallythe mustsubmitatleasttwo signedstatement.orestimatesbyreliable, disinterestedeoneerns,or,Ifpaymenthasbeenmade,the signedreceiptsahowin9actualpayment. (c)ForlostordestroyedpropertyOrfor to whicl.Isnoteeonomicallyreparable,theclaimantmust submitst.tementsastotheoriginalcostoftheproperty, ofandthevalueoftheproperty,bothbefore andatLerincident..suchstatementsshouldbeby competentpersons,preferablyreputabledealers oroffielal .familiarwith' thetypeofpropertydamaged,Orby twoOrmorecompetitive andshouldbecertifiedal beingjustandcorrect. rrinLininkoruseatypewriterto the claimformandsUbmitto: DepartmentofAccounting& GeneralServices RiskManagement StateofHawaii 1151PunchbowlStreet Honolulu.Hawaii96813 Anyfurlh@rinslructionsOrinformationnecessaryinthe pr@raratlonofyourwillbe uponrequest,by tha tof f1 ce. YOURCLAIMWl!.LHOTBECOnSIDEREDUIITILYOUPROVIDETHE REQUIREDSUPPUR"I"lfiGDUI::JIIfI!S. . CLAIMFORDAMAGEORINJURY (Attachadditionalif (Printininkor 1.Fullnam-:ofclaimant/victim: ___________________________ 2R-:sid-:nc-:{includingzipcode): _______________ 3. Phone:Res:______________ BUs: 4.Occupation: __________......:.. ____________ 5. placeofEmployment: ______________________________ 6.Locationoflncident/Address: _________________________ 7.Dat-:ofIncident:Dayofweek: 8.DescriptionofIncident.(Stat-:below,indetail,all knownfactsandcircumstanc-:s,identifypersonsand propertyinvolv-:d,andwhyyoubeli-:vetheStat-:ofHawail wasatfault.) I I .' 9.WitnessestoAddressPhone10.propertyDamage.orLoss(Natureandextentofdamageor LOSS): 11.PersonalInjury(Natureandextentofinjuryorloss): 12.Amountofclaim(Seeinstructionsforhowtoprove amount) : Personalinjury$ ....________________ Propertydamage/loss$ ....________________ Total$ ________________ Dated: Signatureofpersonfilllngclalm 198.6 08231 Address City,State 2 Zip , '1 ___ _ STATEOFHAWAII INCIDENT/ACCIDENTREPORT ji Architectural.Barriers: 1- 'Everylocationthatisrented,leased,orCenterFY ownedbyAMHDwillhaveaplaninplaceforChief/Operating basicaccessibility;e.g.,entry,exit,DesigneeBudget treatment/privacyareas,restrooms,etc. 2.WhenapersonservedprefersnottobeseenCenterFY atoneofAMHD'sfacilities,thenChief!Operating ar::::-angementswillbemadetoengagetheSupervisorBudget personinlocationswheretheyare comfortableie.g. ,incommunity,inhomes. 3.WhenaqualifiedAMHDemployeeisunabletoCenterFY accesstheworkareainoneofAMHO'sChief/Operating facilitiesbecauseofphysicaldisabilities,DesigneeBudget AMHDwillmakeareasonableaccommodation; e,g. ,arrangingtheworkspaceforthe employeeinanaccessiblearea. Att.itudinalBarriers: 1- CreateadditionalprogramreferraloptionsCenterFY andparticipateinactivitiestoreducetheChief!Operating stigmaofpersonsserved,includingbutnotSupervisorBudget limitedtoAMHDcommunityrelationsand publicationsfortargetedgroups ie.g. , intern/healthfairswithlocaluniversities; advocacygroupsforyouthandadults(e.g. , AMI);civicgroupsandlocalchambersof commerce. \ '.ADULTMENTALHEALTHDIVISION POLICYANDPROCEDUREMANUAL AMHDAdministration Number:60.511 Page:2of2 )/ ....;;.... -pliance"",iththerequirementsforGroupIoccupancies asdefinedintheUniformBuildingCodeandasdetailed inapplicablechaptersoftheNFPA101LifeSafety Codeadoptedbyreferencebvthestatefirecodeand respectivecountyfirec o d e ~ ."Complianceshallinclude 100-23 . 1l-lOO-20 butarenotlimitedtothefollowing: (A)Allexitsin IIhomesshallbelightedfrom sunsettosunriseandunderotherconditions requiredbyapplicableprovisionsoftheState andcountyfirecodes; (B)Nightlightingshallbeprovidedinhallwaysand ba throoms:' (e)Anapprovedsecondarysourceofpower(generator orbattery operated)foremergencylightingof exitsshallbeoperationalatalltimes. ec)Thefacilityshallmaintainall ingoodrepair tominimizehazardstoresidentsandstaff. (1)Housekeeping: (.\)A planshallbemadeandimplementedforroutine c\ea.ning oftheentirebuildingand premIses;"# (B)Afterdischargeofanrresident,thebed,bed furnishings,bedsidefurnitureandequipmentshall oethoroughlycleansedpriortosubsequentresident admission; (e)Floorsinresidentareasshallbecleanedatleast oncedaily; (D)All ceilings,windowsandfixturesshall bekeptclean. (2)Temperaturecontrol: (A)Temperatureandhumiditymaybemaintainedvithin apracticalcomfortrangebyheating,aircondi-tioning.orothermeanSinaccordancevith residents'n.eedsanddesires; (B)Anyheatingapparatusorappliances.oropenflame instoves,heatersandfireplaces conformtoUndervriters'Laboratoriesstandards astheyexistedonthedateofacoptionofthis chapter.. (3)Allhomesshallcomplywithapplicablestatelawsand rules tosanitation. andenvironmerital safety; (4)supply.coldwatershallbereadily availabletoresidentsforpersonalpurposes. Temperatureofhotwateratplumbingfixturesused byresidentsshallberegulatedandshallnot1IO"F.. (d)constructionoralterationstoexistingfacility shallcomplywithcurrentcountybuildingcodesinthestate. Thefacilityshallbeaccessibletoandfunctionalfor,physically handicappedresidentsiftheyaretobeadmitted. (1)Windows: (A)A habitableroomshallhaveanaggregatewindow 100-24 1l-l00-20 areaofnotone-tenthofthegrossfloor area; (8)Inroomsusedbyyheelchairresidents,vindovs shallbeloyenoughtoperMitcomfortablevieving oftheoutsidebyresidentsinvheelchairs; (C)Windovsinresidents'roomsshallhaveadequate meansofinsuringprivacy; (D)Servicerooms,exceptclosetsandotherrooms whicharenotdesigned foroIinoralterationswhichdonotaffectstructural integrity,fire,safety,orwhichdonotchange functionaloperation,or. increasebedsorservices overthatfor..hichthefacilityislicensedmav besubmittedbyfreehanddrawingsorsketches. 100-29 1l-100-20 (8)(A).'1aintenanceandrepai!'routinelyperformedby thefacilitydonotrequire orapproval brthedepartment; (9) (0) (8)Facilitiesshallbemaintainedinaccordancewith provisionsofstate!ndlocalzoning,building, fire. safetyandhealthcodes:' Anyfacilityholdingavalidlicense.tooperatean adultboardinghomeatthedateofadoptionofthese rulesshallbeexemptfromthe ofthis sectionaslongasallresidentsrelllltinfullyambulatory exceptthatthedepartmentmayrejectanapplication forlicenseifgrantingalicensewouldseriously jeopardizethehealthorsafetyoftheresidentsof suchafacility:4 Anywaiversgrantedin.respecttotheprovisionsof thissectiontocarehomeswhicharelicensedatthe timeofadoptionoftheseruleswillcontinueinforce untilsuchtimeastheownershipchanges.orthelicense isrevokedorsuspended.orlapsed:atwhichtimethe waiversare cancelled.Thedefinitionfor"resident" appliesatalltimes.[EffJune30.19861(Auth: HRS321-9.321-10.321-11.321-15.6)(Imp:HRS 32l-10.321-11.321-15.6.342-33) 11-100-2lViolations:licensesuspension.revocation, andotherpenalties.(a),jheneverthedepartmentcausesan investigationorinspectiontobemadeanddiscoversthatany oftherequirementsofthischapterhavebeenviolated,the departmentshallnotifythelicenseeofsuchviolationsin vriting.Insuchnotification,the shallsetforth thespecificviolationsandestablishaspecificandreasonable timeforthecorrectionofeachviolation.Intheeventdeficien-ciesarenotcorrected'inaccor'danceviththenotice.thedepart-mentmarinitiateproceedingsforinvokingfinesasprovided inchapter321HRS,ormay.suspendorrevokethelicenseafter proceedingsinaccordancewithchapter91,HRSanddepartment ofhealthrulesofpracticeandprocedure. (b)Thedepartment,afterduewrittennotice,andafter suitableopportunityforahearingmaysuspend.revoke,or.refuse toissueor licensetoanypersonbecauseoffailure tomeet: (1) (2) Therequirementsofthischapter;or Theconditionsunderwhich thelicenseissued. (c)Anypersonaffectedbythedepartment'sdecisionto deny,suspend,revoke.orrenewalicensemayappealthisdecision 100-30 1l-100-21 inaccordancewithchapter91,HRS. (d)Anypersonwhoviolatesanyruleofthedepartment shallbepenalizedasprovidedinchapter321-20.HRS. (e)AnTfacilitybelievedtobeoperatingasanadultresi-dentialcarehomeshallbesubjecttoinspectionbypersonsautho-rizedbythedirector..' (1)If thelItrector'srepresentativeisrefusedentryinto thehome,thedepartmentmayobtainaninspection warrantfromajudgeofthecircuitcourt: (2)IfthefacilitymeetSthedefinitionsinsection 11-100-2.theresponsiblepersoninthehome,within tenworkingdays,shallfilewiththedepartment,an applicationtoacquirelicensureaccordingtothis chapter;~ (3)Personswhofailtofileanapplicationwiththedepart-mentwithintenworkingdaysofnoticetofile,shall besubjecttopenaltiesinvokedundersection321, HRS. (f)Personswhodonotmeetadultresidentialcarehome requirements andare deniedlicensurebythedepartment,but vhocontinuetorenderadultreSidentialcarehomeservice$.to individualsintheirhomesshallbesubjecttopenaltiesinvoked underchapter321-20,HRS.. (g)Seriousandsubstantiveviolationswhichmayresult insuspensionorrevocationofalicenseinclude,butarenot limitedto,thefolloving: (1)Absenceofthelicenseefromthefacilityvithoutbeing replacedbyaresponsibleadult; (2)Admittingresidentstothehomeinexcessofthe licensedcapacitystipulatedonthecurrentlicense; (3)Transferofresidentstoanotherfacilitywithout informingtheagencyorpersonvhichispayingfor allorapore ionoftheresident'scare; (4)failuretoinformallresidentsoftheirrightson orbeforeadmission: (5)Corporalabuse orpunishmentofresidents; (6)failuretomaintainawrittenaccountingofreSident's personalfundsreceivedandexpendedonthereSident's behalfbythestaff; (7)Failuretoproperlysafeguardallmedicationsandcomply vithphysicianrsorders: (8)Failuretomaintain",rittenrecordsoftreatment includingmedicationsasorderedbyaphysician; (9)Failuretodevelopandpracticedrillsforrapidevacua-tionofresidentsincaseoffireorotherdisaster; (10)Failuretonotifythedepartmentof~significantChange inthelevelofoutsidethehomeremUnerativeactivity bytheoperator; 100-31 11-100-21 (11)or successivecitationsforthesamedeficien-cies; (12)Failuretocorrectcited "ithinaspecified time: (f)Licensesareissuedtoanamedlie. nseeandterminate onthedatesuchindividualwithdrawsfromt",:management.control oroperationofafacilityduetoachangeinovnership,termina-tionofemploymentor The. shallbepersonally liableforfailuretonotify .thedepartmentdortoth.eterOlina-tiondaterequested.[EffJune30.1986](Auth:HRS 321-9,321-10.321-11,321-15.0.321-15.7)(Imp:HRS 321-9,321-10,321-11,321-15.0,321-15.7.321-18.) 1l-100-22Discontinuanceofhomeand.:evocationoflicense. (a)Ahallieshallbediscontinuedandthehe,,,,,operator' Slicens" revokedbythedepartment: (1)Attherequestofthehomeoperator.Thehomeoperator shallwrittennoticetothedepartmentof intenttodiscontinueoperatinga,'enadultreSidential carehomeatleastthirtydaysprj,ortotheintended cerminationdate.Thedepartmentshallconfirmthe homeoperator's tooperationsby sendingawrittennoticeofdisco[.:inuancean6revoca-tionoflicensebytheintendedte.:'",oinationdate; (2)ForfailureofthehomeoperatortocorrectdeficienCies withintimelimitssetbytherepeesentativeofthe department.\/henthehomeoperatl...failstocorrect defiCiencies.thehomeoperator benotifiedin ",nHngbycertifiedmailoftheintentofthede?an-menttodiscontinueuSeofthehomeandtorevokethe licenseofthehomeoperatoratthirtydaysbefore theplanned 'dateof andrevocation; or (3)Due,totheilltreatment.abuse,neglect,orexploita-tionofresidentsbythehomeoperator.deSignated responsibleadults,atotherhouseholdmembersasdeter-minedbyarepresentativeofthedepartment. (A)\/henilltreatmentofaresir:'Jntisevident.the homeoperatorshallbecontaccedimmediately. by thedepartmentorcooperatinp- agency.todiscuss thecircumstances. (B)Thedepartmentshallnotify"hecooperatingagency ofthehomeimmediatelyvhenitisfactuallydeter-minedthatthereisill 'treatment.abuse,neglect. orexploitationofaresidenc.A thirtydayprior noticeshallnotberequired,butanotice 100-32 11-100-24 ofdiscontinuationshallbeprovidedbycertified mailpriortothediscontinuance. (b)Thedepartment'swrittennoticeofdiscontinuanceand revocationoflicenseshallcontsi'nastatementofthereasons fortheaction,theeffectivedateoftheactioR.andthehome operator's.righttoappealthedepartment'saction. (c)lIhenahomeisdiscontinuedbythedepartment,residents shallbeimmediatelyassistedin findingotheraccommodations exceptwhentheresidentsknowinglyandviII fullypreferto continuetoliveinthehomeandthehomeoperatorisawarethat keepingtheresidentsmeansthattheoperatorisoperatingan unlicensedhomeandissubjecttopenaltyunderthelaw. (EffJune30,1986J(Auth:HRS321-9,321-10,321-11, 321-15.6,321-15.7)HRS321-9,321-10,.321-11,321-15.6, 321-15.7) Aooealofdepartment'sdecision.(a)Anyadult residentialcarehom.eapplicantoroperatorshallhavetheright andopportunitytoappealthedecisioninvritingtothedirector vi thinthethirtydaynoticeperiodofproposedactionordecision underchapter91.HRS,anddepartmentofhealthrulesofpractice andprocedure.Exception: homeisdiscontinuedundersection 11-loo-22(a)(3),thehomeoperatorshallhavethirtydaysfrom thedateofthenoticetoappealthedecisioninvritingtothe directorofthedepartmentprovidedthelicenseshallbeimme-diatelyrevoked. (b)Uponthedepartment'sreceiptofarequesttoappeal thecepartment'sdecision,the operator'slicenseshall bereinstatedtoprOVisionallicensependingthedecisionon theappealandforaperiodnottoexceedthreefullcalendar months.Duringtheprovisionallicenseperiodthedepartment shallinformallindividualsinterestedinbeingplacedorin makingaplacementintothehomethereasonsforthehome operator'sproviSionallicense. (c)Theprovisionallicenseshallberevokedbythedepart-mentaftertheappealhearingisheldandthedepartment's deCisionisupheld.Ifthe actionisnotupheld bytheappealhearing,action,asappropriate.toreinstatethe homeoperatorshallbemade. June30,1986J-(Auth:HRS321.:.9.321-10,321-11.321-15.6)(l,,;p:HRS321-9, 321-10,321-11,321-15.6) 11-100-24Reoealofexistingrules.Allversionsof chapter12B.PublicHealthRegulations,whichwereineffect onJanuary1.1986.arerepealed.[EffJune30,1986J 100-33 11-100'